The Jerusalem Inter-Cultural Center Blog

During the last couple of weeks we have had two more staff training as a part of our program on Cultural Competence in Health in Jerusalem, together with the Jerusalem Foundation.

On May 6, 2010, we had a second training program for educational staff of Alyn Hospital. The JICC adapted a workshop originally aimed at medical staff for the specific needs of teachers in the hospital. The result, as reported by the participants at the end of the workshop, was excellent, with participants reporting that they were more aware of the cultural and linguistic needs of the people they serve.

Alyn Training - Educational Staff

A week later, on May 13, 2010, we focused on issues surrounding cultural competency in health care delivery to the medical staff of the Clalit HMO. Again, participants agreed that the workshop covered exactly what they needed for the inter-cultural challenges they meet.

Clalit Training May 2010

It is positive feedback like this that lets us continue with these training workshops knowing that we are making a difference!

As a part of our project Cultural Competence in Health in Jerusalem, supported by the Jerusalem Foundation, the Alyn Children Rehabilitation Hospital has decided to open a Muslim Prayer Room. It is important to note that it is the first Muslim prayer room in a non-Arab hospital in the city, and the second in Israel. It is a result of a deep understanding of the importance of prayer to the healing process.

Opening of Alyn Muslim Prayer Room

Community leaders from Tsur Baher, Fuad Abu Hamed and Sheikh Issam, were consulted to ensure that the room was well adapted to the special religious needs of Muslims. These leaders generously helped us to know how to furnish the room allocated for use as a prayer room and gave gifts of Korans and prayer carpets. Alyn Hospital made all the necessary adjustments to ensure that the room included a feet bathing corner, a special clock that shows the time of prayer each day and other essential furbishings. Appropriate signage in Hebrew and Arabic marks the location for visitors, patients and staff.

Today was the formal opening; a few weeks of pilot operation showed that the room is already well used by the Muslim community of the hospital. We at the JICC are very proud to be a part of this initiative of Alyn. Experience shows that patients who feel that the hospital is open to their spiritual needs respond much better to medical treatments.

We hope with time to convince other hospitals in Jerusalem similarly to allow people of all religions room for prayer and reflection in a respectful way.

We have just completed the second medical interpretation training in Jerusalem (read here about the first one we conducted in October 2008). This time, 10 of the participants came from the Clalit HMO clinics from all over Jerusalem, while another 4 came from the Alyn hospital. This training is one of the components of the Jerusalem Cultural Competence in Health Project initiated by the Jerusalem Inter-Cultural Center and the Jerusalem Foundation. The medical interpretation training includes three elements: theoretical lectures on translation and interpretation, presented by Prof. Miriam Schlesinger and Dr. Michal Schuster from the Bar-Ilan University, simulations and case studies, and language-specific training on medical terms and their usage, in this case in Arabic, Russian and Amharic.

The Medical Interpretation Training at Clalit Medical Services

On February 13, 2010, after visiting our training, Judy Siegel-Itzkovich from the Jerusalem Post published an article titled “Risky misunderstandings”, asserting that “the state’s failure to require trained medical interpreters may pose a danger.” While most health systems and the state are not taking responsibility to do whatever is required in this life-risking situations, Siegel-Itzkovich describes our training as an important step towards resolving language barriers in medical treatment. The article can be found here, or downloaded as a PDF file (see below for full text).

It is important to note that in the near future the Hadassah Mount Scopus hospital, in partnership with the Jerusalem Foundation and ourselves, is planning to initiate a volunteer-based interpretation service in Arabic and Russian. The JICC will train the interpreters as well as provide additional cultural competency trainings to medical staff in the hospital. This can be seen as a first and important response of the Hadassah organization to the urgent need at the Hadassah Mount Scopus hospital, where 55% of the patients are Arabic-speaking (see our previous article about this issue here).

