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Category: Cultural Competence

Learning from a Model, Adapting to their Needs: Visit to the Western Galilee Hospital in Nahariya

Sunday, November 10th, 2013

It’s not easy being a Cultural Competency Coordinator. There are so many aspects that need to be dealt with it can seem overwhelming. It is exactly for that reason that we formed the Cultural Competency Coordinators’ Forum, so that they would not need to go it alone. Even more recently we formed an offshoot - a Forum for Cultural Competency Coordinators from Public Mental Health Institutions - since the field of mental health is drastically different than general health care. The 8-member forum includes representatives from all 7 public mental health institutions in Israel - from Acco to Beer Sheva to Jerusalem to Tel Aviv - and was formed on the heels of our networking / feedback session, before the Manual for Cultural Competency Coordinators was published. This forum meets monthly.

Members have already learned a great deal from one another. For example, the coordinator from Be’er Ya’akov heard about the medical interpreter’s course at Abarbanel, and the course is being implemented at Be’er Ya’akov. Similarly, the coordinator from Mizra heard about the workshops we did for the administration at the Jerusalem Center for Mental Health, and in January it will start workshops for its 50 administrative and managerial personnel.

On November 5, 2013 mental health forum had a special treat - a visit to the Western Galilee Hospital in Nahariya. Why Nahariya? The first few meetings of the Forum had included introductions, peer learning and setting goals for the group, and after that it decided that it was time to learn from the field. Nahariya is a model example of both administration and staff being committed to making its care culturally sensitive to all its patients, and using creative means to do so.

Touring the Western Galilee Hospital in Nahariya

Touring the Western Galilee Hospital in Nahariya

The Cultural Competency coordinators at Nahariya had participated in our first course for cultural competency coordinators in 2012, and have come a long way in a short time, thanks to the continued support of the management at all levels. We came to see how they did it, and how we can adapt their methods to mental health institutions.

The visit had 3 parts:

  1. A presentation on how the hospital led the Cultural Competency training sessions for its staff. It was very important to the administration that local hospital staff lead the training sessions. This showed seriousness on the part of the hospital and sent a message to the staff that ‘we value this enough to dedicate two staff members for in-house training and integration, who will be here to follow up and make sure that the principles are implemented.’ Because the training was performed by local staff, there was more motivation, there was no need to wait for the training, and more help was on hand in assimilating the principles.
  2. A tour of the hospital. Participants were taken to the hospital’s Muslim prayer room, one of only a handful in all Israeli hospitals, which was established in cooperation with the Ministry of Religious Services. They were also shown the hospital’s creative method of multi-lingual signage. The hospital had already had signage in Hebrew and English, but needed to add signs in Russian and Arabic, and did not want to spend the high cost of re-printing all the hospital’s signage. Its solution - printing the requisite signs on giant stickers that were stuck to the floor. What a novel idea!
  3. Participants were also shown the pilot of a telephone interpreting system, which is being funded by the Ministry of Health. They first learned how the telephone system works. It uses a special telephone with two handsets - one for the patient and one for the physician. Both are listening to the interpreter, who is on the other side of the line, in a call center. The idea is that eventually all health care institutions in Israel will be hooked up to this system, and will be able to use it all day, every day, without having to wait for an interpreter to be on call in the building.

An example of a dual-handset telephone for interpreting

An example of a dual-handset telephone for interpreting

The day ended with participants discussing their thoughts on the most important points, and how they can assimilate any of the ideas into their own institutions. One action item that arose was the need for a Cultural Competency Manual dedicated to the unique needs of mental health facilities. We will begin to write this manual at the next meeting, which is in the middle of December 2013.

Let’s Make Ourselves a Holiday: Multi-Cultural Holiday Information Sheets to Improve Cultural Competency

Friday, November 1st, 2013

Hag Sigd Sameach. Yesterday, October 31, was the Sigd holiday, which is celebrated by the Ethiopian Jewish community. As part of our comprehensive support for cultural competency coordinators and health care providers in general, we prepared a special information sheet to help health care providers to give better care to their Ethiopian patients. It includes a short description of the holiday, special traditions that might affect patients on that day, and links to resources that can provide further information.

This isn’t the first time we’ve prepared these information sheets. We also prepared them for the Muslim holidays of Ramadan and Eid el-Fitr and Tisha b’Av, as noted above, and we’re going to continue to produce them for Eid el-Adha (Muslim), Passover and the 10th of Tevet (Jewish) and more. We’ve found that these information sheets have been immensely popular. They’ve been sent not only to our mailing lists, but we’ve found out that they’ve also been distributed throughout the different health insurance companies (Kupot Holim), and more.

In general, these information sheets offer comprehensive, concise overviews of the holidays, and cover particular issues that can affect patient care such as:

  • Special meals or foods related to the holiday;
  • Special fasts related to the holiday, and how it affects taking medication;
  • If there are conflicts regarding the taking of certain medications, who is the religious authority to turn to to discuss the issue;
  • Special daytime schedule during the holiday - more prayers or family visits, and more.

