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The Critical Role of Workplace Inclusion in Fostering Innovation, Job

Satisfaction, and Quality of Care in a Diverse Human Service Organization

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DOI: 10.1080/23303131.2018.1526151

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 Human Service Organizations: Management, Leadership
& Governance

ISSN: 2330-3131 (Print) 2330-314X (Online) Journal homepage: http://www.tandfonline.com/loi/wasw21

The Critical Role of Workplace Inclusion in

Fostering Innovation, Job Satisfaction, and Quality
of Care in a Diverse Human Service Organization

Kim C. Brimhall & Michálle E. Mor Barak

To cite this article: Kim C. Brimhall & Michálle E. Mor Barak (2018) The Critical Role of Workplace
Inclusion in Fostering Innovation, Job Satisfaction, and Quality of Care in a Diverse Human Service
Organization, Human Service Organizations: Management, Leadership & Governance, 42:5,
474-492, DOI: 10.1080/23303131.2018.1526151

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HUMAN SERVICE ORGANIZATIONS: MANAGEMENT, LEADERSHIP & GOVERNANCE
2018, VOL. 42, NO. 5, 474–492
https://doi.org/10.1080/23303131.2018.1526151

The Critical Role of Workplace Inclusion in Fostering Innovation,

Job Satisfaction, and Quality of Care in a Diverse Human Service
Organization
a
Kim C. Brimhall and Michálle E. Mor Barakb
a
College of Community and Public Affairs, Binghamton University State University of New York, Binghamton, New
York, USA; bUSC Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles,
California USA

ABSTRACT KEYWORDS
With increases in workforce diversity, human service leaders are recognizing diverse human service
the need to create inclusive workplaces. Yet little research exists about the organizations; innovation;
influence of inclusion on innovation, job satisfaction, and perceived quality job satisfaction; perceived
of care. Using a sample of 213 participants within 21 departmental units (10 quality of care; workplace
employees on average) in a diverse human service organization, the authors inclusion
performed multilevel path analysis. Results suggested significant relation-
ships between inclusion and quality of care through increased innovation
and job satisfaction. Findings indicate that to improve quality of care,
leaders must strive to promote a climate of inclusion in human service
organizations.

Introduction
Population projections indicate that the American workforce will become increasingly diverse
(Colby & Ortman, 2014; Roberson, Holmes, & Perry, 2017). For example, by the year 2030, one in
five Americans will be age 65 and older; by 2044, more than one half of all Americans will be
members of a racial and ethnic minority group; and by 2060, nearly one in five of the nation’s total
population is projected to be foreign born (Colby & Ortman, 2014). With current increases in
workforce diversity, and the projected growth of heterogeneity, human service organizations (HSOs)
are facing the challenge of channeling diversity into beneficial outcomes (Köllen, 2015; Mor Barak,
2015; Shore, Cleveland, & Sanchez, 2017). Research indicates that diverse workforces are associated
with positive and negative outcomes (Acquavita, Pittman, Gibbons, & Castellanos-Brown, 2009;
Gonzalez & DeNisi, 2009; Mor Barak et al., 2016; Nishii, 2013; Shore et al., 2011). A recent meta-
analysis and review of the literature of workforce diversity in HSOs (Mor Barak et al., 2016) indicate
that some of the positive effects of diversity include enhanced creativity and innovation, improved
workplace commitment, and increased retention. Conversely, workforce diversity has also been
found to potentially lead to intergroup conflict, increased turnover, and losses in productivity and
performance (Acquavita et al., 2009; Gonzalez & DeNisi, 2009; Mor Barak et al., 2016; Nishii, 2013;
Shore et al., 2011; Travis & Mor Barak, 2010). Finding ways to leverage the benefits of diversity is
particularly important for human service leaders and managers striving to improve quality of care
(Lightfoote et al., 2014). Although workplace inclusion has been found to help channel diversity into
positive outcomes (Mor Barak et al., 2016; Shore et al., 2011), little is known about the potential
influence of climate for inclusion on climate for innovation and quality of care in human service

CONTACT Kim C. Brimhall brimhall@binghamton.edu College of Community and Public Affairs, Binghamton University
State University of New York, 67 Washington St., Binghamton, NY 13902 USA.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wasw.
© 2018 Taylor & Francis Group, LLC
 HUMAN SERVICE ORGANIZATIONS: MANAGEMENT, LEADERSHIP & GOVERNANCE 475

health care settings. Climate for inclusion may be critical to fostering a climate for innovation that
would lead to improved quality of services. Thus, the current study examined possible pathways by
which climate for inclusion may influence quality of care through climate for innovation and job
satisfaction in one type of HSO, those organizations that deliver health care services.

