Week 6-42

Labour Market Integration of Refugee Health
Professionals in Germany: Challenges and

Strategies

Sidra Khan-G€okkaya* and Mike M€osko*

ABSTRACT

Refugee health professionals are a vulnerable group in a host country’s labour market as they
experience several barriers on their path to labour market integration. This study aims to iden-
tify challenges refugee health professionals and their supervisors experience at their work-
places and strategies they have developed to overcome these barriers. Semi-structured
interviews were conducted with refugee health professionals who have been living in Germany
for an average of four years and their supervisors (n = 24). The interviews were analysed
using qualitative content analysis. Nine themes were identified: (1) recognition of qualifica-
tions, (2) language competencies, (3) differing healthcare systems, (4) working culture, (5)
challenges with patients, (6) challenges with team members, (7) emotional challenges, (8) dis-
crimination and (9) exploitation. Results indicate the need to implement structural changes in
order to improve the labour market experiences of refugee health professionals.

BACKGROUND

The global healthcare workforce is facing skilled labour shortage. The World Health Organization
(WHO) estimates a global shortage of 14.5 million health professionals by 2030 (World Health Orga-
nization, 2006). The European Commission estimates a shortfall of 1 million health workers in Europe
by 2020 (European Commission, 2012), and employment agencies in Germany predict a nationwide
lack of health professionals (Bundesagentur f€ur Arbeit, 2018). In order to address this shortage, nearly
all European countries depend on the recruitment of foreign-trained health professionals (Organisation
for Economic Co-operation and Development (OECD), 2017). Another strategy that has been imple-
mented by the German government to address this shortage is the so-called “activation of domestic
potential” (Bundesregierung, 2018). With that, the German government aims to address those groups
that have difficult access to the labour market, such as refugees in order to improve their employability
and use them to fill shortages (Bundesregierung, 2018). As the number of refugees in Germany has
increased since 2015, the German government has recognized the need to address their labour market
integration (Bundesregierung, 2016). However, refugees belong to a particularly vulnerable group in
the labour market facing unemployment or underemployment (Tanay et al., 2016).

University Medical Center Hamburg-Eppendorf, Hamburg,
This paper is part of a special issue on the “Labour Market Integration of Highly Skilled Refugees in Sweden, Ger-
many and the Netherlands”

doi: 10.1111/imig.12752

© 2020 The Authors. International Migration
published by John Wiley & Sons Ltd on behalf

of International Organization for Migration
International Migration

ISSN 0020-7985

This is an open access article under the terms of the Crea
tive Commons Attribution-NonCommercial-NoDerivs
License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-
commercial and no modifications or adaptations are made.

The barriers and difficulties that refugees face in the context of their labour market integration
are multidimensional and manifold. First, their access to the labour market in Germany is restricted
and depends on their legal status and the likelihood of getting a residency permit which in turn
depends on the country of origin (Bundesministerium f€ur Arbeit und Soziales, 2019). In Germany,
there is a ban on employment for all refugees within the first three months. After three months,
their access to the labour market is dependent on the individual residency status. As of the fourth
month, refugees need work permission from the foreign authority office in Germany and the local
employment agencies in order to work (Bundesministerium f€ur Arbeit und Soziales, 2019). Their
access to language courses depends on their legal status and the likelihood of receiving a residence
permit (Bundesministerium f€ur Arbeit und Soziales, 2019). Moreover, participating in job-related
language courses is described as challenging either due to long waiting times or course availability
(United Nations High Commissioner for Refugees-Organisation for Economic Co-operation and
Development (UNHCR-OECD), 2016). Second, refugee health professionals need to go through a
difficult and long recognition process (K€ortek, 2015; Desiderio, 2016) which is described as the
starting point for permanent downward mobility (Hawthorne, 2002). Moreover, refugees may not
be able to provide identity documents (Bucken-Knapp et al., 2019) or official documents about
their education (Bloch, 2008) due to the flight which impedes the recognition process. Third, a lack
of information about career pathways (Cohn et al., 2006), such as knowledge about job search
strategies (Willott and Stevenson, 2013) and unfamiliarity with the healthcare system of the host
country (Ong et al., 2004), are reported barriers. Fourth, due to their flight they may have had a
break in their professional career and/or experienced the loss of their professional status (Willott
and Stevenson, 2013) which is related to the loss of professional identity (Peisker and Tilbury,
2003). It may also result in deskilling (Stewart, 2003), loss of self-confidence (Willott and Steven-
son, 2013), high levels of frustration (Mozetic, 2018) and negative psychological impacts (Cohn
et al., 2006). Additionally, the lack of recognition of their previously gained experiences leads to a
feeling of being disadvantaged compared to locally trained team members (Mozetic, 2018) which
might be intensified by the experience of multiple forms of discrimination (Jirovsky et al., 2015)
and exclusion (Bloch, 2008).
Studies in Germany have also focused on the working experiences of migrant physicians and

international nurses from within the European Union as well as from non-European countries. They
report similar barriers as the above-mentioned. A study on migrant physicians (Klingler and Marck-
mann, 2016) describes difficulties in three fields. The first field refers to the organization of health-
care institutions and other institutional difficulties such as insufficient support or being assigned to
tasks below their level of expertise. Moreover, difficult career advancement opportunities and unfair
treatment of migrant physicians were mentioned as institutional difficulties. The second field relates
to experienced difficulties with own competencies such as language competencies and knowledge
about the healthcare system. The third field relates to difficulties in interpersonal relations and inter-
actions such as inadequate treatment of patients and co-workers. In this context, a study on the
workplace integration of internationally recruited nurses in Germany points out that conflicts often
arise between migrated nurses and locally trained team members. These conflicts arise because
locally trained team members either hold back or do not comprehensively share key information in
order to organize their work. Thus, the incorporation of migrated nurses into daily work routine is
impeded and the potential for conflicts in everyday work is increased (P€utz et al., 2019). These
studies illustrate that international healthcare professionals and refugee healthcare professionals
experience similar barriers at their workplaces. However, refugees were forced to flee by the cir-
cumstances of their home countries (Yarris and Casta~neda, 2015), whereas internationally recruited
health professionals may be considered as voluntary migrants. This distinction between refugees
and voluntary migrants has effects on the barriers they experience. While voluntary migrants were
most likely able to prepare for their migration, refugees had to flee under extreme conditions (Jack-
son et al., 2004). Stressors of the flight, the loss of family members, traumatic experiences and the

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

uncertainty about their residency permit (Carlsson and Sonne, 2018) may also influence their pre-
requisites to work. Rather, in comparison to other highly qualified migrants, highly qualified refu-
gees are more likely to stay in jobs they are overqualified for which mainly relates to the fact that
documentation of their education is missing (Tanay et al., 2016). Moreover, some other barriers,
such as housing, health, absence of networks or childcare, may indirectly influence employment
outcomes (OECD/UNHCR, 2018).
The European Parliament recommends qualification programmes to prepare refugees for work

and strengthen their employability (Konle-Seidl, 2016). These recommendations comprise individu-
ally tailored programmes to the specific needs of refugees. Amongst others, it is recommended to
provide (occupational specific) language courses combined with working opportunities, skills
assessment, mentoring and career advice. For highly skilled refugees, it is especially recommended
to increase availability of on the job trainings, recognize existing qualifications and offer vocational
training. However, in order to implement tailored programmes that match the host countries’ legal
and social requirements it is essential to identify and analyse the barriers refugee health profession-
als face when entering the labour market. While the legal situation of refugees and their access to
the labour market in Germany is documented through policy papers (European Commission, 2012;
Platonova and Urso, 2012; Konle-Seidl, 2016; Tanay et al., 2016; UNHCR-OECD, 2016; OECD,
2017; United Nations Department of Economic and Social Affairs Population Division, 2017;
UNHCR, 2017; Bundesministerium f€ur Arbeit und Soziales, 2019), little attention has been paid to
the challenges they face in everyday working life and their own perspective and strategies. Thus, in
this study, refugee health professionals and their supervisors across Germany were interviewed
about the challenges they faced at their workplaces as workplaces are a “key site of sociocultural
incorporation” (van Riemsdijk et al., 2016). Moreover, this paper advances this field by giving rec-
ommendations for healthcare providers and organizations based on the experiences of refugee
health professionals and their supervisors in order to implement changes on structural levels and
improve the working environment. These changes refer to establishing supporting structures as well
as measures of diversity management and anti-discrimination.

METHODS

The reporting of methods is in accordance with the consolidated criteria for reporting qualitative
research (COREQ) guidelines (Tong et al., 2007).

Researcher characteristics

Qualitative research depends on the personal qualities of the researcher and the theoretical sensitiv-
ity that the researcher brings to a research (Strauss and Corbin, 1990). Thus, it is important to
reflect on the researcher’s characteristics and its impact on the interview situation. All interviews
were conducted in person by the first author, female, person of color, PhD student of the Depart-
ment of Medical Psychology at the University Medical Center Hamburg-Eppendorf. The first author
is trained in cultural studies, international migration and intercultural studies and has several years
of training in conducting qualitative studies. For transparency reasons, participants were informed
that the study was part of a PhD study.

Recruitment

Major educational organizations and projects for the labour market integration of refugee health
professionals (RHPs) across Germany were identified through internet research. The organizations

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

(n = 15) were contacted and informed about the study. Their consent was obtained. Three of the
major organizations agreed to participate in the study. Participants were divided into RHPs and
supervisors as the refugees’ self-perception about their experiences might differ from the supervi-
sors’ perception. Since the group of RHPs comprises different professions, we decided on subdivid-
ing the stratum of RHPs into two groups: physicians and other health professions. In terms of data
saturation, it is recommended to conduct six to twelve interviews per stratum (Guest et al., 2006).
Thus, 24 interviews were conducted in three major cities in Germany (Hamburg, Hannover and
Frankfurt). All three organizations provided persons that matched the inclusion criteria with infor-
mation on this study and either arranged appointments or provided participants with the research-
ers’ contact information. Inclusion criteria for participants referred to the following aspects:
Target group1.:

• Refugees (regardless of their residency status and form of protection) who have obtained a
qualification in a health profession in their home country or a country other than Germany;

• Supervisors that were responsible for the integration of refugee health professionals, their
supervision or support

Language competencies:

• Required minimum level of German language competencies on the European Reference
level of A2-B12.

Working experiences in Germany:

• RHPs must have had contact with the German healthcare system with a minimum duration
of one month – be it a steady job, an internship or job shadowing

• Supervisors had to work in jobs with close contact with refugee health professionals regard-
less of their hierarchical status. They must have had supervised RHPs at their ward or as an
external supervisor

Context:

• RHPs and supervisors in all healthcare institutions comprising primary, secondary and ter-
tiary care were included

Providers were informed about the inclusion criteria and selected fitting participants. All inter-
views were conducted in German. In one case the inclusion criteria did not match as the participant
was a student of the educational organization without sufficient working experience. Participants
that matched the inclusion criteria were approached via phone followed by an invitation to live
interviews. Participants received two consent forms: one for their participation in the study and one
for their consent to audio recording. The consent form and the study information were orally
explained prior to the interview.

Data collection

The interview guide was developed based on literature focused on the daily work experiences of
refugee health professionals using the SPSS3. approach by Helfferich (2009). The interview guide
was sent to experts in the field of migration research to be critically reviewed. Based on this
review, the authors discussed and adapted the interview guide. Finally, the interview guide was

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

piloted with two migrant nurses that resulted in the specification of some questions. The interview
guide was structured into six main themes:

(1) General experiences while working in a hospital
(2) Experiences with team members and supervisors
(3) Experiences with patients
(4) Experiences with the working culture
(5) Experiences with the healthcare system
(6) Suggestions for improvement

In each interview, the same semi-structured guide was used. After the interview was finished and
the audio recorder was switched off, demographic data were retrieved. The interviews lasted from
00:18 to 00:55 min with a median range of 00:40. Some (n = 4) interviews were transcribed by a
student researcher but the majority (n = 20) of the interviews were transcribed verbatim by a pro-
fessional agency. All transcripts were proofread by the first author.

Data analysis

The interviews were analysed using content analysis (Mayring, 2015). The first author coded all
interviews by means of a computer-based coding programme (MAXQDA, version 10). Deductive
codes were derived from the interview guide but as an explorative approach was preferred more
inductive categories were derived from the material. Code memos were created for all codes includ-
ing a description of the code and typical quotes. For the purpose of quality assurance, a research
assistant coded a random selection of one-quarter of all interviews. Differences in coding were dis-
cussed until a consensus was reached that led to the creation of some new sub codes and a revision
of the category system. Results were presented and discussed with other experts in an interdisci-
plinary research colloquium to ensure comprehensibility and intersubjective reproducibility. The
revised system was then crosschecked by the main author in a second round of coding taking all
interviews into consideration.

Description of sample

Sixteen RHPs and 8 supervisors participated in the study. Two interviews were conducted via tele-
phone due to reduced mobility of the participants. The sample is described in Table 1.

RESULTS

In general, nine major challenges could be identified which either RHPs or supervisors described as
relevant: (1) the recognition of professional qualifications, (2) language competencies, (3) different
healthcare systems, (4) working culture, (5) challenges with patients, (6) challenges with team
members, (7) emotional challenges, (8) discrimination, (9) exploitation. Table 2 provides an over-
view of the identified fields and their specifications.

Recognition4. of professional qualifications

Both supervisors and RHPs pointed out the challenges they faced with regard to the recognition
process of their professional qualifications. Supervisors especially emphasized the difficulties
regarding the recognition process. They criticized the long waiting times for the recognition process

Labour market: Refugee health professionals 5

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

TABLE 1

SAMPLE DESCRIPTION (REFUGEE HEALTH PROFESSIONALS AND SUPERVISORS)

Refugee health professionals (RHPs)

Participant Sex Age
Country
of birth Occupation

Working
experience
in Germany

Working experience
in birth country

A1 m 26 Iran Nurse 1 month 6 years as a nurse
A2 m 23 Iraq Physician 3 months 2 years as a general

physician and
3 years as a
surgeon

A3 m 28 Syria Physiotherapist 2 years 4 years as a physio-
therapist

A4 m 28 Syria Physician
(specialized
in Anaesthesia)

8 months 2,5 years as a medi-
cal assistant in sur-
gery

A6 m 33 Syria Physician 5 months 5 years as a physi-
cian

A7 m 38 Afghanistan Physician one year 1 year as a medical
assistant, 3 years in
public health depart-
ment

A8 w 29 Syria Physician 1,5 years 1 year as a physician
A9 m 30 Afghanistan Physician 3 months 1 year as a medical

assistant
A10 m 44 Syria Physician

(specialized
in anaesthesia)

3, 5 years 4 years as a medical
assistant, two years
as a senior physi-
cian, 9 years as a
chief physician

A11 w 52 Afghanistan Physician (specialized
in gynaecology)

6 months 23 years as a gynae-
cologist (also as a
chief gynaecologist)

A12 m 39 Yemen Physician 4 months 10 years as a physi-
cian

A13 m 45 Afghanistan Physician 2 years 2,5 years as a physi-
cian

A14 m 51 Syria Dentist 3 months 21 years as a dentist
A15 m 39 Afghanistan Physician

(specialized
in
otorhinolaryngology)

6 weeks 3 years as an ear-
nose-throat (ENT)
specialist

A16 w 33 Senegal Midwife and Nurse 3 months eleven months as a
midwife, 15 years
as a nurse

A17 w 36 Azerbaijan Nurse 3 months 2 years as a nurse

Supervisors

Participant Sex Age
Country
of birth Education Current job Experience

B1 m 34 Germany Physiotherapist Part time
physiothera-
pist, part
time supervi-
sor for RHPs
and migrants

5 years as a
physiotherapist,
1 year as a
supervisor

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

(B2-B4, B8) and noted that the bureaucratic procedures for recognition in Germany were not clear
and prolonged the recognition process (B4, B7, B8). RHPs also criticized the length and complex-
ity of the recognition process (A4, A7, A8, A11, A12). Two supervisors (B4, B8) criticized that
former positions such as leadership titles of RHPs were not recognized in Germany. They also criti-
cized that RHP’s specialist medical training or their internships in Germany were not considered
for recognition as working experiences. Furthermore, in one case there was confusion about the
legal foundations of the responsible authorities’ bodies:

One colleague receives a temporary work permit [from the recognition authority] but federal medi-
cal council law and health insurance company’s law contradict each other which inhibits him from
working as a physician unless he has a full licence to practise medicine. But he can only acquire
the full license after taking an exam. Taking that exam is on hold because the [recognition] authori-
ties are understaffed. (B3)5.

