Labour Market Integration of Refugee Health
\nProfessionals in Germany: Challenges and\n<\/p>\n

Strategies\n<\/p>\n

Sidra Khan-G\u20acokkaya* and Mike M\u20acosko*\n<\/p>\n

ABSTRACT\n<\/p>\n

Refugee health professionals are a vulnerable group in a host country\u2019s labour market as they
\nexperience several barriers on their path to labour market integration. This study aims to iden-
\ntify challenges refugee health professionals and their supervisors experience at their work-
\nplaces and strategies they have developed to overcome these barriers. Semi-structured
\ninterviews were conducted with refugee health professionals who have been living in Germany
\nfor an average of four years and their supervisors (n = 24). The interviews were analysed
\nusing qualitative content analysis. Nine themes were identified: (1) recognition of qualifica-
\ntions, (2) language competencies, (3) differing healthcare systems, (4) working culture, (5)
\nchallenges with patients, (6) challenges with team members, (7) emotional challenges, (8) dis-
\ncrimination and (9) exploitation. Results indicate the need to implement structural changes in
\norder to improve the labour market experiences of refugee health professionals.\n<\/p>\n

BACKGROUND\n<\/p>\n

The global healthcare workforce is facing skilled labour shortage. The World Health Organization
\n(WHO) estimates a global shortage of 14.5 million health professionals by 2030 (World Health Orga-
\nnization, 2006). The European Commission estimates a shortfall of 1 million health workers in Europe
\nby 2020 (European Commission, 2012), and employment agencies in Germany predict a nationwide
\nlack of health professionals (Bundesagentur f\u20acur Arbeit, 2018). In order to address this shortage, nearly
\nall European countries depend on the recruitment of foreign-trained health professionals (Organisation
\nfor Economic Co-operation and Development (OECD), 2017). Another strategy that has been imple-
\nmented by the German government to address this shortage is the so-called \u201cactivation of domestic
\npotential\u201d (Bundesregierung, 2018). With that, the German government aims to address those groups
\nthat have difficult access to the labour market, such as refugees in order to improve their employability
\nand use them to fill shortages (Bundesregierung, 2018). As the number of refugees in Germany has
\nincreased since 2015, the German government has recognized the need to address their labour market
\nintegration (Bundesregierung, 2016). However, refugees belong to a particularly vulnerable group in
\nthe labour market facing unemployment or underemployment (Tanay et al., 2016).\n<\/p>\n

University Medical Center Hamburg-Eppendorf, Hamburg,
\nThis paper is part of a special issue on the \u201cLabour Market Integration of Highly Skilled Refugees in Sweden, Ger-
\nmany and the Netherlands\u201d\n<\/p>\n

doi: 10.1111\/imig.12752\n<\/p>\n

\u00a9 2020 The Authors. International Migration
\npublished by John Wiley & Sons Ltd on behalf\n<\/p>\n

of International Organization for Migration
\nInternational Migration\n<\/p>\n

ISSN 0020-7985\n<\/p>\n

This is an open access article under the terms of the Crea
\ntive Commons Attribution-NonCommercial-NoDerivs
\nLicense, which permits use and distribution in any medium,
\nprovided the original work is properly cited, the use is non-
\ncommercial and no modifications or adaptations are made.<\/p>\n<\/p>\n

\nhttp:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/<\/a>\n<\/div>\n

\n http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/<\/a>\n<\/div>\n<\/div>\n

The barriers and difficulties that refugees face in the context of their labour market integration
\nare multidimensional and manifold. First, their access to the labour market in Germany is restricted
\nand depends on their legal status and the likelihood of getting a residency permit which in turn
\ndepends on the country of origin (Bundesministerium f\u20acur Arbeit und Soziales, 2019). In Germany,
\nthere is a ban on employment for all refugees within the first three months. After three months,
\ntheir access to the labour market is dependent on the individual residency status. As of the fourth
\nmonth, refugees need work permission from the foreign authority office in Germany and the local
\nemployment agencies in order to work (Bundesministerium f\u20acur Arbeit und Soziales, 2019). Their
\naccess to language courses depends on their legal status and the likelihood of receiving a residence
\npermit (Bundesministerium f\u20acur Arbeit und Soziales, 2019). Moreover, participating in job-related
\nlanguage courses is described as challenging either due to long waiting times or course availability
\n(United Nations High Commissioner for Refugees-Organisation for Economic Co-operation and
\nDevelopment (UNHCR-OECD), 2016). Second, refugee health professionals need to go through a
\ndifficult and long recognition process (K\u20acortek, 2015; Desiderio, 2016) which is described as the
\nstarting point for permanent downward mobility (Hawthorne, 2002). Moreover, refugees may not
\nbe able to provide identity documents (Bucken-Knapp et al., 2019) or official documents about
\ntheir education (Bloch, 2008) due to the flight which impedes the recognition process. Third, a lack
\nof information about career pathways (Cohn et al., 2006), such as knowledge about job search
\nstrategies (Willott and Stevenson, 2013) and unfamiliarity with the healthcare system of the host
\ncountry (Ong et al., 2004), are reported barriers. Fourth, due to their flight they may have had a
\nbreak in their professional career and\/or experienced the loss of their professional status (Willott
\nand Stevenson, 2013) which is related to the loss of professional identity (Peisker and Tilbury,
\n2003). It may also result in deskilling (Stewart, 2003), loss of self-confidence (Willott and Steven-
\nson, 2013), high levels of frustration (Mozetic, 2018) and negative psychological impacts (Cohn
\net al., 2006). Additionally, the lack of recognition of their previously gained experiences leads to a
\nfeeling of being disadvantaged compared to locally trained team members (Mozetic, 2018) which
\nmight be intensified by the experience of multiple forms of discrimination (Jirovsky et al., 2015)
\nand exclusion (Bloch, 2008).
\nStudies in Germany have also focused on the working experiences of migrant physicians and\n<\/p>\n

international nurses from within the European Union as well as from non-European countries. They
\nreport similar barriers as the above-mentioned. A study on migrant physicians (Klingler and Marck-
\nmann, 2016) describes difficulties in three fields. The first field refers to the organization of health-
\ncare institutions and other institutional difficulties such as insufficient support or being assigned to
\ntasks below their level of expertise. Moreover, difficult career advancement opportunities and unfair
\ntreatment of migrant physicians were mentioned as institutional difficulties. The second field relates
\nto experienced difficulties with own competencies such as language competencies and knowledge
\nabout the healthcare system. The third field relates to difficulties in interpersonal relations and inter-
\nactions such as inadequate treatment of patients and co-workers. In this context, a study on the
\nworkplace integration of internationally recruited nurses in Germany points out that conflicts often
\narise between migrated nurses and locally trained team members. These conflicts arise because
\nlocally trained team members either hold back or do not comprehensively share key information in
\norder to organize their work. Thus, the incorporation of migrated nurses into daily work routine is
\nimpeded and the potential for conflicts in everyday work is increased (P\u20acutz et al., 2019). These
\nstudies illustrate that international healthcare professionals and refugee healthcare professionals
\nexperience similar barriers at their workplaces. However, refugees were forced to flee by the cir-
\ncumstances of their home countries (Yarris and Casta~neda, 2015), whereas internationally recruited
\nhealth professionals may be considered as voluntary migrants. This distinction between refugees
\nand voluntary migrants has effects on the barriers they experience. While voluntary migrants were
\nmost likely able to prepare for their migration, refugees had to flee under extreme conditions (Jack-
\nson et al., 2004). Stressors of the flight, the loss of family members, traumatic experiences and the\n<\/p>\n

2 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

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

and strengthen their employability (Konle-Seidl, 2016). These recommendations comprise individu-
\nally tailored programmes to the specific needs of refugees. Amongst others, it is recommended to
\nprovide (occupational specific) language courses combined with working opportunities, skills
\nassessment, mentoring and career advice. For highly skilled refugees, it is especially recommended
\nto increase availability of on the job trainings, recognize existing qualifications and offer vocational
\ntraining. However, in order to implement tailored programmes that match the host countries\u2019 legal
\nand social requirements it is essential to identify and analyse the barriers refugee health profession-
\nals face when entering the labour market. While the legal situation of refugees and their access to
\nthe labour market in Germany is documented through policy papers (European Commission, 2012;
\nPlatonova and Urso, 2012; Konle-Seidl, 2016; Tanay et al., 2016; UNHCR-OECD, 2016; OECD,
\n2017; United Nations Department of Economic and Social Affairs Population Division, 2017;
\nUNHCR, 2017; Bundesministerium f\u20acur Arbeit und Soziales, 2019), little attention has been paid to
\nthe challenges they face in everyday working life and their own perspective and strategies. Thus, in
\nthis study, refugee health professionals and their supervisors across Germany were interviewed
\nabout the challenges they faced at their workplaces as workplaces are a \u201ckey site of sociocultural
\nincorporation\u201d (van Riemsdijk et al., 2016). Moreover, this paper advances this field by giving rec-
\nommendations for healthcare providers and organizations based on the experiences of refugee
\nhealth professionals and their supervisors in order to implement changes on structural levels and
\nimprove the working environment. These changes refer to establishing supporting structures as well
\nas measures of diversity management and anti-discrimination.\n<\/p>\n

METHODS\n<\/p>\n

The reporting of methods is in accordance with the consolidated criteria for reporting qualitative
\nresearch (COREQ) guidelines (Tong et al., 2007).\n<\/p>\n

Researcher characteristics\n<\/p>\n

Qualitative research depends on the personal qualities of the researcher and the theoretical sensitiv-
\nity that the researcher brings to a research (Strauss and Corbin, 1990). Thus, it is important to
\nreflect on the researcher\u2019s characteristics and its impact on the interview situation. All interviews
\nwere conducted in person by the first author, female, person of color, PhD student of the Depart-
\nment of Medical Psychology at the University Medical Center Hamburg-Eppendorf. The first author
\nis trained in cultural studies, international migration and intercultural studies and has several years
\nof training in conducting qualitative studies. For transparency reasons, participants were informed
\nthat the study was part of a PhD study.\n<\/p>\n

Recruitment\n<\/p>\n

Major educational organizations and projects for the labour market integration of refugee health
\nprofessionals (RHPs) across Germany were identified through internet research. The organizations\n<\/p>\n

Labour market: Refugee health professionals 3\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

(n = 15) were contacted and informed about the study. Their consent was obtained. Three of the
\nmajor organizations agreed to participate in the study. Participants were divided into RHPs and
\nsupervisors as the refugees\u2019 self-perception about their experiences might differ from the supervi-
\nsors\u2019 perception. Since the group of RHPs comprises different professions, we decided on subdivid-
\ning the stratum of RHPs into two groups: physicians and other health professions. In terms of data
\nsaturation, it is recommended to conduct six to twelve interviews per stratum (Guest et al., 2006).
\nThus, 24 interviews were conducted in three major cities in Germany (Hamburg, Hannover and
\nFrankfurt). All three organizations provided persons that matched the inclusion criteria with infor-
\nmation on this study and either arranged appointments or provided participants with the research-
\ners\u2019 contact information. Inclusion criteria for participants referred to the following aspects:
\nTarget group1.:\n<\/p>\n

\u2022 Refugees (regardless of their residency status and form of protection) who have obtained a
\nqualification in a health profession in their home country or a country other than Germany;\n<\/p>\n

\u2022 Supervisors that were responsible for the integration of refugee health professionals, their
\nsupervision or support\n<\/p>\n

Language competencies:\n<\/p>\n

\u2022 Required minimum level of German language competencies on the European Reference
\nlevel of A2-B12.\n<\/p>\n

Working experiences in Germany:\n<\/p>\n

\u2022 RHPs must have had contact with the German healthcare system with a minimum duration
\nof one month \u2013 be it a steady job, an internship or job shadowing\n<\/p>\n

\u2022 Supervisors had to work in jobs with close contact with refugee health professionals regard-
\nless of their hierarchical status. They must have had supervised RHPs at their ward or as an
\nexternal supervisor\n<\/p>\n

Context:\n<\/p>\n

\u2022 RHPs and supervisors in all healthcare institutions comprising primary, secondary and ter-
\ntiary care were included\n<\/p>\n

Providers were informed about the inclusion criteria and selected fitting participants. All inter-
\nviews were conducted in German. In one case the inclusion criteria did not match as the participant
\nwas a student of the educational organization without sufficient working experience. Participants
\nthat matched the inclusion criteria were approached via phone followed by an invitation to live
\ninterviews. Participants received two consent forms: one for their participation in the study and one
\nfor their consent to audio recording. The consent form and the study information were orally
\nexplained prior to the interview.\n<\/p>\n

Data collection\n<\/p>\n

The interview guide was developed based on literature focused on the daily work experiences of
\nrefugee health professionals using the SPSS3. approach by Helfferich (2009). The interview guide
\nwas sent to experts in the field of migration research to be critically reviewed. Based on this
\nreview, the authors discussed and adapted the interview guide. Finally, the interview guide was\n<\/p>\n

4 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

piloted with two migrant nurses that resulted in the specification of some questions. The interview
\nguide was structured into six main themes:\n<\/p>\n

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

In each interview, the same semi-structured guide was used. After the interview was finished and
\nthe audio recorder was switched off, demographic data were retrieved. The interviews lasted from
\n00:18 to 00:55 min with a median range of 00:40. Some (n = 4) interviews were transcribed by a
\nstudent researcher but the majority (n = 20) of the interviews were transcribed verbatim by a pro-
\nfessional agency. All transcripts were proofread by the first author.\n<\/p>\n

Data analysis\n<\/p>\n

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

Description of sample\n<\/p>\n

Sixteen RHPs and 8 supervisors participated in the study. Two interviews were conducted via tele-
\nphone due to reduced mobility of the participants. The sample is described in Table 1.\n<\/p>\n

RESULTS\n<\/p>\n

In general, nine major challenges could be identified which either RHPs or supervisors described as
\nrelevant: (1) the recognition of professional qualifications, (2) language competencies, (3) different
\nhealthcare systems, (4) working culture, (5) challenges with patients, (6) challenges with team
\nmembers, (7) emotional challenges, (8) discrimination, (9) exploitation. Table 2 provides an over-
\nview of the identified fields and their specifications.\n<\/p>\n

Recognition4. of professional qualifications\n<\/p>\n

Both supervisors and RHPs pointed out the challenges they faced with regard to the recognition
\nprocess of their professional qualifications. Supervisors especially emphasized the difficulties
\nregarding the recognition process. They criticized the long waiting times for the recognition process\n<\/p>\n

Labour market: Refugee health professionals 5\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

TABLE 1\n<\/p>\n

SAMPLE DESCRIPTION (REFUGEE HEALTH PROFESSIONALS AND SUPERVISORS)\n<\/p>\n

Refugee health professionals (RHPs)\n<\/p>\n

Participant Sex Age
\nCountry
\nof birth Occupation\n<\/p>\n

Working
\nexperience
\nin Germany\n<\/p>\n

Working experience
\nin birth country\n<\/p>\n

A1 m 26 Iran Nurse 1 month 6 years as a nurse
\nA2 m 23 Iraq Physician 3 months 2 years as a general\n<\/p>\n

physician and
\n3 years as a
\nsurgeon\n<\/p>\n

A3 m 28 Syria Physiotherapist 2 years 4 years as a physio-
\ntherapist\n<\/p>\n

A4 m 28 Syria Physician
\n(specialized
\nin Anaesthesia)\n<\/p>\n

8 months 2,5 years as a medi-
\ncal assistant in sur-
\ngery\n<\/p>\n

A6 m 33 Syria Physician 5 months 5 years as a physi-
\ncian\n<\/p>\n

A7 m 38 Afghanistan Physician one year 1 year as a medical
\nassistant, 3 years in
\npublic health depart-
\nment\n<\/p>\n

A8 w 29 Syria Physician 1,5 years 1 year as a physician
\nA9 m 30 Afghanistan Physician 3 months 1 year as a medical\n<\/p>\n

assistant
\nA10 m 44 Syria Physician\n<\/p>\n

(specialized
\nin anaesthesia)\n<\/p>\n

3, 5 years 4 years as a medical
\nassistant, two years
\nas a senior physi-
\ncian, 9 years as a
\nchief physician\n<\/p>\n

A11 w 52 Afghanistan Physician (specialized
\nin gynaecology)\n<\/p>\n

6 months 23 years as a gynae-
\ncologist (also as a
\nchief gynaecologist)\n<\/p>\n

A12 m 39 Yemen Physician 4 months 10 years as a physi-
\ncian\n<\/p>\n

A13 m 45 Afghanistan Physician 2 years 2,5 years as a physi-
\ncian\n<\/p>\n

A14 m 51 Syria Dentist 3 months 21 years as a dentist
\nA15 m 39 Afghanistan Physician\n<\/p>\n

(specialized
\nin
\notorhinolaryngology)\n<\/p>\n

6 weeks 3 years as an ear-
\nnose-throat (ENT)
\nspecialist\n<\/p>\n

A16 w 33 Senegal Midwife and Nurse 3 months eleven months as a
\nmidwife, 15 years
\nas a nurse\n<\/p>\n

A17 w 36 Azerbaijan Nurse 3 months 2 years as a nurse\n<\/p>\n

Supervisors\n<\/p>\n

Participant Sex Age
\nCountry
\nof birth Education Current job Experience\n<\/p>\n

B1 m 34 Germany Physiotherapist Part time
\nphysiothera-
\npist, part
\ntime supervi-
\nsor for RHPs
\nand migrants\n<\/p>\n

5 years as a
\nphysiotherapist,
\n1 year as a
\nsupervisor\n<\/p>\n

6 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

(B2-B4, B8) and noted that the bureaucratic procedures for recognition in Germany were not clear
\nand prolonged the recognition process (B4, B7, B8). RHPs also criticized the length and complex-
\nity of the recognition process (A4, A7, A8, A11, A12). Two supervisors (B4, B8) criticized that
\nformer positions such as leadership titles of RHPs were not recognized in Germany. They also criti-
\ncized that RHP\u2019s specialist medical training or their internships in Germany were not considered
\nfor recognition as working experiences. Furthermore, in one case there was confusion about the
\nlegal foundations of the responsible authorities\u2019 bodies:\n<\/p>\n

One colleague receives a temporary work permit [from the recognition authority] but federal medi-
\ncal council law and health insurance company\u2019s law contradict each other which inhibits him from
\nworking as a physician unless he has a full licence to practise medicine. But he can only acquire
\nthe full license after taking an exam. Taking that exam is on hold because the [recognition] authori-
\nties are understaffed. (B3)5.\n<\/p>\n

RHPs (A1, A11, A13, A15) also indicated their anxiety regarding the licensing examinations as
\nthey feared the examination would be too difficult.\n<\/p>\n

Language competencies\n<\/p>\n

Supervisors and RHPs considered acquiring German language proficiency and German technical
\nand medical language as a major topic. Supervisors emphasized especially the need to learn the\n<\/p>\n

TABLE 1\n<\/p>\n

(CONTINUED)\n<\/p>\n

Supervisors\n<\/p>\n

Participant Sex Age
\nCountry
\nof birth Education Current job Experience\n<\/p>\n

B2 m 64 Germany Librarian and editor Commissioner
\nfor refugees
\nat the medi-
\ncal associa-
\ntion in lower
\nSaxony\n<\/p>\n

2,5 years as
\na commissioner\n<\/p>\n

B3 m 64 Germany Physician Physician and
\nSupervisor
\nfor RHPs\n<\/p>\n

34 years as a
\nphysician,
\none year as
\na supervisor\n<\/p>\n

B4 m 73 Germany Physician Supervisor for
\nRHPs\/
\nretired\n<\/p>\n

47 years as
\na physician,
\n2 years as
\na supervisor\n<\/p>\n

B5 w 50 Germany Nurse and
\nprofessional
\nadvisor\n<\/p>\n

Professional
\nadvisor\n<\/p>\n

15 years as
\nan advisor\n<\/p>\n

B6 w 54 Germany Nurse Nurse and
\nsupervisor\n<\/p>\n

37 years as nurse
\nand supervisor\n<\/p>\n

B7 w 38 Germany Nurse and
\nPsychologist\n<\/p>\n

Psychologist seven years as a
\npsychologist\n<\/p>\n

B8 m 52 Germany Physician,
\nMedical
\njournalist\n<\/p>\n

Managing
\ndirector of
\nrefugee and
\nmigrant edu-
\ncation centre\n<\/p>\n

2 years as
\nmanaging director\n<\/p>\n

Labour market: Refugee health professionals 7\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

technical language. They (B1, B5, B8) described that RHPs were afraid to admit there were
\nparts they did not understand and continued to say \u201cyes\u201d in order to maintain the conversation
\nflow. This has often led to misunderstandings. RHPs described difficulties in speaking everyday
\nlanguage and technical language. They (A1, A2, A4) found it difficult to understand handover
\nreports from physicians or keep up in meetings and written documentation. They (A1, A3, A7,
\nA12) were also afraid of not being able to understand the language which influenced their
\nbehaviour:\n<\/p>\n

I am afraid if [a patient] someone rings the bell. [. . .] Because my language is not [well] enough
\nand I am afraid of understanding something wrong or not being able to answer [the patient\u2019s ques-
\ntion]. That\u2019s why I remain seated and others [colleagues] keep asking me \u201cwhy are you always sit-
\nting?\u201d (A1)\n<\/p>\n

One of them also expressed their fear of being deemed to be incompetent due to their language
\ncompetencies: \u201cThey think I have learned it wrong in Iran. But in fact I couldn\u2019t understand what
\nthey were asking me\u201d (A1). Moreover, RHPs (A1, A3, A12) felt their language competencies held
\nthem back as they were reluctant to share their opinion: \u201cIf we discuss a patient\u2019s case and some-
\none has a contradicting opinion on that patient\u2019s case I am afraid to discuss our opinions as I fear
\nthey will say \u2018I can\u2019t express myself\u2019\u201d (A3).\n<\/p>\n

Different healthcare systems\n<\/p>\n

Supervisors and RHPs described challenges that derived from differing standards in the home
\nand host countries\u2019 healthcare system. All supervisors described that RHPs would have to
\nfamiliarize themselves and catch up with the healthcare system in Germany. Eleven RHPs (A1,
\nA2, A8, A9, A11-17) emphasized the difference in the medical equipment, the names of\n<\/p>\n

TABLE 2\n<\/p>\n

CHALLENGES EXPERIENCED BY REFUGEE HEALTH PROFESSIONALS\n<\/p>\n

Recognition of professional
\nqualifications\n<\/p>\n

Difficulties in the context of the recognition process
\nNon-recognition of former experiences
\nExaminations for recognition\n<\/p>\n

Language competencies Knowledge of everyday language
\nKnowledge of technical language
\nFeelings and consequences of lacking language competencies\n<\/p>\n

Different healthcare systems Unfamiliarity with and differences between the healthcare systems
\nUnfamiliarity with bureaucratic procedures within the healthcare system
\nConsequences of differences and unfamiliarity\n<\/p>\n

Working culture Adaption to formal aspects of work
\nAdaption to cultural aspects of work
\nIntercultural and interpersonal differences\n<\/p>\n

Difficulties with patients Language difficulties
\nDifficulties in delivering bad news
\nDistrust from patients\n<\/p>\n

Difficulties with team members Difficulties during internships
\nInterpersonal and interprofessional difficulties\n<\/p>\n

General Emotional Difficulties Discouragement
\nNegative feelings of RHPs in the context of labour market integration.\n<\/p>\n

Discrimination Discrimination by patients
\nDiscrimination by team members\n<\/p>\n

Exploitation Financial exploitation of RHPs in the context of work.
\nProfessional exploitation of RHPs in the context of work\n<\/p>\n

8 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

medication and working habits and the feeling to need to familiarize themselves with these dif-
\nferences. In this context, supervisors referred especially to the differing professional role of
\nnurses in Germany:\n<\/p>\n

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

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

Yes, the situation was unpleasant that I could not do anything alone. And if I wanted to do some-
\nthing, someone had to stay with me, a senior physician or chief physician. That was a bit uncom-
\nfortable for me because I already graduated from university and I also worked as an assistant
\nphysician in my home country for a year. But I didn\u2019t have a solution. I had to come to Germany
\nand here, the rule is if someone doesn\u2019t have a license he has to cooperate with a chief physician
\nor with a senior physician. (A9)\n<\/p>\n

Working culture\n<\/p>\n

Supervisors described two facets of working culture that they found important in the context of
\ntheir experiences with RHPs: formal and cultural aspects of work and RHPs adaption to these
\naspects. They emphasized formal aspects such as being punctual, submitting holiday applications
\ncorrectly, calling in sick, being polite and committed to work. Some of the supervisors (B1, B2,
\nB3, B6, B7, B8) criticized some of these aspects in the context of RHPs as deficits. With regard to
\ncultural aspects, supervisors mentioned that RHPs had different values that sometimes inhibited
\ntheir integration such as examining other-sex patients (B1, B6-B8), taking off headscarves for sev-
\neral reasons (B1, B8), dealing with homosexuality (B1) or accepting female superiors (B1-B4, B7).
\nThese values were often attributed to cultural differences although they may result from context-
\nspecific causes, as one supervisor who had a mediatory role describes:\n<\/p>\n

The [female] colleague shouted at him [the RHP] in front of the patients [. . .] Luckily, we heard
\nabout it and picked it up [. . .] she said he was a macho and suggested women were worth less than
\nmen. The trigger was a basic nursing situation which is difficult for our participants as they haven\u2019t
\nlearned it in their home countries. And she gave instructions that were too brief, for example
\n\u201cwash\u201d and he didn\u2019t know what to do with that instruction. […] And that caused the escalation
\nspiral. (B7)\n<\/p>\n

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

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

Labour market: Refugee health professionals 9\n<\/p>\n

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\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

maybe the other colleague does not say anything at all but for me it is a bit ok \u2013 maybe she has
\nproblem with men and so on, so I ask. (A1)\n<\/p>\n

Challenges with patients\n<\/p>\n

RHPs experienced difficulties with patients especially if patients did not speak clearly due to their
\nillness, their age or their way of speaking:\n<\/p>\n

The problem was that I couldn\u2019t understand. For example, the patient said \u201cbring me this and that\u201d.
\nAnd the problem was that they spoke very unclearly and for German people it [is] also difficult to
\nunderstand and for me of course [it is] especially difficult. (A1)\n<\/p>\n

Some described that talking to patients\u2019 relatives was a new challenging experience especially if
\nthey were furious (A8) or if they had to pass bad news to them (A7). Another challenge was asso-
\nciated with distrust from patients: \u201cMaybe they don\u2019t trust the foreign physicians as much but that\u2019s
\ngeneral [generally the case]. All patients are like that, almost all of them. […] You can tell, they\u2019re
\na little scared or something\u201d (A4).\n<\/p>\n

Challenges with team members\n<\/p>\n

Almost all supervisors (B2, B4-8) mentioned the important role of internships in the context of
\nteam integration. However, one supervisor reported that finding internship placements became more
\nand more difficult due to lower capacities of the hospitals (B4). During some internships, partici-
\npants were not given appropriate tasks or were not supervised (B2, B5, B7, B8) as \u201cit is associated
\nwith effort to take along someone\u201d (B7). Sometimes local trained team members were not aware of
\nwhat RHPs were allowed or permitted to do which often led to misunderstandings (B5, B7, B8).
\nAlmost all of the RHPs mentioned several other challenges in the context of teamwork, such as a
\ndistanced relationship towards local trained team members (A8, A11, A15, A16), their expectation
\nthat RHPs could do and know everything and wrong ideas of them and their education (A1, A9,
\nA10).\n<\/p>\n

General Emotional challenges\n<\/p>\n

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

I wanted to go to the hospital and see how this works. And I wasn\u2019t sure if I could do that again. I
\nthought it is not possible. Because everywhere where I had asked [they said]: \u201cNo, you can\u2019t do
\nthat. Do another one. Do a retraining and so on. Do some care. But you can\u2019t do midwife.\u201d And I
\ncame to my ward. I saw it, it is the same thing. (A16)\n<\/p>\n

Additionally to being discouraged, supervisors thought RHPs felt impeded (B4), afraid (B5, B7,
\nB8), frustrated (B1, B6), under pressure and isolated (B1) as a consequence of the experienced bar-
\nriers. Moreover, they acknowledged RHPs\u2019 loss of their professional status and mentioned that
\nRHPs were reduced to their language deficits (B1, B6, B7) which influenced their self-perception
\nand made them question themselves (B7).\n<\/p>\n

10 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n

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\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

Discrimination\n<\/p>\n

RHPs experienced several forms of discrimination. One supervisor reported that RHPs were some-
\ntimes rejected and ignored in decision-making. He describes a situation between a refugee physi-
\ncian and a locally trained nurse:\n<\/p>\n

I can give you an example: my [refugee] physician is treating a patient. Another [locally trained]
\nnurse has a question about that patient. He [the nurse] is standing in front of my [refugee] physi-
\ncian and tells him: \u201cI don\u2019t want to clarify this with you. I will talk to your colleague who under-
\nstands me.\u201d And that is a nice form of rejection. There are even more blatant cases. (B1)\n<\/p>\n

Five supervisors (B1, B5, B6, B7, B8) and six RHPs (A1, A2, A3, A7, A10, A15) also reported
\ndiscrimination from patients towards foreign health professionals: \u201cI was in the room, I had to take
\n[a] blood [sample] and the patient and also her husband said: \u2018No, you may not come here. We do
\nnot want a foreign physician here\u2019\u201d (A15). However, supervisors differentiated between open dis-
\ncrimination and subtle racism from patients. They also differentiated between patients who did not
\nfully trust RHPs and patients who treated them in a racist manner from the beginning. In the con-
\ntext of foreign-trained health professionals, one supervisor described intersectional discrimination as
\nsome patients racially and sexually harassed female nurses from Thailand:\n<\/p>\n

There was a situation where an older \u201cfascist grandfather\u201d in quotation marks somehow said he
\ndidn\u2019t want that or the Thai ladies \u2013 how shall I say, perhaps sexualised? So, with Thai participants
\nor Asian looking participants, the gentlemen often become a little bit, how can you say, more
\ncheeky. (B1)\n<\/p>\n

Although this quote does not explicitly refer to refugee health professionals, it is likely that
\nRHPs also experience intersectional discrimination.
\nAdditionally, RHPs (A3, A4, A8, A10-A13, A15) experienced discrimination from senior team\n<\/p>\n

members as one female physicians describes:\n<\/p>\n

I was at that interview with the chief physician and at the end he said: \u201cYour German is well, […]
\nbut there is something negative. [. . .] You have this headscarf. You are Muslim and there are a lot
\nof (tourist? terrorists? [incomprehensible]). How can the patients be sure that you are not a (tourist?
\nterrorist?)?\u201d That moment was horrible for me. (A8)\n<\/p>\n

The physician described that she refused the position afterwards due to this experience and
\nstarted working in a catholic hospital as her headscarf is not a problem there \u201cbecause nuns also
\nwear a headscarf\u201d (A8).\n<\/p>\n

Exploitation\n<\/p>\n

In addition to the discrimination faced by patients and team members, two supervisors (B2, B8)
\ndescribed experiences of exploitation:\n<\/p>\n

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

(B8)\n<\/p>\n

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\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

This would also affect RHPs\u2019 claims for benefits after terminating the employment (B8). Addi-
\ntionally to financial exploitation, one supervisor also mentioned that RHPs were sometimes hired as
\ngap fillers not correspondingly to their qualifications and did not have a long-term perspective
\n(B8). RHPs did not explicitly mention being exploited. However, many of them were not yet per-
\nmanently working and one reported doing unpaid overtime, as he did not know about working
\nrights in Germany (A4).\n<\/p>\n

Resources and strategies\n<\/p>\n

RHPS and supervisors described several strategies they had developed in order to address the experi-
\nenced barriers. These strategies refer to individual strategies of RHPs, strategies in the context of edu-
\ncation and support, strategies on the team level and strategies on the organizational and societal level.\n<\/p>\n

Individual strategies\n<\/p>\n

All RHPs described several individual strategies to cope with challenges they had faced such as being
\npatient (A1, A2, A6, A9), trusting and believing in their own power resources (A3, A13, A16) or pre-\/
\npost-processing relevant professional content (A1, A7, A12, A16). They also actively engaged with
\ntheir colleagues, asked them questions, demanded feedback (A9, A16) in order to cope with language
\ndeficits. Furthermore, RHPs developed several strategies to cope with patients\u2019 discrimination. They
\neither tried to reassure patients (A10, A12), accepted patients\u2019 wishes and called a team member (A4),
\nignored (A7) or avoided patients that rejected them (A16). In dealing with discrimination from team
\nmembers, some RHPs would focus on their goal instead of focusing on conflicts and try not to think
\ntoo much about these experiences (A12, A15). Others would use humour in order to unburden a
\ntensed situations with jokes (A10). Staying silent was described as a strategy as well:\n<\/p>\n

I didn\u2019t do anything and I didn\u2019t say anything because I knew that if I said something, the situation
\nwould get worse and I didn\u2019t want that to happen. Yes, I was very calm and I wanted this nurse to
\ngo home and think for herself, then she would understand. […] Yes, later she was a little better. All
\nbeginnings are difficult. (A9)\n<\/p>\n

Supervisors pointed out individual competencies of RHPs in dealing with the barriers. They
\nemphasized RHPs\u2019 great commitment and their positive working attitudes. They also highlighted
\nthe competencies of RHPs such as their intercultural competence (B4, B8), their openness to new
\nexperiences (B1, B6, B7), a high motivation to work (BB7, B4, B3, B2), their cooperation capabil-
\nity (B3), their gratefulness (B5) and their fighting spirit (B7).\n<\/p>\n

Strategies in the context of education and support\n<\/p>\n

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

Strategies on the team level\n<\/p>\n

Generally speaking, positive contact towards patients and team members was perceived as very
\nhelpful. One supervisor described RHPs\u2019 and patients\u2019 relationships as \u201ca mutual connection as
\nthey are stronger dependent on each other\u201d (B7) than in other cases. Likewise, team members were
\ndescribed by all RHPS to be open, interested and supportive: \u201cThey were all friendly and every\n<\/p>\n

12 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n

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\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

morning when I came to work they smiled at me and said \u2018good morning\u2019. And that I find really
\nimportant for a newly arrived\u201d (A12). Almost all of them (A1-A4, A7-A9, A11-A14, A16-A17)
\nemphasized that colleagues were forthcoming if they had questions and that they benefitted from
\ntheir induction and their feedback. Two of them (A8, A11) pointed out the role of other (locally
\ntrained) interns and students who helped them in their free time. Supervisors focused more on
\nstructural resources for teams. They suggested training for local team members and mediators (B1,
\nB7), more personnel and more time to induct RHPs (B3, B6, B7), clear contact persons that RHPs
\ncan talk to (B1, B4) and clear instructions of team members (B3). They also mentioned time to
\nfamiliarize for RHPs (B1, B2, B6, B7), less patients to care for at the beginning (B7) and sensitiza-
\ntion and reflexivity of locally trained team members (B1, B3, B7).\n<\/p>\n

Strategies on an organizational and societal level\n<\/p>\n

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

But we also need the attitude from above [the management board] that says: \u201cWe want that [the
\nlabour market integration of RHPs], and we also provide time and resources, and teams also get a
\nbenefit for getting involved\u201d. (B7)\n<\/p>\n

One supervisor referred to the commitment of supervisors and the healthcare providers when
\nobserving racism and sexism: \u201cIf the hospital positions itself clearly and says \u2018take your documents
\nand go home because we are not going to treat you\u2019. Great, because that is a clear line. But if they
\ntalk around the issue the patient will continue to show racist behaviour\u201d (B8).\n<\/p>\n

DISCUSSION\n<\/p>\n

This paper aimed to explore the barriers and resources RHPs faced at their workplaces. The broad
\nrange of identified barriers and difficulties indicates that their experiences depend very much on their
\nemployers and their working environment. Moreover, as understaffing is a common problem in
\nhealth care (Angerer et al., 2011; Deutscher Gewerkschaftsbund (DGB), 2018), it is questionable to
\nwhat extent only RHPs are affected by these experiences or if they are a consequence of the precari-
\nous staffing situations. Moreover, it remains open to what degree the migration status influences the
\nexperienced challenges. Since no questions were asked about their flight, their psychological well-
\nbeing or their residency permit and none of the participants mentioned it in the context of their
\nworkplace experiences, it is not possible to state whether only refugees experience these barriers.
\nInstead, our results indicate that when focusing at their workplaces, RHPs face similar barriers as
\ninternationally recruited professionals and voluntary migrants (Humphries et al., 2013; Jirovsky
\net al., 2015; Klingler and Marckmann, 2016; P\u20acutz et al., 2019). Nine major challenges were identi-
\nfied: 1) recognition of qualifications, (2) language competencies, (3) different healthcare systems, (4)
\nworking culture, (5) challenges with patients, (6) challenges with team members, (7) emotional chal-
\nlenges, (8) discrimination and (9) exploitation. These challenges illustrate that hiring RHPs should
\nnot be a quick response to filling shortages. Instead, the integration process should be carefully pre-
\npared in order to prevent some of these challenges. Labour market integration is a two-sided process
\nthat requires not only a welcoming culture but also welcoming structures (Knuth, 2019). Educational
\nproviders, employers as well as authorities need to address these barriers and implement structural
\nchanges in order to contribute to a sustainable labour market integration of RHPs.\n<\/p>\n

Labour market: Refugee health professionals 13\n<\/p>\n

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\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

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

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

sors and team members. Deviations from these local standards were seen as problematic and
\nobstructive. This coincided with results from other studies (Klingler et al., 2018; P\u20acutz et al., 2019)
\nHowever, it remains problematic due to several reasons. Firstly, the term \u201clocal standards\u201d pre-
\nsumes shared standards (Klingler et al., 2018). However, it remains unclear if these standards refer
\nto professional standards, legal regulations, norms, cultural aspects or hospital routines. Secondly,
\nthe knowledge about certain established standards may be tacit and implicit (Sakamoto et al., 2010)
\nthus unspoken. As RHPs are unaware of these unspoken standards, deviations in behaviour can
\nlead to frustration, conflicts and exclusion (Lai et al., 2017). Thirdly, most of the perceived differ-
\nences in the context of working culture from the supervisors were culturalized. Supervisors saw the
\ncauses of conflicts in cultural distinctions, although they could as well be interpreted situation and
\nperson specifically or result from differing concepts of work. This is consistent with previous find-
\nings (P\u20acutz et al., 2019) that in the process of labour market integration differing concepts attributed
\nto work clash. These concepts may be influenced by stereotypes and prejudices. As a result, on the
\none hand immigrated employees identify themselves as the \u201coutsiders\u201d contrary to local employees.
\nOn the other hand, an enhancement of the existing working culture that could have been adaptable
\nto a new environment is excluded (Steinberg et al., 2019). Fourthly, the performance of RHPs is
\nmeasured according to their adaption and stabilization to the system. But the potential that RHPs
\nbring along is wasted if adaption and stabilization are the only possible and acceptable outcomes
\nsince they bring along important working experiences and attitudes that may enrich local standards.
\nThus, it is important to verbalize standards and address them before or ideally concomitant to
\nRHPs labour market integration (Sakamoto et al., 2010). At the same time, it is important to offer
\nlocal team members opportunities to reflect on their own standards of work and their expectations.
\nThis could also contribute to an overall improvement of the working atmosphere and reduce the
\nchallenges experienced with team members. However, difficulties with team members were also
\nattributed to a lack of supervision during internships. Results indicate that most of the time, indi-
\nvidual team members were intrinsically motivated to support RHPs and engaged in their induction.
\nBut the responsibility of integrating RHPs should not only be outsourced to committed employees
\nor in the worst case, as described in the results, to unwilling employees. The support of RHPs
\nshould be implemented on a structural level. It is estimated that a one and a half additional hours
\nof individual support per month are sufficient to generate good integration prospects (Baic et al.,
\n2017). However, it remains open to question if team members who provide individual support
\nshould be further trained and\/or remunerated for their effort. In order to expand the support possi-
\nbilities, mentoring programmes could also be helpful in supporting RHPs. These findings are\n<\/p>\n

