Increasing gender and ethnic diversity in the health care workforce: The case of Arab male nurses in Israel

Arab representation in Israeli healthcare professions: achievements, challenges and opportunities

BACKGROUND

Israel is a multiethnic society with a population of 9.8 million at the end of 2023. Israeli Arabs (i.e., Arab Palestinian citizens of Israel) account for 21% of the Israel's overall population, 22% of its working age population and 16% of the employed population. This study has several objectives: (1) To provide an overview of the current representation of Israeli Arabs in four key health care professions (medicine, nursing, dentistry, and pharmacy) in terms of employment, licensure, and professional studies; (2) To document changes in those parameters over the past decade, subject to limitations of data availability; (3) To provide a broader context on the employment of Israeli Arabs; (4) To explore the policy implications of the key findings.

METHODS

Estimates of employment levels are based on the Labor Force Survey (LFS) of the Central Bureau of Statistics (CBS). Data on licensure (i.e., professional qualification) and place of professional studies were extracted from the Ministry of Health report series entitled "The Health Care Professions". Data on enrollment in degree programs in Israel was provided by the Council of Higher Education. Important background information was elicited from relevant policy documents and policy experts.

RESULTS

In 2023, among employed Israelis up to age 67, Arabs constituted approximately one-quarter of Israel's physicians (25%), nurses (27%), and dentists (27%), and half of Israel's pharmacists (49%). These percentages are substantially higher than they were in 2010, with the increase being particularly marked in the case of physicians (25% versus 8%). The number of new licenses granted annually increased significantly between 2010 and 2022 for both Arabs and Jews in each of the professions covered. The percentage of newly licensed professionals who are Arab increased substantially among physicians and nurses, while remaining stable among dentists and pharmacists. In medicine, dentistry, and pharmacy, many of the licensed Arab health professionals had studied outside of Israel; this phenomenon also exists for nursing but is less widespread there. In the 2022/3 academic year, the percentage of first-degree students in Israeli colleges and universities who were Arab was 70% in pharmacy, 33% in nursing, 23% in dentistry, and 9% in medicine. Between 2012/3 and 2022/3 the percentage of first-degree students who are Arab increased substantially for pharmacy, declined slightly for nursing, and declined substantially for medicine and dentistry.

CONCLUSIONS

Arab professionals play a substantial and recently increased role in the provision of health care services in Israel. It is important to recognize, appreciate, and maintain this substantial role. Moreover, its potential as a model for sectors other than health care should be explored. To build on achievements to date, and to promote continued progress, policymakers should expand access to health professional education within Israel, upgrade the skills of graduates of non-Israeli universities, promote diversity in leadership positions and key specialties, and expand specialty care services in Arab localities.

Patient racism toward nurses in a divided society: The case of Jews and Arabs in Israel

AIM

This study examines whether racism exists among Jewish and Arab patients in Israel, as reflected in patient preference for receiving treatment from a nurse with the same ethnic background.

BACKGROUND

We examine the relationship between racism and the level of trust in a nurse from a different ethnic group than the patient, as well as the preferred level of social distance, in the context of ongoing conflicts between the Jewish majority and the Arab minority in Israel.

METHODS

A cross-sectional study was conducted using a unique study questionnaire that asked 534 Jewish and 478 Arab respondents to express their preference for an Arab and a Jewish nurse.

RESULTS

Among both the Jews and the Arabs, there is a similar tendency of racism toward nurses of the dissimilar ethnic group. This racism was also prevalent among participants who live in a mixed environment or those who studied or are studying and worked or work in a mixed environment. As the trust in nursing staff members from the other group increases, the level of racism decreases. The greater the social distance the participants felt from the members of the other group, the more racist the attitudes they expressed.

CONCLUSIONS

Both Jews and Arabs preferred to be treated by nurses of their own ethnic group. In contrast to the contact hypothesis theory, participants who live in a mixed environment did not express fewer racist preferences. We conclude with some useful practical suggestions aimed at decreasing racism in health care.