RHPs (A1, A11, A13, A15) also indicated their anxiety regarding the licensing examinations as
they feared the examination would be too difficult.

Language competencies

Supervisors and RHPs considered acquiring German language proficiency and German technical
and medical language as a major topic. Supervisors emphasized especially the need to learn the

TABLE 1

(CONTINUED)

Supervisors

Participant Sex Age
Country
of birth Education Current job Experience

B2 m 64 Germany Librarian and editor Commissioner
for refugees
at the medi-
cal associa-
tion in lower
Saxony

2,5 years as
a commissioner

B3 m 64 Germany Physician Physician and
Supervisor
for RHPs

34 years as a
physician,
one year as
a supervisor

B4 m 73 Germany Physician Supervisor for
RHPs/
retired

47 years as
a physician,
2 years as
a supervisor

B5 w 50 Germany Nurse and
professional
advisor

Professional
advisor

15 years as
an advisor

B6 w 54 Germany Nurse Nurse and
supervisor

37 years as nurse
and supervisor

B7 w 38 Germany Nurse and
Psychologist

Psychologist seven years as a
psychologist

B8 m 52 Germany Physician,
Medical
journalist

Managing
director of
refugee and
migrant edu-
cation centre

2 years as
managing director

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

technical language. They (B1, B5, B8) described that RHPs were afraid to admit there were
parts they did not understand and continued to say “yes” in order to maintain the conversation
flow. This has often led to misunderstandings. RHPs described difficulties in speaking everyday
language and technical language. They (A1, A2, A4) found it difficult to understand handover
reports from physicians or keep up in meetings and written documentation. They (A1, A3, A7,
A12) were also afraid of not being able to understand the language which influenced their
behaviour:

I am afraid if [a patient] someone rings the bell. [. . .] Because my language is not [well] enough
and I am afraid of understanding something wrong or not being able to answer [the patient’s ques-
tion]. That’s why I remain seated and others [colleagues] keep asking me “why are you always sit-
ting?” (A1)

One of them also expressed their fear of being deemed to be incompetent due to their language
competencies: “They think I have learned it wrong in Iran. But in fact I couldn’t understand what
they were asking me” (A1). Moreover, RHPs (A1, A3, A12) felt their language competencies held
them back as they were reluctant to share their opinion: “If we discuss a patient’s case and some-
one has a contradicting opinion on that patient’s case I am afraid to discuss our opinions as I fear
they will say ‘I can’t express myself’” (A3).

Different healthcare systems

Supervisors and RHPs described challenges that derived from differing standards in the home
and host countries’ healthcare system. All supervisors described that RHPs would have to
familiarize themselves and catch up with the healthcare system in Germany. Eleven RHPs (A1,
A2, A8, A9, A11-17) emphasized the difference in the medical equipment, the names of

TABLE 2

CHALLENGES EXPERIENCED BY REFUGEE HEALTH PROFESSIONALS

Recognition of professional
qualifications

Difficulties in the context of the recognition process
Non-recognition of former experiences
Examinations for recognition

Language competencies Knowledge of everyday language
Knowledge of technical language
Feelings and consequences of lacking language competencies

Different healthcare systems Unfamiliarity with and differences between the healthcare systems
Unfamiliarity with bureaucratic procedures within the healthcare system
Consequences of differences and unfamiliarity

Working culture Adaption to formal aspects of work
Adaption to cultural aspects of work
Intercultural and interpersonal differences

Difficulties with patients Language difficulties
Difficulties in delivering bad news
Distrust from patients

Difficulties with team members Difficulties during internships
Interpersonal and interprofessional difficulties

General Emotional Difficulties Discouragement
Negative feelings of RHPs in the context of labour market integration.

Discrimination Discrimination by patients
Discrimination by team members

Exploitation Financial exploitation of RHPs in the context of work.
Professional exploitation of RHPs in the context of work

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medication and working habits and the feeling to need to familiarize themselves with these dif-
ferences. In this context, supervisors referred especially to the differing professional role of
nurses in Germany:

They mostly come from countries where nursing care is much higher regarded as a profession, it
gets a very high recognition. And here they have to understand this in such a way that the job
description or the professional role is not so highly regarded. (B6)

RHPs (A1-4, A7, A9-A10, A12-A15) criticized bureaucratic procedures in hospitals in Germany
as it was challenging to keep up with all the procedures of them. They (A4, A17, A16) did not
know about occupational law and were also insecure about their rights and obligations in their pro-
fessional duties. During internships or work, they (A2, A3, A8, A9, A10, A13-17) felt held back
as some of them were not allowed to work either because of their status as interns or because they
did not have their license yet:

Yes, the situation was unpleasant that I could not do anything alone. And if I wanted to do some-
thing, someone had to stay with me, a senior physician or chief physician. That was a bit uncom-
fortable for me because I already graduated from university and I also worked as an assistant
physician in my home country for a year. But I didn’t have a solution. I had to come to Germany
and here, the rule is if someone doesn’t have a license he has to cooperate with a chief physician
or with a senior physician. (A9)

Working culture

Supervisors described two facets of working culture that they found important in the context of
their experiences with RHPs: formal and cultural aspects of work and RHPs adaption to these
aspects. They emphasized formal aspects such as being punctual, submitting holiday applications
correctly, calling in sick, being polite and committed to work. Some of the supervisors (B1, B2,
B3, B6, B7, B8) criticized some of these aspects in the context of RHPs as deficits. With regard to
cultural aspects, supervisors mentioned that RHPs had different values that sometimes inhibited
their integration such as examining other-sex patients (B1, B6-B8), taking off headscarves for sev-
eral reasons (B1, B8), dealing with homosexuality (B1) or accepting female superiors (B1-B4, B7).
These values were often attributed to cultural differences although they may result from context-
specific causes, as one supervisor who had a mediatory role describes:

The [female] colleague shouted at him [the RHP] in front of the patients [. . .] Luckily, we heard
about it and picked it up [. . .] she said he was a macho and suggested women were worth less than
men. The trigger was a basic nursing situation which is difficult for our participants as they haven’t
learned it in their home countries. And she gave instructions that were too brief, for example
“wash” and he didn’t know what to do with that instruction. […] And that caused the escalation
spiral. (B7)

RHPs were also asked about their experiences in the context of working culture. They pointed
out that formal aspects of work, such as being punctual and committed, were universal. However,
they (A1, A3, A8, A13, A16) experienced differences on the intercultural and interpersonal level,
such as the value of families and treating other sex patients, and developed several strategies to get
adapted to it:

I was born in an Islamic country. I am not Muslim but born there and I grew up there. And some-
times I think, maybe the [female] patient is embarrassed. Or I ask may I look, may I do. Because

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

maybe the other colleague does not say anything at all but for me it is a bit ok – maybe she has
problem with men and so on, so I ask. (A1)

Challenges with patients

RHPs experienced difficulties with patients especially if patients did not speak clearly due to their
illness, their age or their way of speaking:

The problem was that I couldn’t understand. For example, the patient said “bring me this and that”.
And the problem was that they spoke very unclearly and for German people it [is] also difficult to
understand and for me of course [it is] especially difficult. (A1)

Some described that talking to patients’ relatives was a new challenging experience especially if
they were furious (A8) or if they had to pass bad news to them (A7). Another challenge was asso-
ciated with distrust from patients: “Maybe they don’t trust the foreign physicians as much but that’s
general [generally the case]. All patients are like that, almost all of them. […] You can tell, they’re
a little scared or something” (A4).

Challenges with team members

Almost all supervisors (B2, B4-8) mentioned the important role of internships in the context of
team integration. However, one supervisor reported that finding internship placements became more
and more difficult due to lower capacities of the hospitals (B4). During some internships, partici-
pants were not given appropriate tasks or were not supervised (B2, B5, B7, B8) as “it is associated
with effort to take along someone” (B7). Sometimes local trained team members were not aware of
what RHPs were allowed or permitted to do which often led to misunderstandings (B5, B7, B8).
Almost all of the RHPs mentioned several other challenges in the context of teamwork, such as a
distanced relationship towards local trained team members (A8, A11, A15, A16), their expectation
that RHPs could do and know everything and wrong ideas of them and their education (A1, A9,
A10).

General Emotional challenges

Some of the RHPs (A3, A8, A16) experienced discouragement on their path to reintegration. They
were told by their employment agency consultants that they could not succeed as health profession-
als in Germany and were advised to pursue other career options:

I wanted to go to the hospital and see how this works. And I wasn’t sure if I could do that again. I
thought it is not possible. Because everywhere where I had asked [they said]: “No, you can’t do
that. Do another one. Do a retraining and so on. Do some care. But you can’t do midwife.” And I
came to my ward. I saw it, it is the same thing. (A16)

Additionally to being discouraged, supervisors thought RHPs felt impeded (B4), afraid (B5, B7,
B8), frustrated (B1, B6), under pressure and isolated (B1) as a consequence of the experienced bar-
riers. Moreover, they acknowledged RHPs’ loss of their professional status and mentioned that
RHPs were reduced to their language deficits (B1, B6, B7) which influenced their self-perception
and made them question themselves (B7).

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

Discrimination

RHPs experienced several forms of discrimination. One supervisor reported that RHPs were some-
times rejected and ignored in decision-making. He describes a situation between a refugee physi-
cian and a locally trained nurse:

I can give you an example: my [refugee] physician is treating a patient. Another [locally trained]
nurse has a question about that patient. He [the nurse] is standing in front of my [refugee] physi-
cian and tells him: “I don’t want to clarify this with you. I will talk to your colleague who under-
stands me.” And that is a nice form of rejection. There are even more blatant cases. (B1)

Five supervisors (B1, B5, B6, B7, B8) and six RHPs (A1, A2, A3, A7, A10, A15) also reported
discrimination from patients towards foreign health professionals: “I was in the room, I had to take
[a] blood [sample] and the patient and also her husband said: ‘No, you may not come here. We do
not want a foreign physician here’” (A15). However, supervisors differentiated between open dis-
crimination and subtle racism from patients. They also differentiated between patients who did not
fully trust RHPs and patients who treated them in a racist manner from the beginning. In the con-
text of foreign-trained health professionals, one supervisor described intersectional discrimination as
some patients racially and sexually harassed female nurses from Thailand:

There was a situation where an older “fascist grandfather” in quotation marks somehow said he
didn’t want that or the Thai ladies – how shall I say, perhaps sexualised? So, with Thai participants
or Asian looking participants, the gentlemen often become a little bit, how can you say, more
cheeky. (B1)

Although this quote does not explicitly refer to refugee health professionals, it is likely that
RHPs also experience intersectional discrimination.
Additionally, RHPs (A3, A4, A8, A10-A13, A15) experienced discrimination from senior team

members as one female physicians describes:

I was at that interview with the chief physician and at the end he said: “Your German is well, […]
but there is something negative. [. . .] You have this headscarf. You are Muslim and there are a lot
of (tourist? terrorists? [incomprehensible]). How can the patients be sure that you are not a (tourist?
terrorist?)?” That moment was horrible for me. (A8)

The physician described that she refused the position afterwards due to this experience and
started working in a catholic hospital as her headscarf is not a problem there “because nuns also
wear a headscarf” (A8).

Exploitation

In addition to the discrimination faced by patients and team members, two supervisors (B2, B8)
described experiences of exploitation:

There are hospitals who misuse the situation of RHPs. There are hospitals that pay below the pay
scale (Tarifvertrag), very far below the scale. I will give you an example. There are hospitals in the
[anonymized] region who employ physicians from Afghanistan, Syria, Iraq. They hire them for-
mally as assistants, pay them 800 to 1200 Euros for a full time job, but they work as normal physi-
cians and are involved in normal hospital routine. No plaintiff, no judge6.. For the RHP it is at
least something. He can work as a physician after a long time and familiarize with procedures,
improve his language and do what he is qualified to do. But, by our standards, that is exploitation.

(B8)

Labour market: Refugee health professionals 11

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

This would also affect RHPs’ claims for benefits after terminating the employment (B8). Addi-
tionally to financial exploitation, one supervisor also mentioned that RHPs were sometimes hired as
gap fillers not correspondingly to their qualifications and did not have a long-term perspective
(B8). RHPs did not explicitly mention being exploited. However, many of them were not yet per-
manently working and one reported doing unpaid overtime, as he did not know about working
rights in Germany (A4).

Resources and strategies

RHPS and supervisors described several strategies they had developed in order to address the experi-
enced barriers. These strategies refer to individual strategies of RHPs, strategies in the context of edu-
cation and support, strategies on the team level and strategies on the organizational and societal level.

Individual strategies

All RHPs described several individual strategies to cope with challenges they had faced such as being
patient (A1, A2, A6, A9), trusting and believing in their own power resources (A3, A13, A16) or pre-/
post-processing relevant professional content (A1, A7, A12, A16). They also actively engaged with
their colleagues, asked them questions, demanded feedback (A9, A16) in order to cope with language
deficits. Furthermore, RHPs developed several strategies to cope with patients’ discrimination. They
either tried to reassure patients (A10, A12), accepted patients’ wishes and called a team member (A4),
ignored (A7) or avoided patients that rejected them (A16). In dealing with discrimination from team
members, some RHPs would focus on their goal instead of focusing on conflicts and try not to think
too much about these experiences (A12, A15). Others would use humour in order to unburden a
tensed situations with jokes (A10). Staying silent was described as a strategy as well:

I didn’t do anything and I didn’t say anything because I knew that if I said something, the situation
would get worse and I didn’t want that to happen. Yes, I was very calm and I wanted this nurse to
go home and think for herself, then she would understand. […] Yes, later she was a little better. All
beginnings are difficult. (A9)

Supervisors pointed out individual competencies of RHPs in dealing with the barriers. They
emphasized RHPs’ great commitment and their positive working attitudes. They also highlighted
the competencies of RHPs such as their intercultural competence (B4, B8), their openness to new
experiences (B1, B6, B7), a high motivation to work (BB7, B4, B3, B2), their cooperation capabil-
ity (B3), their gratefulness (B5) and their fighting spirit (B7).

Strategies in the context of education and support

In the field of education, supervisors demanded: mandatory, well organized, on the job programmes for
all RHPs that are funded (B8), career advice services (B6, B7), follow-up support (B7), more resources
and equipment for the training of RHPs (B4, B6, B7), material and support for language training.

Strategies on the team level

Generally speaking, positive contact towards patients and team members was perceived as very
helpful. One supervisor described RHPs’ and patients’ relationships as “a mutual connection as
they are stronger dependent on each other” (B7) than in other cases. Likewise, team members were
described by all RHPS to be open, interested and supportive: “They were all friendly and every

12 Khan-G€okkaya and M€osko

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

morning when I came to work they smiled at me and said ‘good morning’. And that I find really
important for a newly arrived” (A12). Almost all of them (A1-A4, A7-A9, A11-A14, A16-A17)
emphasized that colleagues were forthcoming if they had questions and that they benefitted from
their induction and their feedback. Two of them (A8, A11) pointed out the role of other (locally
trained) interns and students who helped them in their free time. Supervisors focused more on
structural resources for teams. They suggested training for local team members and mediators (B1,
B7), more personnel and more time to induct RHPs (B3, B6, B7), clear contact persons that RHPs
can talk to (B1, B4) and clear instructions of team members (B3). They also mentioned time to
familiarize for RHPs (B1, B2, B6, B7), less patients to care for at the beginning (B7) and sensitiza-
tion and reflexivity of locally trained team members (B1, B3, B7).

Strategies on an organizational and societal level

On an organizational and societal level, supervisors suggested enhancing an overall integration
approach so that RHPs can have a quick arrival in the system (B1), build up networks (B1, B6)
and earn their own money (B1). They also mentioned an opening welcoming culture (B1), public
sensitivity actions and support from the management boards (B7):

But we also need the attitude from above [the management board] that says: “We want that [the
labour market integration of RHPs], and we also provide time and resources, and teams also get a
benefit for getting involved”. (B7)

One supervisor referred to the commitment of supervisors and the healthcare providers when
observing racism and sexism: “If the hospital positions itself clearly and says ‘take your documents
and go home because we are not going to treat you’. Great, because that is a clear line. But if they
talk around the issue the patient will continue to show racist behaviour” (B8).