14 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

consistent with recommendations given by the German Employer Association stating that mentor-
\ning programmes are a classical approach towards integrating foreign workers (Robra and B\u20acohne,
\n2013).
\nIn general, more acknowledgement and empowerment for RHPs is needed. This is consistent\n<\/p>\n

with previous findings describing the loss of RHPs\u2019 professional status (Leblanc et al., 2013) result-
\ning in deskilling (Stewart, 2003), the loss of self-confidence (Jirovsky et al., 2015), feelings of frus-
\ntration (Mozetic, 2018) and negative psychological impacts (Cohn et al., 2006). Results in this
\nstudy further indicate that RHPs experience several forms of discouragement, discrimination as well
\nas disparagement, although they are fully educated and bring along valuable human capital (A9).
\nAlthough RHPs have already developed several strategies in dealing with negative feelings and the
\nbarriers they face, organizations and educational institutions could further engage in strengthening
\nRHPs\u2019 professional identity, acknowledge their strategies and\/or make the potential of RHPs visible
\nin order to empower them.
\nIn the light of the discrimination that RHPs faced by team members and patients, healthcare pro-\n<\/p>\n

viders need to promote measures of diversity management as discrimination may be one result of
\npoor diversity management (Dickie and Soldan, 2008). Discrimination influences the motivation
\nand job satisfaction of RHPs and in the long term, it can also have negative psychological impact
\nand lead to leaves of RHPs (Bouncken et al., 2015). On the contrary, a diversity climate within the
\norganization can enrich the psychological capital of refugee employees and contribute to their com-
\nmitment (Newman et al., 2018). Nevertheless, several forms of discrimination from patients and
\ncolleagues were commonly mentioned topics consistent with previous findings on RHPs\u2019 experi-
\nences (Cohn et al., 2006; Bloch, 2008; Jirovsky et al., 2015). According to the federal German law
\n\u201cGeneral Act on equal Treatment,\u201d employers are legally obliged to protect their employees from
\ndiscrimination (Allgemeines Gleichbehandlungsgesetz, 2006). But especially experiences of racism
\nare often denied in health care as \u201cthe illusion of non-racism\u201d exists and impedes progressive poli-
\ncies (Johnstone and Kanitsaki, 2008). Progressive policies may refer to promoting equal opportu-
\nnity policies (Wrench, 1999) and prevent any form of discrimination (B8). Condemning racist
\ncomments (B8), establishing anti-discrimination commissioners, setting up transparent complaint
\nsystems and offering anti-discrimination and empowerment workshops could be first steps (Wrench,
\n1999) towards an inclusive and healthier working environment for both staff and patients.
\nSimilarly, the exploitation of RHPs needs to be addressed and employers as well as policymakers\n<\/p>\n

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

scholars criticize the term for numerous reasons. Firstly, in Germany the term \u201cintegration\u201d mostly
\nrefers to regulatory policies which focus on integrating migrants into the existing social orders
\n(Karakayali and Bodjadzijev, 2010). However, social orders are predefined and shaped by members
\nof the majority group (Essed, 2000). Secondly, the term is based on negative narratives about the
\nunwillingness or failed integration of migrants which contributes to the fact that new demands are
\nconstantly being claimed on migrants (Mecheril, 2011). Hence, the term puts migrants into the
\nfocus while structural and institutional deficits as well as power asymmetries within the host coun-
\ntries are ignored. Subsequently, the experiences of racism and exploitation that RHPs describe in\n<\/p>\n

Labour market: Refugee health professionals 15\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

this study point to the need to focus research on structural and institutional inequalities, power
\nasymmetries and intersectional discrimination. For further research in this context, it would be help-
\nful to consider the Critical Race Theory (CRT) as it is based on principles of race equity and social
\njustice and provides tools in order \u201cto elucidate contemporary racial phenomena, expand the vocab-
\nulary with which to discuss complex racial concepts and challenge racial hierarchies\u201d (Ford and
\nAirhihenbuwa, 2010). Furthermore, activists and scholars who contributed to the CRT study and
\ntransform the relationship between race, racism and power (Delgado and Stefancic, 2017). How-
\never, for the purpose of this study it can be concluded that equal participation in the labour market
\nand society requires equal treatment, equal opportunities and protection against discrimination
\n(Uslucan, 2017).\n<\/p>\n

Policy recommendations\n<\/p>\n

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

Strengths and limitations\n<\/p>\n

This study identified major challenges in the context of the working experiences of RHPs. By
\nchoosing an explorative approach, a broad range of topics could be identified which provide a basis
\nfor further research and in-depth analysis of the difficulties in the identified fields. The perspective
\nof RHPs and their supervisors were integrated in order to get an insight into the field of health pro-
\nfessions and the labour market integration into health professions. For further research, it could also
\nbe helpful to interview colleagues of RHPs and focus on specific healthcare settings. Participants in
\nthis study were selected from rural as well as urban areas and comprised several health professions.
\nAnother strength of this study lies in the methodology. Discussing data with an interdisciplinary
\ngroup ensures comprehensibility and critical reflection. Nevertheless, as participants were not
\nrecruited representative and most participants worked only for a short time in Germany, there might
\nbe a selection bias and results are questionable in terms of generalizability. Another limitation is
\nthe compilation of the sample as more physicians and more men in urban areas were interviewed.
\nIntersectional barriers, language competencies, training experience and other demographic-specific
\naspects were neglected. Hence, no conclusions could be drawn for subgroups. Furthermore,
\nalthough a certain language competency was required, language barriers and socially desirable
\nanswers may have influenced the interview process. However, due to the researchers\u2019 background
\nand the reflection of her characteristics, a trustful interview situation could be created and reflected
\nafterwards.\n<\/p>\n

16 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n

ACKNOWLEDGEMENT\n<\/p>\n

We are grateful to the participants and to the organizations who have made this study possible
\nthrough their support. Open access funding enabled and organized by Projekt DEAL.\n<\/p>\n

FUNDER INFORMATION\n<\/p>\n

The study was funded by the European Social Fund. SKG and MM received the funding. The fun-
\nders did not play any role in the study design, data collection, decision to publish or preparation of
\nthe manuscript.\n<\/p>\n

DECLARATION OF INTERESTS\n<\/p>\n

We have no conflicts of interest to disclose.\n<\/p>\n

Peer Review\n<\/p>\n

The peer review history for this article is available at https:\/\/publons.com\/publon\/10.1111\/imig.
\n12752.\n<\/p>\n

NOTES\n<\/p>\n

1. The terms \u201crefugee health professionals\u201d and \u201csupervisors\u201d were selected as they describe a shared experi-
\nence. However, it should be noted that both terms reduce these persons to only one aspect of identity. The
\nterms do not reflect the multiple aspects of identity and the social and ethical dimensions of the workplace
\nidentity that all interviewed person and health care professionals have.\n<\/p>\n

2. The Common European Framework of Reference for Languages: Learning, Teaching, Assessment (CEFR)
\nis a reference system to describe six levels (A1, A2, B1, B2, C1, and C2) of language proficiency from
\nbeginners (A1) to experts (C2).\n<\/p>\n

3. SPSS is an abbreviation for Sammeln, Pr\u20acufen, Sortieren and Subsumieren (Collect, Check, Sort, Subsume).
\n4. Health professions are registered professions in Germany which is why foreign health professionals need\n<\/p>\n

to have a full or temporary license before they can practise. In order to obtain a license, they have to
\ngo through a recognition process. The first step of the recognition process is an equivalence assessment.
\nBased on this assessment, recognition bodies grant full recognition, no recognition or partial recognition.
\nIf qualifications are only partly recognised, foreign health professionals can participate (professional
\ngroups like nurses must participate) in adaption training programmes or internships and prove their
\nrequired knowledge through language and proficiency tests. The proficiency tests covers internal medi-
\ncine and surgery. However, based on the equivalence assessment authorities may also evaluate other
\nsubjects.\n<\/p>\n

5. As the interviews were conducted in German, citations in this section were translated one-on-one from Ger-
\nman to English. If terms were not equivalent in English, then those terms were translated one-on-one and
\nsupplemented with further explanations in the reference mark (Koller, 2011 Einf\u20acuhrung in die \u20acUberset-
\nzungswissenschaft [Introduction to translation science], Francke, T\u20acubingen; Basel.).\n<\/p>\n

6. \u201cNo plaintiff, No judge\u201d (German translation: Wo kein Kl\u20acager, da kein Richter) is a common phrase in
\nGerman. It describes that certain irregularities or grievances remain uncovered as no one complains about
\nthem.\n<\/p>\n

Labour market: Refugee health professionals 17\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n

\nhttps:\/\/publons.com\/publon\/10.1111\/imig.12752<\/a>\n<\/div>\n

\n https:\/\/publons.com\/publon\/10.1111\/imig.12752<\/a>\n<\/div>\n<\/div>\n

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\n2013 \u201cAttitudes to Employment of Professionally Qualified Refugees in the United Kingdom\u201d, Interna-\n<\/p>\n

tional Migration, 51(5): 120\u2013132.
\nWorld Health Organization
\n2006 The World Health Report 2006. Working together for health. WHO, Geneva, Switzerland.\n<\/p>\n

Labour market: Refugee health professionals 21\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n

\n https:\/\/www.unhcr.org\/research\/working\/3fbb94a32\/bitter-pill-swallow-obstacles-facing-refugee-overseas-doctors-uk-emma-stewart.html<\/a>\n<\/div>\n

\n https:\/\/publications.europa.eu\/en\/publication-detail\/-\/publication\/87a8f92d-9aa8-11e6-868c-01aa75ed71a1<\/a>\n<\/div>\n

\n https:\/\/www.un.org\/en\/development\/desa\/population\/migration\/publications\/migrationreport\/docs\/MigrationReport2017_Highlights.pdf<\/a>\n<\/div>\n

\n https:\/\/www.oecd.org\/els\/mig\/migration-policy-debates-10_de.pdf<\/a>\n<\/div>\n

\n https:\/\/www.unhcr.org\/5b27be547.pdf<\/a>\n<\/div>\n<\/div>\n

Wrench, J.
\n1999 \u201cEmployers and anti-Discrimination Measures in Europe: Good Practises and Bad Faith\u201d, in J.\n<\/p>\n

Wrench, A. Rea and N. Ouali (Eds.), Ethnic Minorities and the Labour Market. Integration and
\nExclusion in Europe. Palgrave, United Kingdom.\n<\/p>\n

Yarris, K. and H. Casta~neda
\n2015 \u201cSpecial issue discourses of displacement and deservingness: interrogating distinctions between\n<\/p>\n

\u201ceconomic\u201d and \u201cforced\u201d migration\u201d, International Migration, 53(3): 64\u201369.\n<\/p>\n

22 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n

\u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
\nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n<\/div>\n

WORKFORCE DIVERSITY\n<\/p>\n

Rupert M. Evans, Sr., DHA, FACHE\n<\/p>\n

CHAPTER\n<\/p>\n

6\n<\/p>\n

145\n<\/p>\n

Learning Objectives\n<\/p>\n

After completing this chapter, the reader should be able to\n<\/p>\n

\u2022 understand how proactive use of diversity principles can transform the
\norganization\u2019s culture;\n<\/p>\n

\u2022 understand the business case for diversity and inclusion in healthcare
\norganizations;\n<\/p>\n

\u2022 work toward creating an inclusive organizational culture;
\n\u2022 define the roles that healthcare providers, management, and governance\n<\/p>\n

play in building a business imperative for diversity within the
\norganization; and\n<\/p>\n

\u2022 discuss how healthcare leaders can develop a diversity program in their
\norganizations.\n<\/p>\n

Introduction\n<\/p>\n

When you hear the term \u201cdiversity,\u201d what comes to mind? To some, the word
\nmeans the differences between human beings related to race or ethnicity. To
\nothers, it means the uniqueness of each individual. A few people still may jump
\nup to argue that diversity is just a code word for affirmative action.\n<\/p>\n

Healthcare organizations across the United States are beginning to
\nmove toward embracing and fostering workforce diversity. This cultural
\nchange means adopting new values that are inclusive and appropriately man-
\naging a diverse workforce. In the future, diversity will drive the business prac-
\ntices of hospitals and other healthcare organizations, and this dynamic will re-
\nquire strong leadership. This change will take time, but in the words of
\nReverend Jesse Jackson, \u201cTime is neutral and does not change things. With
\ncourage and initiative, leaders change things.\u201d\n<\/p>\n

In this chapter, we provide a definition of diversity and a framework for
\nunderstanding the different ways people view the term. In addition, we high-
\nlight several studies and legal issues pertaining to this topic and enumerate
\nmethods for building a case for and establishing a diversity program.\n<\/p>\n

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\nAN: 237620 ; Fottler, Myron D., Fried, Bruce.; Human Resources in Healthcare : Managing for Success
\nAccount: s8993066.main.ehost<\/p>\n<\/p>\n<\/div>\n

A Definition of Diversity\n<\/p>\n

People define diversity in many ways, depending on the way they live in and
\nview society. In his book, The 10 Lenses: Your Guide to Living and Working in
\na Multicultural World, author Mark Williams (2001) discusses the framework
\nthat explains the way people see the world:\n<\/p>\n

1. The assimilationist wants to conform and fit in with the group to
\nwhich he or she belongs.\n<\/p>\n

2. The colorblind ignores race, color, ethnicity, and other cultural factors.
\n3. The cultural centrist seeks to improve the welfare of his or her cultural\n<\/p>\n

group by accentuating its history and identity.
\n4. The elitist believes in the superiority of the upper class and embraces\n<\/p>\n

the importance of family roots, wealth, and social status.
\n5. The integrationist supports breaking down all barriers between racial\n<\/p>\n

groups by merging people of different cultures together in
\ncommunities and in the workplace.\n<\/p>\n

6. The meritocratist lives by the adage, \u201ccream rises to the top\u201d\u2014the
\nbelief that hard work, personal merit, and winning a competition
\ndetermine one\u2019s success.\n<\/p>\n

7. The multiculturist celebrates the diversity of cultures, seeking to retain
\nthe native customs, languages, and ideas of people from other
\ncountries.\n<\/p>\n

8. The seclusionist protects himself or herself from racial, cultural, and\/or
\nethnic groups in fear that they may diminish the character and quality
\nof his or her group\u2019s experiences within society.\n<\/p>\n

9. The transcendent focuses on the human spirit and people\u2019s universal
\nconnection and shared humanity.\n<\/p>\n

10. The victim\/caretaker views liberation from societal barriers as a
\ncrucial goal and sees oppression as not only historical but also
\ncontemporary.\n<\/p>\n

With this framework in mind, it is easier to understand why so many
\ninterpretations of the same idea exist. For our purposes, we describe diversity
\nin the context of three key dimensions: (1) human diversity, (2) cultural di-
\nversity, and (3) systems diversity. Each dimension needs to be understood and
\nmanaged in the healthcare workplace.\n<\/p>\n

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

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how we are perceived by others. A workplace definition of diversity includes
\nhuman diversity as a minimum.\n<\/p>\n

Cultural diversity encompasses a person\u2019s beliefs, values, family struc-
\nture practice (nuclear or extended family, independent living), and mind-set
\nas a result of his or her cultural, community, and environmental experiences.
\nThis dimension includes language, social class, learning style, ethics or moral
\ncompass, religion, lifestyle, work style, global perspectives, and military views.
\nCultural diversity is a secondary dimension, but it can have a powerful impact
\non how a person behaves in the workplace. The cultural norms vary from one
\nculture to another and influence how individuals interact with their work en-
\nvironments. For example, some religious groups are forbidden from working
\non the Sabbath, and this exemption has an impact on work scheduling and
\neven hiring decisions.\n<\/p>\n

Systems diversity relates to the differences among organizations in work
\nstructure and pursuits. This dimension includes teamwork reengineering,
\nstrategic alliances, employee empowerment, quality focus, educational devel-
\nopment, corporate acquisitions, and innovation. Systems diversity deals with
\nsystems thinking and the ability to recognize how functions in the work envi-
\nronment are connected with diversity. In a multicultural, diverse, and inclu-
\nsive workplace, organizational systems are integrated to enhance innovation,
\nencourage teamwork, and improve productivity.\n<\/p>\n

All of these dimensions are important and are present in the health-
\ncare workplace, and all leaders should recognize them. The challenge is in
\nseeing not only our differences but also our similarities as individuals, as
\nprofessionals, and as members of a group. Leaders must develop effective
\nstrategies to manage the differences (and highlight similarities), and this
\nwill lead to building effective teams and a higher-performing organization
\n(Guillory 2003).\n<\/p>\n

Managing diversity is not an easy task, as a number of barriers often get
\nin the way of achieving a harmonious working environment. Some of these bar-
\nriers, which revolve around the diversity dimensions mentioned earlier, can be
\na great source of tension and conflict. For instance, a person\u2019s culture can be a
\nbarrier to a work team when other members of the group are not respectful of
\nor misunderstand the person\u2019s values, beliefs, or even clothing, which that per-
\nson gained through his or her cultural background. Examples of a cultural dif-
\nference may be the person\u2019s hairstyle or affinity to wear religious artifacts. The
\neducation, race\/ethnicity, work style, empowerment, and relationship\/task
\norientation of an individual can also become barriers if they are not properly
\nunderstood and managed.\n<\/p>\n

Prejudice in the Workplace\n<\/p>\n

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

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It affects the way people react toward and think of other people, and it can be
\nas innocent as children choosing to not play with children they deem different
\nfrom themselves or as harmful as adults not associating with certain people be-
\ncause English is not their native language.\n<\/p>\n

Formally, prejudice can be defined as a set of institutionalized assump-
\ntions, attitudes, and practices that has an invisible-hand effect in systematically
\nadvantaging members of more powerful groups over members of less domi-
\nnant groups. This type of prejudice occurs in many healthcare institutions.
\nSome examples include culturally biased assessment and selection criteria, cul-
\ntural norms that condone or permit racial or sexual harassment, lower per-
\nformance expectations for certain groups, and a collective misconception
\nabout a specific group that relegates the group\u2019s members to unfair positions.
\nAn example of the latter is stereotyping.\n<\/p>\n

Stereotypes are generalizations about individuals based on their identity,
\ngroup membership, or affiliations (Dreachslin 1996). A common stereotype
\nin the healthcare management field is the assumption that black executives are
\nnot as qualified as their white counterparts. Thus, African-American execu-
\ntives are tested more often to prove their competence, while their white con-
\ntemporaries are assumed to be capable from the start. (This fact is substanti-
\nated in the race\/ethnic surveys discussed later in the chapter.)\n<\/p>\n

The concept of \u201ccomfort and risk\u201d relates to a human being\u2019s natural
\nneed to feel comfortable and to avoid risk. People tend to prefer to work with
\nothers from similar racial or ethnic backgrounds because doing so provides
\nthem with a certain amount of comfort and shields them from a certain
\namount of risk. Although subordinate\u2013superior relationships that involve peo-
\nple from different backgrounds work sufficiently to allow people to get the
\njob done, they often fail to lead to the close bonds that form between a men-
\ntor and a prot\u00e9g\u00e9.\n<\/p>\n

Given the systemic existence of prejudice and the way it influences
\npeople\u2019s mind-set and behavior in the workplace, the fair and accurate assess-
\nment of minority employees (caregivers, support staff, and managers alike)
\nremains an organizational dilemma rather than an established practice. For
\ninstance, existing literature provides evidence that managers systematically
\ngive higher performance ratings to subordinates who belong to the same
\nracial group as they do, while high performers from minority groups remain
\ncomparatively invisible in the managerial\/leadership selection process (Thomas
\nand Gabarro 1999).\n<\/p>\n

The Business Case for Diversity\n<\/p>\n

In 1900, one in eight Americans was non-white; today, this ratio is one in
\nfour. By 2050, the ratio will be one in three (IOM 2004). The healthcare\n<\/p>\n

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industry needs physicians, nurses, and other providers, but it also needs care-
\ngivers who reflect the diversity of the population, who, at one point or an-
\nother, become patients. The same is true for healthcare managers and exec-
\nutives. Therefore, healthcare organizations must ensure that their caregivers
\nand leaders represent the backgrounds of the communities they serve. In ad-
\ndition, healthcare executives must look for new insights, examples, and best
\npractices to help navigate their organizations through a diversity journey. A
\nkey challenge in this journey is establishing a business case for having a di-
\nverse workforce.\n<\/p>\n

The business case for diversity is unique for each organization. The cir-
\ncumstances, environment, and community demographics of one organization
\ncannot be generalized to another institution. However, some elements are
\ncommon in all organizations, which can be the basis of a diversity program:
\nthe healthcare marketplace, employee skills and talent, and organizational ef-
\nfectiveness. These elements will drive the institution\u2019s investment in and com-
\nmitment to diversity. An organization can achieve and sustain growth and
\nprofitability by doing the following:\n<\/p>\n

\u2022 Expand market share by adding or enhancing services that target diverse
\npopulations.\n<\/p>\n

\u2022 Link the marketplace with the workplace through recruiting, developing,
\nand retaining employees with diverse racial\/ethnic backgrounds.\n<\/p>\n

\u2022 Create and implement workplace policies and management practices that
\nmaximize the talent and productivity of employees with diverse
\nbackgrounds.\n<\/p>\n

The facts are that all minority groups buy and consume healthcare serv-
\nices, many of them are educated and trained to either provide healthcare serv-
\nices or manage operations, and many of them currently work within the field
\nand understand its complexities. Hospitals and other healthcare organizations
\ncannot afford to miss such opportunities. They can seek, cultivate, and retain
\nminority talent to help them compete in today\u2019s diverse healthcare environ-
\nment. Failure to take advantage of these opportunities will mean the differ-
\nence between being a provider and employer of choice and losing ground to
\ncompetitors.\n<\/p>\n

Governance Impact\n<\/p>\n

The organization\u2019s board of governance can help in this regard. Members of
\nthe board or trustees are the ultimate links to the communities served by a
\nhealthcare organization. They know the makeup of the population the organ-
\nization serves and seeks to target, and they have insights into their communi-
\nties\u2019 healthcare needs. Because board members are part of the community,
\nthey have an interest in making sure that the organization that they represent
\nis not only providing inclusive services but is also being a fair and equitable\n<\/p>\n

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employer and neighbor. With this perspective in mind, governance should
\nsupport a business strategy that promotes community goodwill, encourages
\ngrowth, considers present social and demographic transformations and hence
\nfuture needs, and emphasizes culturally competent and sensitive healthcare.
\nMost importantly, members of the board should also reflect the multicultural
\nmix of the surrounding communities.\n<\/p>\n

Considering all of the challenges faced by any healthcare board, why
\nshould it be concerned with diversity? One of the many reasons is to protect
\nthe organization\u2019s bottom line. The financial impact of problems stemming
\nfrom racial discrimination and discriminatory practices can be substantial.
\nWell-publicized cases of large organizations committing or turning their backs
\non such practices provide evidence of the extent of cost consequences. For ex-
\nample, in 2007, two Equal Employment Opportunity Commission lawsuits
\nwere filed alleging racial and sexual discrimination. The first was filed in South
\nFlorida claiming that a manager at two Nordstrom stores in Palm Beach
\nCounty harassed a Hispanic woman and other \u201csimilarly situated individuals\u201d
\nbased on these individuals\u2019 national origin and race and that the company
\nfailed to take prompt action (Puget Sound Business Journal 2007). The second
\nwas a lawsuit against United HealthCare of Florida that accused a male execu-
\ntive of subjecting another male executive to repeated verbal sexual harassment
\n(EEOC. 2007). This latter case resulted in a $1.8 million settlement and an
\norder for United HealthCare to distribute a new antiharassment policy to all
\nof its employees (EEOC 2007). Another reason that the board should sup-
\nport diversity initiatives is to encourage and strengthen employee commit-
\nment to the organization. Simply, a diverse workforce is an asset. It differen-
\ntiates an organization in the marketplace, giving it an edge against its
\ncompetitors in terms of inclusiveness, cultural sensitivity and competency, and
\neven progressive practice.\n<\/p>\n

Board commitment to the principles of diversity may lead to shifts in
\nthe corporate culture as well, allowing all stakeholders to contribute to the
\noverall success of the organization and its mission. Trustees should hold orga-
\nnizational leaders and managers accountable for setting and following high di-
\nversity standards. This practice will lead to an improved organization and to
\nhealthy communities.\n<\/p>\n

Legal Issues\n<\/p>\n

The debate continues over whether having a diversity program is the right thing
\nto do or whether it enhances shareholder\/stakeholder value. The answer is
\nboth\u2014not only is it the right thing to do, but it also adds value to the organiza-
\ntion. Educated, skilled, and experienced professionals and workers who are con-
\nsidered in the minority (including but are not limited to women, racial and eth-
\nnic minorities, and people with physical challenges) bring strategic and unique
\nperspectives into their roles, generate productive dialogue, and challenge the\n<\/p>\n

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status quo. All of these are essential to the practices, products and services, and
\noperations of a healthcare organization. If these are not reasons enough to main-
\ntain a diverse workforce, various laws also prohibit employment discrimination.\n<\/p>\n

The Civil Rights Act of 1964 was signed into law on July 2, 1964. This
\nlegislation was intended to ensure that the financial resources of the federal
\ngovernment would no longer subsidize racial discrimination (Smith 1999).
\nThis law bans discrimination in any activities, such as training, employment,
\nor construction, that are funded by federal monies. Discrimination is also pro-
\nhibited in entities that contract with organizations that receive federal funds.
\nEvery recipient of federal funds is required to provide written assurances that
\nnondiscrimination is practiced throughout the institution. Among the first
\nmajor tests of the Civil Rights Act was the decision of the U.S. Court of Ap-
\npeals for the Fourth Circuit on the case of Simkins v. Moses Cone Memorial
\nHospital. The decision struck down the separate-but-equal provisions of the
\nHill-Burton Act and gave the federal government the necessary power to en-
\nforce the Civil Rights Act (Smith 1999).\n<\/p>\n

The Civil Rights Act also protects individuals whose native language is
\nnot English. The U.S. Department of Justice has issued the \u201cNational Origin
\nDiscrimination Against Persons with Limited English Proficiency (LEP)
\nGuidance.\u201d This guidance, intended for recipients of federal funds, prohibits
\ndiscrimination of people who have limited English-language proficiency. It re-
\nquires federally funded entities to ensure that people whose primary language
\nis not English can access and understand services, programs, and activities pro-
\nvided by these organizations. This mandate has made a serious impact in the
\nway healthcare organizations, especially those in areas with large numbers of
\nindividuals who speak English as a second language (ESL), frame their serv-
\nice offerings. The National Council on Interpreting in Health Care has put
\ntogether \u201cThe Terminology of Health Care Interpreting,\u201d a glossary of terms
\nintended to help healthcare leaders in developing programs for ESL patients;
\nvisit www.ncihc.org for more information on this glossary.\n<\/p>\n

See Chapter 5 for a comprehensive discussion of the Civil Rights Act
\nand other laws that protect groups who are considered in the minority.\n<\/p>\n

Diversity in Healthcare Leadership: Two Major Studies\n<\/p>\n

Despite the demographic changes in the U.S. population, and hence in the
\nhealthcare field, few minorities are present in the executive suite. Within the
\nlast decades, two major studies were undertaken to understand the factors be-
\nhind minorities\u2019 difficult climb on the healthcare management ladder. As the
\nfindings of these studies indicate, although improvements are continually be-
\ning made in terms of how workforce and leadership diversity is viewed and val-
\nued in healthcare organizations, a lot of work is left to be done.\n<\/p>\n

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Study 1: A Race\/Ethnic Comparison of Career Attainments\n<\/p>\n

in Healthcare Management\n<\/p>\n

In 1992, the American College of Healthcare Executives (ACHE) and the
\nNational Association of Health Services Executives (NAHSE) conducted a
\nstudy that compared the career attainment of Caucasian and African-American
\nhealthcare executives. The study found that among executives with similar
\ntraining and experience, African Americans were in lower-level positions,
\nmade less money, and had lower levels of job satisfaction (ACHE 2002). The
\nresults of this study made way for the creation of the Institute for Diversity in
\nHealth Management (IFD), the only organization committed exclusively to
\npromoting managerial diversity within the healthcare field.\n<\/p>\n

In 1996, ACHE, with assistance and support from NAHSE, IFD, the
\nAssociation of Hispanic Healthcare Executives (AHHE), and the Executive
\nLeadership Development Program of the Indian Health Services (IHS), con-
\nducted a follow-up survey using many of the items included in the first sur-
\nvey. This second survey, completed and published in 1997, revealed that 23
\npercent of the U.S. hospital workforce was made up of African Americans and
\nHispanics. Unfortunately, less than 2 percent of these minority groups held
\nthe positions of president, chief executive officer, and chief operating officer.\n<\/p>\n

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

Following is a summary of the most important findings of the third
\nstudy (ACHE 2003):\n<\/p>\n

\u2022 More white administrators than minority administrators worked in
\nhospital settings.\n<\/p>\n

\u2022 White female administrators earned more than female minority
\nadministrators. When controlling for education and experience,
\ncompensation earned by white women remained higher than the
\ncompensation for male and female members of minority groups.\n<\/p>\n

\u2022 White male administrators earned more than male minority
\nadministrators. When controlling for experience and education, the total
\ncompensation of male African-American and Hispanic administrators was
\napproximately equal to that of their white counterparts.\n<\/p>\n

\u2022 Minority administrators expressed lower levels of job satisfaction than
\ndid white administrators. The items with which low satisfaction was
\nreported included the following:
\n1. Pay and fringe benefits were not proportionate to the minority\n<\/p>\n

administrators\u2019 contribution to their organization.\n<\/p>\n

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2. The degree of respect and fair treatment that minority administrators
\nreceived from their leaders was inadequate.\n<\/p>\n

3. The sanctions and treatment that minority administrators faced when
\nthey made a mistake were more severe than their action called for.\n<\/p>\n

\u2022 Fewer minority administrators than white administrators expressed that
\ntheir organizations had great personal meaning to them.\n<\/p>\n

\u2022 More minority administrators than white administrators stated that
\nthey experienced racial\/ethnic discriminatory acts in the past five years,
\nsuch as not being hired or being evaluated with inappropriate
\nstandards.\n<\/p>\n

\u2022 Only about 15 percent of female minority administrators aspired to be
\nchief executive officers. More white male administrators had such
\naspirations than male minority administrators.\n<\/p>\n

\u2022 The majority of minority administrators endorsed efforts to increase the
\npercentage of racial\/ethnic minorities in senior healthcare management
\npositions. Nearly half of their white counterparts were neutral or
\nopposed to such efforts.\n<\/p>\n

Recommendations to address the disparities found between the white and mi-
\nnority groups are being developed. A fourth race\/ethnic survey is expected to
\nbe conducted in 2008.\n<\/p>\n

Study 2: Advancing Diversity Leadership in Healthcare\n<\/p>\n

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

In 2006, Witt\/Kieffer conducted a follow-up survey that involved hu-
\nman resources executives and minority leaders in hospitals and health systems
\nnationwide. Seventy-one percent of respondents were nonminorities, and 29
\npercent were from minority groups. The project also included phone inter-
\nviews with respondents who were willing to share additional thoughts regard-
\ning diversity leadership (Witt\/Kieffer 2006).\n<\/p>\n

The following are the main findings of the 2006 study:\n<\/p>\n

\u2022 Eighty-two percent of the nonminority respondents and 81 percent of
\nthe minority group agreed or strongly agreed with the statement,
\n\u201cInternal diversity programs support the organization\u2019s overall
\nmission\/vision.\u201d\n<\/p>\n

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\u2022 Seventy-nine percent of minority and 68 percent of nonminority
\nrespondents agreed that \u201cInternal diversity programs are strategic to
\norganizational success.\u201d\n<\/p>\n

\u2022 Virtually all respondents agreed that \u201cInternal diversity programs
\ndemonstrate the value of cultural differences in an organization.\u201d By and
\nlarge, both groups also shared the belief that organizations commit to
\ndiversity recruiting because they want to achieve \u201ccultural competence\u201d
\norganization-wide.\n<\/p>\n

\u2022 Seventy-two percent of minority and 63 percent of nonminority
\nrespondents agreed that \u201cInternal diversity programs provide diversity
\nstaffing that mirrors the diversity of the patient population.\u201d\n<\/p>\n

\u2022 Only 28 percent of nonminority respondents and 12 percent of the
\nminority group agreed that \u201cHealthcare organizations have been
\neffective in closing the diversity leadership gap over the past five years.\u201d\n<\/p>\n

\u2022 Nearly 73 percent of nonminority respondents personally believed that
\nopportunities for diversity in leadership have improved over the past five
\nyears. Only 34 percent of minorities shared that personal belief. Also, 67
\npercent of nonminorities agreed that \u201cThe availability of diversity
\nleadership positions in healthcare organizations has improved over the
\npast five years,\u201d but only 30 percent of minority respondents agreed.\n<\/p>\n

\u2022 Minority respondents remained unconvinced that they are \u201cwell
\nrepresented today in healthcare organization management teams.\u201d\n<\/p>\n

\u2022 Both respondent groups agreed that internal diversity programs drive
\norganizational success and cultural competence. However, respondents,
\nparticularly minorities, expressed skepticism about whether hospitals and
\nhealthcare systems commit to diversity recruiting because those
\norganizations believe diversity is good for business.\n<\/p>\n

\u2022 Seventy-two percent of nonminorities and 53 percent of minorities
\nagreed that healthcare organizations are effective in diversity recruiting
\nbecause they have a genuine interest in it. Seventy-three percent of
\nnonminorities and about 50 percent of minorities believed healthcare
\norganizations are effective at diversity recruiting because they take their
\nresponsibility to do so seriously.\n<\/p>\n

\u2022 Respondents held widely divergent views on the most important barriers
\nto diversity recruitment, retention, and leadership development. The
\nonly barrier for which general agreement was reached was the \u201clack of
\ncommitment by top management.\u201d\n<\/p>\n

Diversity Management\n<\/p>\n

According to the Institute for Diversity in Health Management (2007), man-
\naging a diverse workforce involves the following elements:\n<\/p>\n

\u2022 Employee perspective. Diversity management creates an environment
\nwhere every hospital or health system employee feels valued, appreciated\n<\/p>\n

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and respected and who, in turn, talks about the organization within the
\ncommunity with pride. Diversity management allows 100 percent of
\nemployees, whatever their capabilities, to achieve 100 percent of their
\npotential 100 percent of the time.\n<\/p>\n

\u2022 Patient focus. Diversity management creates an environment where
\nbecause all patients feel valued, they are highly satisfied and loyal.
\nDiversity management means understanding the cultural and ethnic
\nvalues within a community. As a result, community members choose the
\norganization, which increases market share.\n<\/p>\n

\u2022 Inclusion. Diversity management means sending a message to minorities
\nthat there are leaders within the organization to champion their medical
\nneeds. If a minority patient knows the COO [chief operating officer]
\nshares his or her ethnicity, for example, then that patient likely assumes
\nhis or her best interests will be served.\n<\/p>\n

\u2022 Community perspective. Diversity management means bringing the
\ncommunity into the organization, specifically at the governance level.
\nPutting prominent minority leaders on the hospital or health system
\nboard forges a bond with the community, which in turn creates patient
\ncomfort with and loyalty to the organization.\n<\/p>\n

The Impact of Diversity on Care Delivery\n<\/p>\n

According to the National Institutes of Health, \u201cthe diversity of the Ameri-
\ncan population is one of the nation\u2019s greatest assets; one of its greatest chal-
\nlenges is reducing the profound disparity in health status of America\u2019s racial
\nand ethnic minorities\u201d (Smedley and Stith 2002). The Institute of Medicine\u2019s
\nlandmark report in 2002, entitled Unequal Treatment, reveals the presence of
\nsignificant disparities in the way white and minority patients receive healthcare
\nservices, especially in treatment for heart disease, cancer, and HIV (Smedley
\nand Stith 2002). Addressing such disparities in care, including the dispropor-
\ntionate recruitment and selection of a minority workforce, and ensuring cul-
\ntural competence of caregivers are interconnected. To minimize care dispari-
\nties, institutions and providers have to develop cultural competence. To
\ndevelop cultural competence, a diverse group of providers, support staff, and
\nmanagers needs to be in place and diversity training and policies for all employ-
\nees and caregivers have to be established. Simply, the lack of a culturally com-
\npetent healthcare workforce is a possible contributor to the disparities in care.\n<\/p>\n

Having examined how a diverse physician community also benefits
\nhealthcare, researchers Cohen, Gabriel, and Terrell (2002) posited at least
\nfour practical reasons for attaining greater diversity: (1) it advances cultural
\ncompetency, (2) it increases access to high-quality care, (3) it strengthens the
\nmedical research agenda, and (4) it ensures optimal management. These find-
\nings are relevant and applicable to healthcare management and leadership as\n<\/p>\n

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well. As stated by Cohen, Gabriel, and Terrell, \u201cthe first and perhaps most
\ncompelling reason for increasing the proportion of medical students and other
\nprospective health care professionals who are drawn from underrepresented
\nminority groups: preparing a culturally competent health care workforce.\u201d\n<\/p>\n

Cultural competence may be defined as a set of complementary behav-
\niors, practices, attitudes, and policies that enables a system, an agency, or in-
\ndividuals to effectively work and serve pluralistic, multiethnic, and linguisti-
\ncally diverse communities. The demographic makeup of this country will
\ncontinue to change in the years ahead, and culturally competent and sensi-
\ntive care is and will be expected from current and future healthcare profes-
\nsionals. To effectively provide such care, leaders, clinical staff, and all the em-
\nployees in between must have a firm understanding of how and why belief
\nsystems, personal biases, ethnic origins, family structures, and other cultur-
\nally determined factors influence the manner in which patients experience ill-
\nness, adhere to medical advice, and respond to treatment. Such factors ulti-
\nmately affect the outcomes of care. Physicians and other healthcare
\nprofessionals who are not mindful of the potential impact of language barri-
\ners, religious taboos, unconventional views of illness and disease, or alterna-
\ntive remedies are not only unlikely to satisfy their patients but, more impor-
\ntant, are also unlikely to provide their patients with optimally effective care
\n(Cohen, Gabriel, and Terrell 2002).\n<\/p>\n

A study finds that although African-American physicians make up only
\n4 percent of the total physician workforce in the United States, they care for
\nmore than 20 percent of African-American patients in the United States
\n(Saha et al. 2000). The study suggests that African Americans prefer to get
\ncare from black physicians, and a contributing factor to this may be that many
\nAfrican-American physicians locate their practices in predominantly black
\ncommunities and are, therefore, more geographically accessible to African-
\nAmerican healthcare consumers. If the hypothesis is true that minority con-
\nsumers prefer care from physicians of their own race simply because of geo-
\ngraphic accessibility, then organizational policies aimed at better serving the
\nneeds of minority communities need not consider physician race and ethnic-
\nity in the equation. If, however, minority patients have this preference be-
\ncause of a shared language or culture, for example, then increasing the sup-
\nply of underrepresented minority physicians is justifiable and necessary.\n<\/p>\n

An understanding of the factors that influence the disparities in health-
\ncare is essential in developing effective strategies to minimize the problem.
\nFigure 6.1 presents two sets of factors: patient-related factors and health-system-
\nrelated factors. Patient-related factors are cultural characteristics of patients
\nthat prevent them from getting fair and adequate treatment in an organiza-
\ntion that is not culturally competent or sensitive. Health-system-related fac-
\ntors are organizational dynamics (e.g., employee attributes and biases) that in-
\nfluence the methods used to treat patients.\n<\/p>\n

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Components of an Effective Diversity Program\n<\/p>\n

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

\u2022 Ensure that senior management and the governing board are committed
\nto the development and implementation of a diversity program.\n<\/p>\n

\u2022 Broaden the definition of diversity to include factors beyond race and
\nethnicity.\n<\/p>\n

\u2022 Recognize the business case for bringing in diversity at the leadership level.
\n\u2022 Tie diversity goals to business objectives.
\n\u2022 Hold recruiting events that target racial and ethnic groups, women,\n<\/p>\n

people with disabilities, older but capable workers, and others who are
\nconsidered minorities.\n<\/p>\n

\u2022 Encourage senior executives to mentor minorities.
\n\u2022 Develop employee programs that emphasize and celebrate diversity and\n<\/p>\n

inclusivity.\n<\/p>\n

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\n<\/p>\n

FIGURE 6.1
\nFactors that
\nInfluence
\nDisparities in
\nHealthcare\n<\/p>\n

Patient-Related Factors Health-System-Related Factors\n<\/p>\n

Socioeconomic Cultural competence
\nLow income and education Insufficient knowledge of and sensitivity\n<\/p>\n

to cultural differences\n<\/p>\n

Health education Language
\nLack of knowledge of health Inability to communicate sufficiently
\nsymptoms, conditions, and with patients and families whose native
\npossible treatments language is not English\n<\/p>\n