We work very closely with different organizations to ensure that important points are not missed, and that they are presented in a respectful, informative manner. For example, for Eid el-Fitr we consulted with the Al-Taj organization, which seeks to advance awareness of health issues in the Arabic-speaking population. We consulted with Rabbi Moshe Peleg of Sha’are Zedek Hospital for the Fast of the 10th of Tevet information sheet. For help on the Sigd information sheet, we consulted with the Tene Briut organization, which seeks to advance health care among Ethiopian immigrants in Israel.

When we are all finished we’ll have an entire year’s worth of holiday information sheets - an incredibly valuable resource for cultural competency coordinators and anyone who works in Israel’s multicultural health care system.

Making a Mental ‘Switch’: Cultural Sensitivity Professional Development Workshop for Staff at the Jerusalem Center for Mental Health, Kiryat Hayovel Clinic

Wednesday, October 23rd, 2013

What is the essence of cultural competency? More than the manuals, more than the training sessions - cultural sensitivity is the switch in approach to the patient-caregiver relationship, from ‘let me make you better’ (on my terms, using my rules) to ‘let’s work together to enable you to heal’ (mutual communication, bridging communication gaps of language and culture, realization that one’s background and culture dictates one’s actions and reactions).

The intention of the workshop held on October 21, 2013 for members of the Kiryat Hayovel public mental health clinic, part of the Jerusalem Center for Mental Health, was to help the 25 participants make that switch in their approach. The all-day workshop included a discussion of the present situation, and staff members raised a number of examples of social and political tensions in the clinic. As in other Cultural Competency Workshops, we also covered a theoretical section, in which we went over basic aspects of cultural competency - interpersonal communication, core issues, cultural dimensions, medical interpretation, social and political tension and more. In the afternoon the medical actress joined us and we practiced 2 real-life situations.

The director of the Kiryat Hayovel Clinic was very cooperative, both during and after the workshop. He told us that he received positive feedback from his staff, and that everyone recognizes the need for changing their approach, with an emphasis on everyday work. He noted that many of the staff were aware of the concept of cultural competency, but this all-day workshop allowed them to concentrate solely on how cultural competency / or cultural sensitivity influences their work as mental health caregivers.

The workshop also made the director as well as the staff more aware of the need for medical interpreters (translators) when working with patients whose mother tongue is not Hebrew. The workshop therefore increased his motivation for including his staff members in the upcoming medical interpreter’s course at the Jerusalem Center for Mental Health in Givat Shaul.

Creating a Cultural Competency Learning Community

Thursday, October 10th, 2013

We’ve talked about our growing national network of cultural competency coordinators here before . As part of this effort, we held our quarterly workshop for 25 cultural competency coordinators from around Israel at the Tel Aviv Sourasky Medical Center (Ichilov) on October 7. Participants came from hospitals as far north as Tiberias and Hadera, as well as the Jerusalem and Tel Aviv area. There were also representatives of the different HMO’s as well. This workshop focused on the Connection between the Community and Health Care Organizations.

The meeting included a panel discussion of 4 different perspectives:

  • Mr. Pekadu Gadamo, director of the Tene Briut organization, which works to improve health care for the Ethiopian community in Israel.
  • Mr. Or-El Ben Ari, director of the Ministry of Health’s clinic for migrants and political asylum seekers at the Central Bus Station in Tel Aviv.
  • Rabbi Zvi Porath, rabbinic consultant to the ALYN Rehabilitative Hospital
  • Mr. Gabriel Pransky, the Pransky Project

Each member of the panel spoke about his organization, and the connection each one has to health care organizations. Mr. Ben Ariand Mr. Paransky also distributed information sheets about their organizations. Click here to see the Refugees Clinic information sheet and here to see the information sheet on the Pransky project.

We’d like to focus on two of them, Mr. Ben Ari, from what was formerly referred to as the Refugees’ Clinic, and Rabbi Porath, from ALYN. Mr. Ben Ari first described his clinic. Located in the Central Bus Station in Tel Aviv, the clinic serves the tens of thousands of refugees and political asylum seekers that live in the Tel Aviv area, none of whom have health insurance. Instead, they often rely on hospital emergency rooms for care, and then only in real emergencies. And it was found that many of the emergencies could have been prevented if they had sought medical care earlier. The clinic was established in 2008 by the Israel Medical Association and other partners and staffed largely by volunteer doctors and other medical personnel. In January 2013 the clinic came under the auspices of the Israel Ministry of Health. Today it includes a staff of 20 and offers a range of medical services, from regular clinics to urgent care facilities, operated by the Terem organization. In the discussion, Mr. Ben Ari asked the cultural competency coordinators to make the clinic known to the refugees / asylum seekers they treat, since after they are released they rarely seek follow-up care that the clinic can provide.