Appendix: full text of the Jerusalem Post Article:

Risky misunderstandings
By JUDY SIEGEL-ITZKOVICH
13/02/2010
The state’s failure to require trained medical interpreters may pose a danger.

Suppose you felt very sick, but when you reached an Israeli hospital, the doctors and nurses spoke only Swahili. You couldn’t describe your problem, ask or answer questions, understand the forms you had to sign or even identify the WC. Like the Bantu language of eastern Africa, Hebrew is spoken by only five to 10 million natives.

But even though no US hospital or clinic is eligible for federal funds unless it has a team of professional medical translators and experts in cultural competency, the Health Ministry has not set any requirements that will help masses of immigrants and Israeli Arabs communicate in health facilities. And Israel has an even higher proportion of immigrants speaking languages other than the native tongue than the US.

There have been some reported cases of non-Hebrew speakers dying because of their failure to understand or be understood in hospitals; surely other tragedies have not been reported.

But when asked by The Jerusalem Post to comment on this problem, Health Ministry associate director-general Dr. Boaz Lev shrugged and said: “I’m afraid I don’t have a good answer. I think it is a very important matter, but it isn’t on our list of top priorities. I wish we could ensure that there are professional medical translators everywhere.” He added that the matter of cultural competency in medical institutions was raised in the ministry’s executive and there were even seminar days to discuss it. “It is not foreign to us. But we don’t have the financial resources to deal with it seriously.”

WITH A vacuum left by the ministry, at least a number of voluntary and public organizations are trying to provide some training and services on a relatively small basis. The Jerusalem Inter-Cultural Center (directed by Dr. Hagai Agmon-Snir and with support from the Jerusalem Foundation) has begun to offer three-day medical interpretation courses for people – mostly women – employed in different capacities in hospitals and clinics. Established a decade ago, the Inter-Cultural Center on Mount Zion aims to promote dialogues among different cultures, so cultural competency and medical translation in medical facilities made it a natural for initiating the project.

Although they were never trained as medical translators or cultural “bridgers,” the class participants have been doing it without additional salary or benefits and not even after volunteering to do so. They are nurses, secretaries and even maintenance workers who speak other languages such as Arabic, Amharic, Russian and Spanish and were asked by their bosses to help out when patients could not understand or be understood. English is usually not a problem, as most doctors and nurses speak it adequately. Several of the particiipants, including a man from Beit Shemesh, were former Ethiopian immigrants, while many of the Arab women work in the Sheikh Jarrah outpatient medical center in east Jerusalem.

The Inter-Cultural Center found a teacher, and Clalit Health Services – the largest health fund – and Alyn Hospital (the National Pediatric and Adolescence Rehabilitation Center) sent 15 staffers (only one of them male) to take the first-ever course in Clalit’s community clinic in the capital’s largely low-income Katamonim quarter. Pazit Kalian of Clalit’s Jerusalem district was instrumental in getting her staffers to participate in the eight-hour-a-day course.

Almost two years ago, Alyn held a one-day symposium on cultural competency in medical institutions that featured experts from New York City’s Coney Island Hospital and described advanced work done there.

In front of the class in the Katamonim was Dr. Michal Schuster, who studied translation and interpreting at Bar-Ilan University, while Prof. Miriam Shlesinger – the veteran chairman of that BIU department – sat in to observe and comment.

THEY TOLD the Post that some medical institutions have specifically hired Ethiopian immigrant women to fill cleaning worker jobs so they could “double” as medical translators. Yet these maintenance staffers are not familiar with medical terms, psychology or the ethical boundaries of professional interpreting, they said.

Some of the class participants, said Schuster, are “very bitter” about doing medical interpreting in addition to their regular job without getting any compensation. She also said one government medical center even turned down the free medical interpreting service provided by Rabbi Yechiel Eckstein’s International Fellowship of Christians and Jews. The hospital claimed some its own personnel were able to translate when necessary, and that a phone service “doesn’t fit the structure of the hospital.” Now the service will work specifically in Amharic and Hebrew with help from the Tene Briut organization and Magen David Adom. One need only call MDA’s 101 number to access it.