DISCUSSION

This paper aimed to explore the barriers and resources RHPs faced at their workplaces. The broad
range of identified barriers and difficulties indicates that their experiences depend very much on their
employers and their working environment. Moreover, as understaffing is a common problem in
health care (Angerer et al., 2011; Deutscher Gewerkschaftsbund (DGB), 2018), it is questionable to
what extent only RHPs are affected by these experiences or if they are a consequence of the precari-
ous staffing situations. Moreover, it remains open to what degree the migration status influences the
experienced challenges. Since no questions were asked about their flight, their psychological well-
being or their residency permit and none of the participants mentioned it in the context of their
workplace experiences, it is not possible to state whether only refugees experience these barriers.
Instead, our results indicate that when focusing at their workplaces, RHPs face similar barriers as
internationally recruited professionals and voluntary migrants (Humphries et al., 2013; Jirovsky
et al., 2015; Klingler and Marckmann, 2016; P€utz et al., 2019). Nine major challenges were identi-
fied: 1) recognition of qualifications, (2) language competencies, (3) different healthcare systems, (4)
working culture, (5) challenges with patients, (6) challenges with team members, (7) emotional chal-
lenges, (8) discrimination and (9) exploitation. These challenges illustrate that hiring RHPs should
not be a quick response to filling shortages. Instead, the integration process should be carefully pre-
pared in order to prevent some of these challenges. Labour market integration is a two-sided process
that requires not only a welcoming culture but also welcoming structures (Knuth, 2019). Educational
providers, employers as well as authorities need to address these barriers and implement structural
changes in order to contribute to a sustainable labour market integration of RHPs.

Labour market: Refugee health professionals 13

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

Both RHPs and supervisors emphasized the challenges with the recognition process. This is con-
sistent with previous findings that many legal and formal barriers inhibit a successful labour market
integration and prevent organizations to invest in RHPs integration (Schmidt, 2019).
RHPs and supervisors both stressed the role of acquiring the language and the consequences of

lacking language competencies. RHPs suffered from not speaking German fluently, and it affected
their self-esteem. Likewise, the knowledge and familiarization with the local healthcare system is
an important prerequisite in order to deliver a good working performance. Both barriers are
reported to be common challenges in the context of labour market integration of refugees as well
as other migrant groups (Cohn et al., 2006; Bloch, 2008; Leblanc et al., 2013; Klingler and Marck-
mann, 2016). This indicates a stronger need for occupational specific language courses and infor-
mation on the healthcare system of the host country. This would not only concern educational
providers but also employers. In order to maintain a good quality of care and prevent misunder-
standings or mistreatment due to language barriers (Klingler and Marckmann, 2016), employers
can invest in further education of their RHP employees. Although this would mean additional
financial investment from the employer, a corporate study indicates that those investments would
pay off within a year (Baic et al., 2017).
In the context of working culture, a fast adaptation to local standards was expected by supervi-

sors and team members. Deviations from these local standards were seen as problematic and
obstructive. This coincided with results from other studies (Klingler et al., 2018; P€utz et al., 2019)
However, it remains problematic due to several reasons. Firstly, the term “local standards” pre-
sumes shared standards (Klingler et al., 2018). However, it remains unclear if these standards refer
to professional standards, legal regulations, norms, cultural aspects or hospital routines. Secondly,
the knowledge about certain established standards may be tacit and implicit (Sakamoto et al., 2010)
thus unspoken. As RHPs are unaware of these unspoken standards, deviations in behaviour can
lead to frustration, conflicts and exclusion (Lai et al., 2017). Thirdly, most of the perceived differ-
ences in the context of working culture from the supervisors were culturalized. Supervisors saw the
causes of conflicts in cultural distinctions, although they could as well be interpreted situation and
person specifically or result from differing concepts of work. This is consistent with previous find-
ings (P€utz et al., 2019) that in the process of labour market integration differing concepts attributed
to work clash. These concepts may be influenced by stereotypes and prejudices. As a result, on the
one hand immigrated employees identify themselves as the “outsiders” contrary to local employees.
On the other hand, an enhancement of the existing working culture that could have been adaptable
to a new environment is excluded (Steinberg et al., 2019). Fourthly, the performance of RHPs is
measured according to their adaption and stabilization to the system. But the potential that RHPs
bring along is wasted if adaption and stabilization are the only possible and acceptable outcomes
since they bring along important working experiences and attitudes that may enrich local standards.
Thus, it is important to verbalize standards and address them before or ideally concomitant to
RHPs labour market integration (Sakamoto et al., 2010). At the same time, it is important to offer
local team members opportunities to reflect on their own standards of work and their expectations.
This could also contribute to an overall improvement of the working atmosphere and reduce the
challenges experienced with team members. However, difficulties with team members were also
attributed to a lack of supervision during internships. Results indicate that most of the time, indi-
vidual team members were intrinsically motivated to support RHPs and engaged in their induction.
But the responsibility of integrating RHPs should not only be outsourced to committed employees
or in the worst case, as described in the results, to unwilling employees. The support of RHPs
should be implemented on a structural level. It is estimated that a one and a half additional hours
of individual support per month are sufficient to generate good integration prospects (Baic et al.,
2017). However, it remains open to question if team members who provide individual support
should be further trained and/or remunerated for their effort. In order to expand the support possi-
bilities, mentoring programmes could also be helpful in supporting RHPs. These findings are

14 Khan-G€okkaya and M€osko

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

consistent with recommendations given by the German Employer Association stating that mentor-
ing programmes are a classical approach towards integrating foreign workers (Robra and B€ohne,
2013).
In general, more acknowledgement and empowerment for RHPs is needed. This is consistent

with previous findings describing the loss of RHPs’ professional status (Leblanc et al., 2013) result-
ing in deskilling (Stewart, 2003), the loss of self-confidence (Jirovsky et al., 2015), feelings of frus-
tration (Mozetic, 2018) and negative psychological impacts (Cohn et al., 2006). Results in this
study further indicate that RHPs experience several forms of discouragement, discrimination as well
as disparagement, although they are fully educated and bring along valuable human capital (A9).
Although RHPs have already developed several strategies in dealing with negative feelings and the
barriers they face, organizations and educational institutions could further engage in strengthening
RHPs’ professional identity, acknowledge their strategies and/or make the potential of RHPs visible
in order to empower them.
In the light of the discrimination that RHPs faced by team members and patients, healthcare pro-

viders need to promote measures of diversity management as discrimination may be one result of
poor diversity management (Dickie and Soldan, 2008). Discrimination influences the motivation
and job satisfaction of RHPs and in the long term, it can also have negative psychological impact
and lead to leaves of RHPs (Bouncken et al., 2015). On the contrary, a diversity climate within the
organization can enrich the psychological capital of refugee employees and contribute to their com-
mitment (Newman et al., 2018). Nevertheless, several forms of discrimination from patients and
colleagues were commonly mentioned topics consistent with previous findings on RHPs’ experi-
ences (Cohn et al., 2006; Bloch, 2008; Jirovsky et al., 2015). According to the federal German law
“General Act on equal Treatment,” employers are legally obliged to protect their employees from
discrimination (Allgemeines Gleichbehandlungsgesetz, 2006). But especially experiences of racism
are often denied in health care as “the illusion of non-racism” exists and impedes progressive poli-
cies (Johnstone and Kanitsaki, 2008). Progressive policies may refer to promoting equal opportu-
nity policies (Wrench, 1999) and prevent any form of discrimination (B8). Condemning racist
comments (B8), establishing anti-discrimination commissioners, setting up transparent complaint
systems and offering anti-discrimination and empowerment workshops could be first steps (Wrench,
1999) towards an inclusive and healthier working environment for both staff and patients.
Similarly, the exploitation of RHPs needs to be addressed and employers as well as policymakers

should take responsibility for it. Due to their uncertain legal status, foreign workers are at high risk
of being exploited (Rights, 2010). Labour unions have recognized that and demanded that refugees
must be given access not only to the labour market but also to career advice services (Deutscher
Gewerkschaftsbund (DGB), 2015) in order to increase awareness of their working rights. Another
way for employers to prevent exploitation could be to appoint an integration commissioner for their
organizations. These commissioners could monitor the integration process and ensure compliance
with working rights. Educational providers working with clinics could inform RHPs as well as clin-
ics on the legal rights and duties of RHPs. In any case, this finding points to a severe grievance
that has not been reported in previous studies in this context. Further research is necessary to find
out if these are selective experiences or structural problems in the health care sector.
In general, results indicate the need to reflect on the term integration itself. Several migration

scholars criticize the term for numerous reasons. Firstly, in Germany the term “integration” mostly
refers to regulatory policies which focus on integrating migrants into the existing social orders
(Karakayali and Bodjadzijev, 2010). However, social orders are predefined and shaped by members
of the majority group (Essed, 2000). Secondly, the term is based on negative narratives about the
unwillingness or failed integration of migrants which contributes to the fact that new demands are
constantly being claimed on migrants (Mecheril, 2011). Hence, the term puts migrants into the
focus while structural and institutional deficits as well as power asymmetries within the host coun-
tries are ignored. Subsequently, the experiences of racism and exploitation that RHPs describe in

Labour market: Refugee health professionals 15

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

this study point to the need to focus research on structural and institutional inequalities, power
asymmetries and intersectional discrimination. For further research in this context, it would be help-
ful to consider the Critical Race Theory (CRT) as it is based on principles of race equity and social
justice and provides tools in order “to elucidate contemporary racial phenomena, expand the vocab-
ulary with which to discuss complex racial concepts and challenge racial hierarchies” (Ford and
Airhihenbuwa, 2010). Furthermore, activists and scholars who contributed to the CRT study and
transform the relationship between race, racism and power (Delgado and Stefancic, 2017). How-
ever, for the purpose of this study it can be concluded that equal participation in the labour market
and society requires equal treatment, equal opportunities and protection against discrimination
(Uslucan, 2017).

Policy recommendations

Refugee health professionals face personal, structural and institutional barriers at their workplaces.
Although they have developed strategies to overcome these barriers, structural and institutional
changes are needed in order to improve the working environment. In the following, the most impor-
tant conclusions from this study are pointed out as recommendations in order to contribute to a bet-
ter labour market and workplace integration of refugee health professionals. First, there is a need to
offer job-specific language courses and courses addressing formal and cultural aspects of work (as it
is done for example in Sweden (Ministry of Employment and Sweden, 2016)). Similarly, local team
members need to be sensitized for cooperation with refugee health professionals in order to decrease
the potential for conflict. Second, structural changes within teams need to be implemented in order
to supervise refugee health professionals and ensure a proper induction at the beginning. Third, in
light of the experienced barriers, the discrimination and the exploitation, there is a need to empower
refugee health professionals and make their qualifications and their potential visible. Fourth, mea-
sures of diversity management and anti-discrimination need to be implemented and supported by the
management board. Fifth, compliance with working rights must be ensured and team members as
well as refugee health professionals need to be informed about their working rights.

Strengths and limitations

This study identified major challenges in the context of the working experiences of RHPs. By
choosing an explorative approach, a broad range of topics could be identified which provide a basis
for further research and in-depth analysis of the difficulties in the identified fields. The perspective
of RHPs and their supervisors were integrated in order to get an insight into the field of health pro-
fessions and the labour market integration into health professions. For further research, it could also
be helpful to interview colleagues of RHPs and focus on specific healthcare settings. Participants in
this study were selected from rural as well as urban areas and comprised several health professions.
Another strength of this study lies in the methodology. Discussing data with an interdisciplinary
group ensures comprehensibility and critical reflection. Nevertheless, as participants were not
recruited representative and most participants worked only for a short time in Germany, there might
be a selection bias and results are questionable in terms of generalizability. Another limitation is
the compilation of the sample as more physicians and more men in urban areas were interviewed.
Intersectional barriers, language competencies, training experience and other demographic-specific
aspects were neglected. Hence, no conclusions could be drawn for subgroups. Furthermore,
although a certain language competency was required, language barriers and socially desirable
answers may have influenced the interview process. However, due to the researchers’ background
and the reflection of her characteristics, a trustful interview situation could be created and reflected
afterwards.

16 Khan-G€okkaya and M€osko

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

ACKNOWLEDGEMENT

We are grateful to the participants and to the organizations who have made this study possible
through their support. Open access funding enabled and organized by Projekt DEAL.

FUNDER INFORMATION

The study was funded by the European Social Fund. SKG and MM received the funding. The fun-
ders did not play any role in the study design, data collection, decision to publish or preparation of
the manuscript.

DECLARATION OF INTERESTS

We have no conflicts of interest to disclose.

Peer Review

The peer review history for this article is available at https://publons.com/publon/10.1111/imig.
12752.

NOTES

1. The terms “refugee health professionals” and “supervisors” were selected as they describe a shared experi-
ence. However, it should be noted that both terms reduce these persons to only one aspect of identity. The
terms do not reflect the multiple aspects of identity and the social and ethical dimensions of the workplace
identity that all interviewed person and health care professionals have.

2. The Common European Framework of Reference for Languages: Learning, Teaching, Assessment (CEFR)
is a reference system to describe six levels (A1, A2, B1, B2, C1, and C2) of language proficiency from
beginners (A1) to experts (C2).

3. SPSS is an abbreviation for Sammeln, Pr€ufen, Sortieren and Subsumieren (Collect, Check, Sort, Subsume).
4. Health professions are registered professions in Germany which is why foreign health professionals need

to have a full or temporary license before they can practise. In order to obtain a license, they have to
go through a recognition process. The first step of the recognition process is an equivalence assessment.
Based on this assessment, recognition bodies grant full recognition, no recognition or partial recognition.
If qualifications are only partly recognised, foreign health professionals can participate (professional
groups like nurses must participate) in adaption training programmes or internships and prove their
required knowledge through language and proficiency tests. The proficiency tests covers internal medi-
cine and surgery. However, based on the equivalence assessment authorities may also evaluate other
subjects.

5. As the interviews were conducted in German, citations in this section were translated one-on-one from Ger-
man to English. If terms were not equivalent in English, then those terms were translated one-on-one and
supplemented with further explanations in the reference mark (Koller, 2011 Einf€uhrung in die €Uberset-
zungswissenschaft [Introduction to translation science], Francke, T€ubingen; Basel.).

6. “No plaintiff, No judge” (German translation: Wo kein Kl€ager, da kein Richter) is a common phrase in
German. It describes that certain irregularities or grievances remain uncovered as no one complains about
them.

Labour market: Refugee health professionals 17

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

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22 Khan-G€okkaya and M€osko

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International Organization for Migration

WORKFORCE DIVERSITY

Rupert M. Evans, Sr., DHA, FACHE

CHAPTER

6

145

Learning Objectives

After completing this chapter, the reader should be able to

• understand how proactive use of diversity principles can transform the
organization’s culture;

• understand the business case for diversity and inclusion in healthcare
organizations;

• work toward creating an inclusive organizational culture;
• define the roles that healthcare providers, management, and governance

play in building a business imperative for diversity within the
organization; and

• discuss how healthcare leaders can develop a diversity program in their
organizations.

Introduction

When you hear the term “diversity,” what comes to mind? To some, the word
means the differences between human beings related to race or ethnicity. To
others, it means the uniqueness of each individual. A few people still may jump
up to argue that diversity is just a code word for affirmative action.

Healthcare organizations across the United States are beginning to
move toward embracing and fostering workforce diversity. This cultural
change means adopting new values that are inclusive and appropriately man-
aging a diverse workforce. In the future, diversity will drive the business prac-
tices of hospitals and other healthcare organizations, and this dynamic will re-
quire strong leadership. This change will take time, but in the words of
Reverend Jesse Jackson, “Time is neutral and does not change things. With
courage and initiative, leaders change things.”

In this chapter, we provide a definition of diversity and a framework for
understanding the different ways people view the term. In addition, we high-
light several studies and legal issues pertaining to this topic and enumerate
methods for building a case for and establishing a diversity program.

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A Definition of Diversity

People define diversity in many ways, depending on the way they live in and
view society. In his book, The 10 Lenses: Your Guide to Living and Working in
a Multicultural World, author Mark Williams (2001) discusses the framework
that explains the way people see the world:

1. The assimilationist wants to conform and fit in with the group to
which he or she belongs.

2. The colorblind ignores race, color, ethnicity, and other cultural factors.
3. The cultural centrist seeks to improve the welfare of his or her cultural

group by accentuating its history and identity.
4. The elitist believes in the superiority of the upper class and embraces

the importance of family roots, wealth, and social status.
5. The integrationist supports breaking down all barriers between racial

groups by merging people of different cultures together in
communities and in the workplace.

6. The meritocratist lives by the adage, “cream rises to the top”—the
belief that hard work, personal merit, and winning a competition
determine one’s success.

7. The multiculturist celebrates the diversity of cultures, seeking to retain
the native customs, languages, and ideas of people from other
countries.

8. The seclusionist protects himself or herself from racial, cultural, and/or
ethnic groups in fear that they may diminish the character and quality
of his or her group’s experiences within society.