CLINICAL RELEVANCE

Findings imply that prospective patients prefer to receive nursing care from nurses of their own ethnic group and trust these nurses more than they trust nurses of different ethnic group.

What do physicians think about the white coat, about patients' view of the white coat, and how empathetic are physicians toward patients in hospital gowns? An enclothed cognition view

The receipt of the white coat by medical students is a significant milestone. Extensive research has focused on the white coat, its purity, representation of authority and professionalism, its role in consolidating a medical hierarchy, and the professional status attributed to physicians wearing it. Studies suggest that the white coat is a symbol of medical competence, and patients expect physicians to wear it. Research, however, has paid little attention to what physicians think about their white coat, how they perceive the patient's view of the white coat and the hospital gown, within the patient-physician power asymmetry, which is the focus of the current study. In total, 85 physicians from three Israeli medical centers completed a questionnaire (62% Muslims, 33% Jewish, and 5% Christians; 68% men, ages ranging from 21 to 73 years). Employing the enclothed cognition theory and adopting a within-person approach, we found that the more physicians perceived the white coat as important, the more they attributed a positive view of the white coat to patients and the more they perceived the patient's view of the hospital gown as positive. In addition, the higher the perceived importance of the white coat, the higher the reported empathy of physicians toward inpatients, which is consistent with the hospital's values of care. Interestingly, although medicine is a symbol of protection and care for others, the symbolic meaning of the white coat was potent enough to elicit empathy only when physicians perceived it as important. This study extends the theoretical knowledge on the theory of enclothed cognition in healthcare regarding self-perceptions and professional conduct.

Choosing a nursing specialty: connection to nursing students' personality traits, clinical self-efficacy, adoption of technology changes, and specialty prestige; a cross-sectional study

BACKGROUND

Choosing a field of specialization within the nursing profession is affected by nurses' personality traits, self-confidence in performing clinical skills, and the field's prestige. A successful choice of area of expertise may improve nurses' job satisfaction and reduce job mobility. This study aims to examine the relationship between personality traits, clinical self-efficacy, perceived prestige, adoption of technological changes, and choice of specialty field among nursing students.

METHODS

A cross-sectional study was conducted. One-hundred-twenty-seven undergraduate nursing students in their fourth year of studies at a large university in Israel participated in the study. The questionnaire administered was comprised of six parts: demographic data, personality traits, adoption of technological changes, clinical self-efficacy, perceived prestige, and intention to select a field of specialization.

RESULTS

Acute disciplines were rated more prestigious than chronic disciplines, with intensive care and emergency medicine considered the most prestigious, while mental health and geriatrics were the least prestigious. Students' mean perceived confidence in performing nursing clinical skills was high and more than half considered themselves open to technology changes. Positive correlations were found between prestige and intention to choose a field of expertise (r = 0.41, p < 0.001) and the personality trait of openness and the intention to choose an acute care area (r = 0.26, p < 0.01).

CONCLUSIONS

Despite the gradual aging of the population and the increase in chronic morbidity, which demand a greater nursing focus on older adults, and notwithstanding the mental health reforms, nursing students perceive geriatrics and mental health as less prestigious fields. A career development path can be applied by developing a tool for occupational guidance designed to rank students' suitability for specialty fields and thus help them choose the area that best suits them.

Factors associated with seasonal influenza and HPV vaccination uptake among different ethnic groups in Arab and Jewish society in Israel

Background

Parents in the Arab population of Israel are known to be “pro-vaccination” and vaccinate their children at higher rates than the Jewish population, specifically against human papilloma virus (HPV) and seasonal influenza.

Objectives

This study seeks to identify and compare variables associated with mothers’ uptake of two vaccinations, influenza and HPV, among different subgroups in Arab and Jewish society in Israel.