Health behavior Discrimination
\nPatient willingness and ability to Healthcare system and provider
\nseek care, adhere to treatment bias and stereotyping
\nprotocols, and trust and work
\nwith healthcare providers Workforce diversity\n<\/p>\n

Poor racial and ethnic match between
\nhealthcare professionals and the
\npatients they serve\n<\/p>\n

Payment
\nInsufficient reimbursement for treating
\nMedicare, Medicaid, and uninsured
\npatients\n<\/p>\n

SOURCE: Smedley and Stith (2002)\n<\/p>\n

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The business imperatives and organizational necessities for aggressively
\ncreating a diversity program include, but are not limited to, the following:\n<\/p>\n

1. Reflection of the service population. The healthcare organization\u2019s
\ncaregivers and support staff should mirror the diversity of the population
\nthat the institution serves. Toward this end, the organization should
\nattract and take advantage of the talents, skills, and growth potential of
\nminority professionals within the community.\n<\/p>\n

2. Workforce utilization. Minority employees have a lot to contribute to the
\norganization. Leaders should recognize this fact and should be open to,
\nsensitive to, knowledgeable about, and understanding of the cultures,
\nmind-set, and practices of the organization\u2019s diverse workforce. Doing
\nso will not only enhance staff productivity and overall performance but
\nwill also boost staff morale.\n<\/p>\n

3. Work\u2013life quality and balance. Leaders should recognize that work and
\npersonal activities are interrelated, not separate preoccupations. Both are
\nperformed on the basis of necessity, practicality, efficiency, and spontaneity.\n<\/p>\n

4. Recruitment and retention. Attracting and retaining a diverse workforce
\nhave a lot to do with the state of the workplace. Leaders should create
\nan environment in which minorities feel included, professionally
\ndeveloped, and safe.\n<\/p>\n

5. Bridging generations. Generational differences in expectations,
\neducation, and values exist between younger and older staff. Such gaps
\nshould be acknowledged, and attention should be paid to the physical,
\nmental, and emotional well-being of all caregivers and staff at all ages
\nregardless of backgrounds.\n<\/p>\n

6. Cultural competence. This competence is an in-depth understanding of
\nand sensitivity to the values and viewpoints of minority staff, patients,\n<\/p>\n

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\n<\/p>\n

FIGURE 6.2
\nHow to\n<\/p>\n

Create an
\nInclusive
\nCulture\n<\/p>\n

1. Study the culture, climate (i.e., what employees are thinking, feeling, or
\nhearing about diversity issues), and demographics of the organization.\n<\/p>\n

2. Select the diversity issues that allow the greatest breakthrough.\n<\/p>\n

3. Create a diversity strategic plan.\n<\/p>\n

4. Secure leadership\u2019s financial support for the plan.\n<\/p>\n

5. Establish leadership and management accountabilities for the plan.\n<\/p>\n

6. Implement the plan.\n<\/p>\n

7. Provide continual training related to the new skills and competencies
\nnecessary to successfully achieve the plan goals.\n<\/p>\n

8. Conduct a follow-up survey one or one-and-one-half years after
\nimplementing the plan.\n<\/p>\n

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and other customers. Leaders should master the skills necessary to work
\nwith and serve these groups and should provide training in this matter to
\nall employees to ensure provision of culturally competent care.\n<\/p>\n

7. Organization-wide respect. Leaders should create an environment in
\nwhich the differences in title, role, position, and department are valued
\nand respected but not held too lofty above everything else. Each
\nemployee, regardless of his or her level within the organization, should
\nbe viewed as integral to the overall success of the team.\n<\/p>\n

Summary\n<\/p>\n

Healthcare organizations in the United States are beginning to make a com-
\nmitment to embracing and fostering workforce diversity. This cultural change
\nmeans adopting new values in terms of being inclusive and attracting a diverse
\nworkforce. The business case for diversity is unique for each organization, as
\ncircumstances, the environment, and community demographics of one organ-
\nization vary from those of another. However, elements (such as the market-
\nplace and organizational effectiveness) that are common in all organizations
\ncan be the basis of a diversity program.\n<\/p>\n

One of the many reasons that senior management and the governing
\nboard should pay attention to diversity issues is to protect the organization\u2019s
\nbottom line. The financial costs of problems that stem from racial discrimina-
\ntion and discriminatory practices can be substantial. Studies have found dis-
\nparities in two areas: (1) minority healthcare administrators ascend in rank
\nmore slowly within their organizations than do their white counterparts, and
\n(2) patients who belong to minority groups receive different medical treat-
\nments than patients who are white. Such disparities may be bridged with the
\ndevelopment of a diversity program.\n<\/p>\n

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\n<\/p>\n

Discussion Questions\n<\/p>\n

1. While this chapter discussed the many
\nbenefits of diversity, an alternative view
\nsuggests that no empirical evidence
\nexists that a diverse workforce has a
\npositive effect on organizational
\nperformance, employee commitment,
\nand employee satisfaction. In fact,
\nanecdotal evidence indicates that
\ndiversity can negatively affect business\n<\/p>\n

performance because of the possibility
\nfor internal conflict, dissension, and
\nturnover. What is your reaction to this
\nperspective in light of the content of this
\nchapter? Do these arguments have
\nmerit? Why or why not?\n<\/p>\n

2. Respond to this statement: Diverse
\nleadership is a competitive advantage.
\nWhat is the most compelling business\n<\/p>\n

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argument for or against diverse
\nleadership teams?\n<\/p>\n

3. What are the legal, moral, and ethical
\nconsequences that prohibit hospitals from
\nturning away patients based on race?\n<\/p>\n

4. Why are there are no such consequences
\nto patients who demand doctors, nurses,
\nor workers of a specific race to administer
\ntheir healthcare?\n<\/p>\n

5. Can hospitals that adhere to gender- or
\nrace-based patient demands face
\ndiscrimination lawsuits from their
\nemployees?\n<\/p>\n

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\n<\/p>\n

6. When an employer denies an employee
\n(or a group of employees) his or her
\nfull employment opportunity based on
\nthe racial bias of customers, is the
\nemployer violating the employee\u2019s civil
\nrights?\n<\/p>\n

7. Does workforce diversity enhance
\norganizational performance? Explain
\nyour answer.\n<\/p>\n

8. Can an internal diversity program
\nsupport an organization\u2019s overall
\nmission and vision? How?\n<\/p>\n

Experiential Exercise\n<\/p>\n

Note: This case was adapted from Davis, R.
\nA. 2003. \u201cNo African Americans Allowed:\n<\/p>\n

White Patient\u2019s Racism Rules at Pennsylvania
\nHospital.\u201d DiversityInc.com, October 9.\n<\/p>\n

Abington Memorial Hos-
\npital is a 508-bed hospital\n<\/p>\n

located in Abington, Pennsylvania. It serv-
\nices patients from Philadelphia and the sur-
\nrounding suburbs of Bucks and Mont-
\ngomery counties. The hospital\u2019s mission \u201cis
\nto provide patients with the highest quality
\ncare possible, regardless of the health-care
\nprofessionals\u2019 race. . . .\u201d\n<\/p>\n

Supervisors at the hospital told
\nAfrican-American healthcare professionals, as
\nwell as food-service and housekeeping staff,
\nnot to enter a certain white patient\u2019s room or
\ninteract with the family. This caused an out-
\nrage among the African-American staff.
\nAbington administrators said they broke hos-
\npital policy to avoid a potentially \u201cvolatile sit-
\nuation\u201d by adhering to the request of the pa-\n<\/p>\n

tient\u2019s husband: Only white employees could
\nenter his wife\u2019s room on the maternity ward.
\n\u201cWe were wrong,\u201d said Meg McGoldrick, a
\nvice president at Abington Memorial Hospi-
\ntal. \u201cWe should have followed our policy.
\nThe whole incident has greatly upset many of
\nour employees who perceived that we were
\nacquiescing to the family\u2019s wishes.\u2019\u2019 Despite
\nthe hospital\u2019s policy that states, \u201ccare will be
\nprovided on a nondiscriminatory basis,\u201d the
\nadministrators\u2019 actions seemed as though pa-
\ntients were allowed to discriminate. Catholic
\nHealth Care West\u2019s medical ethicist, Carol
\nBayley, said that Abington failed in its respon-
\nsibility to its employees and the community
\nto accommodate a patient\u2019s racial preference:
\n\u201cThis was a fundamental disrespect of these
\nprofessionals\u2019 skills and their fundamental\n<\/p>\n

Case\n<\/p>\n

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References\n<\/p>\n

American College of Healthcare Executives (ACHE). 2002. A Race\/Ethnic Comparison of
\nCareer Attainments in Healthcare Management. Chicago: ACHE.\n<\/p>\n

\u2014\u2014\u2014. 2003. \u201cIncreasing and Sustaining Racial\/Ethnic Diversity in Healthcare Manage-
\nment.\u201d Healthcare Executive 18 (6): 60\u201361.\n<\/p>\n

Cohen, J., B. Gabriel, and C. Terrell. 2002. \u201cThe Case for Diversity in the Healthcare
\nWorkforce.\u201d Health Affairs 21 (5): 90\u2013102.\n<\/p>\n

Dreachslin, J. L. 1996. Diversity Leadership. Chicago: Health Administration Press.
\nEqual Employment Opportunity Commission (EEOC). 2007. \u201cUnited Healthcare of\n<\/p>\n

Florida to Pay $1.8 Million for Same-Sex Harassment and Retaliation.\u201d [Online in-
\nformation; retrieved 2\/4\/08.] www.eeoc.gov\/press\/10-1-07.html.\n<\/p>\n

Guillory, W. 2003. \u201cThe Business of Diversity: The Case for Action.\u201d Health & Social Work
\n28 (1): 3\u20137.\n<\/p>\n

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\n<\/p>\n

dignities . . . a hospital needs to stand against
\nthis undercurrent of racism in our society.\u201d\n<\/p>\n

The Philadelphia office of the Anti-
\nDefamation League (ADL) said that pro-
\nhibiting African-American employees from
\ncarrying out the full scope of their duties is
\nreprehensible. \u201cI don\u2019t see why and how a
\nhospital could justify accommodating a re-
\nquest that the professionals attending to a
\npatient be of a particular background,\u201d said
\nBarry Morrison, director of the Philadelphia
\nchapter of the ADL; he added, \u201cCertainly,
\nit\u2019s demoralizing for the people who work
\nthere.\u201d The American Hospital Association
\n(AHA), the largest hospital association in the
\nUnited States, acknowledged that no hard-
\nand-fast industry guidelines exist for hospi-
\ntals to follow when a patient or a family
\nmember makes a racially biased request.
\nAHA does not offer hospitals a suggestion
\non how to address this situation. \u201cIt\u2019s subjec-
\ntive,\u201d said Rick Wade, senior vice president at
\nthe AHA. \u201cI\u2019m sure the person who made
\nthe decision at Abington thought they were
\ndoing the right thing.\u201d McGoldrick said su-
\npervisors at Abington were acting with good\n<\/p>\n

intentions and sought to deflect any con-
\nfrontation between its African-American staff
\nand the Caucasian family. No incident was
\nreported during the patient\u2019s stay.\n<\/p>\n

Since then, Abington\u2019s president,
\nRichard L. Jones, sent a letter to all its employ-
\nees and volunteers apologizing for the situa-
\ntion, which he termed \u201cmorally reprehensi-
\nble.\u201d In addition to creating a diversity task
\nforce at the 508-bed hospital, Abington has
\nhired consultants and revised its antidiscrimina-
\ntion policy. The AHA bestowed on Abington
\nthe Quest for Quality Award for raising aware-
\nness of the need for an organizational commit-
\nment to patient safety and quality. Wade said
\nhospitals are constantly evaluating how to pro-
\nvide the best treatment for their patients, while
\nprotecting and maintaining the dignity of their
\nemployees. He said that a hospital\u2019s constant
\npatient turnover sometimes subjected workers
\nto society\u2019s underbelly. \u201cPerhaps Abington
\ncould have been more protective of their em-
\nployees,\u201d Wade said. \u201cPatients come and go,
\n[but] the most important thing at a hospital is
\nthe work-force,\u201d he said.\n<\/p>\n

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Institute for Diversity in Health Management (IFD). 2007. [Online information; re-
\ntrieved 11\/12\/07.] http:\/\/www.diversityconnection.org\/diversityconnection_
\napp\/homepage\/index.jsp?SSO_COOKIE_ID=0a2f011430daf6dc821f57c54388
\nae60bb29ec14700b.\n<\/p>\n

Institute of Medicine (IOM). 2004. In the Nation\u2019s Compelling Interest: Ensuring Diver-
\nsity in the Health Care Workforce. Washington, DC: National Academies Press.\n<\/p>\n

Puget Sound Business Journal. 2007. \u201cEEOC Sues Nordstrom in South Florida Over Ha-
\nrassment.\u201d [Online information; retrieved 6\/1\/07.] http:\/\/seattle.bizjournals.com\/
\nseattle\/stories\/2007\/10\/01\/daily6.html.\n<\/p>\n

Saha, S., S. Taggart, M. Komaromy, and A. Bindman. 2000. \u201cDo Patients Choose Their
\nOwn Race?\u201d Health Affairs 19: 76\u201383.\n<\/p>\n

Smedley, B. D., and A. Y. Stith. 2002. Unequal Treatment, Confronting Racial and Eth-
\nnic Disparities in Health Care. Washington, DC: Institute of Medicine, National
\nAcademies Press.\n<\/p>\n

Smith, D. B. 1999. Health Care Divided: Race and Healing a Nation. Ann Arbor, MI:
\nUniversity of Michigan Press.\n<\/p>\n

Thomas, D., and J. J. Gabarro. 1999. Breaking Through: The Making of Minority Execu-
\ntives in Corporate America. Boston: Harvard Business School Press.\n<\/p>\n

Williams, M. 2001. The 10 Lenses: Your Guide to Living and Working in a Multicultural
\nWorld. Sterling, VA: Capital Books.\n<\/p>\n

Witt\/Kieffer. 2006. Advancing Diversity Leadership in Health Care: A National Survey of
\nHealthcare Executives. Oak Brook, IL: Witt\/Kieffer.\n<\/p>\n

162 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\n<\/p>\n

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HEALTHCARE PROFESSIONALS\n<\/p>\n

Kenneth R. White, PhD, FACHE; Dolores G. Clement,\n<\/p>\n

DrPH, FACHE; and Kristie G. Stover, PhD\n<\/p>\n

CHAPTER\n<\/p>\n

4\n<\/p>\n

71\n<\/p>\n

Learning Objectives\n<\/p>\n

After completing this chapter, the reader should be able to\n<\/p>\n

\u2022 understand the role of healthcare professionals in the human resources
\nmanagement function of healthcare organizations;\n<\/p>\n

\u2022 define the elements of a profession, with an understanding of the
\ntheoretical underpinnings of the healthcare professions in particular;\n<\/p>\n

\u2022 describe the healthcare professions, which include the majority of
\nhealthcare workers, and the required educational levels, scopes of
\npractice, and licensure issues for each;\n<\/p>\n

\u2022 relate knowledge of the healthcare professions to selected human
\nresources management issues and systems development; and\n<\/p>\n

\u2022 comprehend the changing nature of the existing and emerging
\nhealthcare professions in the healthcare workforce, particularly the
\nimpact of managed care.\n<\/p>\n

Introduction\n<\/p>\n

Healthcare professionals are central to the delivery of high-quality healthcare
\nservices. Extensive training, education, and skills are essential in meeting the
\nneeds and demands of the population for safe, competent healthcare. These
\nspecialized techniques and skills that healthcare professionals acquired through
\nsystematic programs of intellectual study are the basis for socialization into
\ntheir profession. Additionally, the healthcare industry is labor intensive and is
\ndistinguished from other service industries by the number of licensed and reg-
\nistered personnel that it employs and the variety of healthcare fields that it pro-
\nduces. These healthcare fields have emerged as a result of the specialization of
\nmedicine, development of public health, increased emphasis on health promo-
\ntion and prevention, and technological advances and growth.\n<\/p>\n

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EBSCO Publishing : eBook Academic Collection (EBSCOhost) – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY
\nAN: 237620 ; Fottler, Myron D., Fried, Bruce.; Human Resources in Healthcare : Managing for Success
\nAccount: s8993066.main.ehost<\/p>\n<\/p>\n<\/div>\n

Because of this division of labor within medical and health services de-
\nlivery, many tasks that were once the responsibility of medical providers have
\nbeen delegated to other healthcare personnel. Such delegation of duties raises
\nimportant questions for the industry: Should healthcare providers other than
\nthose specifically trained to practice medicine be considered professionals in
\ntheir own right? To what extent should their scope of practice be extended?\n<\/p>\n

In this chapter, we respond to the aforementioned questions by defin-
\ning key terms, describing the healthcare professions and labor force, explain-
\ning the role of human resources in healthcare, and discussing key human re-
\nsources issues that affect the delivery of healthcare.\n<\/p>\n

Professionalization\n<\/p>\n

Although the terms \u201coccupation\u201d and \u201cprofession\u201d often are used inter-
\nchangeably, they can be differentiated.\n<\/p>\n

An occupation enables workers to provide services, but it does not re-
\nquire skill specialization. An occupation is the principal activity that supports
\none\u2019s livelihood. However, it is different from a profession in several ways. An
\noccupation typically does not require higher skill specialization. An individual
\nin an occupation is usually supervised, adheres to a defined work schedule, and
\nearns an hourly wage rate. An individual in an occupation may be trained for
\na specific job or function and, as a result, is less able to move from one organ-
\nization to another.\n<\/p>\n

A profession requires specialized knowledge and training that enable
\nprofessionals to gain more authority and responsibility and to provide service
\nthat adheres to a code of ethics. A professional usually has more autonomy in
\ndetermining the content of the service he or she provides and in monitoring
\nthe workload needed to do so. A professional generally earns a salary, requires
\nhigher education, and works with more independence and mobility than do
\nnonprofessionals.\n<\/p>\n

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

A countervailing force against the increasing educational requirements
\nof the healthcare professions is ongoing change in the mechanisms for deliv-
\nery and payment of services. With consolidation of the healthcare system and\n<\/p>\n

72 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\n<\/p>\n

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the rise of managed care, along with its demands for efficiency, fewer financial
\nresources are available. As a result, healthcare organizations are pressured to
\nreplace highly trained\u2014and, therefore, more expensive\u2014healthcare profes-
\nsionals with unlicensed support personnel. Fewer professionals are being
\nasked to do more, and those with advanced degrees are required to supervise
\nmore assistants who are functionally trained for specified organizational roles.\n<\/p>\n

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

1. Novice. At this stage, the novice learns tasks and skills that enable him or
\nher to determine actions based on recognized situations. Rules and
\nguidelines direct the novice\u2019s energy and action at this stage.\n<\/p>\n

2. Advanced beginner. At this stage, the advanced beginner has gained
\nenough experience and knowledge that certain behaviors become
\nautomatic, and he or she can begin to learn when tasks should be
\naddressed.\n<\/p>\n

3. Competent. At this stage, the competent individual has mastered the
\npracticed response of definable tasks and processes and has acquired the
\nability to deal with the unexpected events that may not conform to
\nplans.\n<\/p>\n

4. Proficient. At this stage, the proficient individual has developed the
\nability to discern a situation, intuitively assess it, plan what needs to be
\ndone, decide on an action, and perform the action more effortlessly than
\npossible in the earlier stages.\n<\/p>\n

5. Expert. At this stage, the expert can accomplish the goals without
\nrealizing that rules are being followed because the skill and knowledge
\nrequired to reach the goal have become second nature.\n<\/p>\n

Theoretical understanding is melded with practice in each progressive
\nstage. Functional training can help an individual progress through the first three
\nstages and can provide the individual with calculative rationality or inferential rea-
\nsoning ability to be able to apply and improve theories and rules learned. For skill
\ndevelopment at the proficient and expert levels, deliberative rationality or ability
\nto challenge and improve theories and rules learned is required. Healthcare pro-
\nfessionals need to become experts in fields where self-direction, autonomy, and
\ndecision making for patient care may be required (Dreyfus and Dreyfus 1996).\n<\/p>\n

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Healthcare Professionals\n<\/p>\n

The healthcare industry is the largest and most powerful industry in the
\nUnited States. It constitutes more than 6.5 percent of the country\u2019s total la-
\nbor force and nearly 15 percent of the gross domestic product. Healthcare
\nprofessionals include physicians, nurses, dentists, pharmacists, optometrists,
\npsychologists, nonphysician practitioners such as physician assistants and
\nnurse practitioners, healthcare administrators, and allied health professionals.
\nThe allied health professions are a huge group that consists of therapists,
\nmedical and radiologic technologists, social workers, health educators, and
\nother ancillary personnel. Healthcare professionals are represented by profes-
\nsional associations. Table 4.1 provides a sample of professional associations
\nin healthcare.\n<\/p>\n

Healthcare professionals work in a variety of settings, including hospi-
\ntals; ambulatory care centers; managed care organizations; long-term-care or-
\nganizations; mental health organizations; pharmaceutical companies; commu-
\nnity health centers; physician offices; laboratories; research institutions; and
\nschools of medicine, nursing, and allied health professions. According to the
\nBureau of Labor Statistics (BLS 2007), healthcare professionals are employed
\nby the following:\n<\/p>\n

\u2022 hospitals (34.5 percent),
\n\u2022 nursing and personal and residential care facilities (23.0 percent),
\n\u2022 physician offices and clinics (17.1 percent),
\n\u2022 home health care services (6.9 percent),
\n\u2022 dentist offices and clinics (6.3 percent), and
\n\u2022 other health service sites (12.2 percent).\n<\/p>\n

The U.S. Department of Labor recognizes about 400 different job ti-
\ntles in the healthcare sector; however, many of these job titles are not included
\nin our definition of healthcare professionals. For example, almost one-third of
\nthose employed in the healthcare sector probably belong in the support staff
\ncategory\u2014that is, employees who are part of the patient care team or involved
\nin delivering health services. These approximately 2.2 million nursing aides,
\nhome health aides, and personal attendants are critical to the delivery of
\nhealthcare services (BLS 2007).\n<\/p>\n

The primary reasons for the increased supply and demand for health-
\ncare professionals include the following interrelated forces:\n<\/p>\n

\u2022 technological growth,
\n\u2022 specialization,
\n\u2022 changes in third-party coverage,
\n\u2022 the aging of the population, and
\n\u2022 the proliferation of new and diverse healthcare delivery settings.\n<\/p>\n

74 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\n<\/p>\n

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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\n<\/p>\n

Organization Target Audience Website\n<\/p>\n

Health Professions\n<\/p>\n

Pew Health Professions Future health http:\/\/futurehealth
\nCommission professions .ucsf.edu\n<\/p>\n

American College of Future healthcare www.healthmanage
\nHealthcare Executives: managers and mentcareers.org
\nHealth Management Careers administrators\n<\/p>\n

Accrediting Organizations\n<\/p>\n

Accreditation Association for Ambulatory healthcare www.aaahc
\nAmbulatory Health Care facilities .org\n<\/p>\n

Accreditation Council for Graduate medical www.acgme
\nGraduate Medical Education education programs .org\n<\/p>\n

American Osteopathic Osteopathic hospitals www.osteopathic
\nAssociation and health systems .org\n<\/p>\n

Commission on Accreditation Rehabilitation facilities www.carf.org
\nof Rehabilitation Facilities\n<\/p>\n

The Joint Commission Hospitals and health www.joint
\nsystems commission.org\n<\/p>\n

National Committee for Health plans http:\/\/web
\nQuality Assurance .ncqa.org\n<\/p>\n

American Association of Blood banks www.aabb.org
\nBlood Banks\n<\/p>\n

American College of Surgeons www.facs.org
\nSurgeons\n<\/p>\n

American College of Cancer programs www.facs.org\/
\nSurgeons: Commission cancer
\non Cancer\n<\/p>\n

College of American Clinical laboratories www.cap.org
\nPathologists\n<\/p>\n

Professional Associations\n<\/p>\n

American College of Healthcare Healthcare executives www.ache.org
\nExecutives\n<\/p>\n

National Association of African-American www.nahse.org
\nHealth Services Executives healthcare executives\n<\/p>\n

Institute for Diversity in Health Healthcare managers, www.diversity
\nManagement students, organizations, connection.org\n<\/p>\n

diversity programs\n<\/p>\n

TABLE 4.1
\nResource Guide
\nfor the
\nHealthcare
\nProfessional\n<\/p>\n

(Continued)\n<\/p>\n

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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\n<\/p>\n

Organization Target Audience Website\n<\/p>\n

Medical Group Management Physician practice www.mgma.com
\nAssociation managers and\n<\/p>\n

executives\n<\/p>\n

American Hospital Association: Healthcare human www.hrleader.org
\nAmerican Society for resources
\nHealthcare Human Resources professionals
\nAdministration\n<\/p>\n

American College of Physician Physician executives www.acpe.org
\nExecutives\n<\/p>\n

American College of Health Long-term-care www.achca.org
\nCare Administrators administrators\n<\/p>\n

Association for Healthcare Medical www.ahdionline.org
\nDocumentation Integrity transcriptionists\n<\/p>\n

American Association of Nurse anesthetists www.aana.com
\nNurse Anesthetists\n<\/p>\n

American Association for Respiratory therapists www.aarc.org
\nRespiratory Care\n<\/p>\n

American Health Information Medical records www.ahima.org
\nManagement Association and information\n<\/p>\n

management
\nprofessionals\n<\/p>\n

American Medical Technologists Medical technologists www.amt1.com\n<\/p>\n

American Nurses Association Registered nurses www.ana.org\n<\/p>\n

American Association for Homecare www.aahomecare
\nHomecare administrators .org\n<\/p>\n

American Occupational Occupational www.aota.org
\nTherapy Association, Inc. therapists\n<\/p>\n

American Organization of Nurse executives www.aone.org
\nNurse Executives\n<\/p>\n

National League for Nursing Nurse faculty and www.nln.org
\neducators\n<\/p>\n

American Physical Therapy Physical therapists www.apta.org
\nAssociation\n<\/p>\n

American Society for Clinical Pathologists and www.ascp.org
\nPathology laboratory\n<\/p>\n

professionals\n<\/p>\n

American Society of Health- Health system www.ashp.org
\nSystem Pharmacists pharmacists\n<\/p>\n

TABLE 4.1
\nContinued\n<\/p>\n

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Organization Target Audience Website\n<\/p>\n

American Society of Radiologic Radiologic www.asrt.org
\nTechnologists technologists\n<\/p>\n

American Speech-Language- Speech-language www.asha.org
\nHearing Association pathologists;\n<\/p>\n

audiologists; and
\nspeech, language, and
\nhearing scientists\n<\/p>\n

Healthcare Financial Controllers, chief www.hfma.org
\nManagement Association financial officers,\n<\/p>\n

and accountants\n<\/p>\n

Healthcare Information and Health information www.himss.org
\nManagement Systems Society and technology\n<\/p>\n

managers\n<\/p>\n

National Cancer Registrars Cancer registry www.ncra-usa.org
\nAssociation professionals\n<\/p>\n

Trade Associations\n<\/p>\n

American Hospital Association Hospitals, health www.aha.org
\nsystems, and personal
\nmembership groups\n<\/p>\n

Federation of American Investor-owned www.fah.org
\nHospitals hospitals and health\n<\/p>\n

systems\n<\/p>\n

Association of American Teaching hospitals www.aamc.org\/
\nMedical Colleges: Council of and health systems members\/coth
\nTeaching Hospitals and
\nHealth Systems\n<\/p>\n

Catholic Health Association Catholic hospitals www.chausa.org
\nof the United States and health systems\n<\/p>\n

America\u2019s Health Insurance Health insurers www.ahip.org
\nPlans\n<\/p>\n

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\n<\/p>\n

TABLE 4.1
\nContinued\n<\/p>\n

This chapter focuses primarily on nurses, pharmacists, selected allied
\nhealth professionals, and healthcare administrators.\n<\/p>\n

Nurses\n<\/p>\n

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

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different areas, but the common thread of nursing is the nursing process,
\nwhich has five steps (ANA 2008):\n<\/p>\n

1. Assessment. This involves collecting and analyzing physical,
\npsychological, and sociocultural data about a patient.\n<\/p>\n

2. Diagnosis. This entails making a judgment on the cause, condition, and
\npath of the illness.\n<\/p>\n

3. Planning. This revolves around creating a care plan that sets specific
\ntreatment goals.\n<\/p>\n

4. Implementation. This includes supervising or carrying out the actual
\ntreatment plan.\n<\/p>\n

5. Evaluation. This focuses on continuous assessment of the plan.\n<\/p>\n

Nurses also serve as patient advocates, multidisciplinary team members,
\nmanagers, executives, researchers, and entrepreneurs.\n<\/p>\n

Nurses make up the largest group of licensed healthcare professionals
\nin the United States. According to the \u201cNational Sample Survey of Registered
\nNurses (NSSRN),\u201d the United States has 2.9 million registered nurses (RNs),
\nof whom more than 1.8 million (83.2 percent) are employed in healthcare or-
\nganizations (HRSA 2006a). Approximately 56 percent of employed RNs, or
\n1.6 million, work in hospitals, while 15 percent, or 435,000, work in commu-
\nnity or public health settings. Complementing this workforce are 749,000 li-
\ncensed practical nurses, or licensed vocational nurses as they are known in
\nsome states (BLS 2006).\n<\/p>\n

According to the demographic profiles from the NSSRN (HRSA
\n2006a), most nurses are women. In 2004, the average age of a nurse was 46.8
\nyears old, nearly two years older than in 1997, when the average age was 44.5
\nyears. The aging of the workforce is also reflected in the demographics of
\nnurses: The RN population under 30 years old dropped, from 25 percent in
\n1980 to 8 percent in 2004. Meanwhile, the percentage of nurses older than
\n54 years increased to 25.2 percent in 2004, compared to 20.3 percent in 2000
\nand 16.9 percent in 1980. Only 5.8 percent of RNs are men, and only 11 per-
\ncent of RNs come from racial\/ethnic minority backgrounds.\n<\/p>\n

All U.S. states require nurses to be licensed to practice. The licensure require-
\nments include graduation from an approved nursing program and successful
\ncompletion of a national examination. Educational preparation distinguishes
\nthe two levels of nurses.\n<\/p>\n

RNs must complete an associate\u2019s degree in nursing (ADN), a diploma
\nprogram, or a baccalaureate degree in nursing (BSN) to qualify for the licen-
\nsure examination. ADN programs generally take two years to complete and
\nare offered by community and junior colleges, and hospital-based diploma
\nprograms can be completed in about three years. The fastest growing avenue
\nfor nursing education is the baccalaureate preparation, which typically can be\n<\/p>\n

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\n<\/p>\n

Registered
\nNurses and\n<\/p>\n

Licensed
\nPractical\n<\/p>\n

Nurses\n<\/p>\n

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completed in four years and is offered by colleges and universities. Licensed
\npractical nurses (LPNs), on the other hand, must complete a state-approved
\nprogram in practical nursing and must achieve a passing score on a national
\nexamination. Each state maintains regulations and practice acts that delineate
\nthe scope of nursing practice for RNs and LPNs.\n<\/p>\n

Among employed RNs, about 34 percent hold associate\u2019s degrees,
\n20 percent have hospital-based program diplomas, and 34 percent possess
\nBSN degrees. In 2004, 13 percent of nurses reported having a master\u2019s de-
\ngree or a doctoral degree (HRSA 2006a). In addition to licensure and educa-
\ntional achievements, some nurses obtain certification in specialty areas such as
\ncritical care, infection control, emergency nursing, surgical nursing, and ob-
\nstetric nursing. The nursing field comprises many specialties and subspecial-
\nties; certification in these areas requires specialty education, practical experi-
\nence, and successful completion of a national examination. Some nurses
\nobtain certification in these specialty areas because certification helps them
\nmaintain their professional associations. To remain certified, continued em-
\nployment, continuing education units, or reexamination may be required.\n<\/p>\n

An advanced practice nurse (APN) is a nurse with particular skills and creden-
\ntials, which typically include basic nursing education; basic licensure; a grad-
\nuate degree in nursing; experience in a specialized area; professional certifica-
\ntion from a national certifying body; and, if required in some states, APN
\nlicensure (National Council of State Boards of Nursing 2006). The APN spe-
\ncializes as a nurse practitioner, certified nurse midwife, certified registered
\nnurse anesthetist, or clinical nurse specialist.\n<\/p>\n

The APN role is defined by seven core competencies or skillful per-
\nformance areas. The first core competency of direct clinical practice is central
\nto and informs all of the other areas, as follows (Hamric 2005):\n<\/p>\n

\u2022 Direct clinical practice (central)
\n\u2022 Expert guidance and coaching of patients, families, and other care providers
\n\u2022 Consultation
\n\u2022 Research skills, including use and implementation of evidence-based\n<\/p>\n

practice, evaluation, and conduct
\n\u2022 Clinical and professional leadership, which includes competence as a\n<\/p>\n

change agent
\n\u2022 Collaboration
\n\u2022 Ethical decision-making skills\n<\/p>\n

Additional core competencies may be needed in each specialty area that
\nan APN pursues. The largest number of APNs is made up of nurse practition-
\ners (NPs), who may further specialize in acute care or community settings or
\nfor particular client groups such as adults, children, women, or psychiatric\/
\nmental health populations.\n<\/p>\n

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Advanced
\nPractice
\nNurses\n<\/p>\n

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Each state maintains its own laws and regulations regarding recogni-
\ntion of an APN, but the general requirements in all states include licensure as
\nan RN and successful completion of a national specialty examination. Some
\nstates permit certain categories of APNs to write prescriptions for certain
\nclasses of drugs. This prescriptive authority varies from one state to another
\nand may be regulated by boards of medicine, nursing, pharmacy, or allied
\nhealth. Some states require physician supervision of APN practices, although
\nsome managed care plans now include APNs on their lists of primary care
\nproviders.\n<\/p>\n

Certified nurse midwives (CNMs) specialize in low-risk obstetric care, includ-
\ning all aspects of the prenatal, labor and delivery, and postnatal processes. Cer-
\ntified registered nurse anesthetists (CRNAs) complete additional education to
\nspecialize in the administration of various types of anesthesia and analgesia to
\npatients and clients. Often, nurse anesthetists work collaboratively with sur-
\ngeons and anesthesiologists as part of the perioperative care team. Clinical
\nnurse specialists (CNSs) hold master\u2019s degrees, have successfully completed a
\nspecialty certification examination, and are generally employed by hospitals as
\nnursing \u201cexperts\u2019\u2019 in particular specialties. The scope of the CNS is not as
\nbroad as that of the NP; CNSs work with a specialty population under a some-
\nwhat circumscribed set of conditions, and the management authority of pa-
\ntients still rests with physicians. In contrast, NPs have developed an au-
\ntonomous role in which their collaboration is encouraged, and they generally
\nhave the legal authority to implement management actions.\n<\/p>\n

Pharmacists\n<\/p>\n

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

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

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\n<\/p>\n

APN
\nSpecialization\n<\/p>\n

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Allied Health Professionals\n<\/p>\n

The term \u201callied health professionals\u201d is generally not well understood be-
\ncause of its ambiguous definition (O\u2019Neil and Hare 1990) and a lack of con-
\nsensus about what such a role constitutes. In general, allied health profession-
\nals complement the work of physicians and other healthcare providers,
\nalthough one may also be a provider. The U.S. Public Health Service defines
\nan allied health professional as follows (Health Professions Education Exten-
\nsion Amendments of 1992, Section 701 PHS Act):\n<\/p>\n

. . . a health professional (other than a registered nurse or a physician as-
\nsistant) who has received a certificate, an associate\u2019s degree, a bachelor\u2019s
\ndegree, a master\u2019s degree, a doctoral degree, or post-baccalaureate train-
\ning in a science related to health care; who shares in the responsibility for
\nthe delivery of health care services or related services, including (1) serv-
\nices relating to the identification, evaluation and prevention of disease and
\ndisorders, (2) dietary and nutrition services, (3) health promotion serv-
\nices, (4) rehabilitation services, or (5) health systems management serv-
\nices; and who has not received a degree of doctor of medicine, a degree of
\ndoctor of osteopathy, a degree of doctor of veterinary medicine or equiv-
\nalent degree, a degree of doctor of optometry or equivalent degree, a de-
\ngree of doctor of podiatric medicine or equivalent degree, a degree of
\nbachelor science in pharmacy or equivalent degree, a graduate degree in
\npublic health or equivalent degree, a degree of doctor of chiropractic or
\nequivalent degree, a graduate degree in health administration or equiva-
\nlent degree, a degree of doctor of clinical psychology or equivalent degree,
\nor a degree in social work or equivalent degree.\n<\/p>\n

A debate on the exclusiveness and inclusiveness of this definition con-
\ntinues. Some healthcare observers consider nursing, public health, and social
\nwork to fall under the umbrella of allied health, but these professions are of-
\nten categorized as separate groups. Figure 4.1 lists the major categories that
\ncompose the allied health profession and the job titles and positions that nor-
\nmally fall under each category.\n<\/p>\n

According to the \u201c2006 National Occupational and Wage Estimates
\nfor Healthcare Personnel,\u201d the allied health professions constitute 45.5 per-
\ncent of the healthcare workforce in the United States (BLS 2007). This num-
\nber excludes physicians, nurses, dentists, pharmacists, veterinarians, chiroprac-
\ntors, and podiatrists. The allied health profession is the most heterogeneous
\nof the personnel groupings in healthcare.\n<\/p>\n

The National Commission on Allied Health (1995) broadly divided
\nallied health professionals into two categories of personnel: (1) therapists\/
\ntechnologists and (2) technicians\/assistants. Some of the job titles presented
\nin Figure 4.1 may not fit into these two categories. In general, the therapist\/
\ntechnologist category represents those with higher-level professional training\n<\/p>\n

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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\n<\/p>\n

Behavioral Health Services\n<\/p>\n

\u2022 Substance abuse counselor \u2022 Community health worker
\n\u2022 Home health aide \u2022 Mental health assistant
\n\u2022 Mental health aide\n<\/p>\n

Clinical Laboratory Sciences\n<\/p>\n

\u2022 Laboratory associate \u2022 Laboratory microbiologist
\n\u2022 Laboratory technician \u2022 Chemist (biochemist)\n<\/p>\n

\u2022 Microbiologist
\n\u2022 Associate laboratory microbiologist\n<\/p>\n

Dental Services\n<\/p>\n

\u2022 Dental assistant \u2022 Dental hygienist
\n\u2022 Dental laboratory technologist\n<\/p>\n

Dietetic Services\n<\/p>\n

\u2022 Dietitian \u2022 Assistant director of food service
\n\u2022 Dietary assistant \u2022 Associate supervising dietitian\n<\/p>\n

Emergency Medical Services\n<\/p>\n

\u2022 Ambulance technician \u2022 Emergency medical technician\n<\/p>\n

Health Information Management Services\n<\/p>\n

\u2022 Director of medical records \u2022 Senior analyst of medical records
\n\u2022 Assistant director of medical records \u2022 Health information manager
\n\u2022 Medical record specialist \u2022 Data analyst\n<\/p>\n

\u2022 Coder\n<\/p>\n

Medical and Surgical Services\n<\/p>\n

\u2022 Electroencephalograph technician \u2022 Medical equipment specialist
\n\u2022 Electroencephalograph technologist \u2022 Electrocardiograph technician
\n\u2022 Operating room technician \u2022 Dialysis technologist
\n\u2022 Biomedical equipment technician \u2022 Surgical assistant
\n\u2022 Biomedical engineer \u2022 Ambulatory care technician
\n\u2022 Cardiovascular technologist\n<\/p>\n

Occupational Therapy\n<\/p>\n

\u2022 Occupational therapist \u2022 Occupational therapy aide
\n\u2022 Occupational therapy assistant\n<\/p>\n

Ophthalmology
\n\u2022 Ophthalmic technician \u2022 Optician
\n\u2022 Optometric aide\n<\/p>\n

FIGURE 4.1
\nMajor\n<\/p>\n

Categories of
\nthe Allied\n<\/p>\n

Health
\nProfession and\n<\/p>\n

Professional
\nTitles\n<\/p>\n

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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\n<\/p>\n