9. The transcendent focuses on the human spirit and people’s universal
connection and shared humanity.

10. The victim/caretaker views liberation from societal barriers as a
crucial goal and sees oppression as not only historical but also
contemporary.

With this framework in mind, it is easier to understand why so many
interpretations of the same idea exist. For our purposes, we describe diversity
in the context of three key dimensions: (1) human diversity, (2) cultural di-
versity, and (3) systems diversity. Each dimension needs to be understood and
managed in the healthcare workplace.

Human diversity includes the attributes that make a human being who
he or she is, such as race, ethnicity, age, gender, family status (single, married,
divorced, widowed, with or without children), sexual orientation, physical
abilities, and so on. These traits are what frequently come to mind first when
individuals consider the differences in people. Human diversity is a core di-
mension because it defines who we are as individuals. This dimension is with
us throughout every stage of our lives, guiding how we define ourselves and

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how we are perceived by others. A workplace definition of diversity includes
human diversity as a minimum.

Cultural diversity encompasses a person’s beliefs, values, family struc-
ture practice (nuclear or extended family, independent living), and mind-set
as a result of his or her cultural, community, and environmental experiences.
This dimension includes language, social class, learning style, ethics or moral
compass, religion, lifestyle, work style, global perspectives, and military views.
Cultural diversity is a secondary dimension, but it can have a powerful impact
on how a person behaves in the workplace. The cultural norms vary from one
culture to another and influence how individuals interact with their work en-
vironments. For example, some religious groups are forbidden from working
on the Sabbath, and this exemption has an impact on work scheduling and
even hiring decisions.

Systems diversity relates to the differences among organizations in work
structure and pursuits. This dimension includes teamwork reengineering,
strategic alliances, employee empowerment, quality focus, educational devel-
opment, corporate acquisitions, and innovation. Systems diversity deals with
systems thinking and the ability to recognize how functions in the work envi-
ronment are connected with diversity. In a multicultural, diverse, and inclu-
sive workplace, organizational systems are integrated to enhance innovation,
encourage teamwork, and improve productivity.

All of these dimensions are important and are present in the health-
care workplace, and all leaders should recognize them. The challenge is in
seeing not only our differences but also our similarities as individuals, as
professionals, and as members of a group. Leaders must develop effective
strategies to manage the differences (and highlight similarities), and this
will lead to building effective teams and a higher-performing organization
(Guillory 2003).

Managing diversity is not an easy task, as a number of barriers often get
in the way of achieving a harmonious working environment. Some of these bar-
riers, which revolve around the diversity dimensions mentioned earlier, can be
a great source of tension and conflict. For instance, a person’s culture can be a
barrier to a work team when other members of the group are not respectful of
or misunderstand the person’s values, beliefs, or even clothing, which that per-
son gained through his or her cultural background. Examples of a cultural dif-
ference may be the person’s hairstyle or affinity to wear religious artifacts. The
education, race/ethnicity, work style, empowerment, and relationship/task
orientation of an individual can also become barriers if they are not properly
understood and managed.

Prejudice in the Workplace

Prejudice is a set of views held by individuals about members of other groups.
Prejudice is pre-judgment; hence, it is not based on facts and/or experience.

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It affects the way people react toward and think of other people, and it can be
as innocent as children choosing to not play with children they deem different
from themselves or as harmful as adults not associating with certain people be-
cause English is not their native language.

Formally, prejudice can be defined as a set of institutionalized assump-
tions, attitudes, and practices that has an invisible-hand effect in systematically
advantaging members of more powerful groups over members of less domi-
nant groups. This type of prejudice occurs in many healthcare institutions.
Some examples include culturally biased assessment and selection criteria, cul-
tural norms that condone or permit racial or sexual harassment, lower per-
formance expectations for certain groups, and a collective misconception
about a specific group that relegates the group’s members to unfair positions.
An example of the latter is stereotyping.

Stereotypes are generalizations about individuals based on their identity,
group membership, or affiliations (Dreachslin 1996). A common stereotype
in the healthcare management field is the assumption that black executives are
not as qualified as their white counterparts. Thus, African-American execu-
tives are tested more often to prove their competence, while their white con-
temporaries are assumed to be capable from the start. (This fact is substanti-
ated in the race/ethnic surveys discussed later in the chapter.)

The concept of “comfort and risk” relates to a human being’s natural
need to feel comfortable and to avoid risk. People tend to prefer to work with
others from similar racial or ethnic backgrounds because doing so provides
them with a certain amount of comfort and shields them from a certain
amount of risk. Although subordinate–superior relationships that involve peo-
ple from different backgrounds work sufficiently to allow people to get the
job done, they often fail to lead to the close bonds that form between a men-
tor and a protégé.

Given the systemic existence of prejudice and the way it influences
people’s mind-set and behavior in the workplace, the fair and accurate assess-
ment of minority employees (caregivers, support staff, and managers alike)
remains an organizational dilemma rather than an established practice. For
instance, existing literature provides evidence that managers systematically
give higher performance ratings to subordinates who belong to the same
racial group as they do, while high performers from minority groups remain
comparatively invisible in the managerial/leadership selection process (Thomas
and Gabarro 1999).

The Business Case for Diversity

In 1900, one in eight Americans was non-white; today, this ratio is one in
four. By 2050, the ratio will be one in three (IOM 2004). The healthcare

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industry needs physicians, nurses, and other providers, but it also needs care-
givers who reflect the diversity of the population, who, at one point or an-
other, become patients. The same is true for healthcare managers and exec-
utives. Therefore, healthcare organizations must ensure that their caregivers
and leaders represent the backgrounds of the communities they serve. In ad-
dition, healthcare executives must look for new insights, examples, and best
practices to help navigate their organizations through a diversity journey. A
key challenge in this journey is establishing a business case for having a di-
verse workforce.

The business case for diversity is unique for each organization. The cir-
cumstances, environment, and community demographics of one organization
cannot be generalized to another institution. However, some elements are
common in all organizations, which can be the basis of a diversity program:
the healthcare marketplace, employee skills and talent, and organizational ef-
fectiveness. These elements will drive the institution’s investment in and com-
mitment to diversity. An organization can achieve and sustain growth and
profitability by doing the following:

• Expand market share by adding or enhancing services that target diverse
populations.

• Link the marketplace with the workplace through recruiting, developing,
and retaining employees with diverse racial/ethnic backgrounds.

• Create and implement workplace policies and management practices that
maximize the talent and productivity of employees with diverse
backgrounds.

The facts are that all minority groups buy and consume healthcare serv-
ices, many of them are educated and trained to either provide healthcare serv-
ices or manage operations, and many of them currently work within the field
and understand its complexities. Hospitals and other healthcare organizations
cannot afford to miss such opportunities. They can seek, cultivate, and retain
minority talent to help them compete in today’s diverse healthcare environ-
ment. Failure to take advantage of these opportunities will mean the differ-
ence between being a provider and employer of choice and losing ground to
competitors.

Governance Impact

The organization’s board of governance can help in this regard. Members of
the board or trustees are the ultimate links to the communities served by a
healthcare organization. They know the makeup of the population the organ-
ization serves and seeks to target, and they have insights into their communi-
ties’ healthcare needs. Because board members are part of the community,
they have an interest in making sure that the organization that they represent
is not only providing inclusive services but is also being a fair and equitable

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employer and neighbor. With this perspective in mind, governance should
support a business strategy that promotes community goodwill, encourages
growth, considers present social and demographic transformations and hence
future needs, and emphasizes culturally competent and sensitive healthcare.
Most importantly, members of the board should also reflect the multicultural
mix of the surrounding communities.

Considering all of the challenges faced by any healthcare board, why
should it be concerned with diversity? One of the many reasons is to protect
the organization’s bottom line. The financial impact of problems stemming
from racial discrimination and discriminatory practices can be substantial.
Well-publicized cases of large organizations committing or turning their backs
on such practices provide evidence of the extent of cost consequences. For ex-
ample, in 2007, two Equal Employment Opportunity Commission lawsuits
were filed alleging racial and sexual discrimination. The first was filed in South
Florida claiming that a manager at two Nordstrom stores in Palm Beach
County harassed a Hispanic woman and other “similarly situated individuals”
based on these individuals’ national origin and race and that the company
failed to take prompt action (Puget Sound Business Journal 2007). The second
was a lawsuit against United HealthCare of Florida that accused a male execu-
tive of subjecting another male executive to repeated verbal sexual harassment
(EEOC. 2007). This latter case resulted in a $1.8 million settlement and an
order for United HealthCare to distribute a new antiharassment policy to all
of its employees (EEOC 2007). Another reason that the board should sup-
port diversity initiatives is to encourage and strengthen employee commit-
ment to the organization. Simply, a diverse workforce is an asset. It differen-
tiates an organization in the marketplace, giving it an edge against its
competitors in terms of inclusiveness, cultural sensitivity and competency, and
even progressive practice.

Board commitment to the principles of diversity may lead to shifts in
the corporate culture as well, allowing all stakeholders to contribute to the
overall success of the organization and its mission. Trustees should hold orga-
nizational leaders and managers accountable for setting and following high di-
versity standards. This practice will lead to an improved organization and to
healthy communities.

Legal Issues

The debate continues over whether having a diversity program is the right thing
to do or whether it enhances shareholder/stakeholder value. The answer is
both—not only is it the right thing to do, but it also adds value to the organiza-
tion. Educated, skilled, and experienced professionals and workers who are con-
sidered in the minority (including but are not limited to women, racial and eth-
nic minorities, and people with physical challenges) bring strategic and unique
perspectives into their roles, generate productive dialogue, and challenge the

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status quo. All of these are essential to the practices, products and services, and
operations of a healthcare organization. If these are not reasons enough to main-
tain a diverse workforce, various laws also prohibit employment discrimination.

The Civil Rights Act of 1964 was signed into law on July 2, 1964. This
legislation was intended to ensure that the financial resources of the federal
government would no longer subsidize racial discrimination (Smith 1999).
This law bans discrimination in any activities, such as training, employment,
or construction, that are funded by federal monies. Discrimination is also pro-
hibited in entities that contract with organizations that receive federal funds.
Every recipient of federal funds is required to provide written assurances that
nondiscrimination is practiced throughout the institution. Among the first
major tests of the Civil Rights Act was the decision of the U.S. Court of Ap-
peals for the Fourth Circuit on the case of Simkins v. Moses Cone Memorial
Hospital. The decision struck down the separate-but-equal provisions of the
Hill-Burton Act and gave the federal government the necessary power to en-
force the Civil Rights Act (Smith 1999).

The Civil Rights Act also protects individuals whose native language is
not English. The U.S. Department of Justice has issued the “National Origin
Discrimination Against Persons with Limited English Proficiency (LEP)
Guidance.” This guidance, intended for recipients of federal funds, prohibits
discrimination of people who have limited English-language proficiency. It re-
quires federally funded entities to ensure that people whose primary language
is not English can access and understand services, programs, and activities pro-
vided by these organizations. This mandate has made a serious impact in the
way healthcare organizations, especially those in areas with large numbers of
individuals who speak English as a second language (ESL), frame their serv-
ice offerings. The National Council on Interpreting in Health Care has put
together “The Terminology of Health Care Interpreting,” a glossary of terms
intended to help healthcare leaders in developing programs for ESL patients;
visit www.ncihc.org for more information on this glossary.

See Chapter 5 for a comprehensive discussion of the Civil Rights Act
and other laws that protect groups who are considered in the minority.

Diversity in Healthcare Leadership: Two Major Studies

Despite the demographic changes in the U.S. population, and hence in the
healthcare field, few minorities are present in the executive suite. Within the
last decades, two major studies were undertaken to understand the factors be-
hind minorities’ difficult climb on the healthcare management ladder. As the
findings of these studies indicate, although improvements are continually be-
ing made in terms of how workforce and leadership diversity is viewed and val-
ued in healthcare organizations, a lot of work is left to be done.

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Study 1: A Race/Ethnic Comparison of Career Attainments

in Healthcare Management

In 1992, the American College of Healthcare Executives (ACHE) and the
National Association of Health Services Executives (NAHSE) conducted a
study that compared the career attainment of Caucasian and African-American
healthcare executives. The study found that among executives with similar
training and experience, African Americans were in lower-level positions,
made less money, and had lower levels of job satisfaction (ACHE 2002). The
results of this study made way for the creation of the Institute for Diversity in
Health Management (IFD), the only organization committed exclusively to
promoting managerial diversity within the healthcare field.

In 1996, ACHE, with assistance and support from NAHSE, IFD, the
Association of Hispanic Healthcare Executives (AHHE), and the Executive
Leadership Development Program of the Indian Health Services (IHS), con-
ducted a follow-up survey using many of the items included in the first sur-
vey. This second survey, completed and published in 1997, revealed that 23
percent of the U.S. hospital workforce was made up of African Americans and
Hispanics. Unfortunately, less than 2 percent of these minority groups held
the positions of president, chief executive officer, and chief operating officer.

The third cross-sectional study, released in 2002, was conducted to de-
termine if the race/ethnic disparities in healthcare management careers had
narrowed since the 1997 release of the second survey and was based on the
observations and experiences of a similar pool of respondents. In planning this
study, leaders of ACHE, AHHE, IFD, and NAHSE invited the collaboration
of the Executive Leadership Development Program of the IHS so that the ca-
reer attainments of Native-American executives could also be assessed.

Following is a summary of the most important findings of the third
study (ACHE 2003):

• More white administrators than minority administrators worked in
hospital settings.

• White female administrators earned more than female minority
administrators. When controlling for education and experience,
compensation earned by white women remained higher than the
compensation for male and female members of minority groups.

• White male administrators earned more than male minority
administrators. When controlling for experience and education, the total
compensation of male African-American and Hispanic administrators was
approximately equal to that of their white counterparts.

• Minority administrators expressed lower levels of job satisfaction than
did white administrators. The items with which low satisfaction was
reported included the following:
1. Pay and fringe benefits were not proportionate to the minority

administrators’ contribution to their organization.

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2. The degree of respect and fair treatment that minority administrators
received from their leaders was inadequate.

3. The sanctions and treatment that minority administrators faced when
they made a mistake were more severe than their action called for.

• Fewer minority administrators than white administrators expressed that
their organizations had great personal meaning to them.

• More minority administrators than white administrators stated that
they experienced racial/ethnic discriminatory acts in the past five years,
such as not being hired or being evaluated with inappropriate
standards.

• Only about 15 percent of female minority administrators aspired to be
chief executive officers. More white male administrators had such
aspirations than male minority administrators.

• The majority of minority administrators endorsed efforts to increase the
percentage of racial/ethnic minorities in senior healthcare management
positions. Nearly half of their white counterparts were neutral or
opposed to such efforts.

Recommendations to address the disparities found between the white and mi-
nority groups are being developed. A fourth race/ethnic survey is expected to
be conducted in 2008.

Study 2: Advancing Diversity Leadership in Healthcare

In 1998, Witt/Kieffer, an executive search firm, conducted a national survey
of healthcare leaders (e.g., chief executive officers, presidents, human re-
sources executives) to determine the advances in and barriers to recruiting and
retaining women and minority leaders in the industry. The survey revealed di-
vergences in opinions between nonminority and minority respondents. Non-
minority respondents reported that minority leaders were hard to find, while
minority respondents claimed that these leaders were not looking either hard
enough or in the right places. Another significant difference in perspective was
on the issue of whether organizational or even individual resistance to minor-
ity leadership was part of the problem (Witt/Kieffer 2006).

In 2006, Witt/Kieffer conducted a follow-up survey that involved hu-
man resources executives and minority leaders in hospitals and health systems
nationwide. Seventy-one percent of respondents were nonminorities, and 29
percent were from minority groups. The project also included phone inter-
views with respondents who were willing to share additional thoughts regard-
ing diversity leadership (Witt/Kieffer 2006).

The following are the main findings of the 2006 study:

• Eighty-two percent of the nonminority respondents and 81 percent of
the minority group agreed or strongly agreed with the statement,
“Internal diversity programs support the organization’s overall
mission/vision.”

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• Seventy-nine percent of minority and 68 percent of nonminority
respondents agreed that “Internal diversity programs are strategic to
organizational success.”

• Virtually all respondents agreed that “Internal diversity programs
demonstrate the value of cultural differences in an organization.” By and
large, both groups also shared the belief that organizations commit to
diversity recruiting because they want to achieve “cultural competence”
organization-wide.

• Seventy-two percent of minority and 63 percent of nonminority
respondents agreed that “Internal diversity programs provide diversity
staffing that mirrors the diversity of the patient population.”