Theoretical background and hypotheses

Climate for inclusion
The organizational literature has shifted in focus and come to recognize diversity’s potential benefits,
moving from diversity management to inclusion (Mor Barak, Cherin, & Berkman, 1998; Mor Barak,
2015; Nishii, 2013; Shore et al., 2017). Although the terms diversity and inclusion have in the past
been used interchangeably, diversity is a characteristic of a group or organization and refers to the
composition of differences among individuals (e.g., race, ethnicity, gender, education) in the group
or organization (Gonzalez & DeNisi, 2009; Homan & Greer, 2013; Roberson, 2006). Inclusion, on the
other hand, refers to the extent to which employees feel valued for their unique characteristics and
have a sense of belonging, thus feeling comfortable about sharing their “true selves” within the work
organization (Mor Barak, 2015; Nishii, 2013; Shore et al., 2011). Diversity management refers to the
recruitment strategies, training, and mentoring programs that organizations use to create a more
diverse workforce (Roberson, 2006). Inclusion management refers to the extent to which an organi-
zation creates policies and practices that not only recognize employees’ individual talents but also
encourage the full participation of each employee in formal and informal organizational activities
(Mor Barak, 2015; Nishii, 2013). A climate for inclusion refers to the shared employee perceptions of
the extent to which an organization helps each member feel valued and appreciated as important
members of the group or organization (Mor Barak et al., 2016). In the current study, individual and
group-level diversity characteristics that have been found to be critical in past research (i.e., race/
ethnicity, gender, age, education, job position, and job tenure; Brimhall, Lizano, & Mor Barak, 2014;
Mor Barak et al., 2016; Nishii, 2013) represent the organizational context of workforce heterogeneity
and are treated as control variables for understanding the outcomes of climate for inclusion. The
growing literature on this topic suggests that creating an inclusive workplace, especially among
diverse organizational groups, results in positive outcomes, such as increased job satisfaction,
retention, organizational commitment, trust, well-being, creativity, innovation (Brimhall et al.,
2014; Li, Lin, Tien, & Chen, 2015; Mor Barak, Levin, Nissly, & Lane, 2006; Shore et al., 2011;
Travis & Mor Barak, 2010), decreased conflict, intention to leave, stress, job withdrawal, and
organizational turnover (Hopkins, Cohen-Callow, Kim, & Hwang, 2010; Hwang & Hopkins, 2012;
Mor Barak et al., 2006; Nishii, 2013; Travis & Mor Barak, 2010).
Despite the evidence that workplace inclusion is beneficial for channeling diversity into positive
organizational outcomes, little is known about whether climate for inclusion also translates into
improved quality of care (Lightfoote et al., 2014). Social identity theory (Tajfel, 1982) and optimal
distinctiveness theory (Brewer, 1991) provide insights into why workplace inclusion may result in
improved quality of care. According to social identity theory, feeling valued as an important part of
an organization can foster commonality among its members. When organizational members per-
ceive that they are similar to those around them, their trust and acceptance of one another increases
(Tajfel, 1982). As feelings of acceptance increase, so do feelings of inclusion (Shore et al., 2011).
However, perceiving commonality among organizational members is only one component of inclu-
sion. Another aspect is being valued for the unique characteristics that one brings to the organization
(Mor Barak, 2017; Nishii, 2013; Shore et al., 2011). Optimal distinctiveness theory posits that
individuals strive for a balance between feelings of similarity among organizational members and
recognition of their unique characteristics as individuals (Brewer, 1991). In other words, climate for
inclusion is fostered by achieving balance between belonging to an organizational group and being
appreciated for one’s unique individual characteristics (Shore et al., 2011). When organizational
members feel included, there is improvement in staff attitudes (i.e., job satisfaction, commitment,
476 K. C. BRIMHALL AND M. E. MOR BARAK

intention to leave; Brimhall et al., 2014; Shore et al., 2011) and subsequent work outcomes (i.e.,
increased retention and performance; Mor Barak, 2015; Shore et al., 2011).

Hypothesis 1: Climate for inclusion is positively associated with job satisfaction.

Human relation and human resource theorists argue that satisfied workers are more productive
workers and ultimately have higher job performance (Likert, 1961; McGregor, 1960; Ostroff, 1992).
How employees feel about their job largely dictates whether they will exert their efforts whole-
heartedly toward the work that they do (Ostroff, 1992). In essence, organizational productivity and
performance, such as high quality care, is achieved through employee satisfaction and meeting the
emotional and psychological needs of workers (Likert, 1961; McGregor, 1960; Ostroff, 1992).
Employees who are more satisfied with their jobs not only exert more effort but are also more
committed to the work that they do, have improved teamwork with their colleagues, and are less
likely to leave their jobs, all of which influence the quality of care provided to clients (Chang, Ma,
Chiu, Lin, & Lee, 2009; Laschinger, Zhu, & Read, 2016).

Hypothesis 2: Job satisfaction is positively related to perceived quality of care.

Evidence suggests that an inclusive workplace is associated with favorable employee attitudes,
such as increased job satisfaction (Brimhall et al., 2014), psychological safety (Carmeli, Reiter-
Palmon, & Ziv, 2010; Nembhard & Edmondson, 2006), trust (Downey, Werff, Thomas, & Plaut,
2015), and team identity (Mitchell et al., 2015), and that these favorable attitudes and perceptions are
associated with enhanced performance (Mitchell et al., 2015; Sabharwal, 2014), engagement (Downey
et al., 2015), and quality improvement efforts (Carmeli et al., 2010; Nembhard & Edmondson, 2006).
In other words, climate for inclusion may positively influence work outcomes, such as quality of
care, through improving employee attitudes about their work (e.g., job satisfaction). As organiza-
tional members feel valued and appreciated they may be more satisfied with their jobs (Brimhall
et al., 2014; Shore et al., 2011) and therefore exert more effort toward the work that they do (Platis,
Reklitis, & Zimeras, 2015; Yalabik, Rayton, & Rapti, 2017), ultimately increasing performance
(Mitchell et al., 2015; Platis et al., 2015; Sabharwal, 2014) and quality of care (Carmeli et al., 2010;
Nembhard & Edmondson, 2006).

Hypothesis 3: Climate for inclusion is positively associated with perceived quality of care through
its influence on job satisfaction.

Climate for inclusion and climate for innovation

Innovation has been defined as the introduction and application of ideas, processes, products, or
procedures that are new to the organization and are designed to be useful (Somech & Drach-Zahavy,
2013; West & Farr, 1990). Climate for innovation refers to the shared employee perceptions of the
extent to which the group fosters new and useful ideas, processes, products, or procedures that
significantly benefit the group, organization, or larger society (Anderson & West, 1998; Somech &
Drach-Zahavy, 2013). Diverse human service employees may have greater potential to innovate and
improve quality of care relative to homogenous human service employees (Mor Barak, 2017; Page,
2017), provided the presence of an inclusive organizational climate. Historically, HSOs have been
characterized by a rigid hierarchy and strong professional boundaries that can inhibit open colla-
boration and the willingness of all organizational members to share ideas, thus hindering the
organization’s ability to innovate and improve quality of care (Kajamaa, 2015; Labitzke, 2015).
Nembhard and Edmondson (2006) found that when leaders promote an inclusive environment,
staff participation and engagement in quality improvement efforts increase. Inclusion has been
linked to increased trust among organizational members (Downey et al., 2015; Shore et al., 2011),
 HUMAN SERVICE ORGANIZATIONS: MANAGEMENT, LEADERSHIP & GOVERNANCE 477

which in turn has been linked to an increased willingness of organizational members to share and
collaborate on new ideas, a critical component of innovation (Anderson & West, 1998; Dovey, 2009;
H. S. Lee & Hong, 2014; Proudfoot et al., 2007; Sankowska, 2013). Li and colleagues (2015) found
that when climate for inclusion was high, creativity and innovation was stronger particularly for
multicultural teams, suggesting that when employees from diverse backgrounds feel that they are
valued for their unique perspectives (characteristic of a climate for inclusion), they may be more
willing to share their ideas and collaborate with others (characteristic of a climate for innovation).