The coordinators were fascinated by the clinic. For most this was the first time they had heard of the clinic and its activities. They were so excited about it that they asked to have a tour. This is now being organized.
Another of the speakers was Rabbi Zvi Porath, of ALYN Rehabilitative Hospital. Rabbi Porath, himself Ultra-Orthodox, has done groundbreaking work in his position as an advisor to the staff and on Jewish law. In most hospitals the Rabbi deals mainly with issues regarding Kashruth and Sabbath observance, Rabbi Porath is the first hospital Rabbi in Israel to utilize his role for cultural competency issues as well. He advises both the staff and patients, especially when there are instances in which there are questions of Jewish law as it relates to specific treatments. Rabbi Porath not only gives his own advice, but also knows whom to go to when other authorities’ opinions are needed. This is because each community within the Ultra-Orthodox world follows its own community leaders, but not necessarily leaders from other communities. In this way Rabbi Porath is not only a consultant and an advisor, he is also a mediator, helping the ALYN staff provide the best care for all its patients, sensitive to the cultural traditions of its Ultra-Orthodox patients and their families.

The participants were also very interested in Rabbi Porath’s work, since all of them deal with issues of caring for Ultra-Orthodox patients in ways that are in line with their strict reading of Jewish law. Many even scheduled private meetings with him, to see how he could help in their respective organizations.

Publication of First-Ever Manual for Israeli Cultural Competency Coordinators

Monday, August 5th, 2013

Two weeks ago, in mid-July, we celebrated the publication of our Cultural Competency Manual in Hebrew. It’s been almost 2 years in the making, and a labor of love for a long list of people, from lecturers and researchers from throughout Israel, to cultural competency coordinators in major health care institutions, to officials in the Ministry of Health. It is the first manual of its kind in Israel, and one of the only significant ‘how-to’ guides in the world.

This is a major accomplishment, but we have no intention of resting on our laurels. This manual is only a part our full-service cultural competency support system (see here for previous blog posts), from soup to nuts. We start with introductory workshops for cultural competency coordinators and staff - what is cultural competency? How can we be sensitive to others’ cultures and traditions, without being experts? Our services also include training courses for medical interpreters in a number of languages - Arabic, Russian, Yiddish, Amharic, and more. Medical interpreters and not medical translators? Yes, because they are doing more than translating word for word, they are interpreting the needs of the patients and their families to facilitate full communication with the treatment staff. We just finished a course at Sha’are Zedek Hospital, and not only was the feedback was very positive, participants noted that the issue of translation / interpretation was one of the most important sections in the course. The courses mean little without the day to day mentoring and follow-up with the cultural competency coordinators in the different clinics and institutions - how to increase translations of the different signage and forms to the different languages, helping to assimilate concepts of cultural competency into the different institutions, even with staff who had not yet taken part in a training seminar. Our work does not stop there.

In April, in preparation for publishing the manual, we held a seminar in which one of the original goals was to get feedback for the manual. But a second goal, not less important, was the formation of a peer network of professionals and academicians who work in cultural competency throughout Israel, which is leading to sub-networks according to specific disciplines (mental health, primary clinics, hospitals, etc.), all which have their similarities and whose implementations in the field are slightly different. In addition, we provide supplemental materials to help those involved in cultural competency have a better understanding of major holidays, traditions, and other issues. See the attached explanations on the Jewish commemoration of Tisha b’Av and on the Muslim celebration of Ramadan. Together with the Department of Translation and Interpreting Studies at Bar-Ilan University, we are also working on short films, which will further enhance the training process.

We’d like to thank the Jerusalem Foundation for its partnership in this project since the beginning in 2008, and for the assistance from the New Israel Fund, which has enabled us to expand the project throughout Israel.

Cultural Competency in the Health Care System – for the Haredi sector

Friday, July 12th, 2013

Enabling all of Jerusalem’s populations - Palestinians, immigrants (Ethiopian, from Former Soviet Union), Ultra-Orthodox Haredi Jews - to receive the best health care possible is at the top of our priorities, and our Cultural Competency in the Health Care System project is designed to address the sensitivities of caring for all these populations. Thus, beginning April, we began holding seminars for the staff of a number of primary clinics of Clalit Health Services to help them better communicate with the Haredi populations in their areas.

The location of these seminars was important. They were held in what are considered ‘mixed’ neighborhoods - Neveh Ya’akov, Ramat Eshkol, and Ramot (A and B). These neighborhoods have quickly growing Haredi populations, but they are definitely not the ‘hard core’ (as in Meah Shearim, Geula, Romema, Sanhedria, etc.). Moreover, much of the staff of the Clalit primary clinics in these neighborhoods remains non-Haredi and unequipped to best communicate with their new contingency. Part of the problem, which we will touch on below, is that there is little or no connection between the clinics and the community - and especially the changing community - around them.