• Only 28 percent of nonminority respondents and 12 percent of the
minority group agreed that “Healthcare organizations have been
effective in closing the diversity leadership gap over the past five years.”

• Nearly 73 percent of nonminority respondents personally believed that
opportunities for diversity in leadership have improved over the past five
years. Only 34 percent of minorities shared that personal belief. Also, 67
percent of nonminorities agreed that “The availability of diversity
leadership positions in healthcare organizations has improved over the
past five years,” but only 30 percent of minority respondents agreed.

• Minority respondents remained unconvinced that they are “well
represented today in healthcare organization management teams.”

• Both respondent groups agreed that internal diversity programs drive
organizational success and cultural competence. However, respondents,
particularly minorities, expressed skepticism about whether hospitals and
healthcare systems commit to diversity recruiting because those
organizations believe diversity is good for business.

• Seventy-two percent of nonminorities and 53 percent of minorities
agreed that healthcare organizations are effective in diversity recruiting
because they have a genuine interest in it. Seventy-three percent of
nonminorities and about 50 percent of minorities believed healthcare
organizations are effective at diversity recruiting because they take their
responsibility to do so seriously.

• Respondents held widely divergent views on the most important barriers
to diversity recruitment, retention, and leadership development. The
only barrier for which general agreement was reached was the “lack of
commitment by top management.”

Diversity Management

According to the Institute for Diversity in Health Management (2007), man-
aging a diverse workforce involves the following elements:

• Employee perspective. Diversity management creates an environment
where every hospital or health system employee feels valued, appreciated

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and respected and who, in turn, talks about the organization within the
community with pride. Diversity management allows 100 percent of
employees, whatever their capabilities, to achieve 100 percent of their
potential 100 percent of the time.

• Patient focus. Diversity management creates an environment where
because all patients feel valued, they are highly satisfied and loyal.
Diversity management means understanding the cultural and ethnic
values within a community. As a result, community members choose the
organization, which increases market share.

• Inclusion. Diversity management means sending a message to minorities
that there are leaders within the organization to champion their medical
needs. If a minority patient knows the COO [chief operating officer]
shares his or her ethnicity, for example, then that patient likely assumes
his or her best interests will be served.

• Community perspective. Diversity management means bringing the
community into the organization, specifically at the governance level.
Putting prominent minority leaders on the hospital or health system
board forges a bond with the community, which in turn creates patient
comfort with and loyalty to the organization.

The Impact of Diversity on Care Delivery

According to the National Institutes of Health, “the diversity of the Ameri-
can population is one of the nation’s greatest assets; one of its greatest chal-
lenges is reducing the profound disparity in health status of America’s racial
and ethnic minorities” (Smedley and Stith 2002). The Institute of Medicine’s
landmark report in 2002, entitled Unequal Treatment, reveals the presence of
significant disparities in the way white and minority patients receive healthcare
services, especially in treatment for heart disease, cancer, and HIV (Smedley
and Stith 2002). Addressing such disparities in care, including the dispropor-
tionate recruitment and selection of a minority workforce, and ensuring cul-
tural competence of caregivers are interconnected. To minimize care dispari-
ties, institutions and providers have to develop cultural competence. To
develop cultural competence, a diverse group of providers, support staff, and
managers needs to be in place and diversity training and policies for all employ-
ees and caregivers have to be established. Simply, the lack of a culturally com-
petent healthcare workforce is a possible contributor to the disparities in care.

Having examined how a diverse physician community also benefits
healthcare, researchers Cohen, Gabriel, and Terrell (2002) posited at least
four practical reasons for attaining greater diversity: (1) it advances cultural
competency, (2) it increases access to high-quality care, (3) it strengthens the
medical research agenda, and (4) it ensures optimal management. These find-
ings are relevant and applicable to healthcare management and leadership as

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well. As stated by Cohen, Gabriel, and Terrell, “the first and perhaps most
compelling reason for increasing the proportion of medical students and other
prospective health care professionals who are drawn from underrepresented
minority groups: preparing a culturally competent health care workforce.”

Cultural competence may be defined as a set of complementary behav-
iors, practices, attitudes, and policies that enables a system, an agency, or in-
dividuals to effectively work and serve pluralistic, multiethnic, and linguisti-
cally diverse communities. The demographic makeup of this country will
continue to change in the years ahead, and culturally competent and sensi-
tive care is and will be expected from current and future healthcare profes-
sionals. To effectively provide such care, leaders, clinical staff, and all the em-
ployees in between must have a firm understanding of how and why belief
systems, personal biases, ethnic origins, family structures, and other cultur-
ally determined factors influence the manner in which patients experience ill-
ness, adhere to medical advice, and respond to treatment. Such factors ulti-
mately affect the outcomes of care. Physicians and other healthcare
professionals who are not mindful of the potential impact of language barri-
ers, religious taboos, unconventional views of illness and disease, or alterna-
tive remedies are not only unlikely to satisfy their patients but, more impor-
tant, are also unlikely to provide their patients with optimally effective care
(Cohen, Gabriel, and Terrell 2002).

A study finds that although African-American physicians make up only
4 percent of the total physician workforce in the United States, they care for
more than 20 percent of African-American patients in the United States
(Saha et al. 2000). The study suggests that African Americans prefer to get
care from black physicians, and a contributing factor to this may be that many
African-American physicians locate their practices in predominantly black
communities and are, therefore, more geographically accessible to African-
American healthcare consumers. If the hypothesis is true that minority con-
sumers prefer care from physicians of their own race simply because of geo-
graphic accessibility, then organizational policies aimed at better serving the
needs of minority communities need not consider physician race and ethnic-
ity in the equation. If, however, minority patients have this preference be-
cause of a shared language or culture, for example, then increasing the sup-
ply of underrepresented minority physicians is justifiable and necessary.

An understanding of the factors that influence the disparities in health-
care is essential in developing effective strategies to minimize the problem.
Figure 6.1 presents two sets of factors: patient-related factors and health-system-
related factors. Patient-related factors are cultural characteristics of patients
that prevent them from getting fair and adequate treatment in an organiza-
tion that is not culturally competent or sensitive. Health-system-related fac-
tors are organizational dynamics (e.g., employee attributes and biases) that in-
fluence the methods used to treat patients.

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Components of an Effective Diversity Program

Healthcare leaders can establish a diversity program that will lead to a more
diverse and inclusive organization (see Figure 6.2). Some actions that leaders
can take toward this goal include, but are not limited to, the following:

• Ensure that senior management and the governing board are committed
to the development and implementation of a diversity program.

• Broaden the definition of diversity to include factors beyond race and
ethnicity.

• Recognize the business case for bringing in diversity at the leadership level.
• Tie diversity goals to business objectives.
• Hold recruiting events that target racial and ethnic groups, women,

people with disabilities, older but capable workers, and others who are
considered minorities.

• Encourage senior executives to mentor minorities.
• Develop employee programs that emphasize and celebrate diversity and

inclusivity.

157C h a p t e r 6 : W o r k f o r c e D i v e r s i t y

FIGURE 6.1
Factors that
Influence
Disparities in
Healthcare

Patient-Related Factors Health-System-Related Factors

Socioeconomic Cultural competence
Low income and education Insufficient knowledge of and sensitivity

to cultural differences

Health education Language
Lack of knowledge of health Inability to communicate sufficiently
symptoms, conditions, and with patients and families whose native
possible treatments language is not English

Health behavior Discrimination
Patient willingness and ability to Healthcare system and provider
seek care, adhere to treatment bias and stereotyping
protocols, and trust and work
with healthcare providers Workforce diversity

Poor racial and ethnic match between
healthcare professionals and the
patients they serve

Payment
Insufficient reimbursement for treating
Medicare, Medicaid, and uninsured
patients

SOURCE: Smedley and Stith (2002)

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The business imperatives and organizational necessities for aggressively
creating a diversity program include, but are not limited to, the following:

1. Reflection of the service population. The healthcare organization’s
caregivers and support staff should mirror the diversity of the population
that the institution serves. Toward this end, the organization should
attract and take advantage of the talents, skills, and growth potential of
minority professionals within the community.

2. Workforce utilization. Minority employees have a lot to contribute to the
organization. Leaders should recognize this fact and should be open to,
sensitive to, knowledgeable about, and understanding of the cultures,
mind-set, and practices of the organization’s diverse workforce. Doing
so will not only enhance staff productivity and overall performance but
will also boost staff morale.

3. Work–life quality and balance. Leaders should recognize that work and
personal activities are interrelated, not separate preoccupations. Both are
performed on the basis of necessity, practicality, efficiency, and spontaneity.

4. Recruitment and retention. Attracting and retaining a diverse workforce
have a lot to do with the state of the workplace. Leaders should create
an environment in which minorities feel included, professionally
developed, and safe.

5. Bridging generations. Generational differences in expectations,
education, and values exist between younger and older staff. Such gaps
should be acknowledged, and attention should be paid to the physical,
mental, and emotional well-being of all caregivers and staff at all ages
regardless of backgrounds.

6. Cultural competence. This competence is an in-depth understanding of
and sensitivity to the values and viewpoints of minority staff, patients,

158 H u m a n R e s o u r c e s i n H e a l t h c a r e

FIGURE 6.2
How to

Create an
Inclusive
Culture

1. Study the culture, climate (i.e., what employees are thinking, feeling, or
hearing about diversity issues), and demographics of the organization.

2. Select the diversity issues that allow the greatest breakthrough.

3. Create a diversity strategic plan.

4. Secure leadership’s financial support for the plan.

5. Establish leadership and management accountabilities for the plan.

6. Implement the plan.

7. Provide continual training related to the new skills and competencies
necessary to successfully achieve the plan goals.

8. Conduct a follow-up survey one or one-and-one-half years after
implementing the plan.

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and other customers. Leaders should master the skills necessary to work
with and serve these groups and should provide training in this matter to
all employees to ensure provision of culturally competent care.

7. Organization-wide respect. Leaders should create an environment in
which the differences in title, role, position, and department are valued
and respected but not held too lofty above everything else. Each
employee, regardless of his or her level within the organization, should
be viewed as integral to the overall success of the team.

Summary

Healthcare organizations in the United States are beginning to make a com-
mitment to embracing and fostering workforce diversity. This cultural change
means adopting new values in terms of being inclusive and attracting a diverse
workforce. The business case for diversity is unique for each organization, as
circumstances, the environment, and community demographics of one organ-
ization vary from those of another. However, elements (such as the market-
place and organizational effectiveness) that are common in all organizations
can be the basis of a diversity program.

One of the many reasons that senior management and the governing
board should pay attention to diversity issues is to protect the organization’s
bottom line. The financial costs of problems that stem from racial discrimina-
tion and discriminatory practices can be substantial. Studies have found dis-
parities in two areas: (1) minority healthcare administrators ascend in rank
more slowly within their organizations than do their white counterparts, and
(2) patients who belong to minority groups receive different medical treat-
ments than patients who are white. Such disparities may be bridged with the
development of a diversity program.

159C h a p t e r 6 : W o r k f o r c e D i v e r s i t y

Discussion Questions

1. While this chapter discussed the many
benefits of diversity, an alternative view
suggests that no empirical evidence
exists that a diverse workforce has a
positive effect on organizational
performance, employee commitment,
and employee satisfaction. In fact,
anecdotal evidence indicates that
diversity can negatively affect business

performance because of the possibility
for internal conflict, dissension, and
turnover. What is your reaction to this
perspective in light of the content of this
chapter? Do these arguments have
merit? Why or why not?

2. Respond to this statement: Diverse
leadership is a competitive advantage.
What is the most compelling business

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argument for or against diverse
leadership teams?

3. What are the legal, moral, and ethical
consequences that prohibit hospitals from
turning away patients based on race?

4. Why are there are no such consequences
to patients who demand doctors, nurses,
or workers of a specific race to administer
their healthcare?

5. Can hospitals that adhere to gender- or
race-based patient demands face
discrimination lawsuits from their
employees?

160 H u m a n R e s o u r c e s i n H e a l t h c a r e

6. When an employer denies an employee
(or a group of employees) his or her
full employment opportunity based on
the racial bias of customers, is the
employer violating the employee’s civil
rights?

7. Does workforce diversity enhance
organizational performance? Explain
your answer.

8. Can an internal diversity program
support an organization’s overall
mission and vision? How?

Experiential Exercise

Note: This case was adapted from Davis, R.
A. 2003. “No African Americans Allowed:

White Patient’s Racism Rules at Pennsylvania
Hospital.” DiversityInc.com, October 9.

Abington Memorial Hos-
pital is a 508-bed hospital

located in Abington, Pennsylvania. It serv-
ices patients from Philadelphia and the sur-
rounding suburbs of Bucks and Mont-
gomery counties. The hospital’s mission “is
to provide patients with the highest quality
care possible, regardless of the health-care
professionals’ race. . . .”

Supervisors at the hospital told
African-American healthcare professionals, as
well as food-service and housekeeping staff,
not to enter a certain white patient’s room or
interact with the family. This caused an out-
rage among the African-American staff.
Abington administrators said they broke hos-
pital policy to avoid a potentially “volatile sit-
uation” by adhering to the request of the pa-

tient’s husband: Only white employees could
enter his wife’s room on the maternity ward.
“We were wrong,” said Meg McGoldrick, a
vice president at Abington Memorial Hospi-
tal. “We should have followed our policy.
The whole incident has greatly upset many of
our employees who perceived that we were
acquiescing to the family’s wishes.’’ Despite
the hospital’s policy that states, “care will be
provided on a nondiscriminatory basis,” the
administrators’ actions seemed as though pa-
tients were allowed to discriminate. Catholic
Health Care West’s medical ethicist, Carol
Bayley, said that Abington failed in its respon-
sibility to its employees and the community
to accommodate a patient’s racial preference:
“This was a fundamental disrespect of these
professionals’ skills and their fundamental

Case

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References

American College of Healthcare Executives (ACHE). 2002. A Race/Ethnic Comparison of
Career Attainments in Healthcare Management. Chicago: ACHE.

———. 2003. “Increasing and Sustaining Racial/Ethnic Diversity in Healthcare Manage-
ment.” Healthcare Executive 18 (6): 60–61.

Cohen, J., B. Gabriel, and C. Terrell. 2002. “The Case for Diversity in the Healthcare
Workforce.” Health Affairs 21 (5): 90–102.

Dreachslin, J. L. 1996. Diversity Leadership. Chicago: Health Administration Press.
Equal Employment Opportunity Commission (EEOC). 2007. “United Healthcare of

Florida to Pay $1.8 Million for Same-Sex Harassment and Retaliation.” [Online in-
formation; retrieved 2/4/08.] www.eeoc.gov/press/10-1-07.html.

Guillory, W. 2003. “The Business of Diversity: The Case for Action.” Health & Social Work
28 (1): 3–7.

161C h a p t e r 6 : W o r k f o r c e D i v e r s i t y

dignities . . . a hospital needs to stand against
this undercurrent of racism in our society.”

The Philadelphia office of the Anti-
Defamation League (ADL) said that pro-
hibiting African-American employees from
carrying out the full scope of their duties is
reprehensible. “I don’t see why and how a
hospital could justify accommodating a re-
quest that the professionals attending to a
patient be of a particular background,” said
Barry Morrison, director of the Philadelphia
chapter of the ADL; he added, “Certainly,
it’s demoralizing for the people who work
there.” The American Hospital Association
(AHA), the largest hospital association in the
United States, acknowledged that no hard-
and-fast industry guidelines exist for hospi-
tals to follow when a patient or a family
member makes a racially biased request.
AHA does not offer hospitals a suggestion
on how to address this situation. “It’s subjec-
tive,” said Rick Wade, senior vice president at
the AHA. “I’m sure the person who made
the decision at Abington thought they were
doing the right thing.” McGoldrick said su-
pervisors at Abington were acting with good

intentions and sought to deflect any con-
frontation between its African-American staff
and the Caucasian family. No incident was
reported during the patient’s stay.

Since then, Abington’s president,
Richard L. Jones, sent a letter to all its employ-
ees and volunteers apologizing for the situa-
tion, which he termed “morally reprehensi-
ble.” In addition to creating a diversity task
force at the 508-bed hospital, Abington has
hired consultants and revised its antidiscrimina-
tion policy. The AHA bestowed on Abington
the Quest for Quality Award for raising aware-
ness of the need for an organizational commit-
ment to patient safety and quality. Wade said
hospitals are constantly evaluating how to pro-
vide the best treatment for their patients, while
protecting and maintaining the dignity of their
employees. He said that a hospital’s constant
patient turnover sometimes subjected workers
to society’s underbelly. “Perhaps Abington
could have been more protective of their em-
ployees,” Wade said. “Patients come and go,
[but] the most important thing at a hospital is
the work-force,” he said.