Shlesinger, who said she is “obsessed with translation and interpreting to help people overcome the language gap,” has set up many programs for the Jewish Agency and other organizations, but not until now not in the field of medical care. If immigration tapers off, “there will always be Arabs, deaf people and foreign tourists who need help, as well as older immigrants who don’t adequately comprehend Hebrew. Even my 90-year-old mother who came here from Florida 30 years ago wants to speak English when talking to her physician,” she noted.

“It has become our ideology that interpretion be available for healthcare. We really believe in it. It raises the participants’ self esteem. Big hospitals really should have in-house professional medical interpreters. But for this sea change to happen, there needs to be more lawsuits against hospitals and medical organizations by people who suffered a tragedy due to being unable to understand Hebrew. The Health Ministry needs a push,” said Shlesinger, who in the past has raised the issue with the ministry’s Dr. Lev.

SCHUSTER ADVISED the course participants not to be afraid when the doctors and nurses speak too fast. “You must not add any words of your own, or leave any out. Never give any advice not connected to treatment. It is forbidden for you to sell anything for your own benefit, or to arrange an earlier place in the queue if they want to give you something. You have to listen and know the medical terms and how the health system and procedures work.”

She added more advice: “Make sure you understand both the medical professional and the patient. Correct yourself if you are mistaken. Run a conversation that flows. Sometimes doctors use high-faluting language; sometimes they make up terms so the patient won’t understand. If it is not all clear to you, ask for details.” She advised participants not to believe in stereotypes such as that anyone who cant speak Hebrew or comes from a certain country is “stupid.” In addition, interpreters must “never get involved emotionally. “Don’t give your phone number to a patient. Don’t answer a doctor’s question instead of the patient just to save time. You must guard the boundaries.”

One of the most major issues is secrecy about patients’ medical conditions and other private matters. The course made numerous statements about protecting privacy. In a clinic where the interpreter may live just around the corner, it can be very difficult to translate or for the patient to agree. “In such a case, you really should ask if they are willing for you to interpret or find somebody else,” Schuster advised. There are very few exceptions to the secrecy rule, the instructor added. “If the patient tells you about violence in the family, against children or against herself, or that he wants to commit suicide, you are required to report it.”

Interpreters must also take care when asking patients questions not allowed by their religion or culture. An unmarried Arab or haredi Jewish teenager should not be asked whether they are virgins or use contraceptives, for example. There are also “spirits” called “zar” believed in by some older Ethiopian immigrants that have to be taken into consideration. An Ethiopian could say she had a “dry hand,” leading a physician unaware of such an expression to treat them with a dermatological cream, but in fact referred to “stiff joint” that requires a totally different treatment, Schuster said.

One of the course participants said she refuses to translate bad news, such as a patient being diagnosed with a terminal disease. “I am unable to do it. They have to find somebody else. There is nobody to give me support. You take such bad news home with you; I can’t cope with it. I once sat with a hospital psychologist who wanted me to ask the patient if he has suicidal tendencies. It was very hard for me, as I am not a social worker. I also can’t handle curses and other bad language that I sometimes hear.” A Moscow-born nurse was told by one patient that “all Russians are prostitutes” and asked “why didn’t you die in the Holocaust?” She recalled that she felt stung, especially when none of her bosses offered any sympathy.

Naomi, the Ethiopian cultural “bridger” who came on aliya as a young child almost two decades ago, said she recently encountered a patient who came to his Clalit clinic every day (a “bridger” is allowed to have separate talks and interventions with patients, unlike a translator). “He felt the doctors were not giving him all his test results, but they were. They said all tests were normal and just didn’t understand what his problem was,” but she gradually built up his confidence in the physicians.