In these seminars we dealt with 3 areas:

1) Tools for practical action. Often in this type of work with the ‘other’ we think of the checklist of tips of what to do or not to do when treating the Haredi community - not closing doors, men not offering to shake women’s hands, etc. However, our workshop went beyond the checklist, and sought to change the approach that clinic staff take in treating their Haredi patients. We discussed with them how to bridge major cultural gaps. One example was raised of a Haredi man, whose wife was terminally ill, who came to the clinic to ask for a certain medicine. From the man’s point of view, this medicine, which would stop his wife’s menstrual period and therefore keep her from being ritually impure, would finally enable him to touch her, or even give her a glass of water. The doctor, from her point of view, was appalled. She could not give him the medicine he requested because it reacted with the other medications she was taking. She saw a man who was antipathetic toward his wife - here his wife was very sick and all he could think about was stopping her menstruation? It was a classic case of a cultural gap that needed to be bridged. It was then explained to her the reason behind his request; arrangements are now being made to work around the problem.

2) Community Dialogue. One of the many roles of the community clinic is to raise awareness of preventative health programs and to have an ongoing dialogue with the community to draw the community to take advantage of its services and feel comfortable doing so. Since these clinics had little contact with the community as a whole, it made their work supremely difficult. One of the goals of our seminars was to help the clinic staff first gain acceptance with the community leadership, which will significantly boost neighborhood involvement and patronage. When we surveyed the clinic staffs, we found that they either didn’t know that this fieldwork needed to be done, or did not know how to go about engaging the community. Attempts to call patients directly - without getting the leaders’ OK - led to low turnouts at events. In general, low turnouts leads to lower patronage, which is bad for constituents’ health, and also bad for the health services’ business. With our facilitation, we’re helping the clinic staffs make slow but steady inroads into the community.

For example, in Neveh Ya’akov we facilitated a meeting between the clinic’s staff and the Community Center’s lay leadership (9 out of 10 of whom are Haredi), which we anticipate will lead afterward to inroads into the community’s various spiritual leaders. After this type of connection, we expect a much higher rate of participation in Clalit’s activities in the future. We are using similar means to reach community leadership in the other neighborhoods as well.

3) A Safe Place to Vent. In each neighborhood, because the staff - themselves secular and religious, some, with no religious background - had started out in a religious / secular neighborhood that saw a rapid growth in the Haredi population, there was a general feeling of frustration and despair. They felt they were witnessing the great struggle for control in Jerusalem between Haredi and non-Haredi Jews, and the Haredim seemed to be winning easily, engulfing entire neighborhoods and forcing their beliefs and belief systems on everything around them. On the other hand, clinic staffs must draw patients in; otherwise they’ll go elsewhere and Clalit will lose money. And these workers are measured also according to their economic efficacy in the clinic.

We couldn’t really offer solutions to all the fears the staffs raised, but just the act of venting was important to them. For some, this was the first time that they’d heard other people venting the same fears, and that it’s OK to talk about it, and maybe even find solutions to some of the problems. Interestingly, these issues were raised in all 3 of the neighborhoods, independently.

Paramedical Professional Training Program - Now Physical Therapy

Monday, June 10th, 2013

How sweet it is to see the fruits of your labors pay off, and to see a program expanding to fill critical needs. Thanks to assistance from the Hadassah Foundation and the Jerusalem Foundation (More recently the Leichtag Foundation has also joined us as a partner in this amazing program), this year we’ve expanded our training program for Palestinian graduates of paramedical professions to include students of physical therapy. One by one, we hope to develop courses for all paramedical professions, to enable graduates to pass the Israeli certification examinations, which are required to work legally in East Jerusalem.

We began the project last year, with seed funding from the Jerusalem Foundation (click here for links to posts one and two on the courses), and the results were fantastic - 26 of 39 nursing students passed the exam, and 8 of the 14 occupational therapy students passed the exam.

Nurses in the new course

Nurses in the new course

Given the dearth of paramedical professions across the board in East Jerusalem, our main goal was to develop courses in as many disciplines as possible. Our next discipline - physical therapy. Developing a course for physical therapy was more challenging than for nursing or occupational therapy, especially since there aren’t schools for physical therapy (like there are for occupational therapy and nursing) in Jerusalem. Working with an outside consultant and the Ministry of Health, we planned the curriculum. We gathered 16 participants for our pilot course. Weekly classes began at the beginning of June and will prepare participants for the exam that will be held in November 2013.

Another meeting of the nursing course

Another meeting of the nursing course

These 18 joined another group of 30 who began studying in March for the nursing exam that will take place in September. As for Occupational Therapy, we’ve just finished helping 4 people prepare independently for the June exam, and we’ll start a proper course in September, leading up to the December exam.
We wish all graduates and students the best of luck in their studies and exams.

A Workshop about our Cultural Competence in Healthcare Handbook

Monday, April 22nd, 2013

Americans do it; Europeans do it; even some South Africans do it. But how do Israelis do it? How do Israelis make their health care organizations culturally competent?