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Smedley, B. D., and A. Y. Stith. 2002. Unequal Treatment, Confronting Racial and Eth-
nic Disparities in Health Care. Washington, DC: Institute of Medicine, National
Academies Press.

Smith, D. B. 1999. Health Care Divided: Race and Healing a Nation. Ann Arbor, MI:
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HEALTHCARE PROFESSIONALS

Kenneth R. White, PhD, FACHE; Dolores G. Clement,

DrPH, FACHE; and Kristie G. Stover, PhD

CHAPTER

4

71

Learning Objectives

After completing this chapter, the reader should be able to

• understand the role of healthcare professionals in the human resources
management function of healthcare organizations;

• define the elements of a profession, with an understanding of the
theoretical underpinnings of the healthcare professions in particular;

• describe the healthcare professions, which include the majority of
healthcare workers, and the required educational levels, scopes of
practice, and licensure issues for each;

• relate knowledge of the healthcare professions to selected human
resources management issues and systems development; and

• comprehend the changing nature of the existing and emerging
healthcare professions in the healthcare workforce, particularly the
impact of managed care.

Introduction

Healthcare professionals are central to the delivery of high-quality healthcare
services. Extensive training, education, and skills are essential in meeting the
needs and demands of the population for safe, competent healthcare. These
specialized techniques and skills that healthcare professionals acquired through
systematic programs of intellectual study are the basis for socialization into
their profession. Additionally, the healthcare industry is labor intensive and is
distinguished from other service industries by the number of licensed and reg-
istered personnel that it employs and the variety of healthcare fields that it pro-
duces. These healthcare fields have emerged as a result of the specialization of
medicine, development of public health, increased emphasis on health promo-
tion and prevention, and technological advances and growth.

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Because of this division of labor within medical and health services de-
livery, many tasks that were once the responsibility of medical providers have
been delegated to other healthcare personnel. Such delegation of duties raises
important questions for the industry: Should healthcare providers other than
those specifically trained to practice medicine be considered professionals in
their own right? To what extent should their scope of practice be extended?

In this chapter, we respond to the aforementioned questions by defin-
ing key terms, describing the healthcare professions and labor force, explain-
ing the role of human resources in healthcare, and discussing key human re-
sources issues that affect the delivery of healthcare.

Professionalization

Although the terms “occupation” and “profession” often are used inter-
changeably, they can be differentiated.

An occupation enables workers to provide services, but it does not re-
quire skill specialization. An occupation is the principal activity that supports
one’s livelihood. However, it is different from a profession in several ways. An
occupation typically does not require higher skill specialization. An individual
in an occupation is usually supervised, adheres to a defined work schedule, and
earns an hourly wage rate. An individual in an occupation may be trained for
a specific job or function and, as a result, is less able to move from one organ-
ization to another.

A profession requires specialized knowledge and training that enable
professionals to gain more authority and responsibility and to provide service
that adheres to a code of ethics. A professional usually has more autonomy in
determining the content of the service he or she provides and in monitoring
the workload needed to do so. A professional generally earns a salary, requires
higher education, and works with more independence and mobility than do
nonprofessionals.

The distinction between an occupation and a profession is important
because the evolving process of healthcare delivery requires professionals who
are empowered to make decisions in the absence of direct supervision. The
proliferation of knowledge and the skills needed in the prevention, diagnosis,
and treatment of disease has required increasing levels of education. Under-
graduate- and/or graduate-level degrees are now required for entry into vir-
tually every professional field. Some professions, such as pharmacy and phys-
ical therapy, are moving toward professional doctorates (i.e., PharmD and
DPT, respectively) for practice.

A countervailing force against the increasing educational requirements
of the healthcare professions is ongoing change in the mechanisms for deliv-
ery and payment of services. With consolidation of the healthcare system and

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the rise of managed care, along with its demands for efficiency, fewer financial
resources are available. As a result, healthcare organizations are pressured to
replace highly trained—and, therefore, more expensive—healthcare profes-
sionals with unlicensed support personnel. Fewer professionals are being
asked to do more, and those with advanced degrees are required to supervise
more assistants who are functionally trained for specified organizational roles.

Functional training produces personnel who can perform tasks but
who may not know the theory behind the practice; understanding theory is
essential to becoming fully skilled and able to make complex management and
patient care decisions. Conversely, knowing the theory without having the ex-
perience also makes competent practice difficult. When educating potential
healthcare professionals, on-the-job training or a period of apprenticeship is
needed, particularly in addition to basic coursework. Dreyfus and Dreyfus
(1996) contend that both theoretical knowledge and practiced response are
needed in the acquisition of skill in a profession. These authors lay out five
stages of abilities that an individual passes as he or she develops a skill:

1. Novice. At this stage, the novice learns tasks and skills that enable him or
her to determine actions based on recognized situations. Rules and
guidelines direct the novice’s energy and action at this stage.

2. Advanced beginner. At this stage, the advanced beginner has gained
enough experience and knowledge that certain behaviors become
automatic, and he or she can begin to learn when tasks should be
addressed.

3. Competent. At this stage, the competent individual has mastered the
practiced response of definable tasks and processes and has acquired the
ability to deal with the unexpected events that may not conform to
plans.

4. Proficient. At this stage, the proficient individual has developed the
ability to discern a situation, intuitively assess it, plan what needs to be
done, decide on an action, and perform the action more effortlessly than
possible in the earlier stages.

5. Expert. At this stage, the expert can accomplish the goals without
realizing that rules are being followed because the skill and knowledge
required to reach the goal have become second nature.

Theoretical understanding is melded with practice in each progressive
stage. Functional training can help an individual progress through the first three
stages and can provide the individual with calculative rationality or inferential rea-
soning ability to be able to apply and improve theories and rules learned. For skill
development at the proficient and expert levels, deliberative rationality or ability
to challenge and improve theories and rules learned is required. Healthcare pro-
fessionals need to become experts in fields where self-direction, autonomy, and
decision making for patient care may be required (Dreyfus and Dreyfus 1996).

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Healthcare Professionals

The healthcare industry is the largest and most powerful industry in the
United States. It constitutes more than 6.5 percent of the country’s total la-
bor force and nearly 15 percent of the gross domestic product. Healthcare
professionals include physicians, nurses, dentists, pharmacists, optometrists,
psychologists, nonphysician practitioners such as physician assistants and
nurse practitioners, healthcare administrators, and allied health professionals.
The allied health professions are a huge group that consists of therapists,
medical and radiologic technologists, social workers, health educators, and
other ancillary personnel. Healthcare professionals are represented by profes-
sional associations. Table 4.1 provides a sample of professional associations
in healthcare.

Healthcare professionals work in a variety of settings, including hospi-
tals; ambulatory care centers; managed care organizations; long-term-care or-
ganizations; mental health organizations; pharmaceutical companies; commu-
nity health centers; physician offices; laboratories; research institutions; and
schools of medicine, nursing, and allied health professions. According to the
Bureau of Labor Statistics (BLS 2007), healthcare professionals are employed
by the following:

• hospitals (34.5 percent),
• nursing and personal and residential care facilities (23.0 percent),
• physician offices and clinics (17.1 percent),
• home health care services (6.9 percent),
• dentist offices and clinics (6.3 percent), and
• other health service sites (12.2 percent).

The U.S. Department of Labor recognizes about 400 different job ti-
tles in the healthcare sector; however, many of these job titles are not included
in our definition of healthcare professionals. For example, almost one-third of
those employed in the healthcare sector probably belong in the support staff
category—that is, employees who are part of the patient care team or involved
in delivering health services. These approximately 2.2 million nursing aides,
home health aides, and personal attendants are critical to the delivery of
healthcare services (BLS 2007).

The primary reasons for the increased supply and demand for health-
care professionals include the following interrelated forces:

• technological growth,
• specialization,
• changes in third-party coverage,
• the aging of the population, and
• the proliferation of new and diverse healthcare delivery settings.

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75C h a p t e r 4 : H e a l t h c a r e P r o f e s s i o n a l s

Organization Target Audience Website

Health Professions

Pew Health Professions Future health http://futurehealth
Commission professions .ucsf.edu

American College of Future healthcare www.healthmanage
Healthcare Executives: managers and mentcareers.org
Health Management Careers administrators

Accrediting Organizations

Accreditation Association for Ambulatory healthcare www.aaahc
Ambulatory Health Care facilities .org

Accreditation Council for Graduate medical www.acgme
Graduate Medical Education education programs .org

American Osteopathic Osteopathic hospitals www.osteopathic
Association and health systems .org

Commission on Accreditation Rehabilitation facilities www.carf.org
of Rehabilitation Facilities

The Joint Commission Hospitals and health www.joint
systems commission.org

National Committee for Health plans http://web
Quality Assurance .ncqa.org

American Association of Blood banks www.aabb.org
Blood Banks

American College of Surgeons www.facs.org
Surgeons

American College of Cancer programs www.facs.org/
Surgeons: Commission cancer
on Cancer

College of American Clinical laboratories www.cap.org
Pathologists

Professional Associations

American College of Healthcare Healthcare executives www.ache.org
Executives

National Association of African-American www.nahse.org
Health Services Executives healthcare executives

Institute for Diversity in Health Healthcare managers, www.diversity
Management students, organizations, connection.org

diversity programs

TABLE 4.1
Resource Guide
for the
Healthcare
Professional

(Continued)

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76 H u m a n R e s o u r c e s i n H e a l t h c a r e

Organization Target Audience Website

Medical Group Management Physician practice www.mgma.com
Association managers and

executives

American Hospital Association: Healthcare human www.hrleader.org
American Society for resources
Healthcare Human Resources professionals
Administration

American College of Physician Physician executives www.acpe.org
Executives

American College of Health Long-term-care www.achca.org
Care Administrators administrators

Association for Healthcare Medical www.ahdionline.org
Documentation Integrity transcriptionists

American Association of Nurse anesthetists www.aana.com
Nurse Anesthetists

American Association for Respiratory therapists www.aarc.org
Respiratory Care

American Health Information Medical records www.ahima.org
Management Association and information

management
professionals

American Medical Technologists Medical technologists www.amt1.com

American Nurses Association Registered nurses www.ana.org

American Association for Homecare www.aahomecare
Homecare administrators .org

American Occupational Occupational www.aota.org
Therapy Association, Inc. therapists

American Organization of Nurse executives www.aone.org
Nurse Executives

National League for Nursing Nurse faculty and www.nln.org
educators

American Physical Therapy Physical therapists www.apta.org
Association

American Society for Clinical Pathologists and www.ascp.org
Pathology laboratory

professionals

American Society of Health- Health system www.ashp.org
System Pharmacists pharmacists

TABLE 4.1
Continued

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Organization Target Audience Website

American Society of Radiologic Radiologic www.asrt.org
Technologists technologists

American Speech-Language- Speech-language www.asha.org
Hearing Association pathologists;

audiologists; and
speech, language, and
hearing scientists

Healthcare Financial Controllers, chief www.hfma.org
Management Association financial officers,

and accountants

Healthcare Information and Health information www.himss.org
Management Systems Society and technology

managers

National Cancer Registrars Cancer registry www.ncra-usa.org
Association professionals

Trade Associations

American Hospital Association Hospitals, health www.aha.org
systems, and personal
membership groups

Federation of American Investor-owned www.fah.org
Hospitals hospitals and health

systems

Association of American Teaching hospitals www.aamc.org/
Medical Colleges: Council of and health systems members/coth
Teaching Hospitals and
Health Systems

Catholic Health Association Catholic hospitals www.chausa.org
of the United States and health systems

America’s Health Insurance Health insurers www.ahip.org
Plans

77C h a p t e r 4 : H e a l t h c a r e P r o f e s s i o n a l s

TABLE 4.1
Continued

This chapter focuses primarily on nurses, pharmacists, selected allied
health professionals, and healthcare administrators.

Nurses

The art of caring, combined with the science of healthcare, is the essence of
nursing. Nurses focus not only on a particular health problem but also on
the whole patient and his or her response to treatment. Nurses work in many

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different areas, but the common thread of nursing is the nursing process,
which has five steps (ANA 2008):

1. Assessment. This involves collecting and analyzing physical,
psychological, and sociocultural data about a patient.

2. Diagnosis. This entails making a judgment on the cause, condition, and
path of the illness.

3. Planning. This revolves around creating a care plan that sets specific
treatment goals.

4. Implementation. This includes supervising or carrying out the actual
treatment plan.

5. Evaluation. This focuses on continuous assessment of the plan.

Nurses also serve as patient advocates, multidisciplinary team members,
managers, executives, researchers, and entrepreneurs.

Nurses make up the largest group of licensed healthcare professionals
in the United States. According to the “National Sample Survey of Registered
Nurses (NSSRN),” the United States has 2.9 million registered nurses (RNs),
of whom more than 1.8 million (83.2 percent) are employed in healthcare or-
ganizations (HRSA 2006a). Approximately 56 percent of employed RNs, or
1.6 million, work in hospitals, while 15 percent, or 435,000, work in commu-
nity or public health settings. Complementing this workforce are 749,000 li-
censed practical nurses, or licensed vocational nurses as they are known in
some states (BLS 2006).

According to the demographic profiles from the NSSRN (HRSA
2006a), most nurses are women. In 2004, the average age of a nurse was 46.8
years old, nearly two years older than in 1997, when the average age was 44.5
years. The aging of the workforce is also reflected in the demographics of
nurses: The RN population under 30 years old dropped, from 25 percent in
1980 to 8 percent in 2004. Meanwhile, the percentage of nurses older than
54 years increased to 25.2 percent in 2004, compared to 20.3 percent in 2000
and 16.9 percent in 1980. Only 5.8 percent of RNs are men, and only 11 per-
cent of RNs come from racial/ethnic minority backgrounds.

All U.S. states require nurses to be licensed to practice. The licensure require-
ments include graduation from an approved nursing program and successful
completion of a national examination. Educational preparation distinguishes
the two levels of nurses.

RNs must complete an associate’s degree in nursing (ADN), a diploma
program, or a baccalaureate degree in nursing (BSN) to qualify for the licen-
sure examination. ADN programs generally take two years to complete and
are offered by community and junior colleges, and hospital-based diploma
programs can be completed in about three years. The fastest growing avenue
for nursing education is the baccalaureate preparation, which typically can be

78 H u m a n R e s o u r c e s i n H e a l t h c a r e

Registered
Nurses and

Licensed
Practical

Nurses

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completed in four years and is offered by colleges and universities. Licensed
practical nurses (LPNs), on the other hand, must complete a state-approved
program in practical nursing and must achieve a passing score on a national
examination. Each state maintains regulations and practice acts that delineate
the scope of nursing practice for RNs and LPNs.

Among employed RNs, about 34 percent hold associate’s degrees,
20 percent have hospital-based program diplomas, and 34 percent possess
BSN degrees. In 2004, 13 percent of nurses reported having a master’s de-
gree or a doctoral degree (HRSA 2006a). In addition to licensure and educa-
tional achievements, some nurses obtain certification in specialty areas such as
critical care, infection control, emergency nursing, surgical nursing, and ob-
stetric nursing. The nursing field comprises many specialties and subspecial-
ties; certification in these areas requires specialty education, practical experi-
ence, and successful completion of a national examination. Some nurses
obtain certification in these specialty areas because certification helps them
maintain their professional associations. To remain certified, continued em-
ployment, continuing education units, or reexamination may be required.

An advanced practice nurse (APN) is a nurse with particular skills and creden-
tials, which typically include basic nursing education; basic licensure; a grad-
uate degree in nursing; experience in a specialized area; professional certifica-
tion from a national certifying body; and, if required in some states, APN
licensure (National Council of State Boards of Nursing 2006). The APN spe-
cializes as a nurse practitioner, certified nurse midwife, certified registered
nurse anesthetist, or clinical nurse specialist.

The APN role is defined by seven core competencies or skillful per-
formance areas. The first core competency of direct clinical practice is central
to and informs all of the other areas, as follows (Hamric 2005):

• Direct clinical practice (central)
• Expert guidance and coaching of patients, families, and other care providers
• Consultation
• Research skills, including use and implementation of evidence-based

practice, evaluation, and conduct
• Clinical and professional leadership, which includes competence as a

change agent
• Collaboration
• Ethical decision-making skills

Additional core competencies may be needed in each specialty area that
an APN pursues. The largest number of APNs is made up of nurse practition-
ers (NPs), who may further specialize in acute care or community settings or
for particular client groups such as adults, children, women, or psychiatric/
mental health populations.