Hypothesis 4: Climate for inclusion is positively associated with climate for innovation.

Although limited empirical evidence has connected inclusion, innovation, and quality of care, the
current study posited that when diverse organizations strive to create an inclusive environment, trust
and acceptance among organizational members increase (Mor Barak et al., 2016; Shore et al., 2011).
When organizational members trust one another and feel valued for their unique perspectives, they
may be more willing to take risks with one another and share innovative ideas on how to improve
quality of care. For example, when organizational members feel comfortable sharing information
with other employees, this may lead to improved care through identifying new ways of solving
problems (Blank & Naveh, 2014), improved methods for diagnostic testing, and more efficient
organizational processes and procedures (Duarte, Goodson, & Dougherty, 2014; Page, 2014).
Ultimately, when inclusion and innovation work together, they may create an ideal environment
for improving quality of care.

Hypothesis 5: Climate for inclusion is positively associated with perceived quality of care through
its influence on climate for innovation.

Climate for innovation and job satisfaction

An organizational climate for innovation has been associated with improved job satisfaction
among human service staff (Pantouvakis & Mpogiatzidis, 2013). The interactionist perspective
on organizational creativity and innovation (Woodman, Sawyer, & Griffin, 1993), posits that
group innovation is a complex process that requires interaction between the individual and his
or her group members (Anderson, Potocnik, & Zhou, 2014). As group members feel more
comfortable interacting and sharing ideas with each other, this may enhance creativity and
innovation (Blank & Naveh, 2014, 2015), and the information gained from this interactive
process may help employees feel more active, energized, interested, and excited, which in turn,
increase job satisfaction (Todorova, Bear, & Weingart, 2014). In essence, innovation empowers
employees to engage in idea sharing and learning from peers, which positively affects how
these individuals feel about their jobs (Cortini, 2016; Govaerts, Kyndt, Dochy, & Baert, 2011;
Pantouvakis & Mpogiatzidis, 2013; Wong & Laschinger, 2013). According to the learning
organization perspective, workplaces that foster a learning climate encourage organizational
members to share ideas with one another, welcome individuality, and ensure that mistakes are
viewed as learning opportunities (Gardiner, 1997). Learning organizations are characterized as
being supportive work environments that lead to increased employee trust, engagement,
empowerment, and job satisfaction (Chang, 2007; Dekoulou & Trivellas, 2015; Gardiner,
1997; Pantouvakis & Mpogiatzidis, 2013). In other words, the learning organization perspective
argues that learning climates in which employees are encouraged to share ideas with one
another (critical to innovation climates) increase employee job satisfaction and engagement
(Dekoulou & Trivellas, 2015; Pantouvakis & Mpogiatzidis, 2013), both of which are essential
elements in improving quality of care (Page, 2014).

Hypothesis 6: Climate for innovation is positively associated with job satisfaction.

478 K. C. BRIMHALL AND M. E. MOR BARAK

Climate for innovation and quality

Innovation and quality improvement have become key strategies for HSOs striving to maintain a
competitive advantage (Bourke & Roper, 2017). Human service innovation, such as health care
innovation, is particularly important because it fosters the development of new ideas relevant to
patient care, such as new approaches to solving problems, diagnostic testing, and workplace
procedures and processes that may lead to improved quality of care and ultimately the ability to
save people’s lives (Duarte et al., 2014; Page, 2014). Blank and Naveh (2014) found that when
employees engage in frequent interaction and idea sharing, critical to innovation climate, quality
performance improves. In essence, information exchange with other employees may identify pro-
blems that provide opportunities for improved quality outcomes (Blank & Naveh, 2014).
Innovations, such as incorporating new ideas, technologies, or techniques have been crucial to
improving quality of care, particularly for specialized and complex care (Witiw, Nathan, &
Bernstein, 2015). Ultimately, when employees feel comfortable speaking up and sharing their ideas
(an innovation climate), the opportunity for improving human services, such as health care services,
increase (quality of care; Blank & Naveh, 2014; Duarte et al., 2014; Page, 2014)

Hypothesis 7: Climate for innovation is positively associated with perceived quality of care.

Research has supported the positive associations between innovation and job satisfaction (Cortini,
2016; Govaerts et al., 2011; Pantouvakis & Mpogiatzidis, 2013; Wong & Laschinger, 2013) and
between job satisfaction and quality of care (Djukic, Kovner, Brewer, Fatehi, & Cline, 2013; Snipes,
Oswald, LaTour, & Armenakis, 2005; Stalpers, van der Linden, Kaljouw, & Schuurmans, 2016),
informing the following hypothesis regarding the potential indirect role of job satisfaction in the
relationship between innovation and perceptions of health care quality. In other words, as employees
feel comfortable sharing ideas with others and innovation climate increases, this encourages inter-
action and learning from peers, which positively influences how these individuals feel about their
jobs (Cortini, 2016; Govaerts et al., 2011; Pantouvakis & Mpogiatzidis, 2013; Wong & Laschinger,
2013) and ultimately the quality of care offered to clients (see Figures 1 and 2; Blank & Naveh, 2014;
Duarte et al., 2014; Page, 2014; Witiw et al., 2015).

Hypothesis 8: Climate for innovation is positively associated with perceived quality of care through
its influence on job satisfaction.

Ethnicity Climate for H4 Climate for

Age Inclusion Innovation
Education
Job Tenure
Job Position H7
H1 H6 Level 2
Level 1
Ethnicity
Age
Education Job Perceived
Job Tenure Satisfaction H2 Quality of Care
Job Position

Figure 1. Multilevel conceptual model of direct associations.

Note. Level 1 = individuals, Level 2 = groups, H1 = Hypothesis 1; H2 = Hypothesis 2; H4 = Hypothesis 4;
H6 = Hypothesis 6; H7 = Hypothesis 7.
 HUMAN SERVICE ORGANIZATIONS: MANAGEMENT, LEADERSHIP & GOVERNANCE 479

Ethnicity Climate for Climate for

Age Inclusion Innovation H5
Education
Job Tenure
Job Position H8 Level 2
Level 1
Ethnicity H3
Age
Education Job Perceived
Job Tenure Satisfaction Quality of Care
Job Position

Figure 2. Multilevel conceptual model of indirect associations.