Physical Therapy\n<\/p>\n

\u2022 Physical therapist \u2022 Physical therapy assistant\n<\/p>\n

Radiological Services
\n\u2022 Nuclear medicine technician \u2022 Nuclear medicine technologist
\n\u2022 Radiation technician \u2022 Diagnostic medical sonographer
\n\u2022 Ultrasound technician \u2022 Radiologic (medical) technologist
\n\u2022 Medical radiation dosimetrist\n<\/p>\n

Rehabilitation Services
\n\u2022 Art therapist \u2022 Music therapist
\n\u2022 Exercise physiologist \u2022 Dance therapist
\n\u2022 Recreational therapist \u2022 Rehabilitation counselor
\n\u2022 Recreation therapy assistant \u2022 Rehabilitation technician
\n\u2022 Addiction counselor \u2022 Sign-language interpreter
\n\u2022 Addiction specialist
\n\u2022 Psychiatric social health technician\n<\/p>\n

Orthotics\/Prosthetics\n<\/p>\n

\u2022 Orthopedic assistant\n<\/p>\n

Respiratory Therapy Services\n<\/p>\n

\u2022 Respiratory therapist \u2022 Respiratory therapy technician
\n\u2022 Respiratory therapy assistant\n<\/p>\n

Speech-Language Pathology\/Audiology Services\n<\/p>\n

\u2022 Audiology clinician \u2022 Staff audiologist
\n\u2022 Staff speech pathologist \u2022 Speech clinician\n<\/p>\n

Other Allied Health Services\n<\/p>\n

\u2022 Central supply technician \u2022 Medical illustrator
\n\u2022 Podiatric assistant \u2022 Veterinary assistant
\n\u2022 Health unit coordinator \u2022 Chiropractic assistant
\n\u2022 Home health aide\n<\/p>\n

and who are often responsible for supervising those in the technician\/assistant
\ncategory. Therapists\/technologists usually hold a bachelor\u2019s or a higher-level
\ndegree, and they are trained to evaluate patients, understand diagnoses,
\nand develop treatment plans in their area of expertise. On the other hand,
\ntechnicians\/assistants are most likely to have two years or less postsecondary
\neducation, and they are functionally trained with procedural skills for speci-
\nfied tasks.\n<\/p>\n

FIGURE 4.1
\nContinued\n<\/p>\n

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Educational and training programs for the allied health profession are
\nsponsored by a variety of organizations in different academic and clinical set-
\ntings. They range from degree offerings at colleges and universities to clinical
\nprograms in hospitals and other health facilities. Before 1990, one-third of al-
\nlied health programs were housed in hospitals, although hospitals graduated
\nonly 15 percent of their students (O\u2019Neil and Hare 1990). The Association
\nof Schools of Allied Health Professions (ASAHP 2007) includes these among
\nits membership: 112 academic institutions, 2 professional associations, and
\napproximately 200 individual members. Junior or community colleges, voca-
\ntional or technical schools, and academic health centers can all sponsor allied
\nhealth programs. These programs can also be stand-alone when aligned with
\nan academic health center, or they can be under the auspices of the school of
\nmedicine or nursing if a specific school of allied health professions does not
\nexist. Dental and pharmacy technicians\/assistants may or may not be trained
\nin their respective schools or in a school of allied health professions.\n<\/p>\n

A vast number of the undergraduate allied health programs are accred-
\nited by the Commission on Accreditation of Allied Health Education Programs
\n(CAAHEP), a freestanding agency that in 1994 replaced the American Med-
\nical Association\u2019s Committee on Allied Health Education and Accreditation.
\nThe formation of CAAHEP was intended to simplify the accrediting process,
\nto be more inclusive of allied health programs that provide entry-level educa-
\ntion, and to serve as an initiator of more far-reaching change. Some key allied
\nhealth graduate programs, such as physical therapy and occupational therapy,
\nare accredited through specialty professional accreditation organizations.\n<\/p>\n

Healthcare Administrators\n<\/p>\n

Healthcare administrators organize, coordinate, and manage the delivery of
\nhealth services; provide leadership; and guide the strategic direction of health-
\ncare organizations. The variety and numbers of healthcare professionals they
\nemploy; the complexity of healthcare delivery; and environmental pressures to
\nprovide access, quality, and efficient services make healthcare institutions
\namong the most complex organizations to manage.\n<\/p>\n

Healthcare administration is taught at the undergraduate and graduate
\nlevels in a variety of settings, and these programs lead to a number of different
\ndegrees. The settings include schools of medicine, public health, healthcare
\nbusiness, and allied health professions. A bachelor\u2019s degree in health adminis-
\ntration allows individuals to pursue positions such as nursing home administra-
\ntor, supervisor, or middle manager in healthcare organizations. Most students
\nwho aspire to have a career in healthcare administration go on to receive a mas-
\nter\u2019s degree. (For a detailed description of various career paths and options, see
\nHaddock, McLean, and Chapman 2002).\n<\/p>\n

Graduate education programs in healthcare administration are ac-
\ncredited by the Commission on Accreditation of Healthcare Management\n<\/p>\n

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Education. Most common degrees include the master of health administra-
\ntion (MHA), master of business administration (MBA) with a healthcare em-
\nphasis), master of public health (MPH), or master of public administration
\n(MPA). However, the MHA degree, or its equivalent, has been the accepted
\ntraining model for entry-level managers in the various sectors of the health-
\ncare industry. The MHA program, when compared to the MPH program, of-
\nfers core courses that focus on building business management (theory and ap-
\nplied management), quantitative, and analytical skills and that emphasize
\nexperiential training. In addition, some MHA programs require students to
\ncomplete three-month internships or 12-month residencies as part of their
\ntwo- or three-year curricula. Some graduates elect to complete postgraduate
\nfellowships that are available in selected hospitals, health systems, managed
\ncare organizations, consulting firms, and other health-related organizations.\n<\/p>\n

A growing number of healthcare administrators are physicians and
\nother clinicians. As evidence, membership in the American College of Physi-
\ncian Executives (ACPE 2007) has increased to more than 10,000 in 2007, up
\nfrom 5,700 in 1990, although stable since 2000. Physicians, nurses, and other
\nclinicians refocus their careers on the business side of the enterprise, getting
\ninvolved in the strategy, decision making, resource allocation, and operations
\nof healthcare organizations. A traditional management role for physician ex-
\necutives is the chief medical officer (or a similar position) in a hospital, over-
\nseeing the medical staff and serving as a liaison between clinical care and ad-
\nministration. Likewise, a typical management career path for nurses is to
\nbecome the chief nursing officer, with responsibility for the clinical care pro-
\nvided by employed professional staff.\n<\/p>\n

Typically, chief medical officers begin their careers practicing medi-
\ncine, then they slowly transition into the operations side of healthcare. How-
\never, physician executives work at every level and in every setting in health-
\ncare. Many physician executives earn a graduate degree such as an MHA or
\nan MBA if interested in pursuing a formal educational program in healthcare
\nadministration and management. As of 2007, 49 medical schools offer a
\ncombined MD\/MBA program, and two medical schools offer the
\nMD\/MHA dual degrees (AAMC 2007). Whether physician executives start
\nas administrators or later shift to become executives after clinical practice,
\nthey represent for other doctors an alternative way to make an impact on
\nhealthcare delivery.\n<\/p>\n

Nursing home administrator programs require students to pass a na-
\ntional examination administered by the National Association of Long Term
\nCare Administrator Boards. Passing this examination is a standard require-
\nment in all states, but the educational preparation needed to qualify for this
\nexam varies from state to state. Although more than one-third of states still
\nrequire less than a bachelor\u2019s degree as the minimum academic preparation,
\napproximately 70 percent of the practicing nursing home administrators have,\n<\/p>\n

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at a minimum, a bachelor\u2019s degree. As the population continues to live longer,
\nthe demand and educational requirements for long-term-care administrators
\nare estimated to increase, along with the growth of educational programs tar-
\ngeted to this sector.\n<\/p>\n

Considerations for Human Resources Management\n<\/p>\n

The role of human resources management (HRM) in healthcare organiza-
\ntions is to develop and implement systems, in accordance with regulatory
\nguidelines and licensure laws, that ensure selection, evaluation, and retention
\nof healthcare professionals. In light of this role, human resources (HR) per-
\nsonnel should be aware that each of the healthcare professions, and often the
\nsubspecialties within those professions, has specific requirements that allow an
\nindividual to qualify for an entry-level job in his or her chosen profession. The
\nrequirements of national accrediting organizations (e.g., the Joint Commis-
\nsion), regulatory bodies (e.g., the Centers for Medicare & Medicaid Services),
\nand licensure authorities (e.g., state licensure boards) should be considered in
\nall aspects of HRM. In this section, we briefly discuss some of the issues that
\na healthcare organization\u2019s HR department must consider when dealing with
\nhealthcare professionals.\n<\/p>\n

Qualifications\n<\/p>\n

In developing a comprehensive employee-compensation program, HR per-
\nsonnel must include the specific skill and knowledge required for each job in
\nthe organization. Those qualifications must be determined and stated in
\nwriting for each job. The job description usually contains the level of educa-
\ntion, experience, judgment ability, accountability, physical skills, responsibil-
\nities, communication skills, and any special certification or licensure require-
\nments. HR personnel need to be aware of all specifications for all job titles
\nwithin the organization. This knowledge of healthcare professionals is neces-
\nsary to ensure that essential qualifications of individuals coincide with job
\nspecifications, and it is also necessary for determining wage and salary ranges
\n(see Chapter 7).\n<\/p>\n

Licensure and Certification\n<\/p>\n

An HR department must have policies and procedures in place that describe
\nthe way in which licensure is verified on initial employment. Also, HR must
\nhave a system in place for tracking the expiration dates of licenses and for en-
\nsuring licensure renewal. Therefore, HR must be conscientious about
\nwhether the information it receives is a primary verification (in which the in-
\nformation directly comes from the licensing authority) or a secondary verifica-
\ntion (in which a candidate submits a document copy that indicates licensure\n<\/p>\n

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has been granted, including the expiration date). Certifications must be veri-
\nfied during the selection process, although certifications and licenses are gen-
\nerally not statutory requirements. Many healthcare organizations accept a
\ncopy of a certification document as verification. If the certification is a job re-
\nquirement, systems must be in place to track expiration dates and to access
\nnew certification documents.\n<\/p>\n

Career Ladders\n<\/p>\n

In selecting healthcare professionals, HR personnel must consider past em-
\nployment history, including the explanation of gaps in employment. To assess
\nthe amount of individual experience, evaluating the candidate\u2019s breadth and
\ndepth of responsibility in previous jobs is essential. Many healthcare organiza-
\ntions have career ladders, which are mechanisms that advance a healthcare
\nprofessional within the organization. Career ladders are based on the Dreyfus
\nand Dreyfus model of novice to expert (explained earlier in the chapter), and
\nexperience may be used as a criterion for assignment of an individual to a par-
\nticular job category. In addition, healthcare organizations may conduct annual
\nreviews of employees who have leadership and management potential. This re-
\nview entails that HR works with senior management to assess the competency,
\nability, and career progression of employees on an ongoing basis.\n<\/p>\n

Educational Services\n<\/p>\n

Healthcare professionals require continuous, lifelong learning. Healthcare or-
\nganizations must have in-house training and development plans to ensure that
\ntheir healthcare professionals achieve competency in new technologies, pro-
\ngrams, and equipment and are aware of policy and procedure changes. Cer-
\ntain competencies must be renewed annually in areas such as cardiopulmonary
\nresuscitation, safety and infection control, and disaster planning.\n<\/p>\n

In addition to developing specific training programs, healthcare organ-
\nizations should provide orientation for all new employees. Such organization-
\nspecific training enables the leadership to share the values, mission, goals, and
\npolicies of the institution. Such clear communication often serves as a reten-
\ntion tool that enables employees to better understand how the organization
\nworks and how to be successful in that organization. Similarly, some profes-
\nsions and licensing jurisdictions may require continuing education that is pro-
\nfession specific.\n<\/p>\n

A healthcare organization can provide training and development in a
\nvariety of ways. On one end of the spectrum, training and development can
\nbe outsourced to a firm that specializes in conducting educational programs.
\nConversely, another option is to consolidate all training and development in-
\nhouse, which are managed typically by the HR department. Regardless of how
\neach healthcare organization provides continuing education, training and de-
\nvelopment should be a priority. Strong programs can be viewed as recruitment\n<\/p>\n

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and retention tools. As such, healthcare organizations must be cognizant of
\nfiscal resources necessary to support these educational requirements.\n<\/p>\n

Practitioner Impairment\n<\/p>\n

Healthcare professionals are accountable to the public for maintaining high
\nprofessional standards, and the governing body of a healthcare organization
\nis, by statute, responsible for the quality of care rendered in the organization.
\nThis quality is easily jeopardized by an impaired practitioner. An impaired
\npractitioner is a healthcare professional who is unable to carry out his or her
\nprofessional duties with reasonable skill and safety because of a physical or
\nmental illness, including deterioration through aging, loss of motor skill, or
\nexcessive use of drugs and alcohol.\n<\/p>\n

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

As a result of ever-increasing changes in the health professions, in
\nthe foreseeable future, new challenges and opportunities, such as the issues
\ndescribed in this section, will face the HR department of every healthcare
\norganization.\n<\/p>\n

Changing Nature of the Health Professions\n<\/p>\n

In the 1990s, we entered a new era of uncertainty in healthcare, one faced
\nwith a quickening pace of change (Begun and White 2008). Within this
\nframework, new ways of thinking are rewarded as the meaning of health is re-
\ndefined, the boundaries of healthcare professionals are reshaped, and the out-
\ncomes of healthcare professional interventions are measured in terms of qual-
\nity of life. Changes in the organization and financing of healthcare services
\nhave shifted delivery from the hospital to outpatient facilities, the home,
\nlong-term-care facilities, and the community. This is largely the result of
\nthree major forces: (1) a shift in managed care reimbursement to outpatient
\nsettings and a focus on cost containment; (2) technological advances, such as\n<\/p>\n

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telemedicine and the electronic medical record; and (3) medical innovation\u2014
\nthe science of medicine has progressed to the point that complicated procedures
\nthat once required several nights of stay can now be treated with a simple pro-
\ncedure or even solely with medication. These changes are intended to improve
\nthe delivery of healthcare while reducing cost and increasing access for patients.\n<\/p>\n

As the setting for the delivery of care continued to change, so did
\narrangements between physicians and healthcare organizations. For instance,
\nphysicians can function as individual providers (either in solo or group prac-
\ntice) and refer patients to the hospital. Typically, these private-practice doctors
\nhave admitting privileges to the hospital but are not governed by the hospi-
\ntal, do not serve as attending physicians, and infrequently participate on hos-
\npital committees. Physicians considered \u201con staff\u201d at any hospital are those
\nwho refer and treat patients at that hospital. They are credentialed by the hos-
\npital credentialing committee (usually managed by the chief of staff office)
\nand are governed by the medical staff bylaws. This is a common type of hos-
\npital-provider arrangement.\n<\/p>\n

However, a trend toward hospitals employing physicians has been
\ngrowing. In this arrangement, physicians are on staff, referring to and treat-
\ning at only the hospital that employs them. Because they are considered em-
\nployees, physicians are not only held to the HR policies of the healthcare or-
\nganization but are also governed by the medical staff bylaws. Physicians who
\nare employed by a hospital can also maintain a private practice.\n<\/p>\n

Finally, the field of hospitalists is also growing. Typically, these physi-
\ncians do not run their own practice aside from their hospital employment.
\nHospitalists work full time for the hospital and are trained in delivering spe-
\ncialized inpatient care. Regardless of the type of arrangement, most hospitals
\nhave a chief medical officer, or a similar position, who oversees the roles and
\nresponsibilities of the hospitalist as a member of the medical staff; the hospi-
\ntalist\u2019s employee issues and responsibilities are typically managed by the HR
\ndepartment. These hospital\u2013physician arrangements get more complex in ac-
\nademic medical centers, which must integrate the roles and responsibilities of
\nthe physicians, the hospital, and the medical school.\n<\/p>\n

As a result of the changing environment and decreased reimburse-
\nment, more primary care physicians are joining or forming group practices.
\nLarge physician-owned group practices offer several advantages to physi-
\ncians, including competitive advantage with vendors and manufacturers, im-
\nproved negotiating power with managed care organizations, shared risk and
\ndecision making, and improved flexibility and choice for patients. Physicians
\nusually own or share ownership in the group practice and, therefore, are re-
\nsponsible for the business operations. Typically, group practices employ an
\noffice manager who works closely with the physicians to manage the day-to-
\nday operations. Often, a full-time administrator is on staff not only to man-
\nage everyday issues but also to formulate strategies and oversee personnel,\n<\/p>\n

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billing and collection, purchasing, patient flow, and other functions. Many
\ngroup practices opt to outsource their business functions, including human
\nresources, to specialized firms. For complete details on medical practice man-
\nagement, go to www.mgma.com.\n<\/p>\n

These shifts in various healthcare settings and arrangements have
\nchanged the roles, functions, and expectations of the healthcare workforce
\nand gave way to the emergence of the following issues.\n<\/p>\n

Supply and Demand\n<\/p>\n

Throughout the twentieth century, the nursing labor market cycled through
\nperiods of shortages and surpluses (Lynn and Redman 2005; Aiken et al.
\n2002; Kovner 2002; Coile 2001; Jones 2001; Buerhaus, Staiger, and Auer-
\nbach 2000). The beginning of the twenty-first century brought the nursing
\nand allied health professions the challenge of keeping pace with the demand
\nfor their services. Indicators of demand include numbers of vacancies,
\nturnover rates, and an increase in salaries. To fill positions, hospitals\u2014the
\nlargest employers of nurses and allied health professionals\u2014have raised salaries,
\nprovided scholarships, and given other incentives such as sign-on bonuses and
\ntuition reimbursement.\n<\/p>\n

The supply of nurses and allied health professionals is reflected in the
\nnumber of students in educational programs and those available for the
\nhealthcare workforce. Future supply of such professionals continues to be
\nthreatened by the following factors:\n<\/p>\n

\u2022 The aging of the nursing workforce. According to the results of the 2004
\nNational Sample Survey of Registered Nurses (HRSA 2006a), the
\naverage age for all nursing faculty was 51.6, and for nursing faculty who
\nhave doctoral degrees, it was 55.4 (up from 53.5 in 2003).\n<\/p>\n

\u2022 The decline in available educational resources. Almost two-thirds (68.5
\npercent) of the nursing schools that responded to the 2006 American
\nAssociation of Colleges of Nursing (AACN 2007a) survey identified
\nfaculty shortages as a reason for not accepting all qualified applicants
\ninto entry-level baccalaureate programs. The survey also noted lack of
\nclassroom space and clinical facilities and budgetary restraints.\n<\/p>\n

\u2022 The decline in nursing school enrollees. From 1995 through 2000,
\nenrollment decreased by 21 percent. From 2001 through 2007,
\nincreases of 3.7 to 16.6 percent were observed, but more than 30,000
\nqualified applicants were turned away from baccalaureate nursing
\nprograms in 2007 (AACN 2007a).\n<\/p>\n

As a result, recruitment of nursing and allied health professions stu-
\ndents has become a major focus of practitioners, professional associations, and
\nacademic institutions. In response, healthcare organizations (in addition to in-
\ncreasing salaries) are developing innovative ways to recruit and retain nurses\n<\/p>\n

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and allied health professionals. Such developments include opening or spon-
\nsoring new schools, offering shorter and more flexible shifts, and providing
\nchild care.\n<\/p>\n

Alternative Therapies\n<\/p>\n

Alternative therapies have gained more popularity, judging by the growing
\nnumber of publications on this topic in the lay press and in academic literature.
\nA turning point in this acceptance and increased respectability was the sentinel
\nstudy of the prevalence of the use of alternative or unconventional therapies
\n(Eisenberg et al. 1993). In the study, Eisenberg and colleagues concluded that
\none in three adults relied on treatments and interventions that are not widely
\ntaught at medical schools in the United States; examples of these alternative in-
\nterventions included acupuncture and chiropractic and massage therapies. In a
\nfollow-up study, Eisenberg and colleagues (1998) determined that, from 1990
\nto 1997, visits to alternative medicine practitioners increased by 47.3 percent.
\nAnother study reported that 75 (60 percent) out of the 125 medical schools
\nthat participated in the survey offered a course in complementary or alterna-
\ntive medicine (Wetzel, Eisenberg, and Kaptchuk 1998). Additionally, con-
\nsumers are demanding the use of alternative therapies, and hospitals have be-
\ngun offering more of these services (Clement et al. 2006). As the use of
\nalternative therapies continues to gain acceptance and to be integrated in med-
\nical school curriculum, this specialty area may be more and more considered as
\nan emerging healthcare profession.\n<\/p>\n

Nonphysician Practitioners\n<\/p>\n

With the advent of managed care, greater reliance has been placed on non-
\nphysician practitioners. Collaborative practice models with nurse practition-
\ners, physician assistants, pharmacists, and other therapists are appropriate to
\nboth acute and long-term healthcare delivery. Strides have been made in the
\ndirect reimbursement for some nonphysician healthcare provider services,
\nwhich is an impetus for further collaboration in practice. The consolidation
\nand integration of the healthcare delivery system have not, however, elimi-
\nnated slack and duplication of services. Although the changes attributed to
\nmanaged care have led to the promotion and use of less-costly sites for care
\ndelivery, a larger impact on the division of labor among all healthcare profes-
\nsionals, and thus on health professions, may yet occur.\n<\/p>\n

Licensure and Certification\n<\/p>\n

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

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not only the demise of some healthcare professions but also the proliferation of
\nfunctionally trained, unlicensed personnel. The use of personnel who have less
\neducation will have greater implications for the existence and growth of educa-
\ntional programs in academic medical centers. The use of unlicensed support per-
\nsonnel poses concerns about the intensity and quality of healthcare delivered.
\nWhen fewer highly trained professionals are employed to oversee operations and
\ncare delivery, the potential for adverse outcomes increases. Aiken, Sochalski, and
\nAnderson (1996) found that, although the percentage of RNs increased over-
\nall, fewer nurses per patient were available in the mid-1990s than in the 1980s
\nto provide care for more acutely ill patients. The net effect was a relative increase
\nin nonclinical personnel, which added stress for those who were expected to su-
\npervise unlicensed staff and to care for sicker patients. This is a trend that con-
\ntinues to affect the provision of healthcare (Aiken et al. 2002).\n<\/p>\n

Recruitment and Retention\n<\/p>\n

Recruitment and retention of healthcare professionals are important in the
\nface of continuing shortages in key healthcare professions, including nursing
\nand allied health professions. The American Hospital Association (2007) re-
\nported an average hospital nurse vacancy rate of 8.1 percent. The RN vacancy
\nrate is projected to be 20 percent by 2020 (Buerhaus, Staiger, and Auerbach
\n2000; Heinrich 2001). This vacancy rate is related to an RN shortage, which
\nis estimated to be in the range of 340,000 to 1 million nurses by 2020 (Auer-
\nbach, Buerhaus, and Staiger 2007; HRSA 2006b). Nearly 17 percent of RNs
\nwere not employed in nursing in 2004, which was a 26.2 percent increase over
\nthe 1992 rate (HRSA 2006a). Letvak (2002) predicted that one in five nurses
\nplanned to leave the profession and turnover costs could be up to two times
\na nurse\u2019s salary. Fifty-five percent of nurses reported their intention to retire
\nbetween 2011 and 2020 in a survey released in 2006 (AACN 2007b), which
\nwould further contribute to the RN shortage. Similarly, the American Hospi-
\ntal Association (2007) reported vacancy rates among allied health profession-
\nals (e.g., occupational and physical therapists, laboratory technologists, imag-
\ning technicians) that range from 6 percent to 11 percent of needed positions.
\nThese shortages require current professionals to treat more patients and to
\nwork longer hours. Such conditions can contribute to emergency department
\ndiversions, increased patient wait times, and decreased patient safety.\n<\/p>\n

In response, healthcare organizations need to develop and execute re-
\ncruitment and retention programs. These programs require senior manage-
\nment support and dedicated financial and human resources. Such programs
\nshould focus on building a culture of retention. While salary is an important
\naspect of employee recruitment and retention, other aspects of work are
\nalso influential, such as leadership support, ability to contribute to the organ-
\nization and provide quality care to patients, degree of autonomy, engaging
\nin positive relationships with direct supervisors and peers, good working\n<\/p>\n

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conditions, and ability to maintain a work\u2013life balance. Additional tools for
\nretaining employees include conducting employee-engagement surveys, pro-
\nviding mentoring, and making training programs available.\n<\/p>\n

One innovative way to differentiate a hospital from its competitors,
\nwhich helps in recruitment and retention, is to achieve Magnet status. In
\n1993, the American Nurses Credentialing Center\u2019s Magnet Recognition Pro-
\ngram was developed as a way to specifically recognize excellence in nursing
\nservices at the institutional level and to benchmark best practices to be dissem-
\ninated throughout the industry. Hospitals that apply for and achieve Magnet
\nstatus have created and demonstrated a professional practice environment that
\nensures quality outcomes. These hospitals are recognized for their best prac-
\ntices in nursing care, improved patient outcomes, and increased workplace sat-
\nisfaction. The actual evaluation process is based on nine Magnet standards, the
\ncompletion of an intensive written application, and a two-day site visit by a
\nteam of nurse scholars. Hospitals that do not wish to engage in the applica-
\ntion process can benefit greatly from using Magnet strategies to create a cul-
\nture based on excellence in nursing and patient care (Pieper 2003). For more
\ninformation on Magnet status, see www.nursecredentialing.org\/magnet.\n<\/p>\n

Entrepreneurship\n<\/p>\n

Given the bureaucratic nature of organizations, the regulation of the health-
\ncare industry, and additional constraints by payers and managed care, many
\nhealthcare professionals are choosing to pursue opportunities on their own.
\nThe service economy coupled with knowledge-based professions may encour-
\nage pursuit of new and different ventures for individuals who have the person-
\nality, skills, and tenacity to go into business for themselves. An entrepreneur
\nmust have a mix of management skills and the means to depart from a tradi-
\ntional career path to practice on one\u2019s own.\n<\/p>\n

White and Begun (1998) characterize the entrepreneurial personality
\ntraits of a profession in terms of its willingness to take the risks associated with
\nundertaking new ventures. Each profession may be categorized either as de-
\nfending the status quo, which therefore entails little risk (defender professions),
\nor as looking for new and different opportunities with greater risk (prospector
\nprofessions). White and Begun view the more entrepreneurial professions as
\nmore diversified in terms of processes and services delivered. The accrediting
\nbodies of such entrepreneurial professions encourage educational innovation
\nthat may extend to nontraditional careers. Each of the healthcare professions
\nhas, to greater or lesser extents, defender and prospector aspects.\n<\/p>\n

Workforce Diversity\n<\/p>\n

Each of the healthcare professions must continue to monitor and encourage
\ndiversity in its membership because the demographic shifts that the United
\nStates is going through will have an impact on the workforce composition in\n<\/p>\n

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the coming decades. Although workforce diversity is a broad concept, it fo-
\ncuses on our differences in gender, age, and race; these aspects not only re-
\nflect the population that healthcare serves but also the people who provide the
\nservices. Some professions are dominated by one gender or the other, which
\nis illustrated by the predominantly female field of nursing or the historically
\npredominantly male field of health administration. The health administration
\nprofession, however, has made strides in recent years as more female adminis-
\ntrators have entered the field. Labor shortages and employee turnover are
\ncommon in the healthcare professions. Consequently, healthcare executives
\nmust balance the needs of new entrants into the profession and those already
\nin the profession.\n<\/p>\n

Changes in the ethnic and racial composition of the workforce are pro-
\nportional to the changes in the size and age of the population (D\u2019Aunno,
\nAlexander, and Laughlin 1996). Because many healthcare professionals are
\nracial\/ethnic minorities, a concerted effort needs to be made to recruit and
\nretain them because the diversity of the members of a profession should re-
\nflect the diversity of the members of the population.\n<\/p>\n

Summary\n<\/p>\n

Healthcare professionals are a large segment of the U.S. labor force. Histori-
\ncally, the development of healthcare professionals is related to the following
\ntrends:\n<\/p>\n

\u2022 Supply and demand
\n\u2022 Increased use of technology
\n\u2022 Changes in disease and illness
\n\u2022 The impact of healthcare financing and delivery\n<\/p>\n

The healthcare workforce is very diverse. The different levels of education,
\nscopes of practice, and practice settings contribute to the complexity of manag-
\ning this workforce. The coming decades will be characterized by some reforms
\nwithin the healthcare professions because of increasing pressures to finance and
\ndeliver healthcare with higher-quality, lower-cost, and measurable outcomes.\n<\/p>\n

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\n<\/p>\n

1. Describe the process of profes-
\nsionalization. What is the difference
\nbetween a profession and an
\noccupation?\n<\/p>\n

2. Describe the major types of healthcare
\nprofessionals (excluding physicians and
\ndentists) and their roles, training, licensure
\nrequirements, and practice settings.\n<\/p>\n

Discussion Questions\n<\/p>\n

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References\n<\/p>\n

Aiken, L. H., S. P. Clarke, D. M. Sloane, J. Sochalski, and J. H. Silber. 2002. \u201cHospital
\nNurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction.\u201d
\nJAMA 288 (16): 1987\u201393.\n<\/p>\n

Aiken, L. H., J. Sochalski, and G. F. Anderson. 1996. \u201cDownsizing the Hospital Nursing
\nWorkforce.\u2019\u2019 Health Affairs 15 (4): 88\u201392.\n<\/p>\n

American Association of Colleges of Nursing (AACN). 2007a. \u201cEnrollment Growth Slows
\nat U.S. Nursing Colleges and Universities in 2007 Despite Calls for More Regis-
\ntered Nurses.\u201d [Online news release; retrieved 1\/31\/08.] www.aacn.nche.edu\/
\nMedia\/NewsReleases\/2007\/enrl.htm.\n<\/p>\n

\u2014\u2014\u2014. 2007b. \u201cNursing Shortage.\u201d [Online news release; retrieved 1\/29\/08.] www.aacn
\n.nche.edu\/Media\/FactSheets\/NursingShortage.htm.\n<\/p>\n

American College of Physician Executives (ACPE). 2007. [Online information; retrieved
\n2\/4\/08.] www.acpe.org\/Footer\/AboutACPE.aspx.\n<\/p>\n

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\n<\/p>\n

3. Describe and apply the issues of human
\nresources management and systems
\ndevelopment to healthcare professionals.\n<\/p>\n

4. How has managed care affected the
\nhealthcare professions?\n<\/p>\n

5. Who are nonphysician practitioners who
\nprovide primary care? What is their role
\nin the delivery of health services?\n<\/p>\n

Experiential Exercise\n<\/p>\n

The purpose of this exercise is to give you an
\nopportunity to explore one healthcare pro-
\nfession in detail.\n<\/p>\n

From all of the healthcare professions,
\nselect one for analysis. Table 4.1 provides a
\nstarting point for selection. Describe the fol-
\nlowing characteristics of the profession you
\nselected:\n<\/p>\n

\u2022 Knowledge base
\n\u2022 Collective goals
\n\u2022 Training
\n\u2022 Licensure (this varies by state)
\n\u2022 Number of professionals in practice by\n<\/p>\n

1. Vertical differentiation (position,
\nexperience, education level)\n<\/p>\n

2. Horizontal differentiation
\n(geography, practice setting,
\nspecialty)\n<\/p>\n

\u2022 History and evolution of the profession
\n\u2022 Professional associations and their roles
\n\u2022 Competitor professions
\n\u2022 Current strategic issues that face the\n<\/p>\n

profession and the profession\u2019s position
\non these issues\n<\/p>\n

To get started on this exercise, you
\nmay wish to go to the websites of profes-
\nsional organizations and various state licens-
\ning boards. You may also interview members
\nof the profession as well as leaders in the
\nfield.\n<\/p>\n

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American Hospital Association. 2007. \u201cThe 2007 State of America\u2019s Hospitals\u2014Taking
\nthe Pulse: Findings from the 2007 AHA Survey of Hospital Leaders July 2007.\u201d
\n[Online information; retrieved 1\/31\/08.] www.aha.org\/aha\/content\/2007\/
\nPowerPoint\/StateofHospitalsChartPack2007.ppt.\n<\/p>\n

American Nurses Association (ANA). 2008. \u201cThe Nursing Process: A Common Thread
\nAmongst All Nurses.\u201d [Online article; retrieved 2\/6\/08.] www.
\nnursingworld.org\/EspeciallyForYou\/StudentNurses\/Thenursingprocess.aspx.\n<\/p>\n

Association of American Medical Colleges (AAMC). 2007. \u201cCombined Degree Pro-
\ngrams.\u201d [Online article; retrieved 7\/16\/07.] http:\/services.aamc.org\/currdir\/
\nsection3\/degree2.cfm.\n<\/p>\n

Association of Schools of Allied Health Professions (ASAHP). 2007. [Online information;
\nretrieved 2\/4\/08.] www.asahp.org\/history.htm.\n<\/p>\n

Auerbach, D. I., P. I. Buerhaus, and D. O. Staiger, 2007. \u201cBetter Late than Never: Work-
\nforce Supply Implications of Later Entry into Nursing.\u201d Health Affairs 26 (1):
\n178\u201385.\n<\/p>\n

Begun, J. W., and K. R. White. 2008. \u201cPositioning Nursing for Leadership in a Complex
\nHealthcare System.\u2019\u2019 In On the Edge: Nursing in the Age of Complexity, edited by
\nC. Lindberg, S. Nash, and C. Lindberg. Allentown, NJ: Plexus Institute.\n<\/p>\n

Buerhaus, P. I., D. O. Staiger, and D. I. Auerbach. 2000. \u201cImplications of a Rapidly Ag-
\ning Registered Nurse Workforce.\u201d JAMA 283 (22): 2948\u201354.\n<\/p>\n

Bureau of Labor Statistics (BLS). 2006. \u201cLicensed Practical and Licensed Vocational
\nNurses, 2006.\u201d [Online information; retrieved 2\/5\/08.] www.bls.gov\/oco\/
\nocos102.htm.\n<\/p>\n

\u2014\u2014\u2014. 2007. \u201cHealth Care.\u201d [Online information; retrieved 2\/6\/08.] www.bls.gov\/
\noco\/cg\/cgs035.htm.\n<\/p>\n

Clement, J. P., H. Chen, D. Burke, D. G. Clement, and J. L. Zazzali. 2006. \u201cAre Con-
\nsumers Reshaping Hospitals? Complementary and Alternative Medicine in US
\nHospitals 1999\u20132003.\u201d Health Care Management Review 31 (2): 109\u201318.\n<\/p>\n

Coile, R. C. 2001. \u201cMagnet Hospitals Use Culture, Not Wages, to Solve Nursing Short-
\nage.\u201d Journal of Healthcare Management 46 (3): 224\u201328.\n<\/p>\n

D\u2019Aunno, T., J. A. Alexander, and C. Laughlin. 1996. \u201cBusiness as Usual? Changes in
\nHealth Care\u2019s Workforce and Organization of Work.\u201d Hospital & Health Services
\nAdministration 41 (1): 3\u201318.\n<\/p>\n

Dreyfus, H. L., and S. E. Dreyfus. 1996. \u201cThe Relationship of Theory and Practice in the
\nAcquisition of Skill.\u2019\u2019 In Expertise in Nursing Practice: Caring, Clinical Judgment,
\nand Ethics, edited by P. Benner, C. A. Tanner, and C. A. Chesla. New York:
\nSpringer.\n<\/p>\n

Eisenberg, D. M., R. B. Davis, S. L. Ettner, S. Appel, S. Wilkey, M. Van Rompay, and R.
\nC. Kessler. 1998. \u201cRC Trends in Alternative Medicine Use in the United States,
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you have to do all\u00a0 1- EE2 Weeks 4 and 5. 2- look to Research topic ideas and pick one and do 2-DB5 Project Topic. 3-HCA 542 Research Project Requirements and Grading Guide 5 page. HCA 542, Knowledge Assessment\/ Do not exceed more than one page, double spaced, per question. This knowledge assessment is not […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":"","_joinchat":[]},"categories":[1],"tags":[],"_links":{"self":[{"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/posts\/155493"}],"collection":[{"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/comments?post=155493"}],"version-history":[{"count":0,"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/posts\/155493\/revisions"}],"wp:attachment":[{"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/media?parent=155493"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/categories?post=155493"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/tags?post=155493"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}