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Advanced
Practice
Nurses

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Each state maintains its own laws and regulations regarding recogni-
tion of an APN, but the general requirements in all states include licensure as
an RN and successful completion of a national specialty examination. Some
states permit certain categories of APNs to write prescriptions for certain
classes of drugs. This prescriptive authority varies from one state to another
and may be regulated by boards of medicine, nursing, pharmacy, or allied
health. Some states require physician supervision of APN practices, although
some managed care plans now include APNs on their lists of primary care
providers.

Certified nurse midwives (CNMs) specialize in low-risk obstetric care, includ-
ing all aspects of the prenatal, labor and delivery, and postnatal processes. Cer-
tified registered nurse anesthetists (CRNAs) complete additional education to
specialize in the administration of various types of anesthesia and analgesia to
patients and clients. Often, nurse anesthetists work collaboratively with sur-
geons and anesthesiologists as part of the perioperative care team. Clinical
nurse specialists (CNSs) hold master’s degrees, have successfully completed a
specialty certification examination, and are generally employed by hospitals as
nursing “experts’’ in particular specialties. The scope of the CNS is not as
broad as that of the NP; CNSs work with a specialty population under a some-
what circumscribed set of conditions, and the management authority of pa-
tients still rests with physicians. In contrast, NPs have developed an au-
tonomous role in which their collaboration is encouraged, and they generally
have the legal authority to implement management actions.

Pharmacists

In the foreseeable future, the pharmacy profession will continue to undergo
extensive change. Until the 1970s, pharmacists performed the traditional role
of preparing drug products and filling prescriptions. In the 1980s, however,
pharmacists expanded that role. Pharmacists now act as an expert for clients
and patients on the effects of specific drugs, drug interactions, and generic
drug substitutions for brand-name drugs.

To be eligible for licensure, pharmacists must graduate from an accred-
ited bachelor-degree program in pharmacy, successfully complete a state
board examination, and obtain practical experience or complete a supervised
internship. After passing a national examination, a registered pharmacist
(RPh) is permitted to carry out the scope of practice outlined by state regula-
tions. The trend in pharmacy has been to broaden education to include the
terminal degree Doctor of Pharmacy (PharmD). Many pharmacy schools of-
fer this program for those interested in research careers, teaching, higher ad-
ministrative responsibility, or being part of the patient care team. This educa-
tional preparation also requires successful completion of a state board
examination and other practical clinical experience, as outlined by state laws.

80 H u m a n R e s o u r c e s i n H e a l t h c a r e

APN
Specialization

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Allied Health Professionals

The term “allied health professionals” is generally not well understood be-
cause of its ambiguous definition (O’Neil and Hare 1990) and a lack of con-
sensus about what such a role constitutes. In general, allied health profession-
als complement the work of physicians and other healthcare providers,
although one may also be a provider. The U.S. Public Health Service defines
an allied health professional as follows (Health Professions Education Exten-
sion Amendments of 1992, Section 701 PHS Act):

. . . a health professional (other than a registered nurse or a physician as-
sistant) who has received a certificate, an associate’s degree, a bachelor’s
degree, a master’s degree, a doctoral degree, or post-baccalaureate train-
ing in a science related to health care; who shares in the responsibility for
the delivery of health care services or related services, including (1) serv-
ices relating to the identification, evaluation and prevention of disease and
disorders, (2) dietary and nutrition services, (3) health promotion serv-
ices, (4) rehabilitation services, or (5) health systems management serv-
ices; and who has not received a degree of doctor of medicine, a degree of
doctor of osteopathy, a degree of doctor of veterinary medicine or equiv-
alent degree, a degree of doctor of optometry or equivalent degree, a de-
gree of doctor of podiatric medicine or equivalent degree, a degree of
bachelor science in pharmacy or equivalent degree, a graduate degree in
public health or equivalent degree, a degree of doctor of chiropractic or
equivalent degree, a graduate degree in health administration or equiva-
lent degree, a degree of doctor of clinical psychology or equivalent degree,
or a degree in social work or equivalent degree.

A debate on the exclusiveness and inclusiveness of this definition con-
tinues. Some healthcare observers consider nursing, public health, and social
work to fall under the umbrella of allied health, but these professions are of-
ten categorized as separate groups. Figure 4.1 lists the major categories that
compose the allied health profession and the job titles and positions that nor-
mally fall under each category.

According to the “2006 National Occupational and Wage Estimates
for Healthcare Personnel,” the allied health professions constitute 45.5 per-
cent of the healthcare workforce in the United States (BLS 2007). This num-
ber excludes physicians, nurses, dentists, pharmacists, veterinarians, chiroprac-
tors, and podiatrists. The allied health profession is the most heterogeneous
of the personnel groupings in healthcare.

The National Commission on Allied Health (1995) broadly divided
allied health professionals into two categories of personnel: (1) therapists/
technologists and (2) technicians/assistants. Some of the job titles presented
in Figure 4.1 may not fit into these two categories. In general, the therapist/
technologist category represents those with higher-level professional training

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82 H u m a n R e s o u r c e s i n H e a l t h c a r e

Behavioral Health Services

• Substance abuse counselor • Community health worker
• Home health aide • Mental health assistant
• Mental health aide

Clinical Laboratory Sciences

• Laboratory associate • Laboratory microbiologist
• Laboratory technician • Chemist (biochemist)

• Microbiologist
• Associate laboratory microbiologist

Dental Services

• Dental assistant • Dental hygienist
• Dental laboratory technologist

Dietetic Services

• Dietitian • Assistant director of food service
• Dietary assistant • Associate supervising dietitian

Emergency Medical Services

• Ambulance technician • Emergency medical technician

Health Information Management Services

• Director of medical records • Senior analyst of medical records
• Assistant director of medical records • Health information manager
• Medical record specialist • Data analyst

• Coder

Medical and Surgical Services

• Electroencephalograph technician • Medical equipment specialist
• Electroencephalograph technologist • Electrocardiograph technician
• Operating room technician • Dialysis technologist
• Biomedical equipment technician • Surgical assistant
• Biomedical engineer • Ambulatory care technician
• Cardiovascular technologist

Occupational Therapy

• Occupational therapist • Occupational therapy aide
• Occupational therapy assistant

Ophthalmology
• Ophthalmic technician • Optician
• Optometric aide

FIGURE 4.1
Major

Categories of
the Allied

Health
Profession and

Professional
Titles

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83C h a p t e r 4 : H e a l t h c a r e P r o f e s s i o n a l s

Physical Therapy

• Physical therapist • Physical therapy assistant

Radiological Services
• Nuclear medicine technician • Nuclear medicine technologist
• Radiation technician • Diagnostic medical sonographer
• Ultrasound technician • Radiologic (medical) technologist
• Medical radiation dosimetrist

Rehabilitation Services
• Art therapist • Music therapist
• Exercise physiologist • Dance therapist
• Recreational therapist • Rehabilitation counselor
• Recreation therapy assistant • Rehabilitation technician
• Addiction counselor • Sign-language interpreter
• Addiction specialist
• Psychiatric social health technician

Orthotics/Prosthetics

• Orthopedic assistant

Respiratory Therapy Services

• Respiratory therapist • Respiratory therapy technician
• Respiratory therapy assistant

Speech-Language Pathology/Audiology Services

• Audiology clinician • Staff audiologist
• Staff speech pathologist • Speech clinician

Other Allied Health Services

• Central supply technician • Medical illustrator
• Podiatric assistant • Veterinary assistant
• Health unit coordinator • Chiropractic assistant
• Home health aide

and who are often responsible for supervising those in the technician/assistant
category. Therapists/technologists usually hold a bachelor’s or a higher-level
degree, and they are trained to evaluate patients, understand diagnoses,
and develop treatment plans in their area of expertise. On the other hand,
technicians/assistants are most likely to have two years or less postsecondary
education, and they are functionally trained with procedural skills for speci-
fied tasks.

FIGURE 4.1
Continued

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Educational and training programs for the allied health profession are
sponsored by a variety of organizations in different academic and clinical set-
tings. They range from degree offerings at colleges and universities to clinical
programs in hospitals and other health facilities. Before 1990, one-third of al-
lied health programs were housed in hospitals, although hospitals graduated
only 15 percent of their students (O’Neil and Hare 1990). The Association
of Schools of Allied Health Professions (ASAHP 2007) includes these among
its membership: 112 academic institutions, 2 professional associations, and
approximately 200 individual members. Junior or community colleges, voca-
tional or technical schools, and academic health centers can all sponsor allied
health programs. These programs can also be stand-alone when aligned with
an academic health center, or they can be under the auspices of the school of
medicine or nursing if a specific school of allied health professions does not
exist. Dental and pharmacy technicians/assistants may or may not be trained
in their respective schools or in a school of allied health professions.

A vast number of the undergraduate allied health programs are accred-
ited by the Commission on Accreditation of Allied Health Education Programs
(CAAHEP), a freestanding agency that in 1994 replaced the American Med-
ical Association’s Committee on Allied Health Education and Accreditation.
The formation of CAAHEP was intended to simplify the accrediting process,
to be more inclusive of allied health programs that provide entry-level educa-
tion, and to serve as an initiator of more far-reaching change. Some key allied
health graduate programs, such as physical therapy and occupational therapy,
are accredited through specialty professional accreditation organizations.

Healthcare Administrators

Healthcare administrators organize, coordinate, and manage the delivery of
health services; provide leadership; and guide the strategic direction of health-
care organizations. The variety and numbers of healthcare professionals they
employ; the complexity of healthcare delivery; and environmental pressures to
provide access, quality, and efficient services make healthcare institutions
among the most complex organizations to manage.

Healthcare administration is taught at the undergraduate and graduate
levels in a variety of settings, and these programs lead to a number of different
degrees. The settings include schools of medicine, public health, healthcare
business, and allied health professions. A bachelor’s degree in health adminis-
tration allows individuals to pursue positions such as nursing home administra-
tor, supervisor, or middle manager in healthcare organizations. Most students
who aspire to have a career in healthcare administration go on to receive a mas-
ter’s degree. (For a detailed description of various career paths and options, see
Haddock, McLean, and Chapman 2002).

Graduate education programs in healthcare administration are ac-
credited by the Commission on Accreditation of Healthcare Management

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Education. Most common degrees include the master of health administra-
tion (MHA), master of business administration (MBA) with a healthcare em-
phasis), master of public health (MPH), or master of public administration
(MPA). However, the MHA degree, or its equivalent, has been the accepted
training model for entry-level managers in the various sectors of the health-
care industry. The MHA program, when compared to the MPH program, of-
fers core courses that focus on building business management (theory and ap-
plied management), quantitative, and analytical skills and that emphasize
experiential training. In addition, some MHA programs require students to
complete three-month internships or 12-month residencies as part of their
two- or three-year curricula. Some graduates elect to complete postgraduate
fellowships that are available in selected hospitals, health systems, managed
care organizations, consulting firms, and other health-related organizations.

A growing number of healthcare administrators are physicians and
other clinicians. As evidence, membership in the American College of Physi-
cian Executives (ACPE 2007) has increased to more than 10,000 in 2007, up
from 5,700 in 1990, although stable since 2000. Physicians, nurses, and other
clinicians refocus their careers on the business side of the enterprise, getting
involved in the strategy, decision making, resource allocation, and operations
of healthcare organizations. A traditional management role for physician ex-
ecutives is the chief medical officer (or a similar position) in a hospital, over-
seeing the medical staff and serving as a liaison between clinical care and ad-
ministration. Likewise, a typical management career path for nurses is to
become the chief nursing officer, with responsibility for the clinical care pro-
vided by employed professional staff.

Typically, chief medical officers begin their careers practicing medi-
cine, then they slowly transition into the operations side of healthcare. How-
ever, physician executives work at every level and in every setting in health-
care. Many physician executives earn a graduate degree such as an MHA or
an MBA if interested in pursuing a formal educational program in healthcare
administration and management. As of 2007, 49 medical schools offer a
combined MD/MBA program, and two medical schools offer the
MD/MHA dual degrees (AAMC 2007). Whether physician executives start
as administrators or later shift to become executives after clinical practice,
they represent for other doctors an alternative way to make an impact on
healthcare delivery.

Nursing home administrator programs require students to pass a na-
tional examination administered by the National Association of Long Term
Care Administrator Boards. Passing this examination is a standard require-
ment in all states, but the educational preparation needed to qualify for this
exam varies from state to state. Although more than one-third of states still
require less than a bachelor’s degree as the minimum academic preparation,
approximately 70 percent of the practicing nursing home administrators have,

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at a minimum, a bachelor’s degree. As the population continues to live longer,
the demand and educational requirements for long-term-care administrators
are estimated to increase, along with the growth of educational programs tar-
geted to this sector.

Considerations for Human Resources Management

The role of human resources management (HRM) in healthcare organiza-
tions is to develop and implement systems, in accordance with regulatory
guidelines and licensure laws, that ensure selection, evaluation, and retention
of healthcare professionals. In light of this role, human resources (HR) per-
sonnel should be aware that each of the healthcare professions, and often the
subspecialties within those professions, has specific requirements that allow an
individual to qualify for an entry-level job in his or her chosen profession. The
requirements of national accrediting organizations (e.g., the Joint Commis-
sion), regulatory bodies (e.g., the Centers for Medicare & Medicaid Services),
and licensure authorities (e.g., state licensure boards) should be considered in
all aspects of HRM. In this section, we briefly discuss some of the issues that
a healthcare organization’s HR department must consider when dealing with
healthcare professionals.

Qualifications

In developing a comprehensive employee-compensation program, HR per-
sonnel must include the specific skill and knowledge required for each job in
the organization. Those qualifications must be determined and stated in
writing for each job. The job description usually contains the level of educa-
tion, experience, judgment ability, accountability, physical skills, responsibil-
ities, communication skills, and any special certification or licensure require-
ments. HR personnel need to be aware of all specifications for all job titles
within the organization. This knowledge of healthcare professionals is neces-
sary to ensure that essential qualifications of individuals coincide with job
specifications, and it is also necessary for determining wage and salary ranges
(see Chapter 7).

Licensure and Certification

An HR department must have policies and procedures in place that describe
the way in which licensure is verified on initial employment. Also, HR must
have a system in place for tracking the expiration dates of licenses and for en-
suring licensure renewal. Therefore, HR must be conscientious about
whether the information it receives is a primary verification (in which the in-
formation directly comes from the licensing authority) or a secondary verifica-
tion (in which a candidate submits a document copy that indicates licensure

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has been granted, including the expiration date). Certifications must be veri-
fied during the selection process, although certifications and licenses are gen-
erally not statutory requirements. Many healthcare organizations accept a
copy of a certification document as verification. If the certification is a job re-
quirement, systems must be in place to track expiration dates and to access
new certification documents.

Career Ladders

In selecting healthcare professionals, HR personnel must consider past em-
ployment history, including the explanation of gaps in employment. To assess
the amount of individual experience, evaluating the candidate’s breadth and
depth of responsibility in previous jobs is essential. Many healthcare organiza-
tions have career ladders, which are mechanisms that advance a healthcare
professional within the organization. Career ladders are based on the Dreyfus
and Dreyfus model of novice to expert (explained earlier in the chapter), and
experience may be used as a criterion for assignment of an individual to a par-
ticular job category. In addition, healthcare organizations may conduct annual
reviews of employees who have leadership and management potential. This re-
view entails that HR works with senior management to assess the competency,
ability, and career progression of employees on an ongoing basis.

Educational Services

Healthcare professionals require continuous, lifelong learning. Healthcare or-
ganizations must have in-house training and development plans to ensure that
their healthcare professionals achieve competency in new technologies, pro-
grams, and equipment and are aware of policy and procedure changes. Cer-
tain competencies must be renewed annually in areas such as cardiopulmonary
resuscitation, safety and infection control, and disaster planning.

In addition to developing specific training programs, healthcare organ-
izations should provide orientation for all new employees. Such organization-
specific training enables the leadership to share the values, mission, goals, and
policies of the institution. Such clear communication often serves as a reten-
tion tool that enables employees to better understand how the organization
works and how to be successful in that organization. Similarly, some profes-
sions and licensing jurisdictions may require continuing education that is pro-
fession specific.

A healthcare organization can provide training and development in a
variety of ways. On one end of the spectrum, training and development can
be outsourced to a firm that specializes in conducting educational programs.
Conversely, another option is to consolidate all training and development in-
house, which are managed typically by the HR department. Regardless of how
each healthcare organization provides continuing education, training and de-
velopment should be a priority. Strong programs can be viewed as recruitment

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and retention tools. As such, healthcare organizations must be cognizant of
fiscal resources necessary to support these educational requirements.