Note. Level 1 = individuals; Level 2 = groups; H3 = Hypothesis 3; H5 = Hypothesis 5; H8 = Hypothesis 8.

As HSOs become increasingly more diverse, understanding how to maximize the potential
benefits of workforce diversity becomes critical (Köllen, 2015; Mor Barak, 2017). This may be
especially true for diverse HSOs, such as health care organizations, aiming to improve quality of
care (Lightfoote et al., 2014). Climate for inclusion may be a key factor that improves climate for
innovation, staff job satisfaction, and ultimately the quality of care provided to clients. Information
from this study can inform the design of workplace interventions that improve quality of care by
creating inclusive and innovative workplaces.

Methods
Participants
Participants were recruited in July 2015 from a very diverse urban human service nonprofit hospital
department located in the western region of the United States. This department was primarily in
charge of diagnostic testing and assessment. Employees were engaged in interprofessional collabora-
tion with various departments and with members outside of their immediate department focusing on
procedures and processes related to increasing innovation and quality of care for the entire
healthcare organization. In other words, members of this department interacted with employees
and patients throughout the entire health care organization to provide patient care through diag-
nostic testing, assessment, and pathology and laboratory services. Of the 300 employees, 277 agreed
to participate in the initial demographic survey (92% response rate) and 213 (71% response rate)
agreed to participate in the main survey. The target department featured 23 separate work groups.
Work groups were defined as: employees who (1) shared the same primary work supervisor and (2)
regularly interacted with one another in order to accomplish work objectives and tasks. To ensure
confidentiality, two work groups were removed from the analysis because they had fewer than five
members who participated in the study. This resulted in 21 within-department work groups used in
the analysis, with an average group size of approximately 10 employees (SD = 6.58, range = 5‒25).

Procedures
To ensure confidentiality, the primary investigator of the study emailed two surveys to all current
department employees. To protect against common method bias, demographic questions were
asked in an initial survey 4 weeks prior to the main questionnaire (temporal separation;
Podsakoff, MacKenzie, Lee, & Podsakoff, 2003) and kept separate from the main questionnaire,
which asked about workplace inclusion, innovation, job satisfaction, and perceived quality of
care. Participants created their own unique study ID codes that were used to connect the initial
demographic survey with the main questionnaire. No personally identifying information was
480 K. C. BRIMHALL AND M. E. MOR BARAK

obtained on either survey (e.g., names or email addresses). After completing the main ques-
tionnaire (121 items), participants received $15 Amazon.com gift cards. Participates were invited
to email the principle investigator indicating that they had complete the survey (no other
information was asked or collected). Upon receipt of this email they were sent an e-gift card
via a return email. This approach was used to protect participant confidentiality, and it required
the researchers to trust that participants were being honest and asking for gift cards because they
had truly completed they survey. There was no way to ensure those who obtained a gift card
actually completed the survey, however the number of gift cards requested were approximately
equal the number of surveys completed. To increase participation rates, the principal investigator
emailed all current employees an invitation to participate. Reminder emails were sent weekly. In
addition to the electronic survey option, paper surveys were available for pick up in several
locations in the department and locked drop boxes were placed for participants to return their
completed surveys. The overwhelming majority of the participants completed the electronic
version of the survey, with only about 2% of participants (n = 4) choosing to use the paper
survey option. Last, the principal investigator left invitation announcements and light refresh-
ments in employee break rooms. Prior to data collection, the study was reviewed and approved
by the institutional review boards of the participating hospital and the university.

Measures
Climate for inclusion
Perceptions of work group inclusion were measured using subscales from the MBIE—Mor Barak
Inclusion-Exclusion Scale (Mor Barak, 2017). This measure consists of several scales that measure
inclusion in three areas (decision making, information networks, and involvement in social activ-
ities) and at five levels in the organization (work group, supervisor, social informal, organization,
and upper management). To measure work group inclusion, the work group (3 items), supervisor (3
items), and social informal (3 items) subscales were used. The phrase “my lab section/work group”
was added to each question for clarity regarding the level of analysis for each question. For example,
participants were asked to respond to statements such as “I have influence in the decisions taken by
my lab section/work group regarding our tasks” (work group); “In my lab section/work group, my
supervisor often asks for my opinion before making important decisions” (supervisor); and “In my
lab section/work group, I am rarely invited to join my coworkers when they go for lunch or drinks
after work” (social informal). Two items were reverse scored (Items 5 and 15). Responses were
ranked on a Likert-type scale ranging from 1 (strongly disagree) to 6 (strongly agree). All items were
averaged to create a mean score for work group inclusion, which was treated as an observed variable.
Higher scores represented higher feelings of inclusion. The reliability for work group inclusion
was .85.

Climate for innovation

Perceptions of innovation were measured using Anderson and West’s (1998) eight-item innovation
scale. Responses were given on a Likert-type scale ranging from 1 (strongly disagree) to 6 (strongly
agree). Sample scale items are “My lab section/work group is always moving toward the development
of new answers” and “In my lab section/work group, we take the time needed to develop new ideas.”
All items were averaged to create a mean innovation score, which was treated as an observed
variable. Cronbach’s alpha for the innovation scale was .96.

Job satisfaction
Quinn and Staines’ (1979) four-item work satisfaction scale was used to measure job satisfaction. An
example item is “All in all, I am satisfied with my job.” Responses were rated on a Likert-type scale
ranging from 1 (strongly disagree) to 6 (strongly agree). A composite job satisfaction score was
created, with higher scores indicative of higher job satisfaction. Cronbach’s alpha was .91.
 HUMAN SERVICE ORGANIZATIONS: MANAGEMENT, LEADERSHIP & GOVERNANCE 481

Perceived quality of care

S. M. Lee, Lee, and Kang’s (2011) three-item service quality scale was used to measure perceived
quality of care. Responses were ranked on a Likert-type scale ranging from 1 (strongly disagree) to 6
(strongly agree). An example item is “This hospital department is a good health care environment for
providing treatment/diagnosis.” All items were averaged to create a mean perceived quality score,
which was treated as an observed variable. Higher scores indicated higher perceived quality of care.
The reliability of these items was .96.
All demographic and work-related questions (i.e., gender, race and ethnicity, age, education, job
position, job tenure, lab section or work group, and job location) were asked in an initial survey that
was separate from the main questionnaire that assessed inclusion, innovation, job satisfaction, and
perceived quality of care. Group diversity was measured using the Blau’s diversity index (Blau, 1977)
with scores closer to 1 indicating a higher degree of group diversity for each demographic
characteristic.