\n GRADING CRITERIA<\/p>\n<\/td>\n	\n Possible <\/p>\n Points<\/p>\n<\/td>\n	\n Points Awarded<\/p>\n<\/td>\n<\/tr>\n
\n \nFormat\/Layout (Weight 10%)<\/i>\n<\/p>\n<\/td>\n	\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Presentation of the text, margins, page numbers, <\/p>\n<\/td>\n	\n 5<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Follows requirements of length, font size, spacing<\/p>\n<\/td>\n	\n 5<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n \nContent\/Information (Weight 55%)<\/i>\n<\/p>\n<\/td>\n	\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Main idea about the topic is clear<\/p>\n<\/td>\n	\n 5<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Critical elements of the topic are addressed and developed<\/p>\n<\/td>\n	\n 10<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n The information is coherent, scientifically sound and based on careful research<\/p>\n<\/td>\n	\n 15<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Information is relevant with integrated HR management concepts<\/p>\n<\/td>\n	\n 5<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n \nQuality of Writing (Weight 20%)<\/i>\n<\/p>\n<\/td>\n	\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Clarity of sentences and paragraphs<\/p>\n<\/td>\n	\n 5<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Zero spelling and grammar errors. Demonstrate proper use of English<\/p>\n<\/td>\n	\n 5<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Organization and coherence of ideas, fluency, sequencing<\/p>\n<\/td>\n	\n 5<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Appropriateness of terms and concepts<\/p>\n<\/td>\n	\n 5<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n \nReferences and use of Credible Sources (Weight 15%)<\/i>\n<\/p>\n<\/td>\n	\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Use of scholarly\/peer reviewed references (no blogs!)<\/p>\n<\/td>\n	\n 5<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Appropriate citation of sources, no plagiarism (reasonable Safe Assign score)<\/p>\n<\/td>\n	\n 5<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n APA format followed<\/p>\n<\/td>\n	\n 5<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n
\n Total<\/p>\n<\/td>\n	\n \n80<\/b>\n<\/p>\n<\/td>\n	\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n Page 1 of 2<\/p>\n<\/p>\n <\/a><\/div>\n \n \n Labour Market Integration of Refugee Health \nProfessionals in Germany: Challenges and\n<\/p>\n Strategies\n<\/p>\n Sidra Khan-G\u20acokkaya* and Mike M\u20acosko*\n<\/p>\n ABSTRACT\n<\/p>\n Refugee health professionals are a vulnerable group in a host country\u2019s labour market as they \nexperience several barriers on their path to labour market integration. This study aims to iden- \ntify challenges refugee health professionals and their supervisors experience at their work- \nplaces and strategies they have developed to overcome these barriers. Semi-structured \ninterviews were conducted with refugee health professionals who have been living in Germany \nfor an average of four years and their supervisors (n = 24). The interviews were analysed \nusing qualitative content analysis. Nine themes were identified: (1) recognition of qualifica- \ntions, (2) language competencies, (3) differing healthcare systems, (4) working culture, (5) \nchallenges with patients, (6) challenges with team members, (7) emotional challenges, (8) dis- \ncrimination and (9) exploitation. Results indicate the need to implement structural changes in \norder to improve the labour market experiences of refugee health professionals.\n<\/p>\n BACKGROUND\n<\/p>\n The global healthcare workforce is facing skilled labour shortage. The World Health Organization \n(WHO) estimates a global shortage of 14.5 million health professionals by 2030 (World Health Orga- \nnization, 2006). The European Commission estimates a shortfall of 1 million health workers in Europe \nby 2020 (European Commission, 2012), and employment agencies in Germany predict a nationwide \nlack of health professionals (Bundesagentur f\u20acur Arbeit, 2018). In order to address this shortage, nearly \nall European countries depend on the recruitment of foreign-trained health professionals (Organisation \nfor Economic Co-operation and Development (OECD), 2017). Another strategy that has been imple- \nmented by the German government to address this shortage is the so-called \u201cactivation of domestic \npotential\u201d (Bundesregierung, 2018). With that, the German government aims to address those groups \nthat have difficult access to the labour market, such as refugees in order to improve their employability \nand use them to fill shortages (Bundesregierung, 2018). As the number of refugees in Germany has \nincreased since 2015, the German government has recognized the need to address their labour market \nintegration (Bundesregierung, 2016). However, refugees belong to a particularly vulnerable group in \nthe labour market facing unemployment or underemployment (Tanay et al., 2016).\n<\/p>\n University Medical Center Hamburg-Eppendorf, Hamburg, \nThis paper is part of a special issue on the \u201cLabour Market Integration of Highly Skilled Refugees in Sweden, Ger- \nmany and the Netherlands\u201d\n<\/p>\n doi: 10.1111\/imig.12752\n<\/p>\n \u00a9 2020 The Authors. International Migration \npublished by John Wiley & Sons Ltd on behalf\n<\/p>\n of International Organization for Migration \nInternational Migration\n<\/p>\n ISSN 0020-7985\n<\/p>\n This is an open access article under the terms of the Crea \ntive Commons Attribution-NonCommercial-NoDerivs \nLicense, which permits use and distribution in any medium, \nprovided the original work is properly cited, the use is non- \ncommercial and no modifications or adaptations are made.<\/p>\n<\/p>\n \nhttp:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/<\/a>\n<\/div>\n \n http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/<\/a>\n<\/div>\n<\/div>\n \n The barriers and difficulties that refugees face in the context of their labour market integration \nare multidimensional and manifold. First, their access to the labour market in Germany is restricted \nand depends on their legal status and the likelihood of getting a residency permit which in turn \ndepends on the country of origin (Bundesministerium f\u20acur Arbeit und Soziales, 2019). In Germany, \nthere is a ban on employment for all refugees within the first three months. After three months, \ntheir access to the labour market is dependent on the individual residency status. As of the fourth \nmonth, refugees need work permission from the foreign authority office in Germany and the local \nemployment agencies in order to work (Bundesministerium f\u20acur Arbeit und Soziales, 2019). Their \naccess to language courses depends on their legal status and the likelihood of receiving a residence \npermit (Bundesministerium f\u20acur Arbeit und Soziales, 2019). Moreover, participating in job-related \nlanguage courses is described as challenging either due to long waiting times or course availability \n(United Nations High Commissioner for Refugees-Organisation for Economic Co-operation and \nDevelopment (UNHCR-OECD), 2016). Second, refugee health professionals need to go through a \ndifficult and long recognition process (K\u20acortek, 2015; Desiderio, 2016) which is described as the \nstarting point for permanent downward mobility (Hawthorne, 2002). Moreover, refugees may not \nbe able to provide identity documents (Bucken-Knapp et al., 2019) or official documents about \ntheir education (Bloch, 2008) due to the flight which impedes the recognition process. Third, a lack \nof information about career pathways (Cohn et al., 2006), such as knowledge about job search \nstrategies (Willott and Stevenson, 2013) and unfamiliarity with the healthcare system of the host \ncountry (Ong et al., 2004), are reported barriers. Fourth, due to their flight they may have had a \nbreak in their professional career and\/or experienced the loss of their professional status (Willott \nand Stevenson, 2013) which is related to the loss of professional identity (Peisker and Tilbury, \n2003). It may also result in deskilling (Stewart, 2003), loss of self-confidence (Willott and Steven- \nson, 2013), high levels of frustration (Mozetic, 2018) and negative psychological impacts (Cohn \net al., 2006). Additionally, the lack of recognition of their previously gained experiences leads to a \nfeeling of being disadvantaged compared to locally trained team members (Mozetic, 2018) which \nmight be intensified by the experience of multiple forms of discrimination (Jirovsky et al., 2015) \nand exclusion (Bloch, 2008). \nStudies in Germany have also focused on the working experiences of migrant physicians and\n<\/p>\n international nurses from within the European Union as well as from non-European countries. They \nreport similar barriers as the above-mentioned. A study on migrant physicians (Klingler and Marck- \nmann, 2016) describes difficulties in three fields. The first field refers to the organization of health- \ncare institutions and other institutional difficulties such as insufficient support or being assigned to \ntasks below their level of expertise. Moreover, difficult career advancement opportunities and unfair \ntreatment of migrant physicians were mentioned as institutional difficulties. The second field relates \nto experienced difficulties with own competencies such as language competencies and knowledge \nabout the healthcare system. The third field relates to difficulties in interpersonal relations and inter- \nactions such as inadequate treatment of patients and co-workers. In this context, a study on the \nworkplace integration of internationally recruited nurses in Germany points out that conflicts often \narise between migrated nurses and locally trained team members. These conflicts arise because \nlocally trained team members either hold back or do not comprehensively share key information in \norder to organize their work. Thus, the incorporation of migrated nurses into daily work routine is \nimpeded and the potential for conflicts in everyday work is increased (P\u20acutz et al., 2019). These \nstudies illustrate that international healthcare professionals and refugee healthcare professionals \nexperience similar barriers at their workplaces. However, refugees were forced to flee by the cir- \ncumstances of their home countries (Yarris and Casta~neda, 2015), whereas internationally recruited \nhealth professionals may be considered as voluntary migrants. This distinction between refugees \nand voluntary migrants has effects on the barriers they experience. While voluntary migrants were \nmost likely able to prepare for their migration, refugees had to flee under extreme conditions (Jack- \nson et al., 2004). Stressors of the flight, the loss of family members, traumatic experiences and the\n<\/p>\n 2 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n uncertainty about their residency permit (Carlsson and Sonne, 2018) may also influence their pre- \nrequisites to work. Rather, in comparison to other highly qualified migrants, highly qualified refu- \ngees are more likely to stay in jobs they are overqualified for which mainly relates to the fact that \ndocumentation of their education is missing (Tanay et al., 2016). Moreover, some other barriers, \nsuch as housing, health, absence of networks or childcare, may indirectly influence employment \noutcomes (OECD\/UNHCR, 2018). \nThe European Parliament recommends qualification programmes to prepare refugees for work\n<\/p>\n and strengthen their employability (Konle-Seidl, 2016). These recommendations comprise individu- \nally tailored programmes to the specific needs of refugees. Amongst others, it is recommended to \nprovide (occupational specific) language courses combined with working opportunities, skills \nassessment, mentoring and career advice. For highly skilled refugees, it is especially recommended \nto increase availability of on the job trainings, recognize existing qualifications and offer vocational \ntraining. However, in order to implement tailored programmes that match the host countries\u2019 legal \nand social requirements it is essential to identify and analyse the barriers refugee health profession- \nals face when entering the labour market. While the legal situation of refugees and their access to \nthe labour market in Germany is documented through policy papers (European Commission, 2012; \nPlatonova and Urso, 2012; Konle-Seidl, 2016; Tanay et al., 2016; UNHCR-OECD, 2016; OECD, \n2017; United Nations Department of Economic and Social Affairs Population Division, 2017; \nUNHCR, 2017; Bundesministerium f\u20acur Arbeit und Soziales, 2019), little attention has been paid to \nthe challenges they face in everyday working life and their own perspective and strategies. Thus, in \nthis study, refugee health professionals and their supervisors across Germany were interviewed \nabout the challenges they faced at their workplaces as workplaces are a \u201ckey site of sociocultural \nincorporation\u201d (van Riemsdijk et al., 2016). Moreover, this paper advances this field by giving rec- \nommendations for healthcare providers and organizations based on the experiences of refugee \nhealth professionals and their supervisors in order to implement changes on structural levels and \nimprove the working environment. These changes refer to establishing supporting structures as well \nas measures of diversity management and anti-discrimination.\n<\/p>\n METHODS\n<\/p>\n The reporting of methods is in accordance with the consolidated criteria for reporting qualitative \nresearch (COREQ) guidelines (Tong et al., 2007).\n<\/p>\n Researcher characteristics\n<\/p>\n Qualitative research depends on the personal qualities of the researcher and the theoretical sensitiv- \nity that the researcher brings to a research (Strauss and Corbin, 1990). Thus, it is important to \nreflect on the researcher\u2019s characteristics and its impact on the interview situation. All interviews \nwere conducted in person by the first author, female, person of color, PhD student of the Depart- \nment of Medical Psychology at the University Medical Center Hamburg-Eppendorf. The first author \nis trained in cultural studies, international migration and intercultural studies and has several years \nof training in conducting qualitative studies. For transparency reasons, participants were informed \nthat the study was part of a PhD study.\n<\/p>\n Recruitment\n<\/p>\n Major educational organizations and projects for the labour market integration of refugee health \nprofessionals (RHPs) across Germany were identified through internet research. The organizations\n<\/p>\n Labour market: Refugee health professionals 3\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n (n = 15) were contacted and informed about the study. Their consent was obtained. Three of the \nmajor organizations agreed to participate in the study. Participants were divided into RHPs and \nsupervisors as the refugees\u2019 self-perception about their experiences might differ from the supervi- \nsors\u2019 perception. Since the group of RHPs comprises different professions, we decided on subdivid- \ning the stratum of RHPs into two groups: physicians and other health professions. In terms of data \nsaturation, it is recommended to conduct six to twelve interviews per stratum (Guest et al., 2006). \nThus, 24 interviews were conducted in three major cities in Germany (Hamburg, Hannover and \nFrankfurt). All three organizations provided persons that matched the inclusion criteria with infor- \nmation on this study and either arranged appointments or provided participants with the research- \ners\u2019 contact information. Inclusion criteria for participants referred to the following aspects: \nTarget group1.:\n<\/p>\n \u2022 Refugees (regardless of their residency status and form of protection) who have obtained a \nqualification in a health profession in their home country or a country other than Germany;\n<\/p>\n \u2022 Supervisors that were responsible for the integration of refugee health professionals, their \nsupervision or support\n<\/p>\n Language competencies:\n<\/p>\n \u2022 Required minimum level of German language competencies on the European Reference \nlevel of A2-B12.\n<\/p>\n Working experiences in Germany:\n<\/p>\n \u2022 RHPs must have had contact with the German healthcare system with a minimum duration \nof one month \u2013 be it a steady job, an internship or job shadowing\n<\/p>\n \u2022 Supervisors had to work in jobs with close contact with refugee health professionals regard- \nless of their hierarchical status. They must have had supervised RHPs at their ward or as an \nexternal supervisor\n<\/p>\n Context:\n<\/p>\n \u2022 RHPs and supervisors in all healthcare institutions comprising primary, secondary and ter- \ntiary care were included\n<\/p>\n Providers were informed about the inclusion criteria and selected fitting participants. All inter- \nviews were conducted in German. In one case the inclusion criteria did not match as the participant \nwas a student of the educational organization without sufficient working experience. Participants \nthat matched the inclusion criteria were approached via phone followed by an invitation to live \ninterviews. Participants received two consent forms: one for their participation in the study and one \nfor their consent to audio recording. The consent form and the study information were orally \nexplained prior to the interview.\n<\/p>\n Data collection\n<\/p>\n The interview guide was developed based on literature focused on the daily work experiences of \nrefugee health professionals using the SPSS3. approach by Helfferich (2009). The interview guide \nwas sent to experts in the field of migration research to be critically reviewed. Based on this \nreview, the authors discussed and adapted the interview guide. Finally, the interview guide was\n<\/p>\n 4 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n piloted with two migrant nurses that resulted in the specification of some questions. The interview \nguide was structured into six main themes:\n<\/p>\n (1) General experiences while working in a hospital \n(2) Experiences with team members and supervisors \n(3) Experiences with patients \n(4) Experiences with the working culture \n(5) Experiences with the healthcare system \n(6) Suggestions for improvement\n<\/p>\n In each interview, the same semi-structured guide was used. After the interview was finished and \nthe audio recorder was switched off, demographic data were retrieved. The interviews lasted from \n00:18 to 00:55 min with a median range of 00:40. Some (n = 4) interviews were transcribed by a \nstudent researcher but the majority (n = 20) of the interviews were transcribed verbatim by a pro- \nfessional agency. All transcripts were proofread by the first author.\n<\/p>\n Data analysis\n<\/p>\n The interviews were analysed using content analysis (Mayring, 2015). The first author coded all \ninterviews by means of a computer-based coding programme (MAXQDA, version 10). Deductive \ncodes were derived from the interview guide but as an explorative approach was preferred more \ninductive categories were derived from the material. Code memos were created for all codes includ- \ning a description of the code and typical quotes. For the purpose of quality assurance, a research \nassistant coded a random selection of one-quarter of all interviews. Differences in coding were dis- \ncussed until a consensus was reached that led to the creation of some new sub codes and a revision \nof the category system. Results were presented and discussed with other experts in an interdisci- \nplinary research colloquium to ensure comprehensibility and intersubjective reproducibility. The \nrevised system was then crosschecked by the main author in a second round of coding taking all \ninterviews into consideration.\n<\/p>\n Description of sample\n<\/p>\n Sixteen RHPs and 8 supervisors participated in the study. Two interviews were conducted via tele- \nphone due to reduced mobility of the participants. The sample is described in Table 1.\n<\/p>\n RESULTS\n<\/p>\n In general, nine major challenges could be identified which either RHPs or supervisors described as \nrelevant: (1) the recognition of professional qualifications, (2) language competencies, (3) different \nhealthcare systems, (4) working culture, (5) challenges with patients, (6) challenges with team \nmembers, (7) emotional challenges, (8) discrimination, (9) exploitation. Table 2 provides an over- \nview of the identified fields and their specifications.\n<\/p>\n Recognition4. of professional qualifications\n<\/p>\n Both supervisors and RHPs pointed out the challenges they faced with regard to the recognition \nprocess of their professional qualifications. Supervisors especially emphasized the difficulties \nregarding the recognition process. They criticized the long waiting times for the recognition process\n<\/p>\n Labour market: Refugee health professionals 5\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n TABLE 1\n<\/p>\n SAMPLE DESCRIPTION (REFUGEE HEALTH PROFESSIONALS AND SUPERVISORS)\n<\/p>\n Refugee health professionals (RHPs)\n<\/p>\n Participant Sex Age \nCountry \nof birth Occupation\n<\/p>\n Working \nexperience \nin Germany\n<\/p>\n Working experience \nin birth country\n<\/p>\n A1 m 26 Iran Nurse 1 month 6 years as a nurse \nA2 m 23 Iraq Physician 3 months 2 years as a general\n<\/p>\n physician and \n3 years as a \nsurgeon\n<\/p>\n A3 m 28 Syria Physiotherapist 2 years 4 years as a physio- \ntherapist\n<\/p>\n A4 m 28 Syria Physician \n(specialized \nin Anaesthesia)\n<\/p>\n 8 months 2,5 years as a medi- \ncal assistant in sur- \ngery\n<\/p>\n A6 m 33 Syria Physician 5 months 5 years as a physi- \ncian\n<\/p>\n A7 m 38 Afghanistan Physician one year 1 year as a medical \nassistant, 3 years in \npublic health depart- \nment\n<\/p>\n A8 w 29 Syria Physician 1,5 years 1 year as a physician \nA9 m 30 Afghanistan Physician 3 months 1 year as a medical\n<\/p>\n assistant \nA10 m 44 Syria Physician\n<\/p>\n (specialized \nin anaesthesia)\n<\/p>\n 3, 5 years 4 years as a medical \nassistant, two years \nas a senior physi- \ncian, 9 years as a \nchief physician\n<\/p>\n A11 w 52 Afghanistan Physician (specialized \nin gynaecology)\n<\/p>\n 6 months 23 years as a gynae- \ncologist (also as a \nchief gynaecologist)\n<\/p>\n A12 m 39 Yemen Physician 4 months 10 years as a physi- \ncian\n<\/p>\n A13 m 45 Afghanistan Physician 2 years 2,5 years as a physi- \ncian\n<\/p>\n A14 m 51 Syria Dentist 3 months 21 years as a dentist \nA15 m 39 Afghanistan Physician\n<\/p>\n (specialized \nin \notorhinolaryngology)\n<\/p>\n 6 weeks 3 years as an ear- \nnose-throat (ENT) \nspecialist\n<\/p>\n A16 w 33 Senegal Midwife and Nurse 3 months eleven months as a \nmidwife, 15 years \nas a nurse\n<\/p>\n A17 w 36 Azerbaijan Nurse 3 months 2 years as a nurse\n<\/p>\n Supervisors\n<\/p>\n Participant Sex Age \nCountry \nof birth Education Current job Experience\n<\/p>\n B1 m 34 Germany Physiotherapist Part time \nphysiothera- \npist, part \ntime supervi- \nsor for RHPs \nand migrants\n<\/p>\n 5 years as a \nphysiotherapist, \n1 year as a \nsupervisor\n<\/p>\n 6 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n (B2-B4, B8) and noted that the bureaucratic procedures for recognition in Germany were not clear \nand prolonged the recognition process (B4, B7, B8). RHPs also criticized the length and complex- \nity of the recognition process (A4, A7, A8, A11, A12). Two supervisors (B4, B8) criticized that \nformer positions such as leadership titles of RHPs were not recognized in Germany. They also criti- \ncized that RHP\u2019s specialist medical training or their internships in Germany were not considered \nfor recognition as working experiences. Furthermore, in one case there was confusion about the \nlegal foundations of the responsible authorities\u2019 bodies:\n<\/p>\n One colleague receives a temporary work permit [from the recognition authority] but federal medi- \ncal council law and health insurance company\u2019s law contradict each other which inhibits him from \nworking as a physician unless he has a full licence to practise medicine. But he can only acquire \nthe full license after taking an exam. Taking that exam is on hold because the [recognition] authori- \nties are understaffed. (B3)5.\n<\/p>\n RHPs (A1, A11, A13, A15) also indicated their anxiety regarding the licensing examinations as \nthey feared the examination would be too difficult.\n<\/p>\n Language competencies\n<\/p>\n Supervisors and RHPs considered acquiring German language proficiency and German technical \nand medical language as a major topic. Supervisors emphasized especially the need to learn the\n<\/p>\n TABLE 1\n<\/p>\n (CONTINUED)\n<\/p>\n Supervisors\n<\/p>\n Participant Sex Age \nCountry \nof birth Education Current job Experience\n<\/p>\n B2 m 64 Germany Librarian and editor Commissioner \nfor refugees \nat the medi- \ncal associa- \ntion in lower \nSaxony\n<\/p>\n 2,5 years as \na commissioner\n<\/p>\n B3 m 64 Germany Physician Physician and \nSupervisor \nfor RHPs\n<\/p>\n 34 years as a \nphysician, \none year as \na supervisor\n<\/p>\n B4 m 73 Germany Physician Supervisor for \nRHPs\/ \nretired\n<\/p>\n 47 years as \na physician, \n2 years as \na supervisor\n<\/p>\n B5 w 50 Germany Nurse and \nprofessional \nadvisor\n<\/p>\n Professional \nadvisor\n<\/p>\n 15 years as \nan advisor\n<\/p>\n B6 w 54 Germany Nurse Nurse and \nsupervisor\n<\/p>\n 37 years as nurse \nand supervisor\n<\/p>\n B7 w 38 Germany Nurse and \nPsychologist\n<\/p>\n Psychologist seven years as a \npsychologist\n<\/p>\n B8 m 52 Germany Physician, \nMedical \njournalist\n<\/p>\n Managing \ndirector of \nrefugee and \nmigrant edu- \ncation centre\n<\/p>\n 2 years as \nmanaging director\n<\/p>\n Labour market: Refugee health professionals 7\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n technical language. They (B1, B5, B8) described that RHPs were afraid to admit there were \nparts they did not understand and continued to say \u201cyes\u201d in order to maintain the conversation \nflow. This has often led to misunderstandings. RHPs described difficulties in speaking everyday \nlanguage and technical language. They (A1, A2, A4) found it difficult to understand handover \nreports from physicians or keep up in meetings and written documentation. They (A1, A3, A7, \nA12) were also afraid of not being able to understand the language which influenced their \nbehaviour:\n<\/p>\n I am afraid if [a patient] someone rings the bell. [. . .] Because my language is not [well] enough \nand I am afraid of understanding something wrong or not being able to answer [the patient\u2019s ques- \ntion]. That\u2019s why I remain seated and others [colleagues] keep asking me \u201cwhy are you always sit- \nting?\u201d (A1)\n<\/p>\n One of them also expressed their fear of being deemed to be incompetent due to their language \ncompetencies: \u201cThey think I have learned it wrong in Iran. But in fact I couldn\u2019t understand what \nthey were asking me\u201d (A1). Moreover, RHPs (A1, A3, A12) felt their language competencies held \nthem back as they were reluctant to share their opinion: \u201cIf we discuss a patient\u2019s case and some- \none has a contradicting opinion on that patient\u2019s case I am afraid to discuss our opinions as I fear \nthey will say \u2018I can\u2019t express myself\u2019\u201d (A3).\n<\/p>\n Different healthcare systems\n<\/p>\n Supervisors and RHPs described challenges that derived from differing standards in the home \nand host countries\u2019 healthcare system. All supervisors described that RHPs would have to \nfamiliarize themselves and catch up with the healthcare system in Germany. Eleven RHPs (A1, \nA2, A8, A9, A11-17) emphasized the difference in the medical equipment, the names of\n<\/p>\n TABLE 2\n<\/p>\n CHALLENGES EXPERIENCED BY REFUGEE HEALTH PROFESSIONALS\n<\/p>\n Recognition of professional \nqualifications\n<\/p>\n Difficulties in the context of the recognition process \nNon-recognition of former experiences \nExaminations for recognition\n<\/p>\n Language competencies Knowledge of everyday language \nKnowledge of technical language \nFeelings and consequences of lacking language competencies\n<\/p>\n Different healthcare systems Unfamiliarity with and differences between the healthcare systems \nUnfamiliarity with bureaucratic procedures within the healthcare system \nConsequences of differences and unfamiliarity\n<\/p>\n Working culture Adaption to formal aspects of work \nAdaption to cultural aspects of work \nIntercultural and interpersonal differences\n<\/p>\n Difficulties with patients Language difficulties \nDifficulties in delivering bad news \nDistrust from patients\n<\/p>\n Difficulties with team members Difficulties during internships \nInterpersonal and interprofessional difficulties\n<\/p>\n General Emotional Difficulties Discouragement \nNegative feelings of RHPs in the context of labour market integration.\n<\/p>\n Discrimination Discrimination by patients \nDiscrimination by team members\n<\/p>\n Exploitation Financial exploitation of RHPs in the context of work. \nProfessional exploitation of RHPs in the context of work\n<\/p>\n 8 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n medication and working habits and the feeling to need to familiarize themselves with these dif- \nferences. In this context, supervisors referred especially to the differing professional role of \nnurses in Germany:\n<\/p>\n They mostly come from countries where nursing care is much higher regarded as a profession, it \ngets a very high recognition. And here they have to understand this in such a way that the job \ndescription or the professional role is not so highly regarded. (B6)\n<\/p>\n RHPs (A1-4, A7, A9-A10, A12-A15) criticized bureaucratic procedures in hospitals in Germany \nas it was challenging to keep up with all the procedures of them. They (A4, A17, A16) did not \nknow about occupational law and were also insecure about their rights and obligations in their pro- \nfessional duties. During internships or work, they (A2, A3, A8, A9, A10, A13-17) felt held back \nas some of them were not allowed to work either because of their status as interns or because they \ndid not have their license yet:\n<\/p>\n Yes, the situation was unpleasant that I could not do anything alone. And if I wanted to do some- \nthing, someone had to stay with me, a senior physician or chief physician. That was a bit uncom- \nfortable for me because I already graduated from university and I also worked as an assistant \nphysician in my home country for a year. But I didn\u2019t have a solution. I had to come to Germany \nand here, the rule is if someone doesn\u2019t have a license he has to cooperate with a chief physician \nor with a senior physician. (A9)\n<\/p>\n Working culture\n<\/p>\n Supervisors described two facets of working culture that they found important in the context of \ntheir experiences with RHPs: formal and cultural aspects of work and RHPs adaption to these \naspects. They emphasized formal aspects such as being punctual, submitting holiday applications \ncorrectly, calling in sick, being polite and committed to work. Some of the supervisors (B1, B2, \nB3, B6, B7, B8) criticized some of these aspects in the context of RHPs as deficits. With regard to \ncultural aspects, supervisors mentioned that RHPs had different values that sometimes inhibited \ntheir integration such as examining other-sex patients (B1, B6-B8), taking off headscarves for sev- \neral reasons (B1, B8), dealing with homosexuality (B1) or accepting female superiors (B1-B4, B7). \nThese values were often attributed to cultural differences although they may result from context- \nspecific causes, as one supervisor who had a mediatory role describes:\n<\/p>\n The [female] colleague shouted at him [the RHP] in front of the patients [. . .] Luckily, we heard \nabout it and picked it up [. . .] she said he was a macho and suggested women were worth less than \nmen. The trigger was a basic nursing situation which is difficult for our participants as they haven\u2019t \nlearned it in their home countries. And she gave instructions that were too brief, for example \n\u201cwash\u201d and he didn\u2019t know what to do with that instruction. […] And that caused the escalation \nspiral. (B7)\n<\/p>\n RHPs were also asked about their experiences in the context of working culture. They pointed \nout that formal aspects of work, such as being punctual and committed, were universal. However, \nthey (A1, A3, A8, A13, A16) experienced differences on the intercultural and interpersonal level, \nsuch as the value of families and treating other sex patients, and developed several strategies to get \nadapted to it:\n<\/p>\n I was born in an Islamic country. I am not Muslim but born there and I grew up there. And some- \ntimes I think, maybe the [female] patient is embarrassed. Or I ask may I look, may I do. Because\n<\/p>\n Labour market: Refugee health professionals 9\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n maybe the other colleague does not say anything at all but for me it is a bit ok \u2013 maybe she has \nproblem with men and so on, so I ask. (A1)\n<\/p>\n Challenges with patients\n<\/p>\n RHPs experienced difficulties with patients especially if patients did not speak clearly due to their \nillness, their age or their way of speaking:\n<\/p>\n The problem was that I couldn\u2019t understand. For example, the patient said \u201cbring me this and that\u201d. \nAnd the problem was that they spoke very unclearly and for German people it [is] also difficult to \nunderstand and for me of course [it is] especially difficult. (A1)\n<\/p>\n Some described that talking to patients\u2019 relatives was a new challenging experience especially if \nthey were furious (A8) or if they had to pass bad news to them (A7). Another challenge was asso- \nciated with distrust from patients: \u201cMaybe they don\u2019t trust the foreign physicians as much but that\u2019s \ngeneral [generally the case]. All patients are like that, almost all of them. […] You can tell, they\u2019re \na little scared or something\u201d (A4).\n<\/p>\n Challenges with team members\n<\/p>\n Almost all supervisors (B2, B4-8) mentioned the important role of internships in the context of \nteam integration. However, one supervisor reported that finding internship placements became more \nand more difficult due to lower capacities of the hospitals (B4). During some internships, partici- \npants were not given appropriate tasks or were not supervised (B2, B5, B7, B8) as \u201cit is associated \nwith effort to take along someone\u201d (B7). Sometimes local trained team members were not aware of \nwhat RHPs were allowed or permitted to do which often led to misunderstandings (B5, B7, B8). \nAlmost all of the RHPs mentioned several other challenges in the context of teamwork, such as a \ndistanced relationship towards local trained team members (A8, A11, A15, A16), their expectation \nthat RHPs could do and know everything and wrong ideas of them and their education (A1, A9, \nA10).\n<\/p>\n General Emotional challenges\n<\/p>\n Some of the RHPs (A3, A8, A16) experienced discouragement on their path to reintegration. They \nwere told by their employment agency consultants that they could not succeed as health profession- \nals in Germany and were advised to pursue other career options:\n<\/p>\n I wanted to go to the hospital and see how this works. And I wasn\u2019t sure if I could do that again. I \nthought it is not possible. Because everywhere where I had asked [they said]: \u201cNo, you can\u2019t do \nthat. Do another one. Do a retraining and so on. Do some care. But you can\u2019t do midwife.\u201d And I \ncame to my ward. I saw it, it is the same thing. (A16)\n<\/p>\n Additionally to being discouraged, supervisors thought RHPs felt impeded (B4), afraid (B5, B7, \nB8), frustrated (B1, B6), under pressure and isolated (B1) as a consequence of the experienced bar- \nriers. Moreover, they acknowledged RHPs\u2019 loss of their professional status and mentioned that \nRHPs were reduced to their language deficits (B1, B6, B7) which influenced their self-perception \nand made them question themselves (B7).\n<\/p>\n 10 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n Discrimination\n<\/p>\n RHPs experienced several forms of discrimination. One supervisor reported that RHPs were some- \ntimes rejected and ignored in decision-making. He describes a situation between a refugee physi- \ncian and a locally trained nurse:\n<\/p>\n I can give you an example: my [refugee] physician is treating a patient. Another [locally trained] \nnurse has a question about that patient. He [the nurse] is standing in front of my [refugee] physi- \ncian and tells him: \u201cI don\u2019t want to clarify this with you. I will talk to your colleague who under- \nstands me.\u201d And that is a nice form of rejection. There are even more blatant cases. (B1)\n<\/p>\n Five supervisors (B1, B5, B6, B7, B8) and six RHPs (A1, A2, A3, A7, A10, A15) also reported \ndiscrimination from patients towards foreign health professionals: \u201cI was in the room, I had to take \n[a] blood [sample] and the patient and also her husband said: \u2018No, you may not come here. We do \nnot want a foreign physician here\u2019\u201d (A15). However, supervisors differentiated between open dis- \ncrimination and subtle racism from patients. They also differentiated between patients who did not \nfully trust RHPs and patients who treated them in a racist manner from the beginning. In the con- \ntext of foreign-trained health professionals, one supervisor described intersectional discrimination as \nsome patients racially and sexually harassed female nurses from Thailand:\n<\/p>\n There was a situation where an older \u201cfascist grandfather\u201d in quotation marks somehow said he \ndidn\u2019t want that or the Thai ladies \u2013 how shall I say, perhaps sexualised? So, with Thai participants \nor Asian looking participants, the gentlemen often become a little bit, how can you say, more \ncheeky. (B1)\n<\/p>\n Although this quote does not explicitly refer to refugee health professionals, it is likely that \nRHPs also experience intersectional discrimination. \nAdditionally, RHPs (A3, A4, A8, A10-A13, A15) experienced discrimination from senior team\n<\/p>\n members as one female physicians describes:\n<\/p>\n I was at that interview with the chief physician and at the end he said: \u201cYour German is well, […] \nbut there is something negative. [. . .] You have this headscarf. You are Muslim and there are a lot \nof (tourist? terrorists? [incomprehensible]). How can the patients be sure that you are not a (tourist? \nterrorist?)?\u201d That moment was horrible for me. (A8)\n<\/p>\n The physician described that she refused the position afterwards due to this experience and \nstarted working in a catholic hospital as her headscarf is not a problem there \u201cbecause nuns also \nwear a headscarf\u201d (A8).\n<\/p>\n Exploitation\n<\/p>\n In addition to the discrimination faced by patients and team members, two supervisors (B2, B8) \ndescribed experiences of exploitation:\n<\/p>\n There are hospitals who misuse the situation of RHPs. There are hospitals that pay below the pay \nscale (Tarifvertrag), very far below the scale. I will give you an example. There are hospitals in the \n[anonymized] region who employ physicians from Afghanistan, Syria, Iraq. They hire them for- \nmally as assistants, pay them 800 to 1200 Euros for a full time job, but they work as normal physi- \ncians and are involved in normal hospital routine. No plaintiff, no judge6.. For the RHP it is at \nleast something. He can work as a physician after a long time and familiarize with procedures, \nimprove his language and do what he is qualified to do. But, by our standards, that is exploitation.\n<\/p>\n (B8)\n<\/p>\n Labour market: Refugee health professionals 11\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n This would also affect RHPs\u2019 claims for benefits after terminating the employment (B8). Addi- \ntionally to financial exploitation, one supervisor also mentioned that RHPs were sometimes hired as \ngap fillers not correspondingly to their qualifications and did not have a long-term perspective \n(B8). RHPs did not explicitly mention being exploited. However, many of them were not yet per- \nmanently working and one reported doing unpaid overtime, as he did not know about working \nrights in Germany (A4).\n<\/p>\n Resources and strategies\n<\/p>\n RHPS and supervisors described several strategies they had developed in order to address the experi- \nenced barriers. These strategies refer to individual strategies of RHPs, strategies in the context of edu- \ncation and support, strategies on the team level and strategies on the organizational and societal level.\n<\/p>\n Individual strategies\n<\/p>\n All RHPs described several individual strategies to cope with challenges they had faced such as being \npatient (A1, A2, A6, A9), trusting and believing in their own power resources (A3, A13, A16) or pre-\/ \npost-processing relevant professional content (A1, A7, A12, A16). They also actively engaged with \ntheir colleagues, asked them questions, demanded feedback (A9, A16) in order to cope with language \ndeficits. Furthermore, RHPs developed several strategies to cope with patients\u2019 discrimination. They \neither tried to reassure patients (A10, A12), accepted patients\u2019 wishes and called a team member (A4), \nignored (A7) or avoided patients that rejected them (A16). In dealing with discrimination from team \nmembers, some RHPs would focus on their goal instead of focusing on conflicts and try not to think \ntoo much about these experiences (A12, A15). Others would use humour in order to unburden a \ntensed situations with jokes (A10). Staying silent was described as a strategy as well:\n<\/p>\n I didn\u2019t do anything and I didn\u2019t say anything because I knew that if I said something, the situation \nwould get worse and I didn\u2019t want that to happen. Yes, I was very calm and I wanted this nurse to \ngo home and think for herself, then she would understand. […] Yes, later she was a little better. All \nbeginnings are difficult. (A9)\n<\/p>\n Supervisors pointed out individual competencies of RHPs in dealing with the barriers. They \nemphasized RHPs\u2019 great commitment and their positive working attitudes. They also highlighted \nthe competencies of RHPs such as their intercultural competence (B4, B8), their openness to new \nexperiences (B1, B6, B7), a high motivation to work (BB7, B4, B3, B2), their cooperation capabil- \nity (B3), their gratefulness (B5) and their fighting spirit (B7).\n<\/p>\n Strategies in the context of education and support\n<\/p>\n In the field of education, supervisors demanded: mandatory, well organized, on the job programmes for \nall RHPs that are funded (B8), career advice services (B6, B7), follow-up support (B7), more resources \nand equipment for the training of RHPs (B4, B6, B7), material and support for language training.\n<\/p>\n Strategies on the team level\n<\/p>\n Generally speaking, positive contact towards patients and team members was perceived as very \nhelpful. One supervisor described RHPs\u2019 and patients\u2019 relationships as \u201ca mutual connection as \nthey are stronger dependent on each other\u201d (B7) than in other cases. Likewise, team members were \ndescribed by all RHPS to be open, interested and supportive: \u201cThey were all friendly and every\n<\/p>\n 12 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n morning when I came to work they smiled at me and said \u2018good morning\u2019. And that I find really \nimportant for a newly arrived\u201d (A12). Almost all of them (A1-A4, A7-A9, A11-A14, A16-A17) \nemphasized that colleagues were forthcoming if they had questions and that they benefitted from \ntheir induction and their feedback. Two of them (A8, A11) pointed out the role of other (locally \ntrained) interns and students who helped them in their free time. Supervisors focused more on \nstructural resources for teams. They suggested training for local team members and mediators (B1, \nB7), more personnel and more time to induct RHPs (B3, B6, B7), clear contact persons that RHPs \ncan talk to (B1, B4) and clear instructions of team members (B3). They also mentioned time to \nfamiliarize for RHPs (B1, B2, B6, B7), less patients to care for at the beginning (B7) and sensitiza- \ntion and reflexivity of locally trained team members (B1, B3, B7).\n<\/p>\n Strategies on an organizational and societal level\n<\/p>\n On an organizational and societal level, supervisors suggested enhancing an overall integration \napproach so that RHPs can have a quick arrival in the system (B1), build up networks (B1, B6) \nand earn their own money (B1). They also mentioned an opening welcoming culture (B1), public \nsensitivity actions and support from the management boards (B7):\n<\/p>\n But we also need the attitude from above [the management board] that says: \u201cWe want that [the \nlabour market integration of RHPs], and we also provide time and resources, and teams also get a \nbenefit for getting involved\u201d. (B7)\n<\/p>\n One supervisor referred to the commitment of supervisors and the healthcare providers when \nobserving racism and sexism: \u201cIf the hospital positions itself clearly and says \u2018take your documents \nand go home because we are not going to treat you\u2019. Great, because that is a clear line. But if they \ntalk around the issue the patient will continue to show racist behaviour\u201d (B8).\n<\/p>\n DISCUSSION\n<\/p>\n This paper aimed to explore the barriers and resources RHPs faced at their workplaces. The broad \nrange of identified barriers and difficulties indicates that their experiences depend very much on their \nemployers and their working environment. Moreover, as understaffing is a common problem in \nhealth care (Angerer et al., 2011; Deutscher Gewerkschaftsbund (DGB), 2018), it is questionable to \nwhat extent only RHPs are affected by these experiences or if they are a consequence of the precari- \nous staffing situations. Moreover, it remains open to what degree the migration status influences the \nexperienced challenges. Since no questions were asked about their flight, their psychological well- \nbeing or their residency permit and none of the participants mentioned it in the context of their \nworkplace experiences, it is not possible to state whether only refugees experience these barriers. \nInstead, our results indicate that when focusing at their workplaces, RHPs face similar barriers as \ninternationally recruited professionals and voluntary migrants (Humphries et al., 2013; Jirovsky \net al., 2015; Klingler and Marckmann, 2016; P\u20acutz et al., 2019). Nine major challenges were identi- \nfied: 1) recognition of qualifications, (2) language competencies, (3) different healthcare systems, (4) \nworking culture, (5) challenges with patients, (6) challenges with team members, (7) emotional chal- \nlenges, (8) discrimination and (9) exploitation. These challenges illustrate that hiring RHPs should \nnot be a quick response to filling shortages. Instead, the integration process should be carefully pre- \npared in order to prevent some of these challenges. Labour market integration is a two-sided process \nthat requires not only a welcoming culture but also welcoming structures (Knuth, 2019). Educational \nproviders, employers as well as authorities need to address these barriers and implement structural \nchanges in order to contribute to a sustainable labour market integration of RHPs.