She also helped a immigrant woman who had cancer and needed surgery. “She refused for months until we persuaded her. But suddenly she demanded that the operation be postponed. She was regarded by doctors as a ‘troublemaker.’ The woman claimed there would be ‘nobody to look after the children,’even though they were already adults. Naomi finally found out that she and her violent husband were in the process of getting a divorce. I advised her how important her health was and of getting early treatment. Finally, she agreed to the surgery.”

Agmon-Snir recalls that a few years ago, his own mother underwent hip replacement surgery. “Before she was discharged, the surgeon gave her quite a few instructions. There were some necessary accessories and equipment: a wheelchair, special pillows and devices to help lift objects. “If you don’t follow the directions I gave you and don’t use the equipment,” said the surgeon, “your leg won’t function the way it’s supposed to and the effects of the excellent and expensive surgery will be wasted.”

Lying next to her in the hospital were Palestinian women from east Jerusalem who had also undergone the same operation. “They were given the same instructions his mother received and sent to the same places for equipment. Yet there is good reason to suspect that, unlike my mother, many of them are limping today. Research carried out in Jerusalem hospitals shows that about half of the Arabic-speaking patients do not understand the instructions they are given for post-treatment care.”

We started today a new series of Cultural Competence trainings to staff members in the Alyn hospital in Jerusalem. We have facilitated three such trainings before in Alyn, mainly focusing on the out-patient clinics. The new series focuses on the in-patient rehabilitation department staff. These efforts are part of our program, together with the Alyn Hospital’s management, to transform Alyn into a cultural competent hospital, the first of its kind in Israel. The work with Alyn is a component of the Jerusalem Cultural Competence in Health Project initiated by the Jerusalem Inter-Cultural Center and the Jerusalem Foundation.

In addition to adapting the training to the rehab department - using simulations and role playing cases that were developed specifically for this department, we also upgraded our methodology; we now use cases throughout the workshop as triggers for discussion on theoretical and practical knowledge and tools. We find this new approach to be much more effective in delivering the training’s input to participants, and in fact, it is also time-saving. It also serves to bridge between different proficiencies - as the participants come from various professional backgrounds - physicians, nurses, physiotherapists, administrative staff, etc. In the new model much of the training is based on events the participants share with us - and these, of course, are very meaningful to them.

Alyn Cultural Competence Training November 25, 2009

We received excellent feedback from the workshop and in the coming months we plan to deliver a few more such workshops to additional staff members of this department.

After the workshops at the Clalit primary care clinics at Ir Ganim and Talpiot, we continued this week with two half-day trainings for the staff of the Gonenim clinic, conducted at the JICC premises on Mount ZIon. These three clinics serve most of the Ethiopian Jewish immigrant population in Jerusalem, and we adapted our cultural competence training to focus on the needs of this group. All clinic staff members, from physicians to administrative staff, attended the workshop, as we see the response to diversity at the clinic as an integrative task.

Gonenim Clinic Training 2009

The workshop was in general very similar to the ones we conducted before. However, we used many more examples, which participants in the previous workshops raised, and based the training on case studies and simulations. This made the training closely related to the practical issues brought up by clinic staff members.

Gonenim Clinic Training 2009 - roleplaying

Following this training the Gonenim clinic now joins the support system we are creating to enhance the Clalit Health Services’ capacity in providing better and more adapted services to new immigrants. We will conduct follow-up meetings with the clinic’s management and mentor them in implementing Cultural Competence in the clinic.

Gonenim Clinic Training 2009 - roleplaying

As a part of our project that aims to incorporate cultural competence into the Jerusalem medical system, we are working with the secondary care clinics of the Clalit medical services. It is a long process in which we are facilitating a day-long workshops to staff of these clinics from all over Jerusalem. The first training in the series was held on June 30, 2009.