Methods

A cross-sectional study of the entire spectrum of the Israeli population was conducted using a stratified sample of Jewish mothers (n = 159) and Arab mothers (n = 534) from different subgroups: Muslim, Christian, Druse and Northern Bedouins. From March 30, 2019 through October 20, 2019, questionnaires were distributed manually to eighth grade pupils (13–14 years old) who had younger siblings in second (7–8 years old) or third (8–9 years old) grades.

Results

Arab mothers exhibited a higher rate of uptake for both vaccinations (p < .0001, HPV – 90%; influenza – 62%) than Jewish mothers (p = 0.0014, HPV – 46%; influenza – 34%). Furthermore, results showed that HPV vaccination uptake is significantly higher than seasonal influenza vaccination uptake in both populations. Examination of the different ethnic subgroups revealed differences in vaccination uptake. For both vaccinations, the Northern Bedouins exhibited the highest uptake rate of all the Arab subgroups (74%), followed by the Druse (74%) and Muslim groups (60%). The Christian Arab group exhibited the lowest uptake rate (46%). Moreover, the uptake rate among secular Jewish mothers was lower than in any of the Arab groups (38%), though higher than among religious/traditional Jewish mothers, who exhibited the lowest uptake rate (26%). A comparison of the variables associated with mothers’ vaccination uptake revealed differences between the ethnic subgroups.

Moreover, the findings of the multiple logistic regression revealed the following to be the most significant factors in Arab mothers’ intake of both vaccinations: school-located vaccination and mothers’ perceived risk and perceived trust in the system and in the family physician. These variables are manifested differently in the different ethnic groups.

Conclusions

This research shows that all Arabs cannot be lumped together as one monolithic group in that they exhibit major differences according to religion, education and access to information. Ranking of variables associated with uptake of the two vaccines can provide decision-makers an empirical basis for tailoring appropriate and specific interventions to each subgroup to achieve the highest vaccine uptake rate possible. Media campaigns targeting the Arab population should be segmented to appeal to the various sub-groups according to their viewpoints, needs and health literacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01523-1.

Ethnic and Gender Diversity Comparison between Surgical Patients and Caring Surgeons

BACKGROUND

Diversity within the medical workforce remains a topic of discussion in academia, particularly when it comes to the underrepresentation of certain ethnic groups and gender in the surgical specialties. In this article, we look at how the gender and ethnicity of surgeons at a large academic institution in a rural setting compare with those of the population it serves.

METHODS

We looked at demographic data from 2008 to 2018 and compared population trends among surgeons and patients.

RESULTS

We found that while whites represent the large majority in both the surgeon and patient populations, absolute number and percentage of whites in the patient population seem to be trending downward from 2008 to 2018, but trending upward among surgeons (attendings and residents). In addition, we found that while Asians make up only 1% of the patient population, they represent the second largest group (17%) among surgeons, with more than twice the proportion percentage of the second largest group within the patient population, composed of Hispanics (6%). Finally, we found a significant gender difference between the 2 populations with almost two-thirds of the surgeons being men, compared with the nearly even split of men and women within the patient population.

CONCLUSIONS

Ultimately, understanding how gender and ethnic diversity in the surgical workforce compares with that of the patient population being served may aid in designing training programs to address cultural competency and awareness as well as in impacting administrative decisions and hiring.

Coping with the COVID-19 pandemic - the role of leadership in the Arab ethnic minority in Israel

BACKGROUND

The Arab ethnic minority makes up 21% of Israel's population, yet comprised just 8.8% of confirmed cases and 3.6% of deaths from COVID-19, despite their higher risk profile and greater burden of underlying illness. This paper presents differences in patterns of morbidity and mortality from COVID-19 in the Arab, ultra-Orthodox and overall populations in Israel, and suggests possible reasons for the low rates of infection in the Arab population.

METHODS

Data were obtained from the Israeli Ministry of Health's (MOH) open COVID-19 database, which includes information on 1270 localities and is updated daily. The database contains the number of COVID-19 diagnostic tests performed, the number of confirmed cases and deaths in Israel.