\n<\/p>\n Labour market: Refugee health professionals 13\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n Both RHPs and supervisors emphasized the challenges with the recognition process. This is con- \nsistent with previous findings that many legal and formal barriers inhibit a successful labour market \nintegration and prevent organizations to invest in RHPs integration (Schmidt, 2019). \nRHPs and supervisors both stressed the role of acquiring the language and the consequences of\n<\/p>\n lacking language competencies. RHPs suffered from not speaking German fluently, and it affected \ntheir self-esteem. Likewise, the knowledge and familiarization with the local healthcare system is \nan important prerequisite in order to deliver a good working performance. Both barriers are \nreported to be common challenges in the context of labour market integration of refugees as well \nas other migrant groups (Cohn et al., 2006; Bloch, 2008; Leblanc et al., 2013; Klingler and Marck- \nmann, 2016). This indicates a stronger need for occupational specific language courses and infor- \nmation on the healthcare system of the host country. This would not only concern educational \nproviders but also employers. In order to maintain a good quality of care and prevent misunder- \nstandings or mistreatment due to language barriers (Klingler and Marckmann, 2016), employers \ncan invest in further education of their RHP employees. Although this would mean additional \nfinancial investment from the employer, a corporate study indicates that those investments would \npay off within a year (Baic et al., 2017). \nIn the context of working culture, a fast adaptation to local standards was expected by supervi-\n<\/p>\n sors and team members. Deviations from these local standards were seen as problematic and \nobstructive. This coincided with results from other studies (Klingler et al., 2018; P\u20acutz et al., 2019) \nHowever, it remains problematic due to several reasons. Firstly, the term \u201clocal standards\u201d pre- \nsumes shared standards (Klingler et al., 2018). However, it remains unclear if these standards refer \nto professional standards, legal regulations, norms, cultural aspects or hospital routines. Secondly, \nthe knowledge about certain established standards may be tacit and implicit (Sakamoto et al., 2010) \nthus unspoken. As RHPs are unaware of these unspoken standards, deviations in behaviour can \nlead to frustration, conflicts and exclusion (Lai et al., 2017). Thirdly, most of the perceived differ- \nences in the context of working culture from the supervisors were culturalized. Supervisors saw the \ncauses of conflicts in cultural distinctions, although they could as well be interpreted situation and \nperson specifically or result from differing concepts of work. This is consistent with previous find- \nings (P\u20acutz et al., 2019) that in the process of labour market integration differing concepts attributed \nto work clash. These concepts may be influenced by stereotypes and prejudices. As a result, on the \none hand immigrated employees identify themselves as the \u201coutsiders\u201d contrary to local employees. \nOn the other hand, an enhancement of the existing working culture that could have been adaptable \nto a new environment is excluded (Steinberg et al., 2019). Fourthly, the performance of RHPs is \nmeasured according to their adaption and stabilization to the system. But the potential that RHPs \nbring along is wasted if adaption and stabilization are the only possible and acceptable outcomes \nsince they bring along important working experiences and attitudes that may enrich local standards. \nThus, it is important to verbalize standards and address them before or ideally concomitant to \nRHPs labour market integration (Sakamoto et al., 2010). At the same time, it is important to offer \nlocal team members opportunities to reflect on their own standards of work and their expectations. \nThis could also contribute to an overall improvement of the working atmosphere and reduce the \nchallenges experienced with team members. However, difficulties with team members were also \nattributed to a lack of supervision during internships. Results indicate that most of the time, indi- \nvidual team members were intrinsically motivated to support RHPs and engaged in their induction. \nBut the responsibility of integrating RHPs should not only be outsourced to committed employees \nor in the worst case, as described in the results, to unwilling employees. The support of RHPs \nshould be implemented on a structural level. It is estimated that a one and a half additional hours \nof individual support per month are sufficient to generate good integration prospects (Baic et al., \n2017). However, it remains open to question if team members who provide individual support \nshould be further trained and\/or remunerated for their effort. In order to expand the support possi- \nbilities, mentoring programmes could also be helpful in supporting RHPs. These findings are\n<\/p>\n 14 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n consistent with recommendations given by the German Employer Association stating that mentor- \ning programmes are a classical approach towards integrating foreign workers (Robra and B\u20acohne, \n2013). \nIn general, more acknowledgement and empowerment for RHPs is needed. This is consistent\n<\/p>\n with previous findings describing the loss of RHPs\u2019 professional status (Leblanc et al., 2013) result- \ning in deskilling (Stewart, 2003), the loss of self-confidence (Jirovsky et al., 2015), feelings of frus- \ntration (Mozetic, 2018) and negative psychological impacts (Cohn et al., 2006). Results in this \nstudy further indicate that RHPs experience several forms of discouragement, discrimination as well \nas disparagement, although they are fully educated and bring along valuable human capital (A9). \nAlthough RHPs have already developed several strategies in dealing with negative feelings and the \nbarriers they face, organizations and educational institutions could further engage in strengthening \nRHPs\u2019 professional identity, acknowledge their strategies and\/or make the potential of RHPs visible \nin order to empower them. \nIn the light of the discrimination that RHPs faced by team members and patients, healthcare pro-\n<\/p>\n viders need to promote measures of diversity management as discrimination may be one result of \npoor diversity management (Dickie and Soldan, 2008). Discrimination influences the motivation \nand job satisfaction of RHPs and in the long term, it can also have negative psychological impact \nand lead to leaves of RHPs (Bouncken et al., 2015). On the contrary, a diversity climate within the \norganization can enrich the psychological capital of refugee employees and contribute to their com- \nmitment (Newman et al., 2018). Nevertheless, several forms of discrimination from patients and \ncolleagues were commonly mentioned topics consistent with previous findings on RHPs\u2019 experi- \nences (Cohn et al., 2006; Bloch, 2008; Jirovsky et al., 2015). According to the federal German law \n\u201cGeneral Act on equal Treatment,\u201d employers are legally obliged to protect their employees from \ndiscrimination (Allgemeines Gleichbehandlungsgesetz, 2006). But especially experiences of racism \nare often denied in health care as \u201cthe illusion of non-racism\u201d exists and impedes progressive poli- \ncies (Johnstone and Kanitsaki, 2008). Progressive policies may refer to promoting equal opportu- \nnity policies (Wrench, 1999) and prevent any form of discrimination (B8). Condemning racist \ncomments (B8), establishing anti-discrimination commissioners, setting up transparent complaint \nsystems and offering anti-discrimination and empowerment workshops could be first steps (Wrench, \n1999) towards an inclusive and healthier working environment for both staff and patients. \nSimilarly, the exploitation of RHPs needs to be addressed and employers as well as policymakers\n<\/p>\n should take responsibility for it. Due to their uncertain legal status, foreign workers are at high risk \nof being exploited (Rights, 2010). Labour unions have recognized that and demanded that refugees \nmust be given access not only to the labour market but also to career advice services (Deutscher \nGewerkschaftsbund (DGB), 2015) in order to increase awareness of their working rights. Another \nway for employers to prevent exploitation could be to appoint an integration commissioner for their \norganizations. These commissioners could monitor the integration process and ensure compliance \nwith working rights. Educational providers working with clinics could inform RHPs as well as clin- \nics on the legal rights and duties of RHPs. In any case, this finding points to a severe grievance \nthat has not been reported in previous studies in this context. Further research is necessary to find \nout if these are selective experiences or structural problems in the health care sector. \nIn general, results indicate the need to reflect on the term integration itself. Several migration\n<\/p>\n scholars criticize the term for numerous reasons. Firstly, in Germany the term \u201cintegration\u201d mostly \nrefers to regulatory policies which focus on integrating migrants into the existing social orders \n(Karakayali and Bodjadzijev, 2010). However, social orders are predefined and shaped by members \nof the majority group (Essed, 2000). Secondly, the term is based on negative narratives about the \nunwillingness or failed integration of migrants which contributes to the fact that new demands are \nconstantly being claimed on migrants (Mecheril, 2011). Hence, the term puts migrants into the \nfocus while structural and institutional deficits as well as power asymmetries within the host coun- \ntries are ignored. Subsequently, the experiences of racism and exploitation that RHPs describe in\n<\/p>\n Labour market: Refugee health professionals 15\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n this study point to the need to focus research on structural and institutional inequalities, power \nasymmetries and intersectional discrimination. For further research in this context, it would be help- \nful to consider the Critical Race Theory (CRT) as it is based on principles of race equity and social \njustice and provides tools in order \u201cto elucidate contemporary racial phenomena, expand the vocab- \nulary with which to discuss complex racial concepts and challenge racial hierarchies\u201d (Ford and \nAirhihenbuwa, 2010). Furthermore, activists and scholars who contributed to the CRT study and \ntransform the relationship between race, racism and power (Delgado and Stefancic, 2017). How- \never, for the purpose of this study it can be concluded that equal participation in the labour market \nand society requires equal treatment, equal opportunities and protection against discrimination \n(Uslucan, 2017).\n<\/p>\n Policy recommendations\n<\/p>\n Refugee health professionals face personal, structural and institutional barriers at their workplaces. \nAlthough they have developed strategies to overcome these barriers, structural and institutional \nchanges are needed in order to improve the working environment. In the following, the most impor- \ntant conclusions from this study are pointed out as recommendations in order to contribute to a bet- \nter labour market and workplace integration of refugee health professionals. First, there is a need to \noffer job-specific language courses and courses addressing formal and cultural aspects of work (as it \nis done for example in Sweden (Ministry of Employment and Sweden, 2016)). Similarly, local team \nmembers need to be sensitized for cooperation with refugee health professionals in order to decrease \nthe potential for conflict. Second, structural changes within teams need to be implemented in order \nto supervise refugee health professionals and ensure a proper induction at the beginning. Third, in \nlight of the experienced barriers, the discrimination and the exploitation, there is a need to empower \nrefugee health professionals and make their qualifications and their potential visible. Fourth, mea- \nsures of diversity management and anti-discrimination need to be implemented and supported by the \nmanagement board. Fifth, compliance with working rights must be ensured and team members as \nwell as refugee health professionals need to be informed about their working rights.\n<\/p>\n Strengths and limitations\n<\/p>\n This study identified major challenges in the context of the working experiences of RHPs. By \nchoosing an explorative approach, a broad range of topics could be identified which provide a basis \nfor further research and in-depth analysis of the difficulties in the identified fields. The perspective \nof RHPs and their supervisors were integrated in order to get an insight into the field of health pro- \nfessions and the labour market integration into health professions. For further research, it could also \nbe helpful to interview colleagues of RHPs and focus on specific healthcare settings. Participants in \nthis study were selected from rural as well as urban areas and comprised several health professions. \nAnother strength of this study lies in the methodology. Discussing data with an interdisciplinary \ngroup ensures comprehensibility and critical reflection. Nevertheless, as participants were not \nrecruited representative and most participants worked only for a short time in Germany, there might \nbe a selection bias and results are questionable in terms of generalizability. Another limitation is \nthe compilation of the sample as more physicians and more men in urban areas were interviewed. \nIntersectional barriers, language competencies, training experience and other demographic-specific \naspects were neglected. Hence, no conclusions could be drawn for subgroups. Furthermore, \nalthough a certain language competency was required, language barriers and socially desirable \nanswers may have influenced the interview process. However, due to the researchers\u2019 background \nand the reflection of her characteristics, a trustful interview situation could be created and reflected \nafterwards.\n<\/p>\n 16 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n \n ACKNOWLEDGEMENT\n<\/p>\n We are grateful to the participants and to the organizations who have made this study possible \nthrough their support. Open access funding enabled and organized by Projekt DEAL.\n<\/p>\n FUNDER INFORMATION\n<\/p>\n The study was funded by the European Social Fund. SKG and MM received the funding. The fun- \nders did not play any role in the study design, data collection, decision to publish or preparation of \nthe manuscript.\n<\/p>\n DECLARATION OF INTERESTS\n<\/p>\n We have no conflicts of interest to disclose.\n<\/p>\n Peer Review\n<\/p>\n The peer review history for this article is available at https:\/\/publons.com\/publon\/10.1111\/imig. \n12752.\n<\/p>\n NOTES\n<\/p>\n 1. The terms \u201crefugee health professionals\u201d and \u201csupervisors\u201d were selected as they describe a shared experi- \nence. However, it should be noted that both terms reduce these persons to only one aspect of identity. The \nterms do not reflect the multiple aspects of identity and the social and ethical dimensions of the workplace \nidentity that all interviewed person and health care professionals have.\n<\/p>\n 2. The Common European Framework of Reference for Languages: Learning, Teaching, Assessment (CEFR) \nis a reference system to describe six levels (A1, A2, B1, B2, C1, and C2) of language proficiency from \nbeginners (A1) to experts (C2).\n<\/p>\n 3. SPSS is an abbreviation for Sammeln, Pr\u20acufen, Sortieren and Subsumieren (Collect, Check, Sort, Subsume). \n4. Health professions are registered professions in Germany which is why foreign health professionals need\n<\/p>\n to have a full or temporary license before they can practise. In order to obtain a license, they have to \ngo through a recognition process. The first step of the recognition process is an equivalence assessment. \nBased on this assessment, recognition bodies grant full recognition, no recognition or partial recognition. \nIf qualifications are only partly recognised, foreign health professionals can participate (professional \ngroups like nurses must participate) in adaption training programmes or internships and prove their \nrequired knowledge through language and proficiency tests. The proficiency tests covers internal medi- \ncine and surgery. However, based on the equivalence assessment authorities may also evaluate other \nsubjects.\n<\/p>\n 5. As the interviews were conducted in German, citations in this section were translated one-on-one from Ger- \nman to English. If terms were not equivalent in English, then those terms were translated one-on-one and \nsupplemented with further explanations in the reference mark (Koller, 2011 Einf\u20acuhrung in die \u20acUberset- \nzungswissenschaft [Introduction to translation science], Francke, T\u20acubingen; Basel.).\n<\/p>\n 6. \u201cNo plaintiff, No judge\u201d (German translation: Wo kein Kl\u20acager, da kein Richter) is a common phrase in \nGerman. It describes that certain irregularities or grievances remain uncovered as no one complains about \nthem.\n<\/p>\n Labour market: Refugee health professionals 17\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n \nhttps:\/\/publons.com\/publon\/10.1111\/imig.12752<\/a>\n<\/div>\n \n https:\/\/publons.com\/publon\/10.1111\/imig.12752<\/a>\n<\/div>\n<\/div>\n \n REFERENCES\n<\/p>\n Allgemeines Gleichbehandlungsgesetz (AGG) [General Act on Equal Treatment] \n2006 Allgemeines Gleichbehandlungsgesetz (AGG) in der Fassung vom [General Act on Equal Treat-\n<\/p>\n ment in the version dated] 14.08.2006, BGBl I, S.1897. \nAngerer, P., J. Glaser, R. Petru, et al. \n2011 “Arbeitsbedingungen der Klinik\u20acarzte: Gezielte Ma\u00dfnahmen, die sich lohnen.” [Working conditions\n<\/p>\n for hospital physicians: measures that pay off] Deutsches \u20acArzteblatt, 108(15): A-832 \/ B-679 \/ C- \n679.\n<\/p>\n Baic, A., H. Rentmeister, R. Strack, et al. \n2017 Integrationskraft Arbeit. 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URL: [http:\/\/www.europarl.europa.eu\/Re \ngData\/etudes\/STUD\/2016\/578956\/IPOL_STU(2016)578956_EN.pdf].\n<\/p>\n K\u20acortek, Y. \n2015 \u201cRechtlicher Rahmen der Anerkennung. [Legal framework for recognition]\u201d, in T. Ayan (Ed.),\n<\/p>\n Anerkennung ausl\u20acandischer Qualifikationen: Forschungsergebnisse und Praxisbeispiele. [Recogni- \ntion of foreign qualifications: Research results and practical examples]. Springer Fachmedien \nWiesbaden, Wiesbaden.\n<\/p>\n Lai, D.W., J. Shankar and E. Khalema \n2017 \u201cUnspoken skills and tactics: Essentials for immigrant professionals in integration to workplace cul-\n<\/p>\n ture\u201d, Journal of International Migration and Integration, 18(3): 937\u2013959. \nLeblanc, Y., I.L. Bourgeault and E. Neiterman \n2013 \u201cComparing approaches to integrating refugee and asylum-seeking healthcare professionals in\n<\/p>\n Canada and the UK\u201d, Health Policy, 9(Spec Issue): 126\u201338. \nMayring, P. \n2015 Qualitative Inhaltsanalyse. Grundlagen und Techniken, [Qualitative content analysis. Basics and\n<\/p>\n techniques], Beltz Verlag, Weinheim und Basel. \nMecheril, P. \n2011 \u201cWirklichkeit schaffen: Integration als Dispositiv \u2013 Essay\u201d, [Create reality: Integration as a disposi-\n<\/p>\n tive] APuZ \u2013 Aus Politik und Zeitgeschichte, 61(43): 49\u201354. \nMinistry of Employment, Sweden \n2016 “Fast track – a quicker introduction of newly arrived immigrants”. URL: [https:\/\/www.government.\n<\/p>\n se\/4a90b3\/contentassets\/e3606aadd3f248da81af73525110bf04\/fact-sheet-fast-track\u2013-a-quicker-introd \nuction-of-newly-arrived-immigrants].\n<\/p>\n Mozetic, K. \n2018 \u201cBeing highly skilled and a refugee: Self-perceptions of non-european physicians in Sweden\u201d, Refu-\n<\/p>\n gee Survey Quarterly, 37(2): 231\u2013251. \nNewman, A., I. Nielsen, R. Smyth, et al. \n2018 \u201cThe effects of diversity climate on the work attitudes of refugee employees: The mediating role of\n<\/p>\n psychological capital and moderating role of ethnic identity\u201d, Journal of Vocational Behavior, 105: \n147\u2013158.\n<\/p>\n Ong, Y.L., M. Bannon and E. Paice \n2004 \u201cGetting refugee doctors back to work : challenges, obstacles and solutions\u201d, in N. Jackson and Y.\n<\/p>\n Carter (Eds.), Refugee Doctors: Support, Development and Integration in the NHS. Radcliffe Pub- \nlishing, Abingdon.\n<\/p>\n Organisation for Economic Co-operation and Development & United Nations High Commisioner for Refugees \n(OECD & UNHCR) \n2018 Engaging with employers in the hiring of refugees. A 10-point multi-stakeholder action plan for\n<\/p>\n employers, refugees, governments and civil society. URL: [https:\/\/www.oecd.org\/els\/mig\/OECD- \nUNHCR-Action-Plan.pdf].\n<\/p>\n Organisation for Economic Co-operation and Development (OECD) \n2017 “Foreign-trained doctors and nurses\u201d. Health at a Glance 2017, OECD Indicators, Paris.\n<\/p>\n Peisker, V.C. and F. Tilbury \n2003 \u201c\u201cActive\u201d and \u201cpassive\u201d resettlement: the influence of support services and refugees\u2019 own resources\n<\/p>\n on resettlement style\u201d, International Migration, 41(5): 61\u201391. \nPlatonova, A. and G. Urso \n2012 Labour Shortages and Migration Policy. International Organization for Migration. URL: [https:\/\/\n<\/p>\n publications.iom.int\/books\/labour-shortages-and-migration-policy]. \nP\u20acutz, R., M. Kontos, C. Larsen, et al. \n2019 Betriebliche Integration von Pflegefachkr\u20acaften aus dem Ausland. Innenansichten zu Heraus-\n<\/p>\n forderungen globalisierter Arbeitsm\u20acarkte. [Integration of nursing staff from abroad. Inside views \non the challenges of globalised labour markets]. Hans-B\u20acockler-Stiftung, D\u20acusseldorf.\n<\/p>\n 20 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n \n http:\/\/www.europarl.europa.eu\/RegData\/etudes\/STUD\/2016\/578956\/IPOL_STU(2016)578956_EN.pdf<\/a>\n<\/div>\n \n http:\/\/www.europarl.europa.eu\/RegData\/etudes\/STUD\/2016\/578956\/IPOL_STU(2016)578956_EN.pdf<\/a>\n<\/div>\n \n https:\/\/www.government.se\/4a90b3\/contentassets\/e3606aadd3f248da81af73525110bf04\/fact-sheet-fast-track%2013-a-quicker-introduction-of-newly-arrived-immigrants<\/a>\n<\/div>\n \n https:\/\/www.government.se\/4a90b3\/contentassets\/e3606aadd3f248da81af73525110bf04\/fact-sheet-fast-track%2013-a-quicker-introduction-of-newly-arrived-immigrants<\/a>\n<\/div>\n \n https:\/\/www.government.se\/4a90b3\/contentassets\/e3606aadd3f248da81af73525110bf04\/fact-sheet-fast-track%2013-a-quicker-introduction-of-newly-arrived-immigrants<\/a>\n<\/div>\n \n https:\/\/www.government.se\/4a90b3\/contentassets\/e3606aadd3f248da81af73525110bf04\/fact-sheet-fast-track%2013-a-quicker-introduction-of-newly-arrived-immigrants<\/a>\n<\/div>\n \n https:\/\/www.oecd.org\/els\/mig\/OECD-UNHCR-Action-Plan.pdf<\/a>\n<\/div>\n \n https:\/\/www.oecd.org\/els\/mig\/OECD-UNHCR-Action-Plan.pdf<\/a>\n<\/div>\n \n https:\/\/publications.iom.int\/books\/labour-shortages-and-migration-policy<\/a>\n<\/div>\n \n https:\/\/publications.iom.int\/books\/labour-shortages-and-migration-policy<\/a>\n<\/div>\n<\/div>\n \n Robra, A. and A. B\u20acohne \n2013 Willkommenskultur \u2013 Ein Leitfaden f\u20acur Unternehmen. [Welcome Culture – a guide for companies]\n<\/p>\n Bundesvereinigung der deutschen Arbeitgeberverb\u20acande [Confederation of German Employers Asso- \nciations], Berlin.\n<\/p>\n Sakamoto, I., M. Chin and M. Young \n2010 \u201cCanadian Experience,” Employment Challenges and Skilled Immigrants. A Close Look through\n<\/p>\n “Tacit Knowledge\u201d, Canadian Social Work, 12(1): 145\u2013151. \nSchmidt, C. \n2019 “Integration von Gefl\u20acuchteten in die Pflege \u2013 Erfahrungen aus der Praxis.” [Integration of refugees\n<\/p>\n into care – experiences] Forschung Aktuell 5. \nSteinberg, S., M. Jegu and R. Klatt \n2019 \u201cEmpowerment und kollaborative Wertsch\u20acopfung. \u20acUberlegungen zu einem postindustriellen Para-\n<\/p>\n digma der Arbeitsintegration. [Empowerment and collaborative value creation. Reflections on a \npost-industrial paradigm of work integration ]\u201d, in A. David (Ed.), Migration und Arbeit – Heraus- \nforderungen, Problemlagen und Gestaltungsinstrumente. [Migration and work – challenges, prob- \nlems and instruments]. Verlag Barbara Budrich GmbH, Opladen, Berlin & Toronto.\n<\/p>\n Stewart, E. \n2003 \u2019A bitter pill to swallow: obstacles facing refugee and overseas doctors in the UK\u2019. Geneva:\n<\/p>\n Switzerland. United Nations High Commissioner for Refugees. URL: [https:\/\/www.unhcr.org\/resea \nrch\/working\/3fbb94a32\/bitter-pill-swallow-obstacles-facing-refugee-overseas-doctors-uk-emma-stewa \nrt.html].\n<\/p>\n Strauss, A. and J.M. Corbin \n1990 Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Sage Publications\n<\/p>\n Inc, Thousand Oaks, CA. \nTanay, F., J.C. Dumont, T. Liebig, et al. \n2016 How are Refugees faring on the Labour Market in Europe. European Commision and OECD, Euro-\n<\/p>\n pean Union. URL: [https:\/\/publications.europa.eu\/en\/publication-detail\/-\/publication\/87a8f92d-9aa8- \n11e6-868c-01aa75ed71a1].\n<\/p>\n Tong, A., P. Sainsbury, J. Craig \n2007 \u201cConsolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for inter-\n<\/p>\n views and focus groups\u201d, International Journal for Quality in Health Care, 19(6): 349\u2013357. \nUnited Nations Department of Economic and Social Affairs Population Division \n2017 International Migration Report 2017: Highlights, United Nations, New York. URL: [https:\/\/www.\n<\/p>\n un.org\/en\/development\/desa\/population\/migration\/publications\/migrationreport\/docs\/MigrationRe \nport2017_Highlights.pdf].\n<\/p>\n United Nations High Commissioner for Refugees & Organisation for Economic Co-operation and \nDevelopment (UNHCR & OECD) \n2016 Besch\u20acaftigung von Fl\u20acuchtlingen. Welche Chancen und Herausforderungen bestehen f\u20acur die Arbeit-\n<\/p>\n geber? [Employment of refugees. What are the opportunities and challenges for employers?] URL: \n[https:\/\/www.oecd.org\/els\/mig\/migration-policy-debates-10_de.pdf].\n<\/p>\n United Nations High Commissioner for Refugees (UNHCR) \n2017 Global Trends. Forced Displacement in 2017. United Nations High Commissioner for Refugees\n<\/p>\n (UNHCR), Switzerland. URL: [https:\/\/www.unhcr.org\/5b27be547.pdf]. \nUslucan, H.H. \n2017 \u201cDiskriminierungserfahrungen t\u20acurkeist\u20acammiger Zuwanderer_innen. [Experiences of discrimination\n<\/p>\n among Turkish migrants]\u201d, in K. Fereidooni and M. El (Eds.), Rassismuskritik und Widerstandsfor- \nmen. [Criticism of racism and forms of resistance]. Springer Fachmedien Wiesbaden, Wiesbaden.\n<\/p>\n Van Riemsdijk, M., S. Basford and A. Burnham \n2016 \u201cSocio-Cultural Incorporation of Skilled Migrants at Work: Employer and Migrant Perspectives\u201d,\n<\/p>\n International Migration, 54(3): 20\u201334. \nWillott, J. and J. Stevenson \n2013 \u201cAttitudes to Employment of Professionally Qualified Refugees in the United Kingdom\u201d, Interna-\n<\/p>\n tional Migration, 51(5): 120\u2013132. \nWorld Health Organization \n2006 The World Health Report 2006. Working together for health. WHO, Geneva, Switzerland.\n<\/p>\n Labour market: Refugee health professionals 21\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n \n https:\/\/www.unhcr.org\/research\/working\/3fbb94a32\/bitter-pill-swallow-obstacles-facing-refugee-overseas-doctors-uk-emma-stewart.html<\/a>\n<\/div>\n \n https:\/\/www.unhcr.org\/research\/working\/3fbb94a32\/bitter-pill-swallow-obstacles-facing-refugee-overseas-doctors-uk-emma-stewart.html<\/a>\n<\/div>\n \n https:\/\/www.unhcr.org\/research\/working\/3fbb94a32\/bitter-pill-swallow-obstacles-facing-refugee-overseas-doctors-uk-emma-stewart.html<\/a>\n<\/div>\n \n https:\/\/publications.europa.eu\/en\/publication-detail\/-\/publication\/87a8f92d-9aa8-11e6-868c-01aa75ed71a1<\/a>\n<\/div>\n \n https:\/\/publications.europa.eu\/en\/publication-detail\/-\/publication\/87a8f92d-9aa8-11e6-868c-01aa75ed71a1<\/a>\n<\/div>\n \n https:\/\/www.un.org\/en\/development\/desa\/population\/migration\/publications\/migrationreport\/docs\/MigrationReport2017_Highlights.pdf<\/a>\n<\/div>\n \n https:\/\/www.un.org\/en\/development\/desa\/population\/migration\/publications\/migrationreport\/docs\/MigrationReport2017_Highlights.pdf<\/a>\n<\/div>\n \n https:\/\/www.un.org\/en\/development\/desa\/population\/migration\/publications\/migrationreport\/docs\/MigrationReport2017_Highlights.pdf<\/a>\n<\/div>\n \n https:\/\/www.oecd.org\/els\/mig\/migration-policy-debates-10_de.pdf<\/a>\n<\/div>\n \n https:\/\/www.unhcr.org\/5b27be547.pdf<\/a>\n<\/div>\n<\/div>\n \n Wrench, J. \n1999 \u201cEmployers and anti-Discrimination Measures in Europe: Good Practises and Bad Faith\u201d, in J.\n<\/p>\n Wrench, A. Rea and N. Ouali (Eds.), Ethnic Minorities and the Labour Market. Integration and \nExclusion in Europe. Palgrave, United Kingdom.\n<\/p>\n Yarris, K. and H. Casta~neda \n2015 \u201cSpecial issue discourses of displacement and deservingness: interrogating distinctions between\n<\/p>\n \u201ceconomic\u201d and \u201cforced\u201d migration\u201d, International Migration, 53(3): 64\u201369.\n<\/p>\n 22 Khan-G\u20acokkaya and M\u20acosko\n<\/p>\n \u00a9 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of \nInternational Organization for Migration<\/p>\n<\/p>\n<\/div>\n<\/div>\n \n \n WORKFORCE DIVERSITY\n<\/p>\n Rupert M. Evans, Sr., DHA, FACHE\n<\/p>\n CHAPTER\n<\/p>\n 6\n<\/p>\n 145\n<\/p>\n Learning Objectives\n<\/p>\n After completing this chapter, the reader should be able to\n<\/p>\n \u2022 understand how proactive use of diversity principles can transform the \norganization\u2019s culture;\n<\/p>\n \u2022 understand the business case for diversity and inclusion in healthcare \norganizations;\n<\/p>\n \u2022 work toward creating an inclusive organizational culture; \n\u2022 define the roles that healthcare providers, management, and governance\n<\/p>\n play in building a business imperative for diversity within the \norganization; and\n<\/p>\n \u2022 discuss how healthcare leaders can develop a diversity program in their \norganizations.\n<\/p>\n Introduction\n<\/p>\n When you hear the term \u201cdiversity,\u201d what comes to mind? To some, the word \nmeans the differences between human beings related to race or ethnicity. To \nothers, it means the uniqueness of each individual. A few people still may jump \nup to argue that diversity is just a code word for affirmative action.\n<\/p>\n Healthcare organizations across the United States are beginning to \nmove toward embracing and fostering workforce diversity. This cultural \nchange means adopting new values that are inclusive and appropriately man- \naging a diverse workforce. In the future, diversity will drive the business prac- \ntices of hospitals and other healthcare organizations, and this dynamic will re- \nquire strong leadership. This change will take time, but in the words of \nReverend Jesse Jackson, \u201cTime is neutral and does not change things. With \ncourage and initiative, leaders change things.\u201d\n<\/p>\n In this chapter, we provide a definition of diversity and a framework for \nunderstanding the different ways people view the term. In addition, we high- \nlight several studies and legal issues pertaining to this topic and enumerate \nmethods for building a case for and establishing a diversity program.\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 145\n<\/p>\n C \no \np \ny \nr \ni \ng \nh \nt<\/p>\n 2 \n0 \n0 \n8 \n.<\/p>\n H \ne \na \nl \nt \nh<\/p>\n A \nd \nm \ni \nn \ni \ns \nt \nr \na \nt \ni \no \nn<\/p>\n P \nr \ne \ns \ns \n.\n<\/p>\n A \nl \nl<\/p>\n r \ni \ng \nh \nt \ns<\/p>\n r \ne \ns \ne \nr \nv \ne \nd \n.<\/p>\n M \na \ny<\/p>\n n \no \nt<\/p>\n b \ne<\/p>\n r \ne \np \nr \no \nd \nu \nc \ne \nd<\/p>\n i \nn<\/p>\n a \nn \ny<\/p>\n f \no \nr \nm<\/p>\n w \ni \nt \nh \no \nu \nt<\/p>\n p \ne \nr \nm \ni \ns \ns \ni \no \nn<\/p>\n f \nr \no \nm<\/p>\n t \nh \ne<\/p>\n p \nu \nb \nl \ni \ns \nh \ne \nr \n,<\/p>\n e \nx \nc \ne \np \nt<\/p>\n f \na \ni \nr<\/p>\n u \ns \ne \ns<\/p>\n p \ne \nr \nm \ni \nt \nt \ne \nd<\/p>\n u \nn \nd \ne \nr<\/p>\n U \n. \nS \n.<\/p>\n o \nr<\/p>\n a \np \np \nl \ni \nc \na \nb \nl \ne<\/p>\n c \no \np \ny \nr \ni \ng \nh \nt<\/p>\n l \na \nw \n.\n<\/p>\n EBSCO Publishing : eBook Academic Collection (EBSCOhost) – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY \nAN: 237620 ; Fottler, Myron D., Fried, Bruce.; Human Resources in Healthcare : Managing for Success \nAccount: s8993066.main.ehost<\/p>\n<\/p>\n<\/div>\n \n A Definition of Diversity\n<\/p>\n People define diversity in many ways, depending on the way they live in and \nview society. In his book, The 10 Lenses: Your Guide to Living and Working in \na Multicultural World, author Mark Williams (2001) discusses the framework \nthat explains the way people see the world:\n<\/p>\n 1. The assimilationist wants to conform and fit in with the group to \nwhich he or she belongs.\n<\/p>\n 2. The colorblind ignores race, color, ethnicity, and other cultural factors. \n3. The cultural centrist seeks to improve the welfare of his or her cultural\n<\/p>\n group by accentuating its history and identity. \n4. The elitist believes in the superiority of the upper class and embraces\n<\/p>\n the importance of family roots, wealth, and social status. \n5. The integrationist supports breaking down all barriers between racial\n<\/p>\n groups by merging people of different cultures together in \ncommunities and in the workplace.\n<\/p>\n 6. The meritocratist lives by the adage, \u201ccream rises to the top\u201d\u2014the \nbelief that hard work, personal merit, and winning a competition \ndetermine one\u2019s success.\n<\/p>\n 7. The multiculturist celebrates the diversity of cultures, seeking to retain \nthe native customs, languages, and ideas of people from other \ncountries.\n<\/p>\n 8. The seclusionist protects himself or herself from racial, cultural, and\/or \nethnic groups in fear that they may diminish the character and quality \nof his or her group\u2019s experiences within society.\n<\/p>\n 9. The transcendent focuses on the human spirit and people\u2019s universal \nconnection and shared humanity.\n<\/p>\n 10. The victim\/caretaker views liberation from societal barriers as a \ncrucial goal and sees oppression as not only historical but also \ncontemporary.\n<\/p>\n With this framework in mind, it is easier to understand why so many \ninterpretations of the same idea exist. For our purposes, we describe diversity \nin the context of three key dimensions: (1) human diversity, (2) cultural di- \nversity, and (3) systems diversity. Each dimension needs to be understood and \nmanaged in the healthcare workplace.\n<\/p>\n Human diversity includes the attributes that make a human being who \nhe or she is, such as race, ethnicity, age, gender, family status (single, married, \ndivorced, widowed, with or without children), sexual orientation, physical \nabilities, and so on. These traits are what frequently come to mind first when \nindividuals consider the differences in people. Human diversity is a core di- \nmension because it defines who we are as individuals. This dimension is with \nus throughout every stage of our lives, guiding how we define ourselves and\n<\/p>\n 146 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 146\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n how we are perceived by others. A workplace definition of diversity includes \nhuman diversity as a minimum.\n<\/p>\n Cultural diversity encompasses a person\u2019s beliefs, values, family struc- \nture practice (nuclear or extended family, independent living), and mind-set \nas a result of his or her cultural, community, and environmental experiences. \nThis dimension includes language, social class, learning style, ethics or moral \ncompass, religion, lifestyle, work style, global perspectives, and military views. \nCultural diversity is a secondary dimension, but it can have a powerful impact \non how a person behaves in the workplace. The cultural norms vary from one \nculture to another and influence how individuals interact with their work en- \nvironments. For example, some religious groups are forbidden from working \non the Sabbath, and this exemption has an impact on work scheduling and \neven hiring decisions.\n<\/p>\n Systems diversity relates to the differences among organizations in work \nstructure and pursuits. This dimension includes teamwork reengineering, \nstrategic alliances, employee empowerment, quality focus, educational devel- \nopment, corporate acquisitions, and innovation. Systems diversity deals with \nsystems thinking and the ability to recognize how functions in the work envi- \nronment are connected with diversity. In a multicultural, diverse, and inclu- \nsive workplace, organizational systems are integrated to enhance innovation, \nencourage teamwork, and improve productivity.\n<\/p>\n All of these dimensions are important and are present in the health- \ncare workplace, and all leaders should recognize them. The challenge is in \nseeing not only our differences but also our similarities as individuals, as \nprofessionals, and as members of a group. Leaders must develop effective \nstrategies to manage the differences (and highlight similarities), and this \nwill lead to building effective teams and a higher-performing organization \n(Guillory 2003).\n<\/p>\n Managing diversity is not an easy task, as a number of barriers often get \nin the way of achieving a harmonious working environment. Some of these bar- \nriers, which revolve around the diversity dimensions mentioned earlier, can be \na great source of tension and conflict. For instance, a person\u2019s culture can be a \nbarrier to a work team when other members of the group are not respectful of \nor misunderstand the person\u2019s values, beliefs, or even clothing, which that per- \nson gained through his or her cultural background. Examples of a cultural dif- \nference may be the person\u2019s hairstyle or affinity to wear religious artifacts. The \neducation, race\/ethnicity, work style, empowerment, and relationship\/task \norientation of an individual can also become barriers if they are not properly \nunderstood and managed.\n<\/p>\n Prejudice in the Workplace\n<\/p>\n Prejudice is a set of views held by individuals about members of other groups. \nPrejudice is pre-judgment; hence, it is not based on facts and\/or experience.\n<\/p>\n 147C 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 147\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n It affects the way people react toward and think of other people, and it can be \nas innocent as children choosing to not play with children they deem different \nfrom themselves or as harmful as adults not associating with certain people be- \ncause English is not their native language.\n<\/p>\n Formally, prejudice can be defined as a set of institutionalized assump- \ntions, attitudes, and practices that has an invisible-hand effect in systematically \nadvantaging members of more powerful groups over members of less domi- \nnant groups. This type of prejudice occurs in many healthcare institutions. \nSome examples include culturally biased assessment and selection criteria, cul- \ntural norms that condone or permit racial or sexual harassment, lower per- \nformance expectations for certain groups, and a collective misconception \nabout a specific group that relegates the group\u2019s members to unfair positions. \nAn example of the latter is stereotyping.\n<\/p>\n Stereotypes are generalizations about individuals based on their identity, \ngroup membership, or affiliations (Dreachslin 1996). A common stereotype \nin the healthcare management field is the assumption that black executives are \nnot as qualified as their white counterparts. Thus, African-American execu- \ntives are tested more often to prove their competence, while their white con- \ntemporaries are assumed to be capable from the start. (This fact is substanti- \nated in the race\/ethnic surveys discussed later in the chapter.)\n<\/p>\n The concept of \u201ccomfort and risk\u201d relates to a human being\u2019s natural \nneed to feel comfortable and to avoid risk. People tend to prefer to work with \nothers from similar racial or ethnic backgrounds because doing so provides \nthem with a certain amount of comfort and shields them from a certain \namount of risk. Although subordinate\u2013superior relationships that involve peo- \nple from different backgrounds work sufficiently to allow people to get the \njob done, they often fail to lead to the close bonds that form between a men- \ntor and a prot\u00e9g\u00e9.\n<\/p>\n Given the systemic existence of prejudice and the way it influences \npeople\u2019s mind-set and behavior in the workplace, the fair and accurate assess- \nment of minority employees (caregivers, support staff, and managers alike) \nremains an organizational dilemma rather than an established practice. For \ninstance, existing literature provides evidence that managers systematically \ngive higher performance ratings to subordinates who belong to the same \nracial group as they do, while high performers from minority groups remain \ncomparatively invisible in the managerial\/leadership selection process (Thomas \nand Gabarro 1999).\n<\/p>\n The Business Case for Diversity\n<\/p>\n In 1900, one in eight Americans was non-white; today, this ratio is one in \nfour. By 2050, the ratio will be one in three (IOM 2004). The healthcare\n<\/p>\n 148 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 148\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n industry needs physicians, nurses, and other providers, but it also needs care- \ngivers who reflect the diversity of the population, who, at one point or an- \nother, become patients. The same is true for healthcare managers and exec- \nutives. Therefore, healthcare organizations must ensure that their caregivers \nand leaders represent the backgrounds of the communities they serve. In ad- \ndition, healthcare executives must look for new insights, examples, and best \npractices to help navigate their organizations through a diversity journey. A \nkey challenge in this journey is establishing a business case for having a di- \nverse workforce.\n<\/p>\n The business case for diversity is unique for each organization. The cir- \ncumstances, environment, and community demographics of one organization \ncannot be generalized to another institution. However, some elements are \ncommon in all organizations, which can be the basis of a diversity program: \nthe healthcare marketplace, employee skills and talent, and organizational ef- \nfectiveness. These elements will drive the institution\u2019s investment in and com- \nmitment to diversity. An organization can achieve and sustain growth and \nprofitability by doing the following:\n<\/p>\n \u2022 Expand market share by adding or enhancing services that target diverse \npopulations.\n<\/p>\n \u2022 Link the marketplace with the workplace through recruiting, developing, \nand retaining employees with diverse racial\/ethnic backgrounds.\n<\/p>\n \u2022 Create and implement workplace policies and management practices that \nmaximize the talent and productivity of employees with diverse \nbackgrounds.\n<\/p>\n The facts are that all minority groups buy and consume healthcare serv- \nices, many of them are educated and trained to either provide healthcare serv- \nices or manage operations, and many of them currently work within the field \nand understand its complexities. Hospitals and other healthcare organizations \ncannot afford to miss such opportunities. They can seek, cultivate, and retain \nminority talent to help them compete in today\u2019s diverse healthcare environ- \nment. Failure to take advantage of these opportunities will mean the differ- \nence between being a provider and employer of choice and losing ground to \ncompetitors.\n<\/p>\n Governance Impact\n<\/p>\n The organization\u2019s board of governance can help in this regard. Members of \nthe board or trustees are the ultimate links to the communities served by a \nhealthcare organization. They know the makeup of the population the organ- \nization serves and seeks to target, and they have insights into their communi- \nties\u2019 healthcare needs. Because board members are part of the community, \nthey have an interest in making sure that the organization that they represent \nis not only providing inclusive services but is also being a fair and equitable\n<\/p>\n 149C 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 149\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n employer and neighbor. With this perspective in mind, governance should \nsupport a business strategy that promotes community goodwill, encourages \ngrowth, considers present social and demographic transformations and hence \nfuture needs, and emphasizes culturally competent and sensitive healthcare. \nMost importantly, members of the board should also reflect the multicultural \nmix of the surrounding communities.