Data analysis
Prior to data analysis, data cleaning and evaluation of distribution of variables and missing data
patterns were completed. All skew and kurtosis values fell below the absolute values of 2 (skew) and
7 (kurtosis), indicating acceptable normality (Curran, West, & Finch, 1996; Ryu, 2011). Patterns of
missing data were also explored. Of the 277 survey respondents, 17 did not answer all questions
about perceived quality of care (6% of the values were missing, and 94% were present). Scholars have
recommended that missing data be handled with nonbiased methods of estimation, such as full
information maximum likelihood (Enders & Bandalos, 2001; Schafer & Graham, 2002). To use full
information maximum likelihood estimation, data must be considered missing at random (Schafer &
Graham, 2002; Scheffer, 2002). As defined by Rubin (1996), data can be reasonably considered
missing at random and full information maximum likelihood estimation methods employed if
missingness in the outcome variable does not depend on the outcome itself. A logistic regression
analysis (data not shown) was conducted to test whether missing data in the outcome variable
(perceived quality of care) was associated with any of the variables in the model (inclusion,
innovation, job satisfaction, perceived quality of care, gender, race and ethnicity, age, education,
job tenure, job position; McArdle, 2013). The logistic regression model yielded null results, suggest-
ing that the data in perceived quality of care scores were not missing due to perceptions of quality
(or any other variable examined) among study respondents. Based on these results, full information
maximum likelihood was used to handle missing data in the analysis.
To examine the study hypotheses, a multilevel path analysis was conducted in Mplus 6.1 statistical
software (Muthén & Muthén, 1998-2010). The CLUSTER command was used to account for the
nested data structure. Inclusion and innovation were measured at the group level, whereas job
satisfaction and perceived quality of care were measured at the individual level. To ensure that the
data supported group-level aggregation, intraclass correlation coefficients (ICCs) were computed,
indicating the amount of dependence among observations within groups (Shrout & Fleiss, 1979).
Inclusion and innovation were conceptualized in the current study as organizational climates, that is,
the shared employee perception of what the work environment is like (Glisson et al., 2008; Reichers
& Schneider, 1990). Organizational climates aim to capture group-level aspects of the work envir-
onment and are measured as a level-two variable (Glisson & James, 2002; Glisson et al., 2008;
Reichers & Schneider, 1990). Using referent shifts in measurement constructs (i.e., shifting from
individual-level to group-level variables), as used in the current study, are recommended to indicate
the level of measurement for each item (Glisson & James, 2002; Glisson et al., 2008; Wallace et al.,
2016). In this case, inclusion and innovation questions used a group-level referent shift to help
participants understand that inclusion and innovation were being measured at the work-group level
(e.g., for inclusion: “In my lab section/work group, my supervisor often asks for my opinion before
making important decisions.” and for innovation: “In my lab section/work group, we take the time
482 K. C. BRIMHALL AND M. E. MOR BARAK

needed to develop new ideas”). The term climate for indicates the particular work climate being
examined (e.g., Ahmed, 1998; Aarons, Ehrhart, Farahnak, & Sklar, 2014; Anderson & West, 1998;
Ekvall, 2008; Mor Barak et al., 2016; Nishii, 2013), in this case we examined a climate for inclusion
and a climate for innovation. As recommended by other researchers, the ICCs and average within
group agreement coefficients were used to indicate the appropriateness for measuring these variables
at the group level (Bliese, 2000; Brown, 2000; Brown & Hauenstein, 2005; Kenny & Judd, 199; Shrout
& Fleiss, 1979;). Multilevel path analysis was used to account for the fact that individual employees
were nested within work groups and likely have shared variance in the constructs being examined.
This approach has been recommended when the data can be clustered by work groups (Hox,
Moerbeek, & van de Schoot, 2017). Model fit was evaluated using the chi-squared (χ2) misfit statistic,
Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), and the root mean square error of
approximation (RMSEA; Hayduk, Cummings, Boadu, Pazderka-Robinson, & Boulianne, 2007; Hu
& Bentler, 1998, 1999).

Results
Sample
Table 1 presents demographic descriptive statistics. The sample was racially and ethnically diverse:
41% of respondents self-reported as Asian, 21% as White, 20% as mixed race or other, 14% as Latino,
and 4% as African American. Approximately 69% of participants were female and 31% were male;
27% self-reported being between ages 30 and 39, 22% between ages 50 and 59, 21% between ages 40
and 49, 15% between ages 18 and 29, and 15% older than age 60. Approximately one half of the
participants in this sample had a bachelor’s degree (49%). The two largest categories in terms of job
positions were clinical lab scientists (31%) and lab technologists (28%). The two largest categories of
job tenure among the participants were those who had worked between 3 and 5 years (22%) and less
than 1 year (20%). Means, Standard Deviations, and correlations of study variables are presented in
Table 2. The variation of group diversity for race and ethnicity, gender, age, education, job tenure,
and job position are presented in Table 3. It is predicted that by 2025 42% of the United States
workforce will be from a racial and ethnic minority group (U.S. Census Bureau, 2008) and almost
one half of the human service workforce younger than age 40 from racial and ethnic minority
backgrounds (Heggeness, Gunsalus, Pacas, & McDowell, 2017). In the current sample, approximately
86% of workgroups currently surpass (n = 14) or are approaching (n = 4) this estimate, indicating
that the sample is heterogeneous in terms of racial and ethnic diversity.