RESULTS

In the first 4 months of Israel's COVID-19 outbreak, just 2060 cases were confirmed in the Arab population, comprising 8.8% of the 23,345 confirmed cases, or 2.38 times less than would be expected relative to the population size. In contrast, the ultra-Orthodox made up 30.1% of confirmed cases yet just 10.1% of the population. Confirmed case rate per 100,000 was twice as high in the general Jewish population compared to the Arab population. The Arab mortality rate was 0.57 per 100,000, compared to 3.37 in the overall population, and to 7.26 in the ultra-Orthodox community. We discuss possible reasons for this low morbidity and mortality including less use of nursing homes, and effective leadership which led to early closure of mosques and high adherence to social distancing measures, even during the month of Ramadan.

CONCLUSIONS

Despite a disproportionate burden of underlying illness, the Arab population did not fulfil initial predictions during the first wave of the COVID-19 outbreak and maintained low numbers of infections and deaths. This contrasts with reports of increased mortality in ethnic minorities and economically disadvantaged populations in other countries, and with high rates of infection in the ultra-Orthodox sector in Israel. Effective leadership and cooperation between individuals and institutions, particularly engagement of community and religious leaders, can reduce a group's vulnerability and build resilience in an emergency situation such as the current pandemic.

Language practice and policy in Israeli hospitals: the case of the Hebrew and Arabic languages

BACKGROUND

Organizational language practice and policy are not neutral elements but reflect social and political power relations. The micro-level of working groups is subject to the influence of political conflicts and power relations at the macro-level. In conflict zones in particular, these involve complex considerations. Consequently, the present research sought to examine tensions arising from the language spoken among mixed Jewish-Arab teams in Israeli public hospitals.

METHODS

In-depth interviews were conducted during 2016-2017, with 50 Jewish and Arab healthcare practitioners - 10 managers, 20 physicians, and 20 nurses - employed in 11 public hospitals in Israel.

RESULTS

Our interviews with healthcare practitioners revealed that speaking Arabic in the presence of the patient (not with the patient) may evoke negative feelings and resentment among both Jewish patients and colleagues. Moreover, conflicting attitudes may come into play when Arab practitioners speak Arabic among themselves. Two contexts of language use in Israeli public hospitals can be noticed: the language used in the presence of the patient; and the language used among the practitioners when no patient is present. The former involves the principles of cultural and linguistic competency, and is therefore governed by clear guidelines and procedures. The latter echoes the tensions between the two ethno-national groups in Israel, Jews and Arabs, and is not regulated by a clear policy formulated by the Ministry of Health or by the hospitals' managements.

CONCLUSIONS

Our analysis of language practice and policy as a multi-leveled phenomenon, where the micro-level of everyday interactions is influenced by the macro-level of political life, indicates a need for meso-level policy, led by the Ministry of Health. A policy of linguistic competency should be publicized and enforced to ensure that in the presence of the patient, practitioners speak a language s/he understands. This policy should also stipulate that among mixed teams of healthcare professionals every language is permissible, while the language spoken in a particular context should be understood by everyone present.

Association between cultural factors and readmissions: the mediating effect of hospital discharge practices and care-transition preparedness

OBJECTIVES

The study examines whether hospital discharge practices and care-transition preparedness mediate the association between patients' cultural factors and readmissions.

METHODS

A prospective study of internal medicine patients (n=599) examining a culturally diverse cohort, at a tertiary medical centre in Israel. The in-hospital baseline questionnaire included sociodemographic, cultural factors (Multidimensional Health Locus of Control, family collectivism, health literacy and minority status) and physical, mental and functional health status. A follow-up telephone survey assessed hospital discharge practices: use of the teach-back method, providers' cultural competence, at-discharge language concordance and caregiver presence and care-transition preparedness using the care transition measure (CTM). Clinical and administrative data, including 30-day readmissions to any hospital, were retrieved from the healthcare organisation's data warehouse. Multiple mediation was tested using Hayes's PROCESS procedure, model 80.