We’ve been training health care staff in cultural competency since 2008, and the Ministry of Health has more recently begun training, in light of the Ministry’s 2011 Directive on Cultural Competency. But what’s been missing has been a guide that spells everything out, which coordinators can refer to once they’ve finished the training courses. One that provides the internationally-tested standards of cultural competency, adapted to the unique makeup of Israeli society and everyday Israeli reality.

We are now in the final stages of such a handbook, our Manual for Integrating Cultural competence in Health Care Organizations. This manual is not only the first of its kind in Israel to deal with cultural competency for health care, it is the first of its kind in Israel to deal with cultural competency in any discipline. It is one of our dreams to bring culturally competency approaches to other areas of life in Jerusalem and throughout Israel - from local and national government offices to the police to other public agencies.

As part of the development process for the handbook, on 22 April 2013 we held a day-long seminar for 30 cultural competency coordinators from major health institutions, as well as others who work and research the field, around the country. Our goal for the day was to improve the handbook and to learn from the many people who are already working in the field in Israel.

We were pleased by the diverse turnout. Some had taken our training course, some had taken that of the Ministry of Health, and others had taken neither. The variety of institutions represented was also rather wide: Sheba-Tel Hashomer and Tel Aviv Sourasky (Ichilov, where the seminar was held) hospitals in Tel Aviv, Rambam in Haifa, both Hadassah hospitals in Jerusalem, as well as hospitals in Tiberias and Sefad; four of the eight mental health facilities in Israel; Ministry of Health; Israeli HMO’s; and independent consultants.
Throughout the morning, we got down to work. We utilized the ‘world café’ deliberation method, with one moderator at each table, each table focusing on a different subject from the handbook: from language accessibility, evaluation and making the workplace accessible, training, and definition of the role of the cultural competency coordinator, to the first 10 steps of cultural competency. The groups discussed each area, commented, made suggestions, and brought up new ideas regarding this part. After some time, participants chose another topic, but the moderators stayed in place. In all, we made such 3 rounds, and we discussed the main suggestions and understandings in the summary session.

All told, we came away from the seminar rich in knowledge that will help us to update the handbook. And the participants were quite enthusiastic about the meeting as well, as a number expressed their desire to continue these professional encounters. “This encounter was very important,” said Maya Tzaban, from Poriyah Hospital near Tiberias. “Now I see that we are not alone, added Varda Stenger from Sheba - Tel Hashomer, “that we are a network, and can work together.”

Indeed, although we’ve held encounters with coordinators who’ve taken our courses, and the Ministry of Health has held encounters for graduates of their courses, this is the first time that all cultural competency coordinators have come together for peer discussion, learning and action as a professional network. In light of the feedback, preliminary plans are underway for follow-up meetings.

Additional take-away suggestions included:

  • Forming smaller, more focused groups that could discuss their common challenges and situations - such as mental health hospitals, HMO’s, etc.
  • Adapt the manual slightly for the different types of institutions that use it - general hospitals, psychiatric hospitals, HMO’s, primary clinics, etc.

Feedback on the manual in general was also very positive. Participants commented that that it helps to give a full picture of cultural competency and initial steps of implementation. They were also eager to provide feedback to refine the document. “I have the time and I’d love to give my input,” said Anat Revach, from the Jerusalem Center for Mental Health. “I want to be part of this process.”

Assisting Medical and Paramedical Professionals in Receiving Certification from the Israeli Ministry of Health - an update and congratulations!

Tuesday, October 23rd, 2012

This is a follow-up to a previous post on this issue. Over the last year, in cooperation with the Jerusalem Foundation and the Community Services Division of the Jerusalem Municipality, we’ve been working to solve the both sides of the same issue regarding health care in East Jerusalem. On the one hand there is a severe lack of personnel in all disciplines that is certified to work in East Jerusalem. On the other hand, there are hundreds of graduates of academic programs, from universities in the West Bank or Jordan, who are living in East Jerusalem but are not able to work in their fields (or are working ‘under the table’ in those fields and are not receiving full salaries or legal benefits), because they did not pass the requisite certification exams given by the Israeli Ministry of Health.

We began this journey exactly a year ago, when we began to explore the issue in two disciplines: occupational therapy and nursing. We learned that the Ministry of Health needs additional Arabic-speaking workers in these disciplines, especially in East Jerusalem. We also learned that only 1-2 nurses and occupational therapists passed the exam each year.

We learned that the first problem was language - the graduates’ Hebrew was not good enough to pass the Hebrew exam, and that the Arabic translation of the exam was a very poor one. Moreover, all of the graduates had studied in English in their universities. Thus, even though it wasn’t their mother tongue, they preferred to take the exam in English. We then learned that the occupational therapy exam had become available in English two years previously, solving this part of the problem for them. In nursing, for some reason East Jerusalem residents had not been allowed to take the exam in English. We then met with officials from the Ministry of Health, who rather easily, agreed to let them take the exam in English as well.