Practitioner Impairment

Healthcare professionals are accountable to the public for maintaining high
professional standards, and the governing body of a healthcare organization
is, by statute, responsible for the quality of care rendered in the organization.
This quality is easily jeopardized by an impaired practitioner. An impaired
practitioner is a healthcare professional who is unable to carry out his or her
professional duties with reasonable skill and safety because of a physical or
mental illness, including deterioration through aging, loss of motor skill, or
excessive use of drugs and alcohol.

The HR department must periodically evaluate the performance of all
healthcare professionals in the organization to ensure their competence (i.e.,
the basic education and training necessary for the job) and proficiency (i.e.,
the demonstrated ability to perform job tasks). Mechanisms must be in place
to identify the impaired practitioner, such as policies and procedures that de-
scribe how the organization will handle investigations, subsequent recom-
mendations for treatment, monitoring, and employment restrictions or sepa-
ration. Hospitals, for instance, usually have a process in place for the board of
directors (which has the ultimate responsibility for the quality of care deliv-
ered in the organization) to review provider credentials and performance and
to oversee any employment actions. Each national or state licensing authority
maintains legal requirements for reporting impaired practitioners.

As a result of ever-increasing changes in the health professions, in
the foreseeable future, new challenges and opportunities, such as the issues
described in this section, will face the HR department of every healthcare
organization.

Changing Nature of the Health Professions

In the 1990s, we entered a new era of uncertainty in healthcare, one faced
with a quickening pace of change (Begun and White 2008). Within this
framework, new ways of thinking are rewarded as the meaning of health is re-
defined, the boundaries of healthcare professionals are reshaped, and the out-
comes of healthcare professional interventions are measured in terms of qual-
ity of life. Changes in the organization and financing of healthcare services
have shifted delivery from the hospital to outpatient facilities, the home,
long-term-care facilities, and the community. This is largely the result of
three major forces: (1) a shift in managed care reimbursement to outpatient
settings and a focus on cost containment; (2) technological advances, such as

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telemedicine and the electronic medical record; and (3) medical innovation—
the science of medicine has progressed to the point that complicated procedures
that once required several nights of stay can now be treated with a simple pro-
cedure or even solely with medication. These changes are intended to improve
the delivery of healthcare while reducing cost and increasing access for patients.

As the setting for the delivery of care continued to change, so did
arrangements between physicians and healthcare organizations. For instance,
physicians can function as individual providers (either in solo or group prac-
tice) and refer patients to the hospital. Typically, these private-practice doctors
have admitting privileges to the hospital but are not governed by the hospi-
tal, do not serve as attending physicians, and infrequently participate on hos-
pital committees. Physicians considered “on staff” at any hospital are those
who refer and treat patients at that hospital. They are credentialed by the hos-
pital credentialing committee (usually managed by the chief of staff office)
and are governed by the medical staff bylaws. This is a common type of hos-
pital-provider arrangement.

However, a trend toward hospitals employing physicians has been
growing. In this arrangement, physicians are on staff, referring to and treat-
ing at only the hospital that employs them. Because they are considered em-
ployees, physicians are not only held to the HR policies of the healthcare or-
ganization but are also governed by the medical staff bylaws. Physicians who
are employed by a hospital can also maintain a private practice.

Finally, the field of hospitalists is also growing. Typically, these physi-
cians do not run their own practice aside from their hospital employment.
Hospitalists work full time for the hospital and are trained in delivering spe-
cialized inpatient care. Regardless of the type of arrangement, most hospitals
have a chief medical officer, or a similar position, who oversees the roles and
responsibilities of the hospitalist as a member of the medical staff; the hospi-
talist’s employee issues and responsibilities are typically managed by the HR
department. These hospital–physician arrangements get more complex in ac-
ademic medical centers, which must integrate the roles and responsibilities of
the physicians, the hospital, and the medical school.

As a result of the changing environment and decreased reimburse-
ment, more primary care physicians are joining or forming group practices.
Large physician-owned group practices offer several advantages to physi-
cians, including competitive advantage with vendors and manufacturers, im-
proved negotiating power with managed care organizations, shared risk and
decision making, and improved flexibility and choice for patients. Physicians
usually own or share ownership in the group practice and, therefore, are re-
sponsible for the business operations. Typically, group practices employ an
office manager who works closely with the physicians to manage the day-to-
day operations. Often, a full-time administrator is on staff not only to man-
age everyday issues but also to formulate strategies and oversee personnel,

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billing and collection, purchasing, patient flow, and other functions. Many
group practices opt to outsource their business functions, including human
resources, to specialized firms. For complete details on medical practice man-
agement, go to www.mgma.com.

These shifts in various healthcare settings and arrangements have
changed the roles, functions, and expectations of the healthcare workforce
and gave way to the emergence of the following issues.

Supply and Demand

Throughout the twentieth century, the nursing labor market cycled through
periods of shortages and surpluses (Lynn and Redman 2005; Aiken et al.
2002; Kovner 2002; Coile 2001; Jones 2001; Buerhaus, Staiger, and Auer-
bach 2000). The beginning of the twenty-first century brought the nursing
and allied health professions the challenge of keeping pace with the demand
for their services. Indicators of demand include numbers of vacancies,
turnover rates, and an increase in salaries. To fill positions, hospitals—the
largest employers of nurses and allied health professionals—have raised salaries,
provided scholarships, and given other incentives such as sign-on bonuses and
tuition reimbursement.

The supply of nurses and allied health professionals is reflected in the
number of students in educational programs and those available for the
healthcare workforce. Future supply of such professionals continues to be
threatened by the following factors:

• The aging of the nursing workforce. According to the results of the 2004
National Sample Survey of Registered Nurses (HRSA 2006a), the
average age for all nursing faculty was 51.6, and for nursing faculty who
have doctoral degrees, it was 55.4 (up from 53.5 in 2003).

• The decline in available educational resources. Almost two-thirds (68.5
percent) of the nursing schools that responded to the 2006 American
Association of Colleges of Nursing (AACN 2007a) survey identified
faculty shortages as a reason for not accepting all qualified applicants
into entry-level baccalaureate programs. The survey also noted lack of
classroom space and clinical facilities and budgetary restraints.

• The decline in nursing school enrollees. From 1995 through 2000,
enrollment decreased by 21 percent. From 2001 through 2007,
increases of 3.7 to 16.6 percent were observed, but more than 30,000
qualified applicants were turned away from baccalaureate nursing
programs in 2007 (AACN 2007a).

As a result, recruitment of nursing and allied health professions stu-
dents has become a major focus of practitioners, professional associations, and
academic institutions. In response, healthcare organizations (in addition to in-
creasing salaries) are developing innovative ways to recruit and retain nurses

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and allied health professionals. Such developments include opening or spon-
soring new schools, offering shorter and more flexible shifts, and providing
child care.

Alternative Therapies

Alternative therapies have gained more popularity, judging by the growing
number of publications on this topic in the lay press and in academic literature.
A turning point in this acceptance and increased respectability was the sentinel
study of the prevalence of the use of alternative or unconventional therapies
(Eisenberg et al. 1993). In the study, Eisenberg and colleagues concluded that
one in three adults relied on treatments and interventions that are not widely
taught at medical schools in the United States; examples of these alternative in-
terventions included acupuncture and chiropractic and massage therapies. In a
follow-up study, Eisenberg and colleagues (1998) determined that, from 1990
to 1997, visits to alternative medicine practitioners increased by 47.3 percent.
Another study reported that 75 (60 percent) out of the 125 medical schools
that participated in the survey offered a course in complementary or alterna-
tive medicine (Wetzel, Eisenberg, and Kaptchuk 1998). Additionally, con-
sumers are demanding the use of alternative therapies, and hospitals have be-
gun offering more of these services (Clement et al. 2006). As the use of
alternative therapies continues to gain acceptance and to be integrated in med-
ical school curriculum, this specialty area may be more and more considered as
an emerging healthcare profession.

Nonphysician Practitioners

With the advent of managed care, greater reliance has been placed on non-
physician practitioners. Collaborative practice models with nurse practition-
ers, physician assistants, pharmacists, and other therapists are appropriate to
both acute and long-term healthcare delivery. Strides have been made in the
direct reimbursement for some nonphysician healthcare provider services,
which is an impetus for further collaboration in practice. The consolidation
and integration of the healthcare delivery system have not, however, elimi-
nated slack and duplication of services. Although the changes attributed to
managed care have led to the promotion and use of less-costly sites for care
delivery, a larger impact on the division of labor among all healthcare profes-
sionals, and thus on health professions, may yet occur.

Licensure and Certification

The use of nonphysician practitioners at various sites may be viewed as an op-
portunity for the growth of nursing, pharmacy, allied health professions, and
health administration. Alternatively, Hurley (1997) contends that it may lead
to concerted efforts to repeal professional licensure and certification in health-
care. If policymakers jump on the bandwagon, this deregulation may lead to

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not only the demise of some healthcare professions but also the proliferation of
functionally trained, unlicensed personnel. The use of personnel who have less
education will have greater implications for the existence and growth of educa-
tional programs in academic medical centers. The use of unlicensed support per-
sonnel poses concerns about the intensity and quality of healthcare delivered.
When fewer highly trained professionals are employed to oversee operations and
care delivery, the potential for adverse outcomes increases. Aiken, Sochalski, and
Anderson (1996) found that, although the percentage of RNs increased over-
all, fewer nurses per patient were available in the mid-1990s than in the 1980s
to provide care for more acutely ill patients. The net effect was a relative increase
in nonclinical personnel, which added stress for those who were expected to su-
pervise unlicensed staff and to care for sicker patients. This is a trend that con-
tinues to affect the provision of healthcare (Aiken et al. 2002).

Recruitment and Retention

Recruitment and retention of healthcare professionals are important in the
face of continuing shortages in key healthcare professions, including nursing
and allied health professions. The American Hospital Association (2007) re-
ported an average hospital nurse vacancy rate of 8.1 percent. The RN vacancy
rate is projected to be 20 percent by 2020 (Buerhaus, Staiger, and Auerbach
2000; Heinrich 2001). This vacancy rate is related to an RN shortage, which
is estimated to be in the range of 340,000 to 1 million nurses by 2020 (Auer-
bach, Buerhaus, and Staiger 2007; HRSA 2006b). Nearly 17 percent of RNs
were not employed in nursing in 2004, which was a 26.2 percent increase over
the 1992 rate (HRSA 2006a). Letvak (2002) predicted that one in five nurses
planned to leave the profession and turnover costs could be up to two times
a nurse’s salary. Fifty-five percent of nurses reported their intention to retire
between 2011 and 2020 in a survey released in 2006 (AACN 2007b), which
would further contribute to the RN shortage. Similarly, the American Hospi-
tal Association (2007) reported vacancy rates among allied health profession-
als (e.g., occupational and physical therapists, laboratory technologists, imag-
ing technicians) that range from 6 percent to 11 percent of needed positions.
These shortages require current professionals to treat more patients and to
work longer hours. Such conditions can contribute to emergency department
diversions, increased patient wait times, and decreased patient safety.

In response, healthcare organizations need to develop and execute re-
cruitment and retention programs. These programs require senior manage-
ment support and dedicated financial and human resources. Such programs
should focus on building a culture of retention. While salary is an important
aspect of employee recruitment and retention, other aspects of work are
also influential, such as leadership support, ability to contribute to the organ-
ization and provide quality care to patients, degree of autonomy, engaging
in positive relationships with direct supervisors and peers, good working

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conditions, and ability to maintain a work–life balance. Additional tools for
retaining employees include conducting employee-engagement surveys, pro-
viding mentoring, and making training programs available.

One innovative way to differentiate a hospital from its competitors,
which helps in recruitment and retention, is to achieve Magnet status. In
1993, the American Nurses Credentialing Center’s Magnet Recognition Pro-
gram was developed as a way to specifically recognize excellence in nursing
services at the institutional level and to benchmark best practices to be dissem-
inated throughout the industry. Hospitals that apply for and achieve Magnet
status have created and demonstrated a professional practice environment that
ensures quality outcomes. These hospitals are recognized for their best prac-
tices in nursing care, improved patient outcomes, and increased workplace sat-
isfaction. The actual evaluation process is based on nine Magnet standards, the
completion of an intensive written application, and a two-day site visit by a
team of nurse scholars. Hospitals that do not wish to engage in the applica-
tion process can benefit greatly from using Magnet strategies to create a cul-
ture based on excellence in nursing and patient care (Pieper 2003). For more
information on Magnet status, see www.nursecredentialing.org/magnet.

Entrepreneurship

Given the bureaucratic nature of organizations, the regulation of the health-
care industry, and additional constraints by payers and managed care, many
healthcare professionals are choosing to pursue opportunities on their own.
The service economy coupled with knowledge-based professions may encour-
age pursuit of new and different ventures for individuals who have the person-
ality, skills, and tenacity to go into business for themselves. An entrepreneur
must have a mix of management skills and the means to depart from a tradi-
tional career path to practice on one’s own.

White and Begun (1998) characterize the entrepreneurial personality
traits of a profession in terms of its willingness to take the risks associated with
undertaking new ventures. Each profession may be categorized either as de-
fending the status quo, which therefore entails little risk (defender professions),
or as looking for new and different opportunities with greater risk (prospector
professions). White and Begun view the more entrepreneurial professions as
more diversified in terms of processes and services delivered. The accrediting
bodies of such entrepreneurial professions encourage educational innovation
that may extend to nontraditional careers. Each of the healthcare professions
has, to greater or lesser extents, defender and prospector aspects.

Workforce Diversity

Each of the healthcare professions must continue to monitor and encourage
diversity in its membership because the demographic shifts that the United
States is going through will have an impact on the workforce composition in

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the coming decades. Although workforce diversity is a broad concept, it fo-
cuses on our differences in gender, age, and race; these aspects not only re-
flect the population that healthcare serves but also the people who provide the
services. Some professions are dominated by one gender or the other, which
is illustrated by the predominantly female field of nursing or the historically
predominantly male field of health administration. The health administration
profession, however, has made strides in recent years as more female adminis-
trators have entered the field. Labor shortages and employee turnover are
common in the healthcare professions. Consequently, healthcare executives
must balance the needs of new entrants into the profession and those already
in the profession.

Changes in the ethnic and racial composition of the workforce are pro-
portional to the changes in the size and age of the population (D’Aunno,
Alexander, and Laughlin 1996). Because many healthcare professionals are
racial/ethnic minorities, a concerted effort needs to be made to recruit and
retain them because the diversity of the members of a profession should re-
flect the diversity of the members of the population.

Summary

Healthcare professionals are a large segment of the U.S. labor force. Histori-
cally, the development of healthcare professionals is related to the following
trends:

• Supply and demand
• Increased use of technology
• Changes in disease and illness
• The impact of healthcare financing and delivery

The healthcare workforce is very diverse. The different levels of education,
scopes of practice, and practice settings contribute to the complexity of manag-
ing this workforce. The coming decades will be characterized by some reforms
within the healthcare professions because of increasing pressures to finance and
deliver healthcare with higher-quality, lower-cost, and measurable outcomes.

94 H u m a n R e s o u r c e s i n H e a l t h c a r e

1. Describe the process of profes-
sionalization. What is the difference
between a profession and an
occupation?

2. Describe the major types of healthcare
professionals (excluding physicians and
dentists) and their roles, training, licensure
requirements, and practice settings.

Discussion Questions

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95C h a p t e r 4 : H e a l t h c a r e P r o f e s s i o n a l s

3. Describe and apply the issues of human
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4. How has managed care affected the
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5. Who are nonphysician practitioners who
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Experiential Exercise

The purpose of this exercise is to give you an
opportunity to explore one healthcare pro-
fession in detail.

From all of the healthcare professions,
select one for analysis. Table 4.1 provides a
starting point for selection. Describe the fol-
lowing characteristics of the profession you
selected:

• Knowledge base
• Collective goals
• Training
• Licensure (this varies by state)
• Number of professionals in practice by

1. Vertical differentiation (position,
experience, education level)

2. Horizontal differentiation
(geography, practice setting,
specialty)

• History and evolution of the profession
• Professional associations and their roles
• Competitor professions
• Current strategic issues that face the

profession and the profession’s position
on these issues

To get started on this exercise, you
may wish to go to the websites of profes-
sional organizations and various state licens-
ing boards. You may also interview members
of the profession as well as leaders in the
field.

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