Role-playing at the Cultural Competence training for Clalit Secondary Care Staff

Today we held the second training. In between these two trainings, we significantly upgraded the workshop, based on the feedback we received after the first workshop. We also developed improved case studies for the simulation and role-playing parts. By the end of the workshop today we felt that the workshop in its current version is fit for replication. The special component of the workshop is the simulation of cross-cultural cases with the help of professional actors. The cases mainly demonstrate interactions with Arab patients and with Ultra-Orthodox and Ethiopian Jewish patients.

Role-playing at the Cultural Competence training for Clalit Secondary Care Staff

The plan is to train in the coming two years all the staff in the Clalit secondary care clinics in Jerusalem. In parallel, we work to assimilate cultural competency in the clinics in additional ways, such as training bilingual interpreters, improving communication between primary-care Arabic-speaking physicians and the secondary-care physicians, etc.

During summer 2008 we developed our first Cultural Competency in Health training. Since then, we piloted the workshop, adapted it as necessary, and implemented it with medical staff at the Alyn hospital and at the Clalit Health Services (both in Primary Care Clinics serving the Ethiopian community and in expert clinics). This was done in partnership with the Jerusalem Foundation. Throughout this process, we got tremendous help from many experts from all over Israel - physicians, nurses, management of the relevant institutes, and researchers and practitioners focusing on cultural sensitivity, awareness and competence. It was important for us to present the training to these people, hear their feedback and insights, and thank them for their valuable contribution.

On September 7, 2009, we were joined by about 20 experts at the JICC premises on Mount Zion in Jerusalem. We went through the details of the workshop in depth and shared with them our ideas for improvements. At midday, we, the cultural competence team at the JICC, felt much enriched with a lot of new ideas and advice. Some of the feedback related to specific modules and parts of the workshop, allowing for further improvement, and some contributed to the overall approach of the workshop.

For example, we realized that learning can be structured around case studies provided by the participants during the workshop, as well as cases that we prepared in advance with the help of professional actors. We now also know how to better simulate with the participants situations they describe, by applying the “Caregiver in the Shoes of the Patient” model: we ask the medical staff member who raised the case to play the role of the patient while another participant plays the role of the medical staff him/herself. Thus the theoretical and practical modules of the workshop, that previously were given as is, are now incorporated and triggered by the stories and situations raised by the participants, as well as by the pre-designed situations we prepared with the actors.

This approach makes the training much more interactive and practical, and most importantly, responsive and well connected to the needs of the participating practitioners. We discussed this new training design with today’s expert participants and they all agreed it was very promising.

Today we finished a set of two training sessions on cultural competency in serving the Ethiopian community in Jerusalem. The training was delivered to all staff members of the Clalit Primary Care Clinic in the Talpiot neighborhood and was basically the same training as the one delivered to the Ir Ganim clinic. Our next step in the near future is to deliver the training also in the Gonenim and Neve-Yaakov clinics. By that we will cover all four clinics that serve the Ethiopian population in Jerusalem.

Talpiot Clinic Training 2009

It is important to note that following these trainings we continue to support the clinics in their efforts to give better and adapted services to new immigrants. In a follow-up process we found that many of the skills that were taught in the trainings are now being used in the clinics. In addition staff members report that patients demonstrate higher levels of satisfaction than before.

We just published an article at the Jerusalem Post and Search for Common Ground (SFCG) News service on our cultural competency program in Jerusalem. Here are the links and the text:

SFCG: English, Arabic, Hebrew.

The Jerusalem Post (English).

PDF (English).

Text:

A call for cultural competency in Jerusalem’s medical services

A few years ago, my mother underwent hip replacement surgery. Before she was discharged, the surgeon gave her quite a few instructions for the period following surgery. There were some necessary accessories and equipment: a wheelchair, special pillows and devices to help lift objects. These were available for almost nothing from Yad Sarah, an organization founded by haredim that lends medical equipment to those who need it.

“If you don’t follow the directions I gave you and you don’t use the equipment,” said the surgeon, “your leg won’t function the way it’s supposed to and the effects of the excellent and expensive surgery will be wasted.” Today my mother traverses the country with her new hip and any memory of the fracture has been erased.