With one obstacle behind us, we discovered that the graduates did not have access to the necessary learning materials - their own universities were far away, and only Hebrew University students have access to materials there and at Hadassah. This was actually very easy to resolve - we bought the books, and the graduates came throughout the year to study in our offices.

And then we discovered that there are occupational therapy materials that are only in Hebrew - position papers of the Occupational Therapists Association, as well as laws, which the students must learn. We translated these position papers into English and donated them to the Association’s web site. (We also received thank-you letters from other students in Israel who used our translations…) The laws were too complicated for us to translate, so we found a successful lawyer from East Jerusalem, who agreed to study the laws and explain them to the students, thus enabling them to learn the information.

We made contact with the relevant schools of occupational therapy and nursing at Hadassah, and convinced them to join our adventure. We then held a preparatory course in English for some 15 graduates in occupational therapy. On the day of the exam, which was held in Tel Aviv, we rented a bus for the participants. We didn’t want to take any chances of them being held up at security checks at the central bus station in Jerusalem. The result: 6 passed and became certified occupational therapists! Those who didn’t pass will sit for the exam at the beginning of November, and we’re keeping our fingers crossed for them.

In nursing, the story was much more complicated. The exam is very difficult, and the preparation requires thousands of practice multiple-choice questions on a number of subjects. The problem was that we didn’t have a reserve of questions that was suitable for the Israeli exam - Hadassah’s pool was entirely in Hebrew, and it would have been exceedingly expensive to translate them. Even proofing the translations would have taken forever. We dared to do something that many thought would not help - we used large question pools in English that are used for the American certification examinations (NCLEX-RN), which is different from the Israeli. At the end of each chapter, we gave the students a small number of questions in English, based on the Israeli exam. The assumption was that in the end it was the same ‘body’ of knowledge (with a number of differences in legal aspects and ethics and emergency room protocol and first aid), and even though the type of questions are different, this model helped. No doubt that we gambled on our unique approach - it turns out that no one remembers that there was ever a preparatory program for the Israeli nursing exam in English.

Before we began the nursing program, we gave a practice test to the participants and no one passed! That was our base point, quite frightening. During the course we gave another practice test in July, and 7 participants passed. A month later, 2 weeks before the official exam, we held another practice test and 12 passed. 12 new nurses in East Jerusalem, the number that usually passes in 8 years, is definitely an achievement, but we wanted more - there were 45 participants in the course! After the exam at the beginning of September, we waited and waited (it turns out that the Ministry of Health takes a month and a half to grade thousands of exams), and yesterday the results came in: 25 (twenty five) passed the nursing exam!!! More than 50% success rate! We are over the moon, I must admit. We really didn’t imagine in our wildest dreams that we would be so successful.

It is important to understand the significance of the success of the nursing program - a large part of the graduates have worked in East Jerusalem as nurses, but without certification, they could not legally perform many medical procedures. Many times they did those procedures anyway, because they had no choice, and without the enforcement of the Ministry of Health. Now, their status is different, and with justification - they learned so many essential things in the preparation program that were important to their work, regardless of the examination. By the way, their salaries are also supposed to jump significantly. So it is good for them, and it is good for the residents of East Jerusalem - who will receive better health care in the clinics and hospitals in East Jerusalem. If we continue this trend, the legitimacy for these institutions to employ uncertified nurses will decrease drastically.

What’s next? There are many things that must be done - continuing the same disciplines and creating a sustainable system of preparatory courses for certification, as well as entering into additional professions - physical therapy, speech therapy, and more. And maybe we’ll succeed in areas that aren’t in the field of health care? We’ll know in time.

Professional Development for Healthcare Cultural Competency Coordinators from around the country - Final report

Monday, May 21st, 2012
On May 21 we finished the first professional development seminar for 17 cultural competency coordinators in Israeli health care organizations. They came from hospitals such as Hadassah, Shiba-Tel Hashomer, Sourasky Medical Center, Rambam, and more. For some this was their first step in the cultural competency process of their respective organizations. The seminar included 5 meetings and a webinar with cultural competency coordinators from the US and Canada. For a link to the post on the opening of the seminar click here.