\n<\/p>\n Considering all of the challenges faced by any healthcare board, why \nshould it be concerned with diversity? One of the many reasons is to protect \nthe organization\u2019s bottom line. The financial impact of problems stemming \nfrom racial discrimination and discriminatory practices can be substantial. \nWell-publicized cases of large organizations committing or turning their backs \non such practices provide evidence of the extent of cost consequences. For ex- \nample, in 2007, two Equal Employment Opportunity Commission lawsuits \nwere filed alleging racial and sexual discrimination. The first was filed in South \nFlorida claiming that a manager at two Nordstrom stores in Palm Beach \nCounty harassed a Hispanic woman and other \u201csimilarly situated individuals\u201d \nbased on these individuals\u2019 national origin and race and that the company \nfailed to take prompt action (Puget Sound Business Journal 2007). The second \nwas a lawsuit against United HealthCare of Florida that accused a male execu- \ntive of subjecting another male executive to repeated verbal sexual harassment \n(EEOC. 2007). This latter case resulted in a $1.8 million settlement and an \norder for United HealthCare to distribute a new antiharassment policy to all \nof its employees (EEOC 2007). Another reason that the board should sup- \nport diversity initiatives is to encourage and strengthen employee commit- \nment to the organization. Simply, a diverse workforce is an asset. It differen- \ntiates an organization in the marketplace, giving it an edge against its \ncompetitors in terms of inclusiveness, cultural sensitivity and competency, and \neven progressive practice.\n<\/p>\n Board commitment to the principles of diversity may lead to shifts in \nthe corporate culture as well, allowing all stakeholders to contribute to the \noverall success of the organization and its mission. Trustees should hold orga- \nnizational leaders and managers accountable for setting and following high di- \nversity standards. This practice will lead to an improved organization and to \nhealthy communities.\n<\/p>\n Legal Issues\n<\/p>\n The debate continues over whether having a diversity program is the right thing \nto do or whether it enhances shareholder\/stakeholder value. The answer is \nboth\u2014not only is it the right thing to do, but it also adds value to the organiza- \ntion. Educated, skilled, and experienced professionals and workers who are con- \nsidered in the minority (including but are not limited to women, racial and eth- \nnic minorities, and people with physical challenges) bring strategic and unique \nperspectives into their roles, generate productive dialogue, and challenge the\n<\/p>\n 150 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 150\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n status quo. All of these are essential to the practices, products and services, and \noperations of a healthcare organization. If these are not reasons enough to main- \ntain a diverse workforce, various laws also prohibit employment discrimination.\n<\/p>\n The Civil Rights Act of 1964 was signed into law on July 2, 1964. This \nlegislation was intended to ensure that the financial resources of the federal \ngovernment would no longer subsidize racial discrimination (Smith 1999). \nThis law bans discrimination in any activities, such as training, employment, \nor construction, that are funded by federal monies. Discrimination is also pro- \nhibited in entities that contract with organizations that receive federal funds. \nEvery recipient of federal funds is required to provide written assurances that \nnondiscrimination is practiced throughout the institution. Among the first \nmajor tests of the Civil Rights Act was the decision of the U.S. Court of Ap- \npeals for the Fourth Circuit on the case of Simkins v. Moses Cone Memorial \nHospital. The decision struck down the separate-but-equal provisions of the \nHill-Burton Act and gave the federal government the necessary power to en- \nforce the Civil Rights Act (Smith 1999).\n<\/p>\n The Civil Rights Act also protects individuals whose native language is \nnot English. The U.S. Department of Justice has issued the \u201cNational Origin \nDiscrimination Against Persons with Limited English Proficiency (LEP) \nGuidance.\u201d This guidance, intended for recipients of federal funds, prohibits \ndiscrimination of people who have limited English-language proficiency. It re- \nquires federally funded entities to ensure that people whose primary language \nis not English can access and understand services, programs, and activities pro- \nvided by these organizations. This mandate has made a serious impact in the \nway healthcare organizations, especially those in areas with large numbers of \nindividuals who speak English as a second language (ESL), frame their serv- \nice offerings. The National Council on Interpreting in Health Care has put \ntogether \u201cThe Terminology of Health Care Interpreting,\u201d a glossary of terms \nintended to help healthcare leaders in developing programs for ESL patients; \nvisit www.ncihc.org for more information on this glossary.\n<\/p>\n See Chapter 5 for a comprehensive discussion of the Civil Rights Act \nand other laws that protect groups who are considered in the minority.\n<\/p>\n Diversity in Healthcare Leadership: Two Major Studies\n<\/p>\n Despite the demographic changes in the U.S. population, and hence in the \nhealthcare field, few minorities are present in the executive suite. Within the \nlast decades, two major studies were undertaken to understand the factors be- \nhind minorities\u2019 difficult climb on the healthcare management ladder. As the \nfindings of these studies indicate, although improvements are continually be- \ning made in terms of how workforce and leadership diversity is viewed and val- \nued in healthcare organizations, a lot of work is left to be done.\n<\/p>\n 151C 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 151\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n Study 1: A Race\/Ethnic Comparison of Career Attainments\n<\/p>\n in Healthcare Management\n<\/p>\n In 1992, the American College of Healthcare Executives (ACHE) and the \nNational Association of Health Services Executives (NAHSE) conducted a \nstudy that compared the career attainment of Caucasian and African-American \nhealthcare executives. The study found that among executives with similar \ntraining and experience, African Americans were in lower-level positions, \nmade less money, and had lower levels of job satisfaction (ACHE 2002). The \nresults of this study made way for the creation of the Institute for Diversity in \nHealth Management (IFD), the only organization committed exclusively to \npromoting managerial diversity within the healthcare field.\n<\/p>\n In 1996, ACHE, with assistance and support from NAHSE, IFD, the \nAssociation of Hispanic Healthcare Executives (AHHE), and the Executive \nLeadership Development Program of the Indian Health Services (IHS), con- \nducted a follow-up survey using many of the items included in the first sur- \nvey. This second survey, completed and published in 1997, revealed that 23 \npercent of the U.S. hospital workforce was made up of African Americans and \nHispanics. Unfortunately, less than 2 percent of these minority groups held \nthe positions of president, chief executive officer, and chief operating officer.\n<\/p>\n The third cross-sectional study, released in 2002, was conducted to de- \ntermine if the race\/ethnic disparities in healthcare management careers had \nnarrowed since the 1997 release of the second survey and was based on the \nobservations and experiences of a similar pool of respondents. In planning this \nstudy, leaders of ACHE, AHHE, IFD, and NAHSE invited the collaboration \nof the Executive Leadership Development Program of the IHS so that the ca- \nreer attainments of Native-American executives could also be assessed.\n<\/p>\n Following is a summary of the most important findings of the third \nstudy (ACHE 2003):\n<\/p>\n \u2022 More white administrators than minority administrators worked in \nhospital settings.\n<\/p>\n \u2022 White female administrators earned more than female minority \nadministrators. When controlling for education and experience, \ncompensation earned by white women remained higher than the \ncompensation for male and female members of minority groups.\n<\/p>\n \u2022 White male administrators earned more than male minority \nadministrators. When controlling for experience and education, the total \ncompensation of male African-American and Hispanic administrators was \napproximately equal to that of their white counterparts.\n<\/p>\n \u2022 Minority administrators expressed lower levels of job satisfaction than \ndid white administrators. The items with which low satisfaction was \nreported included the following: \n1. Pay and fringe benefits were not proportionate to the minority\n<\/p>\n administrators\u2019 contribution to their organization.\n<\/p>\n 152 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 152\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n 2. The degree of respect and fair treatment that minority administrators \nreceived from their leaders was inadequate.\n<\/p>\n 3. The sanctions and treatment that minority administrators faced when \nthey made a mistake were more severe than their action called for.\n<\/p>\n \u2022 Fewer minority administrators than white administrators expressed that \ntheir organizations had great personal meaning to them.\n<\/p>\n \u2022 More minority administrators than white administrators stated that \nthey experienced racial\/ethnic discriminatory acts in the past five years, \nsuch as not being hired or being evaluated with inappropriate \nstandards.\n<\/p>\n \u2022 Only about 15 percent of female minority administrators aspired to be \nchief executive officers. More white male administrators had such \naspirations than male minority administrators.\n<\/p>\n \u2022 The majority of minority administrators endorsed efforts to increase the \npercentage of racial\/ethnic minorities in senior healthcare management \npositions. Nearly half of their white counterparts were neutral or \nopposed to such efforts.\n<\/p>\n Recommendations to address the disparities found between the white and mi- \nnority groups are being developed. A fourth race\/ethnic survey is expected to \nbe conducted in 2008.\n<\/p>\n Study 2: Advancing Diversity Leadership in Healthcare\n<\/p>\n In 1998, Witt\/Kieffer, an executive search firm, conducted a national survey \nof healthcare leaders (e.g., chief executive officers, presidents, human re- \nsources executives) to determine the advances in and barriers to recruiting and \nretaining women and minority leaders in the industry. The survey revealed di- \nvergences in opinions between nonminority and minority respondents. Non- \nminority respondents reported that minority leaders were hard to find, while \nminority respondents claimed that these leaders were not looking either hard \nenough or in the right places. Another significant difference in perspective was \non the issue of whether organizational or even individual resistance to minor- \nity leadership was part of the problem (Witt\/Kieffer 2006).\n<\/p>\n In 2006, Witt\/Kieffer conducted a follow-up survey that involved hu- \nman resources executives and minority leaders in hospitals and health systems \nnationwide. Seventy-one percent of respondents were nonminorities, and 29 \npercent were from minority groups. The project also included phone inter- \nviews with respondents who were willing to share additional thoughts regard- \ning diversity leadership (Witt\/Kieffer 2006).\n<\/p>\n The following are the main findings of the 2006 study:\n<\/p>\n \u2022 Eighty-two percent of the nonminority respondents and 81 percent of \nthe minority group agreed or strongly agreed with the statement, \n\u201cInternal diversity programs support the organization\u2019s overall \nmission\/vision.\u201d\n<\/p>\n 153C 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 153\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n \u2022 Seventy-nine percent of minority and 68 percent of nonminority \nrespondents agreed that \u201cInternal diversity programs are strategic to \norganizational success.\u201d\n<\/p>\n \u2022 Virtually all respondents agreed that \u201cInternal diversity programs \ndemonstrate the value of cultural differences in an organization.\u201d By and \nlarge, both groups also shared the belief that organizations commit to \ndiversity recruiting because they want to achieve \u201ccultural competence\u201d \norganization-wide.\n<\/p>\n \u2022 Seventy-two percent of minority and 63 percent of nonminority \nrespondents agreed that \u201cInternal diversity programs provide diversity \nstaffing that mirrors the diversity of the patient population.\u201d\n<\/p>\n \u2022 Only 28 percent of nonminority respondents and 12 percent of the \nminority group agreed that \u201cHealthcare organizations have been \neffective in closing the diversity leadership gap over the past five years.\u201d\n<\/p>\n \u2022 Nearly 73 percent of nonminority respondents personally believed that \nopportunities for diversity in leadership have improved over the past five \nyears. Only 34 percent of minorities shared that personal belief. Also, 67 \npercent of nonminorities agreed that \u201cThe availability of diversity \nleadership positions in healthcare organizations has improved over the \npast five years,\u201d but only 30 percent of minority respondents agreed.\n<\/p>\n \u2022 Minority respondents remained unconvinced that they are \u201cwell \nrepresented today in healthcare organization management teams.\u201d\n<\/p>\n \u2022 Both respondent groups agreed that internal diversity programs drive \norganizational success and cultural competence. However, respondents, \nparticularly minorities, expressed skepticism about whether hospitals and \nhealthcare systems commit to diversity recruiting because those \norganizations believe diversity is good for business.\n<\/p>\n \u2022 Seventy-two percent of nonminorities and 53 percent of minorities \nagreed that healthcare organizations are effective in diversity recruiting \nbecause they have a genuine interest in it. Seventy-three percent of \nnonminorities and about 50 percent of minorities believed healthcare \norganizations are effective at diversity recruiting because they take their \nresponsibility to do so seriously.\n<\/p>\n \u2022 Respondents held widely divergent views on the most important barriers \nto diversity recruitment, retention, and leadership development. The \nonly barrier for which general agreement was reached was the \u201clack of \ncommitment by top management.\u201d\n<\/p>\n Diversity Management\n<\/p>\n According to the Institute for Diversity in Health Management (2007), man- \naging a diverse workforce involves the following elements:\n<\/p>\n \u2022 Employee perspective. Diversity management creates an environment \nwhere every hospital or health system employee feels valued, appreciated\n<\/p>\n 154 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 154\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n and respected and who, in turn, talks about the organization within the \ncommunity with pride. Diversity management allows 100 percent of \nemployees, whatever their capabilities, to achieve 100 percent of their \npotential 100 percent of the time.\n<\/p>\n \u2022 Patient focus. Diversity management creates an environment where \nbecause all patients feel valued, they are highly satisfied and loyal. \nDiversity management means understanding the cultural and ethnic \nvalues within a community. As a result, community members choose the \norganization, which increases market share.\n<\/p>\n \u2022 Inclusion. Diversity management means sending a message to minorities \nthat there are leaders within the organization to champion their medical \nneeds. If a minority patient knows the COO [chief operating officer] \nshares his or her ethnicity, for example, then that patient likely assumes \nhis or her best interests will be served.\n<\/p>\n \u2022 Community perspective. Diversity management means bringing the \ncommunity into the organization, specifically at the governance level. \nPutting prominent minority leaders on the hospital or health system \nboard forges a bond with the community, which in turn creates patient \ncomfort with and loyalty to the organization.\n<\/p>\n The Impact of Diversity on Care Delivery\n<\/p>\n According to the National Institutes of Health, \u201cthe diversity of the Ameri- \ncan population is one of the nation\u2019s greatest assets; one of its greatest chal- \nlenges is reducing the profound disparity in health status of America\u2019s racial \nand ethnic minorities\u201d (Smedley and Stith 2002). The Institute of Medicine\u2019s \nlandmark report in 2002, entitled Unequal Treatment, reveals the presence of \nsignificant disparities in the way white and minority patients receive healthcare \nservices, especially in treatment for heart disease, cancer, and HIV (Smedley \nand Stith 2002). Addressing such disparities in care, including the dispropor- \ntionate recruitment and selection of a minority workforce, and ensuring cul- \ntural competence of caregivers are interconnected. To minimize care dispari- \nties, institutions and providers have to develop cultural competence. To \ndevelop cultural competence, a diverse group of providers, support staff, and \nmanagers needs to be in place and diversity training and policies for all employ- \nees and caregivers have to be established. Simply, the lack of a culturally com- \npetent healthcare workforce is a possible contributor to the disparities in care.\n<\/p>\n Having examined how a diverse physician community also benefits \nhealthcare, researchers Cohen, Gabriel, and Terrell (2002) posited at least \nfour practical reasons for attaining greater diversity: (1) it advances cultural \ncompetency, (2) it increases access to high-quality care, (3) it strengthens the \nmedical research agenda, and (4) it ensures optimal management. These find- \nings are relevant and applicable to healthcare management and leadership as\n<\/p>\n 155C 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 155\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n well. As stated by Cohen, Gabriel, and Terrell, \u201cthe first and perhaps most \ncompelling reason for increasing the proportion of medical students and other \nprospective health care professionals who are drawn from underrepresented \nminority groups: preparing a culturally competent health care workforce.\u201d\n<\/p>\n Cultural competence may be defined as a set of complementary behav- \niors, practices, attitudes, and policies that enables a system, an agency, or in- \ndividuals to effectively work and serve pluralistic, multiethnic, and linguisti- \ncally diverse communities. The demographic makeup of this country will \ncontinue to change in the years ahead, and culturally competent and sensi- \ntive care is and will be expected from current and future healthcare profes- \nsionals. To effectively provide such care, leaders, clinical staff, and all the em- \nployees in between must have a firm understanding of how and why belief \nsystems, personal biases, ethnic origins, family structures, and other cultur- \nally determined factors influence the manner in which patients experience ill- \nness, adhere to medical advice, and respond to treatment. Such factors ulti- \nmately affect the outcomes of care. Physicians and other healthcare \nprofessionals who are not mindful of the potential impact of language barri- \ners, religious taboos, unconventional views of illness and disease, or alterna- \ntive remedies are not only unlikely to satisfy their patients but, more impor- \ntant, are also unlikely to provide their patients with optimally effective care \n(Cohen, Gabriel, and Terrell 2002).\n<\/p>\n A study finds that although African-American physicians make up only \n4 percent of the total physician workforce in the United States, they care for \nmore than 20 percent of African-American patients in the United States \n(Saha et al. 2000). The study suggests that African Americans prefer to get \ncare from black physicians, and a contributing factor to this may be that many \nAfrican-American physicians locate their practices in predominantly black \ncommunities and are, therefore, more geographically accessible to African- \nAmerican healthcare consumers. If the hypothesis is true that minority con- \nsumers prefer care from physicians of their own race simply because of geo- \ngraphic accessibility, then organizational policies aimed at better serving the \nneeds of minority communities need not consider physician race and ethnic- \nity in the equation. If, however, minority patients have this preference be- \ncause of a shared language or culture, for example, then increasing the sup- \nply of underrepresented minority physicians is justifiable and necessary.\n<\/p>\n An understanding of the factors that influence the disparities in health- \ncare is essential in developing effective strategies to minimize the problem. \nFigure 6.1 presents two sets of factors: patient-related factors and health-system- \nrelated factors. Patient-related factors are cultural characteristics of patients \nthat prevent them from getting fair and adequate treatment in an organiza- \ntion that is not culturally competent or sensitive. Health-system-related fac- \ntors are organizational dynamics (e.g., employee attributes and biases) that in- \nfluence the methods used to treat patients.\n<\/p>\n 156 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 156\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n Components of an Effective Diversity Program\n<\/p>\n Healthcare leaders can establish a diversity program that will lead to a more \ndiverse and inclusive organization (see Figure 6.2). Some actions that leaders \ncan take toward this goal include, but are not limited to, the following:\n<\/p>\n \u2022 Ensure that senior management and the governing board are committed \nto the development and implementation of a diversity program.\n<\/p>\n \u2022 Broaden the definition of diversity to include factors beyond race and \nethnicity.\n<\/p>\n \u2022 Recognize the business case for bringing in diversity at the leadership level. \n\u2022 Tie diversity goals to business objectives. \n\u2022 Hold recruiting events that target racial and ethnic groups, women,\n<\/p>\n people with disabilities, older but capable workers, and others who are \nconsidered minorities.\n<\/p>\n \u2022 Encourage senior executives to mentor minorities. \n\u2022 Develop employee programs that emphasize and celebrate diversity and\n<\/p>\n inclusivity.\n<\/p>\n 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\n<\/p>\n FIGURE 6.1 \nFactors that \nInfluence \nDisparities in \nHealthcare\n<\/p>\n Patient-Related Factors Health-System-Related Factors\n<\/p>\n Socioeconomic Cultural competence \nLow income and education Insufficient knowledge of and sensitivity\n<\/p>\n to cultural differences\n<\/p>\n Health education Language \nLack of knowledge of health Inability to communicate sufficiently \nsymptoms, conditions, and with patients and families whose native \npossible treatments language is not English\n<\/p>\n Health behavior Discrimination \nPatient willingness and ability to Healthcare system and provider \nseek care, adhere to treatment bias and stereotyping \nprotocols, and trust and work \nwith healthcare providers Workforce diversity\n<\/p>\n Poor racial and ethnic match between \nhealthcare professionals and the \npatients they serve\n<\/p>\n Payment \nInsufficient reimbursement for treating \nMedicare, Medicaid, and uninsured \npatients\n<\/p>\n SOURCE: Smedley and Stith (2002)\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 157\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n The business imperatives and organizational necessities for aggressively \ncreating a diversity program include, but are not limited to, the following:\n<\/p>\n 1. Reflection of the service population. The healthcare organization\u2019s \ncaregivers and support staff should mirror the diversity of the population \nthat the institution serves. Toward this end, the organization should \nattract and take advantage of the talents, skills, and growth potential of \nminority professionals within the community.\n<\/p>\n 2. Workforce utilization. Minority employees have a lot to contribute to the \norganization. Leaders should recognize this fact and should be open to, \nsensitive to, knowledgeable about, and understanding of the cultures, \nmind-set, and practices of the organization\u2019s diverse workforce. Doing \nso will not only enhance staff productivity and overall performance but \nwill also boost staff morale.\n<\/p>\n 3. Work\u2013life quality and balance. Leaders should recognize that work and \npersonal activities are interrelated, not separate preoccupations. Both are \nperformed on the basis of necessity, practicality, efficiency, and spontaneity.\n<\/p>\n 4. Recruitment and retention. Attracting and retaining a diverse workforce \nhave a lot to do with the state of the workplace. Leaders should create \nan environment in which minorities feel included, professionally \ndeveloped, and safe.\n<\/p>\n 5. Bridging generations. Generational differences in expectations, \neducation, and values exist between younger and older staff. Such gaps \nshould be acknowledged, and attention should be paid to the physical, \nmental, and emotional well-being of all caregivers and staff at all ages \nregardless of backgrounds.\n<\/p>\n 6. Cultural competence. This competence is an in-depth understanding of \nand sensitivity to the values and viewpoints of minority staff, patients,\n<\/p>\n 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\n<\/p>\n FIGURE 6.2 \nHow to\n<\/p>\n Create an \nInclusive \nCulture\n<\/p>\n 1. Study the culture, climate (i.e., what employees are thinking, feeling, or \nhearing about diversity issues), and demographics of the organization.\n<\/p>\n 2. Select the diversity issues that allow the greatest breakthrough.\n<\/p>\n 3. Create a diversity strategic plan.\n<\/p>\n 4. Secure leadership\u2019s financial support for the plan.\n<\/p>\n 5. Establish leadership and management accountabilities for the plan.\n<\/p>\n 6. Implement the plan.\n<\/p>\n 7. Provide continual training related to the new skills and competencies \nnecessary to successfully achieve the plan goals.\n<\/p>\n 8. Conduct a follow-up survey one or one-and-one-half years after \nimplementing the plan.\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 158\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n and other customers. Leaders should master the skills necessary to work \nwith and serve these groups and should provide training in this matter to \nall employees to ensure provision of culturally competent care.\n<\/p>\n 7. Organization-wide respect. Leaders should create an environment in \nwhich the differences in title, role, position, and department are valued \nand respected but not held too lofty above everything else. Each \nemployee, regardless of his or her level within the organization, should \nbe viewed as integral to the overall success of the team.\n<\/p>\n Summary\n<\/p>\n Healthcare organizations in the United States are beginning to make a com- \nmitment to embracing and fostering workforce diversity. This cultural change \nmeans adopting new values in terms of being inclusive and attracting a diverse \nworkforce. The business case for diversity is unique for each organization, as \ncircumstances, the environment, and community demographics of one organ- \nization vary from those of another. However, elements (such as the market- \nplace and organizational effectiveness) that are common in all organizations \ncan be the basis of a diversity program.\n<\/p>\n One of the many reasons that senior management and the governing \nboard should pay attention to diversity issues is to protect the organization\u2019s \nbottom line. The financial costs of problems that stem from racial discrimina- \ntion and discriminatory practices can be substantial. Studies have found dis- \nparities in two areas: (1) minority healthcare administrators ascend in rank \nmore slowly within their organizations than do their white counterparts, and \n(2) patients who belong to minority groups receive different medical treat- \nments than patients who are white. Such disparities may be bridged with the \ndevelopment of a diversity program.\n<\/p>\n 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\n<\/p>\n Discussion Questions\n<\/p>\n 1. While this chapter discussed the many \nbenefits of diversity, an alternative view \nsuggests that no empirical evidence \nexists that a diverse workforce has a \npositive effect on organizational \nperformance, employee commitment, \nand employee satisfaction. In fact, \nanecdotal evidence indicates that \ndiversity can negatively affect business\n<\/p>\n performance because of the possibility \nfor internal conflict, dissension, and \nturnover. What is your reaction to this \nperspective in light of the content of this \nchapter? Do these arguments have \nmerit? Why or why not?\n<\/p>\n 2. Respond to this statement: Diverse \nleadership is a competitive advantage. \nWhat is the most compelling business\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 159\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n argument for or against diverse \nleadership teams?\n<\/p>\n 3. What are the legal, moral, and ethical \nconsequences that prohibit hospitals from \nturning away patients based on race?\n<\/p>\n 4. Why are there are no such consequences \nto patients who demand doctors, nurses, \nor workers of a specific race to administer \ntheir healthcare?\n<\/p>\n 5. Can hospitals that adhere to gender- or \nrace-based patient demands face \ndiscrimination lawsuits from their \nemployees?\n<\/p>\n 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\n<\/p>\n 6. When an employer denies an employee \n(or a group of employees) his or her \nfull employment opportunity based on \nthe racial bias of customers, is the \nemployer violating the employee\u2019s civil \nrights?\n<\/p>\n 7. Does workforce diversity enhance \norganizational performance? Explain \nyour answer.\n<\/p>\n 8. Can an internal diversity program \nsupport an organization\u2019s overall \nmission and vision? How?\n<\/p>\n Experiential Exercise\n<\/p>\n Note: This case was adapted from Davis, R. \nA. 2003. \u201cNo African Americans Allowed:\n<\/p>\n White Patient\u2019s Racism Rules at Pennsylvania \nHospital.\u201d DiversityInc.com, October 9.\n<\/p>\n Abington Memorial Hos- \npital is a 508-bed hospital\n<\/p>\n located in Abington, Pennsylvania. It serv- \nices patients from Philadelphia and the sur- \nrounding suburbs of Bucks and Mont- \ngomery counties. The hospital\u2019s mission \u201cis \nto provide patients with the highest quality \ncare possible, regardless of the health-care \nprofessionals\u2019 race. . . .\u201d\n<\/p>\n Supervisors at the hospital told \nAfrican-American healthcare professionals, as \nwell as food-service and housekeeping staff, \nnot to enter a certain white patient\u2019s room or \ninteract with the family. This caused an out- \nrage among the African-American staff. \nAbington administrators said they broke hos- \npital policy to avoid a potentially \u201cvolatile sit- \nuation\u201d by adhering to the request of the pa-\n<\/p>\n tient\u2019s husband: Only white employees could \nenter his wife\u2019s room on the maternity ward. \n\u201cWe were wrong,\u201d said Meg McGoldrick, a \nvice president at Abington Memorial Hospi- \ntal. \u201cWe should have followed our policy. \nThe whole incident has greatly upset many of \nour employees who perceived that we were \nacquiescing to the family\u2019s wishes.\u2019\u2019 Despite \nthe hospital\u2019s policy that states, \u201ccare will be \nprovided on a nondiscriminatory basis,\u201d the \nadministrators\u2019 actions seemed as though pa- \ntients were allowed to discriminate. Catholic \nHealth Care West\u2019s medical ethicist, Carol \nBayley, said that Abington failed in its respon- \nsibility to its employees and the community \nto accommodate a patient\u2019s racial preference: \n\u201cThis was a fundamental disrespect of these \nprofessionals\u2019 skills and their fundamental\n<\/p>\n Case\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 160\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n References\n<\/p>\n American College of Healthcare Executives (ACHE). 2002. A Race\/Ethnic Comparison of \nCareer Attainments in Healthcare Management. Chicago: ACHE.\n<\/p>\n \u2014\u2014\u2014. 2003. \u201cIncreasing and Sustaining Racial\/Ethnic Diversity in Healthcare Manage- \nment.\u201d Healthcare Executive 18 (6): 60\u201361.\n<\/p>\n Cohen, J., B. Gabriel, and C. Terrell. 2002. \u201cThe Case for Diversity in the Healthcare \nWorkforce.\u201d Health Affairs 21 (5): 90\u2013102.\n<\/p>\n Dreachslin, J. L. 1996. Diversity Leadership. Chicago: Health Administration Press. \nEqual Employment Opportunity Commission (EEOC). 2007. \u201cUnited Healthcare of\n<\/p>\n Florida to Pay $1.8 Million for Same-Sex Harassment and Retaliation.\u201d [Online in- \nformation; retrieved 2\/4\/08.] www.eeoc.gov\/press\/10-1-07.html.\n<\/p>\n Guillory, W. 2003. \u201cThe Business of Diversity: The Case for Action.\u201d Health & Social Work \n28 (1): 3\u20137.\n<\/p>\n 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\n<\/p>\n dignities . . . a hospital needs to stand against \nthis undercurrent of racism in our society.\u201d\n<\/p>\n The Philadelphia office of the Anti- \nDefamation League (ADL) said that pro- \nhibiting African-American employees from \ncarrying out the full scope of their duties is \nreprehensible. \u201cI don\u2019t see why and how a \nhospital could justify accommodating a re- \nquest that the professionals attending to a \npatient be of a particular background,\u201d said \nBarry Morrison, director of the Philadelphia \nchapter of the ADL; he added, \u201cCertainly, \nit\u2019s demoralizing for the people who work \nthere.\u201d The American Hospital Association \n(AHA), the largest hospital association in the \nUnited States, acknowledged that no hard- \nand-fast industry guidelines exist for hospi- \ntals to follow when a patient or a family \nmember makes a racially biased request. \nAHA does not offer hospitals a suggestion \non how to address this situation. \u201cIt\u2019s subjec- \ntive,\u201d said Rick Wade, senior vice president at \nthe AHA. \u201cI\u2019m sure the person who made \nthe decision at Abington thought they were \ndoing the right thing.\u201d McGoldrick said su- \npervisors at Abington were acting with good\n<\/p>\n intentions and sought to deflect any con- \nfrontation between its African-American staff \nand the Caucasian family. No incident was \nreported during the patient\u2019s stay.\n<\/p>\n Since then, Abington\u2019s president, \nRichard L. Jones, sent a letter to all its employ- \nees and volunteers apologizing for the situa- \ntion, which he termed \u201cmorally reprehensi- \nble.\u201d In addition to creating a diversity task \nforce at the 508-bed hospital, Abington has \nhired consultants and revised its antidiscrimina- \ntion policy. The AHA bestowed on Abington \nthe Quest for Quality Award for raising aware- \nness of the need for an organizational commit- \nment to patient safety and quality. Wade said \nhospitals are constantly evaluating how to pro- \nvide the best treatment for their patients, while \nprotecting and maintaining the dignity of their \nemployees. He said that a hospital\u2019s constant \npatient turnover sometimes subjected workers \nto society\u2019s underbelly. \u201cPerhaps Abington \ncould have been more protective of their em- \nployees,\u201d Wade said. \u201cPatients come and go, \n[but] the most important thing at a hospital is \nthe work-force,\u201d he said.\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 161\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n Institute for Diversity in Health Management (IFD). 2007. [Online information; re- \ntrieved 11\/12\/07.] http:\/\/www.diversityconnection.org\/diversityconnection_ \napp\/homepage\/index.jsp?SSO_COOKIE_ID=0a2f011430daf6dc821f57c54388 \nae60bb29ec14700b.\n<\/p>\n Institute of Medicine (IOM). 2004. In the Nation\u2019s Compelling Interest: Ensuring Diver- \nsity in the Health Care Workforce. Washington, DC: National Academies Press.\n<\/p>\n Puget Sound Business Journal. 2007. \u201cEEOC Sues Nordstrom in South Florida Over Ha- \nrassment.\u201d [Online information; retrieved 6\/1\/07.] http:\/\/seattle.bizjournals.com\/ \nseattle\/stories\/2007\/10\/01\/daily6.html.\n<\/p>\n Saha, S., S. Taggart, M. Komaromy, and A. Bindman. 2000. \u201cDo Patients Choose Their \nOwn Race?\u201d Health Affairs 19: 76\u201383.\n<\/p>\n Smedley, B. D., and A. Y. Stith. 2002. Unequal Treatment, Confronting Racial and Eth- \nnic Disparities in Health Care. Washington, DC: Institute of Medicine, National \nAcademies Press.\n<\/p>\n Smith, D. B. 1999. Health Care Divided: Race and Healing a Nation. Ann Arbor, MI: \nUniversity of Michigan Press.\n<\/p>\n Thomas, D., and J. J. Gabarro. 1999. Breaking Through: The Making of Minority Execu- \ntives in Corporate America. Boston: Harvard Business School Press.\n<\/p>\n Williams, M. 2001. The 10 Lenses: Your Guide to Living and Working in a Multicultural \nWorld. Sterling, VA: Capital Books.\n<\/p>\n Witt\/Kieffer. 2006. Advancing Diversity Leadership in Health Care: A National Survey of \nHealthcare Executives. Oak Brook, IL: Witt\/Kieffer.\n<\/p>\n 162 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\n<\/p>\n Fried_CH06.qxd 6\/11\/08 4:10 PM Page 162\n<\/p>\n EBSCOhost – printed on 2\/27\/2022 8:18 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n<\/div>\n \n \n HEALTHCARE PROFESSIONALS\n<\/p>\n Kenneth R. White, PhD, FACHE; Dolores G. Clement,\n<\/p>\n DrPH, FACHE; and Kristie G. Stover, PhD\n<\/p>\n CHAPTER\n<\/p>\n 4\n<\/p>\n 71\n<\/p>\n Learning Objectives\n<\/p>\n After completing this chapter, the reader should be able to\n<\/p>\n \u2022 understand the role of healthcare professionals in the human resources \nmanagement function of healthcare organizations;\n<\/p>\n \u2022 define the elements of a profession, with an understanding of the \ntheoretical underpinnings of the healthcare professions in particular;\n<\/p>\n \u2022 describe the healthcare professions, which include the majority of \nhealthcare workers, and the required educational levels, scopes of \npractice, and licensure issues for each;\n<\/p>\n \u2022 relate knowledge of the healthcare professions to selected human \nresources management issues and systems development; and\n<\/p>\n \u2022 comprehend the changing nature of the existing and emerging \nhealthcare professions in the healthcare workforce, particularly the \nimpact of managed care.\n<\/p>\n Introduction\n<\/p>\n Healthcare professionals are central to the delivery of high-quality healthcare \nservices. Extensive training, education, and skills are essential in meeting the \nneeds and demands of the population for safe, competent healthcare. These \nspecialized techniques and skills that healthcare professionals acquired through \nsystematic programs of intellectual study are the basis for socialization into \ntheir profession. Additionally, the healthcare industry is labor intensive and is \ndistinguished from other service industries by the number of licensed and reg- \nistered personnel that it employs and the variety of healthcare fields that it pro- \nduces. These healthcare fields have emerged as a result of the specialization of \nmedicine, development of public health, increased emphasis on health promo- \ntion and prevention, and technological advances and growth.\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 71\n<\/p>\n C \no \np \ny \nr \ni \ng \nh \nt<\/p>\n 2 \n0 \n0 \n8 \n.<\/p>\n H \ne \na \nl \nt \nh<\/p>\n A \nd \nm \ni \nn \ni \ns \nt \nr \na \nt \ni \no \nn<\/p>\n P \nr \ne \ns \ns \n.\n<\/p>\n A \nl \nl<\/p>\n r \ni \ng \nh \nt \ns<\/p>\n r \ne \ns \ne \nr \nv \ne \nd \n.<\/p>\n M \na \ny<\/p>\n n \no \nt<\/p>\n b \ne<\/p>\n r \ne \np \nr \no \nd \nu \nc \ne \nd<\/p>\n i \nn<\/p>\n a \nn \ny<\/p>\n f \no \nr \nm<\/p>\n w \ni \nt \nh \no \nu \nt<\/p>\n p \ne \nr \nm \ni \ns \ns \ni \no \nn<\/p>\n f \nr \no \nm<\/p>\n t \nh \ne<\/p>\n p \nu \nb \nl \ni \ns \nh \ne \nr \n,<\/p>\n e \nx \nc \ne \np \nt<\/p>\n f \na \ni \nr<\/p>\n u \ns \ne \ns<\/p>\n p \ne \nr \nm \ni \nt \nt \ne \nd<\/p>\n u \nn \nd \ne \nr<\/p>\n U \n. \nS \n.<\/p>\n o \nr<\/p>\n a \np \np \nl \ni \nc \na \nb \nl \ne<\/p>\n c \no \np \ny \nr \ni \ng \nh \nt<\/p>\n l \na \nw \n.\n<\/p>\n EBSCO Publishing : eBook Academic Collection (EBSCOhost) – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY \nAN: 237620 ; Fottler, Myron D., Fried, Bruce.; Human Resources in Healthcare : Managing for Success \nAccount: s8993066.main.ehost<\/p>\n<\/p>\n<\/div>\n \n Because of this division of labor within medical and health services de- \nlivery, many tasks that were once the responsibility of medical providers have \nbeen delegated to other healthcare personnel. Such delegation of duties raises \nimportant questions for the industry: Should healthcare providers other than \nthose specifically trained to practice medicine be considered professionals in \ntheir own right? To what extent should their scope of practice be extended?\n<\/p>\n In this chapter, we respond to the aforementioned questions by defin- \ning key terms, describing the healthcare professions and labor force, explain- \ning the role of human resources in healthcare, and discussing key human re- \nsources issues that affect the delivery of healthcare.\n<\/p>\n Professionalization\n<\/p>\n Although the terms \u201coccupation\u201d and \u201cprofession\u201d often are used inter- \nchangeably, they can be differentiated.\n<\/p>\n An occupation enables workers to provide services, but it does not re- \nquire skill specialization. An occupation is the principal activity that supports \none\u2019s livelihood. However, it is different from a profession in several ways. An \noccupation typically does not require higher skill specialization. An individual \nin an occupation is usually supervised, adheres to a defined work schedule, and \nearns an hourly wage rate. An individual in an occupation may be trained for \na specific job or function and, as a result, is less able to move from one organ- \nization to another.\n<\/p>\n A profession requires specialized knowledge and training that enable \nprofessionals to gain more authority and responsibility and to provide service \nthat adheres to a code of ethics. A professional usually has more autonomy in \ndetermining the content of the service he or she provides and in monitoring \nthe workload needed to do so. A professional generally earns a salary, requires \nhigher education, and works with more independence and mobility than do \nnonprofessionals.\n<\/p>\n The distinction between an occupation and a profession is important \nbecause the evolving process of healthcare delivery requires professionals who \nare empowered to make decisions in the absence of direct supervision. The \nproliferation of knowledge and the skills needed in the prevention, diagnosis, \nand treatment of disease has required increasing levels of education. Under- \ngraduate- and\/or graduate-level degrees are now required for entry into vir- \ntually every professional field. Some professions, such as pharmacy and phys- \nical therapy, are moving toward professional doctorates (i.e., PharmD and \nDPT, respectively) for practice.\n<\/p>\n A countervailing force against the increasing educational requirements \nof the healthcare professions is ongoing change in the mechanisms for deliv- \nery and payment of services. With consolidation of the healthcare system and\n<\/p>\n 72 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 72\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n the rise of managed care, along with its demands for efficiency, fewer financial \nresources are available. As a result, healthcare organizations are pressured to \nreplace highly trained\u2014and, therefore, more expensive\u2014healthcare profes- \nsionals with unlicensed support personnel. Fewer professionals are being \nasked to do more, and those with advanced degrees are required to supervise \nmore assistants who are functionally trained for specified organizational roles.\n<\/p>\n Functional training produces personnel who can perform tasks but \nwho may not know the theory behind the practice; understanding theory is \nessential to becoming fully skilled and able to make complex management and \npatient care decisions. Conversely, knowing the theory without having the ex- \nperience also makes competent practice difficult. When educating potential \nhealthcare professionals, on-the-job training or a period of apprenticeship is \nneeded, particularly in addition to basic coursework. Dreyfus and Dreyfus \n(1996) contend that both theoretical knowledge and practiced response are \nneeded in the acquisition of skill in a profession. These authors lay out five \nstages of abilities that an individual passes as he or she develops a skill:\n<\/p>\n 1. Novice. At this stage, the novice learns tasks and skills that enable him or \nher to determine actions based on recognized situations. Rules and \nguidelines direct the novice\u2019s energy and action at this stage.\n<\/p>\n 2. Advanced beginner. At this stage, the advanced beginner has gained \nenough experience and knowledge that certain behaviors become \nautomatic, and he or she can begin to learn when tasks should be \naddressed.\n<\/p>\n 3. Competent. At this stage, the competent individual has mastered the \npracticed response of definable tasks and processes and has acquired the \nability to deal with the unexpected events that may not conform to \nplans.\n<\/p>\n 4. Proficient. At this stage, the proficient individual has developed the \nability to discern a situation, intuitively assess it, plan what needs to be \ndone, decide on an action, and perform the action more effortlessly than \npossible in the earlier stages.\n<\/p>\n 5. Expert. At this stage, the expert can accomplish the goals without \nrealizing that rules are being followed because the skill and knowledge \nrequired to reach the goal have become second nature.\n<\/p>\n Theoretical understanding is melded with practice in each progressive \nstage. Functional training can help an individual progress through the first three \nstages and can provide the individual with calculative rationality or inferential rea- \nsoning ability to be able to apply and improve theories and rules learned. For skill \ndevelopment at the proficient and expert levels, deliberative rationality or ability \nto challenge and improve theories and rules learned is required. Healthcare pro- \nfessionals need to become experts in fields where self-direction, autonomy, and \ndecision making for patient care may be required (Dreyfus and Dreyfus 1996).