Aggregation analysis and model fit

ICCs regarding climates for inclusion and innovation indicate the appropriateness of considering
these variables at the group level (Bliese, 2000; Kenny & Judd, 1996). For inclusion, significant
differences existed between work groups, indicating that 15% of the variance in perceptions of
inclusion was explained between groups (ICC = .15, p < .05, 95% confidence interval [CI] [.05, .33]).
Similar results were found for innovation, suggesting that 15% of the variance explaining perceptions
of innovation occurred between groups (ICC = .15, p < .05, 95% CI [.05, .33]). Average within-group
correlations indicated that the climatic strength (or agreement) for inclusion and innovation was .62
(values closer to 1 indicate perfect agreement or a strong climate; Brown, 2000; Brown & Hauenstein,
2005). Model fit statistics for the multilevel path model suggested a good fit for the data (χ2 = 17.247,
df = 11, p < .10; CFI = .99; TLI = .95; RMSEA = .05, 90% CI [.01, .10]).
 HUMAN SERVICE ORGANIZATIONS: MANAGEMENT, LEADERSHIP & GOVERNANCE 483

Table 1. Descriptive Statistics of Demographic Variables.

Variable n %
Race and ethnicity 247
African American 10 4
Asian 102 41
White 51 21
Hispanic or Latino 35 14
Mixed race or other 49 20
Gender 206
Female 142 69
Male 64 31
Position in organization 205
Administrative 19 9
Administrative director 8 4
Clinical lab scientist 64 31
Faculty director 10 5
Lab technologist 57 28
Manager 13 6
Research associate 8 4
Supervisor 8 4
Other 18 9
Education 206
High school diploma 28 14
Associate’s degree 19 9
Bachelor’s degree 100 49
Master’s degree 24 12
MD 17 8
PhD 11 5
Other 7 3
Age 206
18‒29 years 31 15
30‒39 years 56 27
40‒49 years 43 21
50‒59 years 45 22
60‒69 years 26 13
70+ years 5 2
Job tenure 206
Less than 1 year 41 20
1‒2 years 33 16
3‒5 years 45 22
6‒10 years 23 11
11‒20 years 35 17
21‒30 years 16 8
More than 31 years 13 6

Table 2. Descriptive Statistics and Correlations of Study Variables (N = 247).

Variable M SD Range 1 2 3
1. Inclusion 4.22 0.91 1‒6
2. Innovation 4.33 0.96 1‒6 0.70*
3. Job satisfaction 4.63 0.96 1‒6 0.55* 0.61*
4. Perceived quality of care 5.00 0.89 1‒6 0.42* 0.54* 0.61*
*p < .001.

Direct associations
Figure 3 shows the standardized direct associations of the multilevel path model for climate for
inclusion, climate for innovation, job satisfaction and perceived quality of care. After indivi-
dual- and group-level gender, race and ethnicity, job position, job tenure, and education were
controlled for a positive association was found between climates for inclusion and innovation
(β = .67, SE = .03, t = 23.25, p < .001, 95% CI [.63, .72]). Climate for inclusion was also
484 K. C. BRIMHALL AND M. E. MOR BARAK

Table 3. The Variation of Diversity Characteristics by Work Group.

Race/
Work Group ethnicity Gendera Age Education Job Tenure Job Position
1 .70 .31 .79 .77 .84 .77
2 .71 .50 .79 .65 .76 .74
3 0 .50 .50 .63 .63 .50
4 .5 .38 .63 .50 .63 .63
5 .35 .50 .76 .24 .81 .48
6 .49 .32 .48 0 .72 .48
7 0 .50 .66 .41 .53 .66
8 .67 .45 .73 .28 .72 .28
9 0 .30 .76 .55 .73 .56
10 .45 .50 .67 .62 .72 .50
11 .45 0 .45 .45 .45 0
12 .58 .38 .77 .70 .81 .56
13 .63 .49 .68 .73 .79 .70
14 .68 .29 .68 .45 .77 .68
15 .32 .32 .72 0 .72 .64
16 .50 .50 .78 .50 .72 .62
17 .32 .48 .48 .32 .48 .32
18 .50 0 0 .50 .50 .50
19 .30 0 .38 .30 .32 .30
20 .72 .31 .77 .53 .78 .61
21 .57 .41 .61 .61 .82 .73
Note. Scores computed using Blau’s diversity index (Blau, 1977). Scores range from 0 (no diversity) to 1 (high diversity).
a
Proportion scores from 0 (no gender diversity) to .50 (high gender diversity).

.17*
Ethnicity Climate for .67*** Climate for
(.07)
Age Inclusion (.03) Innovation
Education
Job Tenure .41*** .25**
Job Position (.11) (.09) Level 2
-.22** .24** Level 1
Ethnicity (.08) .25*** (.09)
Age
(.04)
Education Job .49*** Perceived
Job Tenure Satisfaction (.04) Quality of Care
Job Position

Figure 3. Direct associations.

Note. Level 1 = individuals; Level 2 = groups.Only significant standardized direct effect coefficients shown; standard
errors shown in parentheses;*p < .05. **p < .01. ***p < .001.

positively related to staff job satisfaction (β = .24, SE = .09, t = 2.57, p < .01, 95% CI [.09, .40]).
Significant associations existed between climate for innovation and job satisfaction (β = .41,
SE = .11, t = 3.69, p < .001, 95% CI [.23, .59]) and climate for innovation and perceived quality
of care (β = .25, SE = .09, t = 2.83, p < .01, 95% CI [.10, .39]). Likewise, a significant positive
association emerged between job satisfaction and perceived quality of care (β = .49, SE = .04,
t = 11.48, p < .001, 95% CI [.42, .56]). In addition, a significant direct association existed
between climate for inclusion and perceived quality of care when not accounting for other
pathways in the model (β = .43, SE = .04, t = 10.00, p < .001, 95% CI [.36, .51]), although it
became nonsignificant when other pathways were adjusted for (β = .00, SE = .09, t = .03,
p = .98, 95% CI [.14, .14]). Last, significant associations were found between individual-level
age (β = -.22, SE = .08, t = −2.65, p < .01, 95% CI [.36, –.08]) and education (β = .25, SE = .04,
 HUMAN SERVICE ORGANIZATIONS: MANAGEMENT, LEADERSHIP & GOVERNANCE 485

Ethnicity Climate for Climate for

Age Inclusion Innovation .20**
Education (.06)
Job Tenure
Job Position
.20** Level 2
(.06)
Level 1
Ethnicity .12*
Age (.05)
Education Job Perceived
Job Tenure Satisfaction Quality of Care
Job Position

Figure 4. Indirect associations.