From the third meeting: panel of hospital directors - from Sheba, Alyn and Bikkur Holim - and the role of management in cultural competence

From the third meeting: panel of hospital directors - from Sheba, Alyn and Bikkur Holim - and the role of management in cultural competence

The Tour of Cultural Competency in Action
The fourth meeting was an all-day tour of cultural competency in action in Jerusalem. The first stop was at the Alyn Rehabilitative Hospital, which began its cultural competency process in 2007. Mrs. Naomi Geffen gave us a tour of the different departments and clinics, explaining the main issues, such as translation in medical and educational settings, ensuring patient and caregiver are the same sex in some cases, dress code, separation of boys and girls in the therapeutic pool, adapting the rehabilitation process to the patient’s culture, and more. Participants also visited the Muslim prayer room that was established in cooperation with the JICC and community members two years ago. We also received examples of materials and documents that had undergone linguistic and cultural adaptations, from a therapy schedule in the patient’s language, the internet site, release letters, and more. We were all amazed at what was accomplished here - today, hospital staff speak in a new language, one that is more advanced and without stereotypes.
The second station on the tour was a well-baby clinic that provides services for the Ultra-Orthodox Jewish (Haredi) population in Meah Shearim. We met the clinic’s manager and a leader from the Toldot Aharon community, which is considered to be one of the more conservative and separatist divisions of ultra-orthodox Judaism. The clinic and its services have undergone a process of adaptation to the needs and approaches of the Haredi population, facilitated by the JICC, which included adaptation of the physical environment (pictures, brochures in Yiddish), training for nurses about how to appropriately approach mothers, and more. We intervened, with the full cooperation of a leader in the Haredi community, after a serious epidemic of whooping cough and measles in the Haredi community that spread because of a low rate of immunizations. We discussed with them a number of issues including: vaccinations and immunizations, developmental delays, and more. We also heard about a unique project for first-time mothers, and the special adaptations that had been made for the Haredi community.
The third stop was Hadassah - Mount Scopus. Ms. Gila Segev gave an overview of the project that began in April 2010, just as she was appointed cultural competency coordinator. Gila recruited volunteers who were trained in verbal translation/ interpretation by the JICC and lecturers from the Department of Translation and Interpreting Studies at Bar Ilan University. Because 60% of the hospital’s patients are Arabic speakers it was decided to concentrate on Arabic. We also heard a first-hand account of the Hebrew - Arabic translating / interpreting process from a volunteer.
The visit concluded with a panel of representatives of different communities to learn about the needs of patients and how to work with the different communities successfully over the long term. The panel included: Dr. Itchik Seffefe Ayecheh (from the Tene Briut organization that advances the health of Ethiopians in Israel), who felt that the focus should be on training and workshops for the medical staff to understand the importance of the relationship with the communities. Dr. Meir Antopolski (“Meeting Point” organization whose goal is to create a new cultural space for the Russian sector) who believes that the linguistic dimension is a critical obstacle in the relationship with the communities, and Mr. Fuad Abu-Hamed (who operates Clalit Health Services clinics in East Jerusalem) gave a fascinating overview of the Palestinian communities of East Jerusalem.

The panel with the Russian, Ethiopian and Palestinian community representatives

The panel with the Russian, Ethiopian and Palestinian community representatives

The webinar was on May 16, focusing on the experience of 3 cultural competency coordinators from abroad. Some of the speakers are full-time cultural competency workers with staffs dedicated to responding to the multicultural needs of patients, from special menus and food preparations to organizing different cultures’ holiday celebrations and commemorations. All speakers presented a model that many of the participants could strive toward. The speakers included:
Virginia Tong, Vice Presidents of Cultural Competence, Lutheran Medical Center, New York
Young Lee, Director of Training and Development, Coney Island Hospital, New York
Branka Agic, PhD., Manager, Health Equity Center for Addiction and Mental Health (CAMH), Toronto, Canada