RESULTS

A total of 101 patients (17%) were readmitted within 30 days. Multiple logistic regressions indicated that all cultural factors, except for minority status, were associated with 30-day readmission when no mediators were included (p<0.05). Multiple mediation analysis indicated significant indirect effects of the cultural factors on readmission through the hospital discharge practices and CTM. Finally, when the mediators were included, strong direct and indirect effects between minority status and readmission were found (B coefficient=-0.95; p=0.021).

CONCLUSIONS

The results show that the association between patients' cultural factors and 30-day readmission is mediated by the hospital discharge practices and care transition. Providing high-quality discharge planning tailored to patients' cultural characteristics is associated with better care-transition preparedness, which, in turn, is associated with reduced 30-day readmissions.

Race-based experiences of ethnic minority health professionals: Arab physicians and nurses in Israeli public healthcare organizations

Increasing workforce diversity was found to contribute to the narrowing of disparities in health. However, racism toward ethnic minority health professionals has not been adequately researched. In Israel, public healthcare organizations that serve a mixed Jewish-Arab population employ Arab minority healthcare professionals. Instances of prejudice and manifestations of racism toward them, which frequently surface in public discussion and the media, have unfortunately gained little scholarly attention. We used the intergroup contact approach and the theory of the social process of everyday racism as a theoretical framework. The objective of the research was to study race-based experiences of Israeli Arab healthcare professionals.

METHODOLOGY

We used a qualitative research method that allows respondents to describe their views, experiences, beliefs and behavior in the way they think about them. During 2013 and 2014 we conducted in-depth interviews with a snowball sample of 10 Arab physicians and 13 Arab nurses who work in Israeli public hospitals. The study protocol was ethically approved.

FINDINGS

Interviewees noted institutional efforts to maintain egalitarianism and equality. However, at the micro-level, interviewees, mostly nurses, reported instances that ranged from refusal to accept treatment from an Arab nurse, through verbal abuse, to the use of physical violence against them. At the meso-level, interviewees, mostly physicians, reported experiences of institutional discrimination. At the macro-level, one physician reported policy-related discrimination in the context of the immigration of Russian Jewish physicians to Israel.

CONCLUSIONS

We recommend combining the intergroup contact approach with the social process theory of racism to examine minorities' subjective perceptions, especially in conflictual and violent contexts; conducting broad-based quantitative research in Israeli healthcare organizations, which may have important implications for the specific strategies to be used; and emphasizing the importance of institutional support. By reconstructing race-based experiences of ethnic minority health professionals, health organizations can better manage racial situations and reduce their frequency.

The Secret Drama at the Patient's Bedside-Refusal of Treatment Because of the Practitioner's Ethnic Identity: The Medical Staff 's Point of View

Patients' refusal of treatment based on the practitioner's ethnic identity reveals a clash of values: neutrality in medicine versus patient-centered care. Taking the Israeli-Palestinian conflict into account, this article aims at examining Israeli health care professionals' points of view concerning patients' refusal of treatment because of a practitioner's ethnic identity. Fifty in-depth interviews were conducted with 10 managers and 40 health care professionals, Jewish and Arab, employed at 11 public hospitals. Most refusal incidents recorded are unidirectional: Jewish patients refusing to be treated by Arab practitioners. Refusals are usually directed toward nurses and junior medical staff members, especially if recognizable as religious Muslims. Refusals are often initiated by the patients' relatives and occur more frequently during periods of escalation in the conflict. The structural competency approach can be applied to increase awareness of the role of social determinants in shaping patients' ethnic-based treatment refusals and to improve the handling of such incidents.