Note. Level 1 = individuals; Level 2 = groups.Only significant standardized direct effect coefficients shown; standard
errors shown in parentheses.*p < .05, **p < .001.

t = 6.17, p < .001, 95% CI [.18, .32]) with climate for inclusion, as well as group-level race and
ethnicity (β = .17, SE = .07, t = 2.30, p < .05, 95% CI [.05, .29]) with climate for inclusion.

Indirect associations
Figure 4 presents the standardized indirect associations of the multilevel path model. Climate for
inclusion was positively associated with perceived quality of care through its influence on climate for
innovation (β = .17, SE = .06, t = 2.81, p < .01, 95% CI [.07, .26]). Likewise, climate for inclusion was
positively related to perceived quality of care through its influence on job satisfaction (β = .12,
SE = .05, t = 2.47, p < .01, 95% CI [.04, .20]). Last, climate for innovation was positively associated
with perceived quality of care through its influence on job satisfaction (β = .20, SE = .06, t = 3.38,
p < .001, 95% CI [.10, .30]).

Discussion
This study examined whether climate for inclusion was associated with perceived quality of care
through its influence on climate for innovation and job satisfaction in a diverse HSO. The findings
supported the study hypotheses and the conceptual model, demonstrating that perceptions of
workplace inclusion favorably influence perceived quality of care by increasing climate for innova-
tion and job satisfaction. More specifically, support was found for Hypothesis 1 (climate for
inclusion is positively associated with job satisfaction), suggesting that increased feelings of work
group inclusion are associated with increased job satisfaction among individual employees. This
corresponds to past research connecting inclusion with job satisfaction (Brimhall et al., 2014; Mor
Barak et al., 2016; Nishii, 2013; Shore et al., 2011) and provides further support of this relationship in
a diverse human service health care setting.
Testing Hypothesis 2, we found that work group inclusion positively influenced perceived quality of
care by increasing employee job satisfaction. This is one of the first studies to have connected climate for
inclusion with quality of care, demonstrating further potential benefits of creating inclusive workplaces.
The results of testing Hypothesis 3 (climate for inclusion is positively associated with climate for
innovation), suggest that favorable perceptions of work group inclusion are associated with increased
work group innovation. This indicates that creating an environment wherein people feel valued and
appreciated for being their true selves (i.e., inclusion; Nishii, 2013) is associated with individuals feeling
comfortable sharing their ideas (i.e., innovation; Anderson & West, 1998).
486 K. C. BRIMHALL AND M. E. MOR BARAK

Ultimately, the current study suggests that climate for inclusion is associated with higher
perceived quality of care through its influence on increasing climate for innovation and job
satisfaction (Hypothesis 4). In this study, similar to the results of past research, innovation was
positively associated with job satisfaction (Hypothesis 5; Cortini, 2016; Govaerts et al., 2011;
Pantouvakis & Mpogiatzidis, 2013; Wong & Laschinger, 2013) and perceived quality of care
(Hypothesis 6; Djukic et al., 2013; Snipes et al., 2005; Stalpers et al., 2016), highlighting the indirect
relationship between climate for innovation and quality of care through job satisfaction. Finally, the
results of testing Hypothesis 7 indicate that favorable perceptions of innovation were associated with
higher levels of job satisfaction, which in turn enhanced perceptions of health care quality.
Although research has demonstrated the positive effects of creating inclusive work environments
(e.g., improved retention, satisfaction, and commitment; Mor Barak et al., 2016; Nishii, 2013; Shore
et al., 2011), few studies have explored the role of inclusion in human service health care organiza-
tions. Some evidence exists of the potentially important role of creating inclusive workplaces in
health care settings. For example, when leaders strive to be inclusive through their behaviors, this
can improve psychological safety and the willingness of organizational members to speak freely
without fear of disapproval by others (Nembhard & Edmondson, 2006). Psychological safety is
associated with engagement in quality improvement efforts (Nembhard & Edmondson, 2006). The
current study expanded these findings by providing another possible way through which inclusion
influences quality of care, by increasing climate for innovation and job satisfaction. Last, this
research extended the inclusion literature (e.g., Mor Barak, 2017; Nishii, 2013; Shore et al., 2011)
by demonstrating other work environments (i.e., human service health care organizations) in which
climate for inclusion may be particularly beneficial in terms of improving the quality of care
provided to clients.
In terms of diversity, results suggest that personal characteristics, such as age and education as well as
group-level characteristics such as the variation of race and ethnicity, are related to climate for inclusion.
More specifically, findings indicate that older employees may feel less included in their work groups.
Previous research suggests that older employees may experience negative work outcomes, such as
increased intention to leave their jobs (Zhang, Punnett, & Gore, 2014) and age discrimination
(Newsom & Vogt, 2016). There is a growing concern that within the workplace bias exists toward
older employees often connected to the stereotype that older workers are unwilling to learn new
technology and no longer competent to complete their tasks and responsibilities (Newsom & Vogt,
2016). Roscigno (2010) suggests that older employees are often pushed out of employment by younger
colleagues primarily based on the negative stereotypes of older workers, and that many older employees
experience feelings of distress and decreased overall well-being (Rippon, Kneale, de Oliveira, Demakakos,
& Steptoe, 2014). Although there may be various reasons why the current study found a negative
association between age and climate for inclusion, it is possible that in this sample older employees
may be experiencing age discrimination where they are being left out of work group activities and
decision-making that may lead them to feel less included in their work groups.
Findings also suggest that further educated employees feel more included. This corroborates with past
research that indicates higher levels of education are associated with increased feelings of inclusion,
particularly in organizational contexts (Pelled, Ledford, & Mohrman, 1999). In addition, the current
study found that high racial and ethnic work group diversity was associated with an increased climate
for inclusion. Studies investigating racial and ethnic diversity with climate for inclusion have typically
focused on individual-level characteristics and how they relate to feelings of inclusion (Mor Barak et al.,
2016), yet few studies have investigated how group-level racial and ethnic diversity may influence feelings of
inclusion. A study by Buse, Bernstein, and Bilimoria (2014) found that workgroups with greater gender
diversity are more likely to have favorable policies and practices related to diversity. This suggests that
increased work group diversity may help create environments that are more supportive of heterogeneity. In
other words, it is possible that work groups with more racial and ethnic diversity help create environments
that support and include group members from different racial and ethnic backgrounds.
 HUMAN SERVICE ORGANIZATIONS: MANAGEMENT, LEADERSHIP & GOVERNANCE 487