Lying next to my Jewish mother in the hospital were Palestinian mothers from east Jerusalem who had also fractured their hips and received hip replacement surgeries. Most of them, like my mother, were covered by national health insurance, which made them luckier than their sisters from the West Bank and Gaza who are not entitled to these benefits. The women from east Jerusalem were given the same instructions my mother received and were also sent to Yad Sarah, which has branches serving east Jerusalem for the Palestinian population.

Yet there is good reason to suspect that, unlike my mother, many of them are limping today. Research carried out in hospitals in Jerusalem shows that about half of the Arabic-speaking patients do not understand the instructions they are given for post-treatment care because they are given in Hebrew.

One third of Jerusalem’s residents are Arabic-speaking Palestinians, both Muslim and Christian. In times of need, these residents will almost always choose to go to hospitals in west Jerusalem. At some of these medical institutions, more than half of the patients are Palestinian, yet none of them are provided translation services into Arabic or any other language. Occasionally, medical staff improvise and ask an Arab hospital worker or a visitor who speaks both Hebrew and Arabic to translate, making them privy to the patient’s personal medical details. It’s not unheard of for the patient’s child to act as a translator, telling his or her mother that the doctor recommends an abortion or that a suspicious lump was found in her breast.

In addition to the lack of language services, none of these establishments provide religious services to Muslims or Christians. Nurses complain about Muslim men washing their feet in sinks designated for hand washing. The simple solution - low sinks for feet-washing before prayers - cannot be found at any of these places. On the other hand, Jews may receive visits from a rabbi, have meals provided by various religious organizations according to their specific kashrut needs, or pray in an in-hospital synagogue.

RECENTLY, THE Jerusalem Intercultural Center hosted senior directors from the Coney Island Hospital in New York City, introduced to us through our collaborative work with Rabbi Bob Kaplan of CAUSE-NY, an organization committed to the availability of health services in New York. In compliance with the law, signs at the hospital appear in five languages, and anyone entering the hospital is entitled to receive hospital services in his or her own language. Sometimes a translator is present in the room and other times (with more obscure languages) translation is provided through a phone service, called tele-interpretation.

The hospital has a synagogue, a Christian church, a mosque and a Hindu temple - in accordance with the needs of the communities that it serves. Kosher food is provided for Jews and halal food for Muslims. In the case of Indians and Pakistanis, the food is prepared and spiced in a way that is suitable for their palate.

Is this hospital anomalous? Not at all. In the past 15 years the “cultural competency” approach has become widely practiced in health systems in North America, Australia and Europe. It has simply skipped over Israel, despite much evidence showing that medical services adjusted to culture, religion and language improve the quality of care and the outcome of treatment. And, of course, such an approach is far more just and ethical.

Shocked by this state of affairs, the Jerusalem Intercultural Center and the Jerusalem Foundation have launched an initiative to encourage cultural competency. The need, by the way, exists not only for the Palestinian population in the city, but also for the Yiddish-speaking haredi community (which comprises about one quarter of the city’s residents), as well as people from a variety of other backgrounds who speak languages like Amharic, Russian, French and Spanish. We are only at the beginning of the road, but already there are medical institutions, such as Alyn hospital (for pediatric rehabilitation) and Clalit Health Services, that are now building up cultural competency in their facilities.

We hope that by introducing cultural competency into the medical services in Jerusalem we will help reduce the current inequality that exists in this field. Moreover, we believe that this is a way to teach the people of this city the value of accepting the other, being considerate of those who are different from us and to encourage people to think in terms of human rights even in a city as fraught with tensions as Jerusalem.

The writer is the director of the Jerusalem Intercultural Center and can be reached at hagai@jicc.org.il. The project Cultural Competency in Jerusalem is sponsored by the Jerusalem Foundation. This article was written for the Common Ground News Service in collaboration with The Jerusalem Post.