Tensions and Coping Strategies in Ethnically Mixed Teams: Findings from a Study in Two Emergency Departments

Diversity of the workforce in healthcare facilities, representative of the general population's ethnic/racial composition, is an important health priority. Nevertheless, this diversity may generate tensions. The objective of the study was to assess tensions and coping strategies among ethnic minority and majority healthcare workers. A questionnaire was delivered to 60 healthcare workers employed in emergency departments in two hospitals, where Jewish majority and Arab minority workers care for a mixed Jewish and Arab population. Internal consistency reliability was assessed and the survey data were statistically analyzed. Several differences were found between Arab and Jewish healthcare workers. The questionnaire may be used to examine tensions in other healthcare systems, characterized by ethnic/racial diversity in the workforce. By exploring ethnic/racial tensions, health organizations should be able to manage them better and reduce their frequency.

Neutrality in medicine and health professionals from ethnic minority groups: The case of Arab health professionals in Israel

The ethos of neutrality dominates biomedicine. It has, however, been criticized for leading to a disregard for diversity in medicine. In this article we employ the 'inclusion and difference' approach to gain an understanding of why the ethos of neutrality, on the one hand, and tensions associated with race/ethnicity, on the other, are relevant to the work of ethnic minority health professionals. We sought to explore tensions associated with neutrality in medicine from the point of view of ethnic minority professionals who work in a context of political conflict. We conducted 33 in-depth interviews with Arab health professionals - physicians, nurses and pharmacists - working in Israeli health organizations. The Arab health professionals perceive medical knowledge as being politically neutral; and medical practice as being impartial, universal and humanitarian. They regard the healthcare sector as a relatively egalitarian workplace, into which they can integrate and gain promotion. Nevertheless, the interviewees experienced various instances of treatment refusal, discrimination and racism. In line with the ethos of neutrality, the Israeli medical code of ethics does not relate specifically to Arab professionals and takes their inclusion and integration in healthcare organizations for granted. The ethos of neutrality in medicine underlies the ambivalence inherent in the approach of 'inclusion and difference'. While perceptions of neutrality, alongside values such as equality, cultural competency, impartiality and humanitarian healthcare, do indeed promote the inclusion of minority professionals in health organizations, these same perceptions mask the need to address political events that impinge on the medical milieu and may present an obstacle to designing specific policies to deal with such events.

Work experiences of ethnic minority nurses: a qualitative study

BACKGROUND

Recruitment and retention of a diverse ethnic workforce in healthcare settings contribute to the provision of culturally competent care in multicultural contexts. Nevertheless, the work experiences of ethnic minority nurses, which impact the attractiveness of the occupation, job burnout and turnover intentions, are not well understood. The present exploratory research seeks to examine the work experiences of ethnic minority Arab nurses in Israeli public hospitals. Israel is an interesting case study as the number of Arab nurses operating in the Israeli workforce has risen significantly over recent decades; many of them work in mixed Jewish-Arab environments, which are affected by the Israeli-Palestinian conflict.

METHODS

In-depth interviews with 13 Arab nurses working in Israeli public hospitals.

RESULTS

The interviewed Arab nurses mentioned various benefits associated with the nursing profession, as well as various difficulties they encounter during their daily work, which are specific to them as ethnic minority nurses. They describe nursing as an occupation that offers numerous employment opportunities, job security, professional development and promotion. They believe that their work as a nurse contributes to the health of the Arab family and community and enhances culturally competent healthcare in Israeli hospitals. However, Arab nurses also feel they are stereotyped; they face disapproving looks, refusal to be treated by them, and incidences of hostility toward them. The dual experience of both integration and rejection shapes their coping strategies.

CONCLUSIONS

The findings can inform a more systematic study that could potentially examine both nurses' and patients' conceptions of multicultural care. Action should be taken to ensure optimal working conditions for Arab healthcare professionals. Institutional policies and actions are needed to cope with their unique difficulties, such as the appointment of a functionary responsible for minimizing and coping with stereotypical and hostile attitudes.