A snapshot from the world cultural competence coordinators webinar

A snapshot from the world cultural competence coordinators webinar

Summing Up
The fifth meeting featured a discussion about socio-political tensions that affect the patient-caregiver relationship and how the caregiver and the cultural competency coordinator can relate to it on an organizational level. One example was of ongoing discussions amongst the staff on social-political tensions, with an understanding that these tensions are not limited to the patient-caregiver relationship, they are also found between staff members, which also requires special attention.
Later on, Dr. Anat Jaffe from the Hillel Yaffe Hospital in Hadera, and one of the founders of Tene Briut, spoke to us. Dr. Jaffe surveyed the medical meeting point from an inter-cultural perspective. In her lecture she focused on her dealings with the Ethiopian community and diabetes, from her expansive experience as a doctor in the community and in the hospital.
The final meeting also included presentations of the pilot initiatives that participants worked on during the seminar. For example, representatives from the Western Galilee Hospital in Nahariya created and passed around a mapping and evaluation survey of different cultural and linguistic aspects of their patients. The representative of Bikkur Holim Hospital in Jerusalem is making the hospital’s voicemail system accessible in 4 languages, and the representative of the Italian Hospital in Nazareth changed the internal signage in the departments to 3 languages. Ms. Avigail Kormes from the New Israel Fund closed the course with warm remarks and wished them success.
For an article in Hebrew in Ha’aretz newspaper by Dan Even 4 June 2012 click here.
A translation from Ha’aretz article :
The Era of Multiculturalism Reaches Israeli Hospitals
The hanging of pictures on the wall of non-blonde children, the creation of prayer rooms, and the translation of discharge papers into French - these are the new practices in hospitals of a new policy that requires cultural competency.
In February 2013 a new Ministry of Health directive goes into effect requiring cultural competency in Israel medical institutions. As part of the directive, each institution is required to appoint one member of management to be in charge of cultural competency, who will be responsible to implement the new practices. Initial training sessions for coordinators in the past month reveal that the process does not include merely cosmetic changes, such as posting direction signs in Arabic, but seeks to change the atmosphere in the entire hospital to make it accessible to the multiple cultures in the state, especially during a period in which the social fabric of the country creates endless difficulties.
One of the organizations that began training cultural competency coordinators is the Jerusalem Intercultural Centre (JICC), that has been advancing this topic in the capital’s hospitals since 2007, with the support of the Jerusalem Foundation and the New Israel Fund. This month the JICC held a course training for for 17 cultural competency coordinators from 14 hospitals at the Schoenbrun School of Nursing, Tel Aviv Sourasky (Ichilov) Medical Center.
According to Dr. Hagai Agmon-Snir, the director of the JICC, “cultural competency is more than signage and the translation of forms. Patients need to receive all the medical services of the facility in a way that is accessible both linguistically and culturally, whether that means adding foreign language newspapers to the waiting rooms or making the pictures on the department walls more culturally applicable. When the pictures on the walls only portray blonde Dutch children, it’s most problematic, and its important to include pictures of children from diverse backgrounds, so that people will feel as much a part of the place as possible.”
One of the issues that the JICC seeks to integrate in this new process is accessibility of diverse religious and cultural services in the medical facilities. “Opening prayer rooms for different religions is not a political matter, but a professional one,” says Agmon-Snir. Muslim prayer rooms currently operate in only a few hospitals in the country, including Rambam, Alyn, and Hillel Yaffe. “In every self-respecting hospital in the West it’s customary to address diverse religious needs. It appears that addressing religious needs favorably influences the medical treatment, and it is important to advance this in Israel as well,” says Agmon-Snir.
Cultural competency also includes the correct usage of terminology that is sensitive to different cultures. Especially now, when social tensions are at their peak, whether related to the ultra-Orthodox, foreign workers or African immigrants, it is incumbent on medical staff to exercise more sensitivity. “It’s important to know the appropriate terminology for each culture. When dealing with the Haredi population, modesty in speech is required. In the ultra-Orthodox community, for example, it’s not customary to says ‘kaki’ or ‘excrement.’ One also has to know how to relate to rabbinic opinions which may influence the type of treatment, just as one has to adapt to secular patients who come to the doctor with information they have gotten on the internet.”
Sensitivity to concepts is also required for immigrant workers. “In our training we teach how to be sensitive to every culture, even to the foreign patient from Eritrea,’ says Agmon-Snir. “In some cultures, for example, ‘no’ is not a firm refusal, but rather a request to hear more information before making a decision. In some cultures, when a patient bows his head he is showing respect for the caregiver, and it is not at all a refusal of care.”
Another course for coordinators responsible for cultural competency coordinators from 24 hospitals began this month, under the auspices of the Ministry of Health, via Dortal Consulting. According to Dr. Emma Auerbuch, coordinator for reducing gaps in health care for the Ministry of Health, “Our approach is a little different. For example, anything related to places of worship, in our opinion, is the decision of the administrator of the medical facility, and should not to be imposed from above. In all matters related to cultural accessibility, one must remember that it is the goal of health facilities to provide medical treatment, and we try as much as possible to avoid tension.”
The different approach between the bodies can also be found with regards to the translation of patients’ forms. The JICC seeks to translate all the forms a patient might receive, including discharge papers, into various languages.. Auerbuch stresses that “the directive requires translation only of forms that require a patient’s signature, but we won’t prevent a hospital from offering translations of other forms as well. Recently a health fund in Netanya began offering medical information in French, since there is a large concentration of French speaking immigrants there. We can only congratulate them for that.” The courses include among other things training in preventing social tensions during the medical treatment. “This is an especially relevant topic in Israel, because people here tend to cross the lines between professional and political. Many times a patient will tell a doctor or a nurse what he thinks, for example, ‘you’re Russian and that’s why you act that way.’ The intercultural contact creates a challenging dynamic, including the use of stereotypes, and medical staff must learn how to maintain professional interaction, as much as possible,” says Agmon-Snir. “One must remember that the patient’s welfare is paramount, and the role of the health system is not to educate the patients. It’s not the doctor or nurse’s job to teach the patient manners or how to behave. A nurse may certainly put a disrespectful patient in his place, but in a professional context. Saying to a patient, ‘you Ethiopians are always late’ is not appropriate.
Special attention is being given to emergency rooms. According to Dr. Agmon-Snir,
“Although the pressure in the emergency room complicates the ability to give a patient detailed explanations, sometimes investing three extra minutes in explanations can save confusion and much time later on.”