Strengths and limitations

This study shows several promising contributions. First, it is one of few studies to examine the
outcomes of climate for inclusion in a diverse human service health care context, thus expanding the
inclusion literature by providing an additional setting for which inclusion may be applicable and
beneficial. In addition, it is one of the first empirical studies to examine how a climate for inclusion
can relate to a climate for innovation. Specifically, it supported the premise that when an inclusive
workplace is created, wherein everyone feels valued and appreciated for their unique personal
characteristics, people will feel more comfortable sharing their ideas, which leads to increased
innovation. This is also one of the few studies to examine inclusion and innovation in relation to
employee job satisfaction and perceived quality of health care services. These findings highlight the
potential critical role climate for inclusion plays in promoting climate for innovation and improving
employee job satisfaction and perceived quality of care. Essentially, this study provided evidence of
the value of inclusion in human service health care organizations.
As with any study, its findings should be considered in light of its limitations. First, this study was
cross-sectional and provides only an initial basis and conceptual model for the pathways between
inclusion and perceived quality of care. Another limitation to consider is the generalizability of the
sample. Although the sample was highly diverse, it came from one HSO and may not be represen-
tative of all diverse HSOs. In addition, although nonprofit hospitals share similar characteristics with
other nonprofit health care providers (Gillingham, 2015; Hopkins, Meyer, Shera, & Peters, 2014;
Mor Barak et al., 2016; Smith, 2015), they may not be representative of all nonprofit health care or
HSOs. More specifically, although nonprofit hospitals, such as the one in this study, share many
characteristics with other HSOs, they probably differ quite remarkably from small HSOs that may
have smaller budgets and staffs that are less professional. Further, the perceived quality of care was
measured rather than more objective measures of health care quality and the average rating was
relatively high (M = 5.00, SE = .89, range = 1‒6). Finally, the fact that participants responded to all
constructs using the same method, self-reporting, introduces the potential bias inherent in self-
reporting measures. To promote accurate and unbiased responses, each construct in the survey was
measured using different scales (e.g., inclusion, innovation, job satisfaction, perceived quality) and
embedded in the survey under specific and separate foci (psychological separation; Podsakoff et al.,
2003; Podsakoff & Organ, 1986) and diversity characteristics measured in an initial separate survey
given to participates 4 weeks prior to the survey that asked about inclusion, innovation, job
satisfaction and healthcare quality (temporal separation; Podsakoff et al., 2003). In addition, parti-
cipation was voluntary and the survey was conducted confidentially, that is, no personally identifying
questions were asked. Participants created their own unique study IDs that connected both surveys.
Last, a single-method common factor approach was explored that tested a one-factor model relative
to the hypothesized model (Podsakoff et al., 2003). The logic underlying the single-method factor
procedure is that if method variance is largely responsible for the covariation among the measures, a
confirmatory factor analysis should indicate that a single (method) factor fits the data (Mossholder,
Bennett, Kemery, & Wesolowski, 1998; Podsakoff et al., 2003; Podsakoff & Organ, 1986). The one
factor model yielded a poor fit to the data (TLI = .74, RMSEA = .22, 90% CI [.14, .31]) minimizing
the probability of common method bias (Mossholder et al., 1998; Podsakoff et al., 2003; Podsakoff &
Organ, 1986).

Implications and future research

Although nonprofit hospitals may be considered a unique subset of nonprofit human service
providers, these organizations share similar characteristics with other kinds of nonprofit agencies
in terms of 501(c)(3) status, struggling with scarce resources, dependence on governmental funding
(e.g., Medicaid and Medicare), pressures to shift from nonprofit to for-profit thinking, struggles to
implement electronic information systems, employee well-being, burnout and retention, leadership
488 K. C. BRIMHALL AND M. E. MOR BARAK

development and workforce diversity management (Gillingham, 2015; Hopkins et al., 2014; Mor
Barak et al., 2016; Smith, 2015). Thus, findings from this study may be particularly useful for a
variety of HSOs striving to improve workplace climates and outcomes (e.g., innovation, job satisfac-
tion, and quality of care). Findings highlight workplace inclusion as a valuable avenue for increasing
innovation and job satisfaction, which in turn improve perceived quality of care. Climate for
inclusion creates an environment in which employees feel comfortable sharing their ideas, which
may lead to improved climate for innovation (e.g., organizational procedures and processes, and
creative and effective problem solving). Thus, human service leaders and managers who strive to
increase feelings of inclusion among organizational members can help foster innovation and increase
employee job satisfaction that can lead to improved quality of care.
Although research on this topic is limited, some evidence exists suggesting that human service
leaders who seek others’ input before making important decisions can help increase feelings of
inclusion in their work groups and organizations (i.e., including others in decision making; Mor
Barak et al., 2016; Nishii, 2013). In addition, human service leaders who seek the opinions of
members from all professions and demonstrate that they value the perspectives of others regardless
of their job titles, increase feelings of psychological safety and inclusiveness (Nembhard &
Edmondson, 2006). For example, leaders who ask for the input of others before making critical
decisions regarding budget cuts, and who express equal appreciation for ideas given from front-line
service provides, middle managers, and higher level supervisors, can help every organizational
member feel valued and appreciated as important members of the group (i.e., foster feelings of
inclusion). Future research could strengthen this study by using longitudinal modeling to elucidate
casual associations. In addition, research could replicate this study’s findings, using more objective
measures of quality, such as client outcomes. Further, multiple source methods should be conducted
to confirm results found using self-report data (e.g., examining some of these findings using
qualitative methods; Spector, 2006). Finally, future investigations can build on the current study
by examining possible antecedents to creating an inclusive workplace (e.g., the role of organizational
leadership) in diverse human service settings.

Acknowledgments
This study was supported by the U.S. Department of Health and Human Services Agency for Healthcare Research and
Quality (Grant No. 1R36HS024650-01); the University of Southern California Suzanne Dworak-Peck School of Social
Work; and the University of Southern California Management, Organizations and Policy Transformation Research
Cluster. Thanks are due to participants for sharing their perspectives and all of their involvement in this study.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by the Agency for Healthcare Research and Quality [1R36HS024650-01].

ORCID
Kim C. Brimhall http://orcid.org/0000-0002-9271-5358

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