\n<\/p>\n 73C 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 73\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n Healthcare Professionals\n<\/p>\n The healthcare industry is the largest and most powerful industry in the \nUnited States. It constitutes more than 6.5 percent of the country\u2019s total la- \nbor force and nearly 15 percent of the gross domestic product. Healthcare \nprofessionals include physicians, nurses, dentists, pharmacists, optometrists, \npsychologists, nonphysician practitioners such as physician assistants and \nnurse practitioners, healthcare administrators, and allied health professionals. \nThe allied health professions are a huge group that consists of therapists, \nmedical and radiologic technologists, social workers, health educators, and \nother ancillary personnel. Healthcare professionals are represented by profes- \nsional associations. Table 4.1 provides a sample of professional associations \nin healthcare.\n<\/p>\n Healthcare professionals work in a variety of settings, including hospi- \ntals; ambulatory care centers; managed care organizations; long-term-care or- \nganizations; mental health organizations; pharmaceutical companies; commu- \nnity health centers; physician offices; laboratories; research institutions; and \nschools of medicine, nursing, and allied health professions. According to the \nBureau of Labor Statistics (BLS 2007), healthcare professionals are employed \nby the following:\n<\/p>\n \u2022 hospitals (34.5 percent), \n\u2022 nursing and personal and residential care facilities (23.0 percent), \n\u2022 physician offices and clinics (17.1 percent), \n\u2022 home health care services (6.9 percent), \n\u2022 dentist offices and clinics (6.3 percent), and \n\u2022 other health service sites (12.2 percent).\n<\/p>\n The U.S. Department of Labor recognizes about 400 different job ti- \ntles in the healthcare sector; however, many of these job titles are not included \nin our definition of healthcare professionals. For example, almost one-third of \nthose employed in the healthcare sector probably belong in the support staff \ncategory\u2014that is, employees who are part of the patient care team or involved \nin delivering health services. These approximately 2.2 million nursing aides, \nhome health aides, and personal attendants are critical to the delivery of \nhealthcare services (BLS 2007).\n<\/p>\n The primary reasons for the increased supply and demand for health- \ncare professionals include the following interrelated forces:\n<\/p>\n \u2022 technological growth, \n\u2022 specialization, \n\u2022 changes in third-party coverage, \n\u2022 the aging of the population, and \n\u2022 the proliferation of new and diverse healthcare delivery settings.\n<\/p>\n 74 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 74\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n 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\n<\/p>\n Organization Target Audience Website\n<\/p>\n Health Professions\n<\/p>\n Pew Health Professions Future health http:\/\/futurehealth \nCommission professions .ucsf.edu\n<\/p>\n American College of Future healthcare www.healthmanage \nHealthcare Executives: managers and mentcareers.org \nHealth Management Careers administrators\n<\/p>\n Accrediting Organizations\n<\/p>\n Accreditation Association for Ambulatory healthcare www.aaahc \nAmbulatory Health Care facilities .org\n<\/p>\n Accreditation Council for Graduate medical www.acgme \nGraduate Medical Education education programs .org\n<\/p>\n American Osteopathic Osteopathic hospitals www.osteopathic \nAssociation and health systems .org\n<\/p>\n Commission on Accreditation Rehabilitation facilities www.carf.org \nof Rehabilitation Facilities\n<\/p>\n The Joint Commission Hospitals and health www.joint \nsystems commission.org\n<\/p>\n National Committee for Health plans http:\/\/web \nQuality Assurance .ncqa.org\n<\/p>\n American Association of Blood banks www.aabb.org \nBlood Banks\n<\/p>\n American College of Surgeons www.facs.org \nSurgeons\n<\/p>\n American College of Cancer programs www.facs.org\/ \nSurgeons: Commission cancer \non Cancer\n<\/p>\n College of American Clinical laboratories www.cap.org \nPathologists\n<\/p>\n Professional Associations\n<\/p>\n American College of Healthcare Healthcare executives www.ache.org \nExecutives\n<\/p>\n National Association of African-American www.nahse.org \nHealth Services Executives healthcare executives\n<\/p>\n Institute for Diversity in Health Healthcare managers, www.diversity \nManagement students, organizations, connection.org\n<\/p>\n diversity programs\n<\/p>\n TABLE 4.1 \nResource Guide \nfor the \nHealthcare \nProfessional\n<\/p>\n (Continued)\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 75\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n 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\n<\/p>\n Organization Target Audience Website\n<\/p>\n Medical Group Management Physician practice www.mgma.com \nAssociation managers and\n<\/p>\n executives\n<\/p>\n American Hospital Association: Healthcare human www.hrleader.org \nAmerican Society for resources \nHealthcare Human Resources professionals \nAdministration\n<\/p>\n American College of Physician Physician executives www.acpe.org \nExecutives\n<\/p>\n American College of Health Long-term-care www.achca.org \nCare Administrators administrators\n<\/p>\n Association for Healthcare Medical www.ahdionline.org \nDocumentation Integrity transcriptionists\n<\/p>\n American Association of Nurse anesthetists www.aana.com \nNurse Anesthetists\n<\/p>\n American Association for Respiratory therapists www.aarc.org \nRespiratory Care\n<\/p>\n American Health Information Medical records www.ahima.org \nManagement Association and information\n<\/p>\n management \nprofessionals\n<\/p>\n American Medical Technologists Medical technologists www.amt1.com\n<\/p>\n American Nurses Association Registered nurses www.ana.org\n<\/p>\n American Association for Homecare www.aahomecare \nHomecare administrators .org\n<\/p>\n American Occupational Occupational www.aota.org \nTherapy Association, Inc. therapists\n<\/p>\n American Organization of Nurse executives www.aone.org \nNurse Executives\n<\/p>\n National League for Nursing Nurse faculty and www.nln.org \neducators\n<\/p>\n American Physical Therapy Physical therapists www.apta.org \nAssociation\n<\/p>\n American Society for Clinical Pathologists and www.ascp.org \nPathology laboratory\n<\/p>\n professionals\n<\/p>\n American Society of Health- Health system www.ashp.org \nSystem Pharmacists pharmacists\n<\/p>\n TABLE 4.1 \nContinued\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 76\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n Organization Target Audience Website\n<\/p>\n American Society of Radiologic Radiologic www.asrt.org \nTechnologists technologists\n<\/p>\n American Speech-Language- Speech-language www.asha.org \nHearing Association pathologists;\n<\/p>\n audiologists; and \nspeech, language, and \nhearing scientists\n<\/p>\n Healthcare Financial Controllers, chief www.hfma.org \nManagement Association financial officers,\n<\/p>\n and accountants\n<\/p>\n Healthcare Information and Health information www.himss.org \nManagement Systems Society and technology\n<\/p>\n managers\n<\/p>\n National Cancer Registrars Cancer registry www.ncra-usa.org \nAssociation professionals\n<\/p>\n Trade Associations\n<\/p>\n American Hospital Association Hospitals, health www.aha.org \nsystems, and personal \nmembership groups\n<\/p>\n Federation of American Investor-owned www.fah.org \nHospitals hospitals and health\n<\/p>\n systems\n<\/p>\n Association of American Teaching hospitals www.aamc.org\/ \nMedical Colleges: Council of and health systems members\/coth \nTeaching Hospitals and \nHealth Systems\n<\/p>\n Catholic Health Association Catholic hospitals www.chausa.org \nof the United States and health systems\n<\/p>\n America\u2019s Health Insurance Health insurers www.ahip.org \nPlans\n<\/p>\n 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\n<\/p>\n TABLE 4.1 \nContinued\n<\/p>\n This chapter focuses primarily on nurses, pharmacists, selected allied \nhealth professionals, and healthcare administrators.\n<\/p>\n Nurses\n<\/p>\n The art of caring, combined with the science of healthcare, is the essence of \nnursing. Nurses focus not only on a particular health problem but also on \nthe whole patient and his or her response to treatment. Nurses work in many\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 77\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n different areas, but the common thread of nursing is the nursing process, \nwhich has five steps (ANA 2008):\n<\/p>\n 1. Assessment. This involves collecting and analyzing physical, \npsychological, and sociocultural data about a patient.\n<\/p>\n 2. Diagnosis. This entails making a judgment on the cause, condition, and \npath of the illness.\n<\/p>\n 3. Planning. This revolves around creating a care plan that sets specific \ntreatment goals.\n<\/p>\n 4. Implementation. This includes supervising or carrying out the actual \ntreatment plan.\n<\/p>\n 5. Evaluation. This focuses on continuous assessment of the plan.\n<\/p>\n Nurses also serve as patient advocates, multidisciplinary team members, \nmanagers, executives, researchers, and entrepreneurs.\n<\/p>\n Nurses make up the largest group of licensed healthcare professionals \nin the United States. According to the \u201cNational Sample Survey of Registered \nNurses (NSSRN),\u201d the United States has 2.9 million registered nurses (RNs), \nof whom more than 1.8 million (83.2 percent) are employed in healthcare or- \nganizations (HRSA 2006a). Approximately 56 percent of employed RNs, or \n1.6 million, work in hospitals, while 15 percent, or 435,000, work in commu- \nnity or public health settings. Complementing this workforce are 749,000 li- \ncensed practical nurses, or licensed vocational nurses as they are known in \nsome states (BLS 2006).\n<\/p>\n According to the demographic profiles from the NSSRN (HRSA \n2006a), most nurses are women. In 2004, the average age of a nurse was 46.8 \nyears old, nearly two years older than in 1997, when the average age was 44.5 \nyears. The aging of the workforce is also reflected in the demographics of \nnurses: The RN population under 30 years old dropped, from 25 percent in \n1980 to 8 percent in 2004. Meanwhile, the percentage of nurses older than \n54 years increased to 25.2 percent in 2004, compared to 20.3 percent in 2000 \nand 16.9 percent in 1980. Only 5.8 percent of RNs are men, and only 11 per- \ncent of RNs come from racial\/ethnic minority backgrounds.\n<\/p>\n All U.S. states require nurses to be licensed to practice. The licensure require- \nments include graduation from an approved nursing program and successful \ncompletion of a national examination. Educational preparation distinguishes \nthe two levels of nurses.\n<\/p>\n RNs must complete an associate\u2019s degree in nursing (ADN), a diploma \nprogram, or a baccalaureate degree in nursing (BSN) to qualify for the licen- \nsure examination. ADN programs generally take two years to complete and \nare offered by community and junior colleges, and hospital-based diploma \nprograms can be completed in about three years. The fastest growing avenue \nfor nursing education is the baccalaureate preparation, which typically can be\n<\/p>\n 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\n<\/p>\n Registered \nNurses and\n<\/p>\n Licensed \nPractical\n<\/p>\n Nurses\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 78\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n completed in four years and is offered by colleges and universities. Licensed \npractical nurses (LPNs), on the other hand, must complete a state-approved \nprogram in practical nursing and must achieve a passing score on a national \nexamination. Each state maintains regulations and practice acts that delineate \nthe scope of nursing practice for RNs and LPNs.\n<\/p>\n Among employed RNs, about 34 percent hold associate\u2019s degrees, \n20 percent have hospital-based program diplomas, and 34 percent possess \nBSN degrees. In 2004, 13 percent of nurses reported having a master\u2019s de- \ngree or a doctoral degree (HRSA 2006a). In addition to licensure and educa- \ntional achievements, some nurses obtain certification in specialty areas such as \ncritical care, infection control, emergency nursing, surgical nursing, and ob- \nstetric nursing. The nursing field comprises many specialties and subspecial- \nties; certification in these areas requires specialty education, practical experi- \nence, and successful completion of a national examination. Some nurses \nobtain certification in these specialty areas because certification helps them \nmaintain their professional associations. To remain certified, continued em- \nployment, continuing education units, or reexamination may be required.\n<\/p>\n An advanced practice nurse (APN) is a nurse with particular skills and creden- \ntials, which typically include basic nursing education; basic licensure; a grad- \nuate degree in nursing; experience in a specialized area; professional certifica- \ntion from a national certifying body; and, if required in some states, APN \nlicensure (National Council of State Boards of Nursing 2006). The APN spe- \ncializes as a nurse practitioner, certified nurse midwife, certified registered \nnurse anesthetist, or clinical nurse specialist.\n<\/p>\n The APN role is defined by seven core competencies or skillful per- \nformance areas. The first core competency of direct clinical practice is central \nto and informs all of the other areas, as follows (Hamric 2005):\n<\/p>\n \u2022 Direct clinical practice (central) \n\u2022 Expert guidance and coaching of patients, families, and other care providers \n\u2022 Consultation \n\u2022 Research skills, including use and implementation of evidence-based\n<\/p>\n practice, evaluation, and conduct \n\u2022 Clinical and professional leadership, which includes competence as a\n<\/p>\n change agent \n\u2022 Collaboration \n\u2022 Ethical decision-making skills\n<\/p>\n Additional core competencies may be needed in each specialty area that \nan APN pursues. The largest number of APNs is made up of nurse practition- \ners (NPs), who may further specialize in acute care or community settings or \nfor particular client groups such as adults, children, women, or psychiatric\/ \nmental health populations.\n<\/p>\n 79C 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\n<\/p>\n Advanced \nPractice \nNurses\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 79\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n Each state maintains its own laws and regulations regarding recogni- \ntion of an APN, but the general requirements in all states include licensure as \nan RN and successful completion of a national specialty examination. Some \nstates permit certain categories of APNs to write prescriptions for certain \nclasses of drugs. This prescriptive authority varies from one state to another \nand may be regulated by boards of medicine, nursing, pharmacy, or allied \nhealth. Some states require physician supervision of APN practices, although \nsome managed care plans now include APNs on their lists of primary care \nproviders.\n<\/p>\n Certified nurse midwives (CNMs) specialize in low-risk obstetric care, includ- \ning all aspects of the prenatal, labor and delivery, and postnatal processes. Cer- \ntified registered nurse anesthetists (CRNAs) complete additional education to \nspecialize in the administration of various types of anesthesia and analgesia to \npatients and clients. Often, nurse anesthetists work collaboratively with sur- \ngeons and anesthesiologists as part of the perioperative care team. Clinical \nnurse specialists (CNSs) hold master\u2019s degrees, have successfully completed a \nspecialty certification examination, and are generally employed by hospitals as \nnursing \u201cexperts\u2019\u2019 in particular specialties. The scope of the CNS is not as \nbroad as that of the NP; CNSs work with a specialty population under a some- \nwhat circumscribed set of conditions, and the management authority of pa- \ntients still rests with physicians. In contrast, NPs have developed an au- \ntonomous role in which their collaboration is encouraged, and they generally \nhave the legal authority to implement management actions.\n<\/p>\n Pharmacists\n<\/p>\n In the foreseeable future, the pharmacy profession will continue to undergo \nextensive change. Until the 1970s, pharmacists performed the traditional role \nof preparing drug products and filling prescriptions. In the 1980s, however, \npharmacists expanded that role. Pharmacists now act as an expert for clients \nand patients on the effects of specific drugs, drug interactions, and generic \ndrug substitutions for brand-name drugs.\n<\/p>\n To be eligible for licensure, pharmacists must graduate from an accred- \nited bachelor-degree program in pharmacy, successfully complete a state \nboard examination, and obtain practical experience or complete a supervised \ninternship. After passing a national examination, a registered pharmacist \n(RPh) is permitted to carry out the scope of practice outlined by state regula- \ntions. The trend in pharmacy has been to broaden education to include the \nterminal degree Doctor of Pharmacy (PharmD). Many pharmacy schools of- \nfer this program for those interested in research careers, teaching, higher ad- \nministrative responsibility, or being part of the patient care team. This educa- \ntional preparation also requires successful completion of a state board \nexamination and other practical clinical experience, as outlined by state laws.\n<\/p>\n 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\n<\/p>\n APN \nSpecialization\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 80\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n Allied Health Professionals\n<\/p>\n The term \u201callied health professionals\u201d is generally not well understood be- \ncause of its ambiguous definition (O\u2019Neil and Hare 1990) and a lack of con- \nsensus about what such a role constitutes. In general, allied health profession- \nals complement the work of physicians and other healthcare providers, \nalthough one may also be a provider. The U.S. Public Health Service defines \nan allied health professional as follows (Health Professions Education Exten- \nsion Amendments of 1992, Section 701 PHS Act):\n<\/p>\n . . . a health professional (other than a registered nurse or a physician as- \nsistant) who has received a certificate, an associate\u2019s degree, a bachelor\u2019s \ndegree, a master\u2019s degree, a doctoral degree, or post-baccalaureate train- \ning in a science related to health care; who shares in the responsibility for \nthe delivery of health care services or related services, including (1) serv- \nices relating to the identification, evaluation and prevention of disease and \ndisorders, (2) dietary and nutrition services, (3) health promotion serv- \nices, (4) rehabilitation services, or (5) health systems management serv- \nices; and who has not received a degree of doctor of medicine, a degree of \ndoctor of osteopathy, a degree of doctor of veterinary medicine or equiv- \nalent degree, a degree of doctor of optometry or equivalent degree, a de- \ngree of doctor of podiatric medicine or equivalent degree, a degree of \nbachelor science in pharmacy or equivalent degree, a graduate degree in \npublic health or equivalent degree, a degree of doctor of chiropractic or \nequivalent degree, a graduate degree in health administration or equiva- \nlent degree, a degree of doctor of clinical psychology or equivalent degree, \nor a degree in social work or equivalent degree.\n<\/p>\n A debate on the exclusiveness and inclusiveness of this definition con- \ntinues. Some healthcare observers consider nursing, public health, and social \nwork to fall under the umbrella of allied health, but these professions are of- \nten categorized as separate groups. Figure 4.1 lists the major categories that \ncompose the allied health profession and the job titles and positions that nor- \nmally fall under each category.\n<\/p>\n According to the \u201c2006 National Occupational and Wage Estimates \nfor Healthcare Personnel,\u201d the allied health professions constitute 45.5 per- \ncent of the healthcare workforce in the United States (BLS 2007). This num- \nber excludes physicians, nurses, dentists, pharmacists, veterinarians, chiroprac- \ntors, and podiatrists. The allied health profession is the most heterogeneous \nof the personnel groupings in healthcare.\n<\/p>\n The National Commission on Allied Health (1995) broadly divided \nallied health professionals into two categories of personnel: (1) therapists\/ \ntechnologists and (2) technicians\/assistants. Some of the job titles presented \nin Figure 4.1 may not fit into these two categories. In general, the therapist\/ \ntechnologist category represents those with higher-level professional training\n<\/p>\n 81C 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 81\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n 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\n<\/p>\n Behavioral Health Services\n<\/p>\n \u2022 Substance abuse counselor \u2022 Community health worker \n\u2022 Home health aide \u2022 Mental health assistant \n\u2022 Mental health aide\n<\/p>\n Clinical Laboratory Sciences\n<\/p>\n \u2022 Laboratory associate \u2022 Laboratory microbiologist \n\u2022 Laboratory technician \u2022 Chemist (biochemist)\n<\/p>\n \u2022 Microbiologist \n\u2022 Associate laboratory microbiologist\n<\/p>\n Dental Services\n<\/p>\n \u2022 Dental assistant \u2022 Dental hygienist \n\u2022 Dental laboratory technologist\n<\/p>\n Dietetic Services\n<\/p>\n \u2022 Dietitian \u2022 Assistant director of food service \n\u2022 Dietary assistant \u2022 Associate supervising dietitian\n<\/p>\n Emergency Medical Services\n<\/p>\n \u2022 Ambulance technician \u2022 Emergency medical technician\n<\/p>\n Health Information Management Services\n<\/p>\n \u2022 Director of medical records \u2022 Senior analyst of medical records \n\u2022 Assistant director of medical records \u2022 Health information manager \n\u2022 Medical record specialist \u2022 Data analyst\n<\/p>\n \u2022 Coder\n<\/p>\n Medical and Surgical Services\n<\/p>\n \u2022 Electroencephalograph technician \u2022 Medical equipment specialist \n\u2022 Electroencephalograph technologist \u2022 Electrocardiograph technician \n\u2022 Operating room technician \u2022 Dialysis technologist \n\u2022 Biomedical equipment technician \u2022 Surgical assistant \n\u2022 Biomedical engineer \u2022 Ambulatory care technician \n\u2022 Cardiovascular technologist\n<\/p>\n Occupational Therapy\n<\/p>\n \u2022 Occupational therapist \u2022 Occupational therapy aide \n\u2022 Occupational therapy assistant\n<\/p>\n Ophthalmology \n\u2022 Ophthalmic technician \u2022 Optician \n\u2022 Optometric aide\n<\/p>\n FIGURE 4.1 \nMajor\n<\/p>\n Categories of \nthe Allied\n<\/p>\n Health \nProfession and\n<\/p>\n Professional \nTitles\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 82\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n 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\n<\/p>\n Physical Therapy\n<\/p>\n \u2022 Physical therapist \u2022 Physical therapy assistant\n<\/p>\n Radiological Services \n\u2022 Nuclear medicine technician \u2022 Nuclear medicine technologist \n\u2022 Radiation technician \u2022 Diagnostic medical sonographer \n\u2022 Ultrasound technician \u2022 Radiologic (medical) technologist \n\u2022 Medical radiation dosimetrist\n<\/p>\n Rehabilitation Services \n\u2022 Art therapist \u2022 Music therapist \n\u2022 Exercise physiologist \u2022 Dance therapist \n\u2022 Recreational therapist \u2022 Rehabilitation counselor \n\u2022 Recreation therapy assistant \u2022 Rehabilitation technician \n\u2022 Addiction counselor \u2022 Sign-language interpreter \n\u2022 Addiction specialist \n\u2022 Psychiatric social health technician\n<\/p>\n Orthotics\/Prosthetics\n<\/p>\n \u2022 Orthopedic assistant\n<\/p>\n Respiratory Therapy Services\n<\/p>\n \u2022 Respiratory therapist \u2022 Respiratory therapy technician \n\u2022 Respiratory therapy assistant\n<\/p>\n Speech-Language Pathology\/Audiology Services\n<\/p>\n \u2022 Audiology clinician \u2022 Staff audiologist \n\u2022 Staff speech pathologist \u2022 Speech clinician\n<\/p>\n Other Allied Health Services\n<\/p>\n \u2022 Central supply technician \u2022 Medical illustrator \n\u2022 Podiatric assistant \u2022 Veterinary assistant \n\u2022 Health unit coordinator \u2022 Chiropractic assistant \n\u2022 Home health aide\n<\/p>\n and who are often responsible for supervising those in the technician\/assistant \ncategory. Therapists\/technologists usually hold a bachelor\u2019s or a higher-level \ndegree, and they are trained to evaluate patients, understand diagnoses, \nand develop treatment plans in their area of expertise. On the other hand, \ntechnicians\/assistants are most likely to have two years or less postsecondary \neducation, and they are functionally trained with procedural skills for speci- \nfied tasks.\n<\/p>\n FIGURE 4.1 \nContinued\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 83\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n Educational and training programs for the allied health profession are \nsponsored by a variety of organizations in different academic and clinical set- \ntings. They range from degree offerings at colleges and universities to clinical \nprograms in hospitals and other health facilities. Before 1990, one-third of al- \nlied health programs were housed in hospitals, although hospitals graduated \nonly 15 percent of their students (O\u2019Neil and Hare 1990). The Association \nof Schools of Allied Health Professions (ASAHP 2007) includes these among \nits membership: 112 academic institutions, 2 professional associations, and \napproximately 200 individual members. Junior or community colleges, voca- \ntional or technical schools, and academic health centers can all sponsor allied \nhealth programs. These programs can also be stand-alone when aligned with \nan academic health center, or they can be under the auspices of the school of \nmedicine or nursing if a specific school of allied health professions does not \nexist. Dental and pharmacy technicians\/assistants may or may not be trained \nin their respective schools or in a school of allied health professions.\n<\/p>\n A vast number of the undergraduate allied health programs are accred- \nited by the Commission on Accreditation of Allied Health Education Programs \n(CAAHEP), a freestanding agency that in 1994 replaced the American Med- \nical Association\u2019s Committee on Allied Health Education and Accreditation. \nThe formation of CAAHEP was intended to simplify the accrediting process, \nto be more inclusive of allied health programs that provide entry-level educa- \ntion, and to serve as an initiator of more far-reaching change. Some key allied \nhealth graduate programs, such as physical therapy and occupational therapy, \nare accredited through specialty professional accreditation organizations.\n<\/p>\n Healthcare Administrators\n<\/p>\n Healthcare administrators organize, coordinate, and manage the delivery of \nhealth services; provide leadership; and guide the strategic direction of health- \ncare organizations. The variety and numbers of healthcare professionals they \nemploy; the complexity of healthcare delivery; and environmental pressures to \nprovide access, quality, and efficient services make healthcare institutions \namong the most complex organizations to manage.\n<\/p>\n Healthcare administration is taught at the undergraduate and graduate \nlevels in a variety of settings, and these programs lead to a number of different \ndegrees. The settings include schools of medicine, public health, healthcare \nbusiness, and allied health professions. A bachelor\u2019s degree in health adminis- \ntration allows individuals to pursue positions such as nursing home administra- \ntor, supervisor, or middle manager in healthcare organizations. Most students \nwho aspire to have a career in healthcare administration go on to receive a mas- \nter\u2019s degree. (For a detailed description of various career paths and options, see \nHaddock, McLean, and Chapman 2002).\n<\/p>\n Graduate education programs in healthcare administration are ac- \ncredited by the Commission on Accreditation of Healthcare Management\n<\/p>\n 84 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 84\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n Education. Most common degrees include the master of health administra- \ntion (MHA), master of business administration (MBA) with a healthcare em- \nphasis), master of public health (MPH), or master of public administration \n(MPA). However, the MHA degree, or its equivalent, has been the accepted \ntraining model for entry-level managers in the various sectors of the health- \ncare industry. The MHA program, when compared to the MPH program, of- \nfers core courses that focus on building business management (theory and ap- \nplied management), quantitative, and analytical skills and that emphasize \nexperiential training. In addition, some MHA programs require students to \ncomplete three-month internships or 12-month residencies as part of their \ntwo- or three-year curricula. Some graduates elect to complete postgraduate \nfellowships that are available in selected hospitals, health systems, managed \ncare organizations, consulting firms, and other health-related organizations.\n<\/p>\n A growing number of healthcare administrators are physicians and \nother clinicians. As evidence, membership in the American College of Physi- \ncian Executives (ACPE 2007) has increased to more than 10,000 in 2007, up \nfrom 5,700 in 1990, although stable since 2000. Physicians, nurses, and other \nclinicians refocus their careers on the business side of the enterprise, getting \ninvolved in the strategy, decision making, resource allocation, and operations \nof healthcare organizations. A traditional management role for physician ex- \necutives is the chief medical officer (or a similar position) in a hospital, over- \nseeing the medical staff and serving as a liaison between clinical care and ad- \nministration. Likewise, a typical management career path for nurses is to \nbecome the chief nursing officer, with responsibility for the clinical care pro- \nvided by employed professional staff.\n<\/p>\n Typically, chief medical officers begin their careers practicing medi- \ncine, then they slowly transition into the operations side of healthcare. How- \never, physician executives work at every level and in every setting in health- \ncare. Many physician executives earn a graduate degree such as an MHA or \nan MBA if interested in pursuing a formal educational program in healthcare \nadministration and management. As of 2007, 49 medical schools offer a \ncombined MD\/MBA program, and two medical schools offer the \nMD\/MHA dual degrees (AAMC 2007). Whether physician executives start \nas administrators or later shift to become executives after clinical practice, \nthey represent for other doctors an alternative way to make an impact on \nhealthcare delivery.\n<\/p>\n Nursing home administrator programs require students to pass a na- \ntional examination administered by the National Association of Long Term \nCare Administrator Boards. Passing this examination is a standard require- \nment in all states, but the educational preparation needed to qualify for this \nexam varies from state to state. Although more than one-third of states still \nrequire less than a bachelor\u2019s degree as the minimum academic preparation, \napproximately 70 percent of the practicing nursing home administrators have,\n<\/p>\n 85C 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 85\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n at a minimum, a bachelor\u2019s degree. As the population continues to live longer, \nthe demand and educational requirements for long-term-care administrators \nare estimated to increase, along with the growth of educational programs tar- \ngeted to this sector.\n<\/p>\n Considerations for Human Resources Management\n<\/p>\n The role of human resources management (HRM) in healthcare organiza- \ntions is to develop and implement systems, in accordance with regulatory \nguidelines and licensure laws, that ensure selection, evaluation, and retention \nof healthcare professionals. In light of this role, human resources (HR) per- \nsonnel should be aware that each of the healthcare professions, and often the \nsubspecialties within those professions, has specific requirements that allow an \nindividual to qualify for an entry-level job in his or her chosen profession. The \nrequirements of national accrediting organizations (e.g., the Joint Commis- \nsion), regulatory bodies (e.g., the Centers for Medicare & Medicaid Services), \nand licensure authorities (e.g., state licensure boards) should be considered in \nall aspects of HRM. In this section, we briefly discuss some of the issues that \na healthcare organization\u2019s HR department must consider when dealing with \nhealthcare professionals.\n<\/p>\n Qualifications\n<\/p>\n In developing a comprehensive employee-compensation program, HR per- \nsonnel must include the specific skill and knowledge required for each job in \nthe organization. Those qualifications must be determined and stated in \nwriting for each job. The job description usually contains the level of educa- \ntion, experience, judgment ability, accountability, physical skills, responsibil- \nities, communication skills, and any special certification or licensure require- \nments. HR personnel need to be aware of all specifications for all job titles \nwithin the organization. This knowledge of healthcare professionals is neces- \nsary to ensure that essential qualifications of individuals coincide with job \nspecifications, and it is also necessary for determining wage and salary ranges \n(see Chapter 7).\n<\/p>\n Licensure and Certification\n<\/p>\n An HR department must have policies and procedures in place that describe \nthe way in which licensure is verified on initial employment. Also, HR must \nhave a system in place for tracking the expiration dates of licenses and for en- \nsuring licensure renewal. Therefore, HR must be conscientious about \nwhether the information it receives is a primary verification (in which the in- \nformation directly comes from the licensing authority) or a secondary verifica- \ntion (in which a candidate submits a document copy that indicates licensure\n<\/p>\n 86 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 86\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n has been granted, including the expiration date). Certifications must be veri- \nfied during the selection process, although certifications and licenses are gen- \nerally not statutory requirements. Many healthcare organizations accept a \ncopy of a certification document as verification. If the certification is a job re- \nquirement, systems must be in place to track expiration dates and to access \nnew certification documents.\n<\/p>\n Career Ladders\n<\/p>\n In selecting healthcare professionals, HR personnel must consider past em- \nployment history, including the explanation of gaps in employment. To assess \nthe amount of individual experience, evaluating the candidate\u2019s breadth and \ndepth of responsibility in previous jobs is essential. Many healthcare organiza- \ntions have career ladders, which are mechanisms that advance a healthcare \nprofessional within the organization. Career ladders are based on the Dreyfus \nand Dreyfus model of novice to expert (explained earlier in the chapter), and \nexperience may be used as a criterion for assignment of an individual to a par- \nticular job category. In addition, healthcare organizations may conduct annual \nreviews of employees who have leadership and management potential. This re- \nview entails that HR works with senior management to assess the competency, \nability, and career progression of employees on an ongoing basis.\n<\/p>\n Educational Services\n<\/p>\n Healthcare professionals require continuous, lifelong learning. Healthcare or- \nganizations must have in-house training and development plans to ensure that \ntheir healthcare professionals achieve competency in new technologies, pro- \ngrams, and equipment and are aware of policy and procedure changes. Cer- \ntain competencies must be renewed annually in areas such as cardiopulmonary \nresuscitation, safety and infection control, and disaster planning.\n<\/p>\n In addition to developing specific training programs, healthcare organ- \nizations should provide orientation for all new employees. Such organization- \nspecific training enables the leadership to share the values, mission, goals, and \npolicies of the institution. Such clear communication often serves as a reten- \ntion tool that enables employees to better understand how the organization \nworks and how to be successful in that organization. Similarly, some profes- \nsions and licensing jurisdictions may require continuing education that is pro- \nfession specific.\n<\/p>\n A healthcare organization can provide training and development in a \nvariety of ways. On one end of the spectrum, training and development can \nbe outsourced to a firm that specializes in conducting educational programs. \nConversely, another option is to consolidate all training and development in- \nhouse, which are managed typically by the HR department. Regardless of how \neach healthcare organization provides continuing education, training and de- \nvelopment should be a priority. Strong programs can be viewed as recruitment\n<\/p>\n 87C 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 87\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n and retention tools. As such, healthcare organizations must be cognizant of \nfiscal resources necessary to support these educational requirements.\n<\/p>\n Practitioner Impairment\n<\/p>\n Healthcare professionals are accountable to the public for maintaining high \nprofessional standards, and the governing body of a healthcare organization \nis, by statute, responsible for the quality of care rendered in the organization. \nThis quality is easily jeopardized by an impaired practitioner. An impaired \npractitioner is a healthcare professional who is unable to carry out his or her \nprofessional duties with reasonable skill and safety because of a physical or \nmental illness, including deterioration through aging, loss of motor skill, or \nexcessive use of drugs and alcohol.\n<\/p>\n The HR department must periodically evaluate the performance of all \nhealthcare professionals in the organization to ensure their competence (i.e., \nthe basic education and training necessary for the job) and proficiency (i.e., \nthe demonstrated ability to perform job tasks). Mechanisms must be in place \nto identify the impaired practitioner, such as policies and procedures that de- \nscribe how the organization will handle investigations, subsequent recom- \nmendations for treatment, monitoring, and employment restrictions or sepa- \nration. Hospitals, for instance, usually have a process in place for the board of \ndirectors (which has the ultimate responsibility for the quality of care deliv- \nered in the organization) to review provider credentials and performance and \nto oversee any employment actions. Each national or state licensing authority \nmaintains legal requirements for reporting impaired practitioners.\n<\/p>\n As a result of ever-increasing changes in the health professions, in \nthe foreseeable future, new challenges and opportunities, such as the issues \ndescribed in this section, will face the HR department of every healthcare \norganization.\n<\/p>\n Changing Nature of the Health Professions\n<\/p>\n In the 1990s, we entered a new era of uncertainty in healthcare, one faced \nwith a quickening pace of change (Begun and White 2008). Within this \nframework, new ways of thinking are rewarded as the meaning of health is re- \ndefined, the boundaries of healthcare professionals are reshaped, and the out- \ncomes of healthcare professional interventions are measured in terms of qual- \nity of life. Changes in the organization and financing of healthcare services \nhave shifted delivery from the hospital to outpatient facilities, the home, \nlong-term-care facilities, and the community. This is largely the result of \nthree major forces: (1) a shift in managed care reimbursement to outpatient \nsettings and a focus on cost containment; (2) technological advances, such as\n<\/p>\n 88 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 88\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n telemedicine and the electronic medical record; and (3) medical innovation\u2014 \nthe science of medicine has progressed to the point that complicated procedures \nthat once required several nights of stay can now be treated with a simple pro- \ncedure or even solely with medication. These changes are intended to improve \nthe delivery of healthcare while reducing cost and increasing access for patients.\n<\/p>\n As the setting for the delivery of care continued to change, so did \narrangements between physicians and healthcare organizations. For instance, \nphysicians can function as individual providers (either in solo or group prac- \ntice) and refer patients to the hospital. Typically, these private-practice doctors \nhave admitting privileges to the hospital but are not governed by the hospi- \ntal, do not serve as attending physicians, and infrequently participate on hos- \npital committees. Physicians considered \u201con staff\u201d at any hospital are those \nwho refer and treat patients at that hospital. They are credentialed by the hos- \npital credentialing committee (usually managed by the chief of staff office) \nand are governed by the medical staff bylaws. This is a common type of hos- \npital-provider arrangement.\n<\/p>\n However, a trend toward hospitals employing physicians has been \ngrowing. In this arrangement, physicians are on staff, referring to and treat- \ning at only the hospital that employs them. Because they are considered em- \nployees, physicians are not only held to the HR policies of the healthcare or- \nganization but are also governed by the medical staff bylaws. Physicians who \nare employed by a hospital can also maintain a private practice.\n<\/p>\n Finally, the field of hospitalists is also growing. Typically, these physi- \ncians do not run their own practice aside from their hospital employment. \nHospitalists work full time for the hospital and are trained in delivering spe- \ncialized inpatient care. Regardless of the type of arrangement, most hospitals \nhave a chief medical officer, or a similar position, who oversees the roles and \nresponsibilities of the hospitalist as a member of the medical staff; the hospi- \ntalist\u2019s employee issues and responsibilities are typically managed by the HR \ndepartment. These hospital\u2013physician arrangements get more complex in ac- \nademic medical centers, which must integrate the roles and responsibilities of \nthe physicians, the hospital, and the medical school.\n<\/p>\n As a result of the changing environment and decreased reimburse- \nment, more primary care physicians are joining or forming group practices. \nLarge physician-owned group practices offer several advantages to physi- \ncians, including competitive advantage with vendors and manufacturers, im- \nproved negotiating power with managed care organizations, shared risk and \ndecision making, and improved flexibility and choice for patients. Physicians \nusually own or share ownership in the group practice and, therefore, are re- \nsponsible for the business operations. Typically, group practices employ an \noffice manager who works closely with the physicians to manage the day-to- \nday operations. Often, a full-time administrator is on staff not only to man- \nage everyday issues but also to formulate strategies and oversee personnel,\n<\/p>\n 89C 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 89\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n billing and collection, purchasing, patient flow, and other functions. Many \ngroup practices opt to outsource their business functions, including human \nresources, to specialized firms. For complete details on medical practice man- \nagement, go to www.mgma.com.\n<\/p>\n These shifts in various healthcare settings and arrangements have \nchanged the roles, functions, and expectations of the healthcare workforce \nand gave way to the emergence of the following issues.\n<\/p>\n Supply and Demand\n<\/p>\n Throughout the twentieth century, the nursing labor market cycled through \nperiods of shortages and surpluses (Lynn and Redman 2005; Aiken et al. \n2002; Kovner 2002; Coile 2001; Jones 2001; Buerhaus, Staiger, and Auer- \nbach 2000). The beginning of the twenty-first century brought the nursing \nand allied health professions the challenge of keeping pace with the demand \nfor their services. Indicators of demand include numbers of vacancies, \nturnover rates, and an increase in salaries. To fill positions, hospitals\u2014the \nlargest employers of nurses and allied health professionals\u2014have raised salaries, \nprovided scholarships, and given other incentives such as sign-on bonuses and \ntuition reimbursement.\n<\/p>\n The supply of nurses and allied health professionals is reflected in the \nnumber of students in educational programs and those available for the \nhealthcare workforce. Future supply of such professionals continues to be \nthreatened by the following factors:\n<\/p>\n \u2022 The aging of the nursing workforce. According to the results of the 2004 \nNational Sample Survey of Registered Nurses (HRSA 2006a), the \naverage age for all nursing faculty was 51.6, and for nursing faculty who \nhave doctoral degrees, it was 55.4 (up from 53.5 in 2003).\n<\/p>\n \u2022 The decline in available educational resources. Almost two-thirds (68.5 \npercent) of the nursing schools that responded to the 2006 American \nAssociation of Colleges of Nursing (AACN 2007a) survey identified \nfaculty shortages as a reason for not accepting all qualified applicants \ninto entry-level baccalaureate programs. The survey also noted lack of \nclassroom space and clinical facilities and budgetary restraints.\n<\/p>\n \u2022 The decline in nursing school enrollees. From 1995 through 2000, \nenrollment decreased by 21 percent. From 2001 through 2007, \nincreases of 3.7 to 16.6 percent were observed, but more than 30,000 \nqualified applicants were turned away from baccalaureate nursing \nprograms in 2007 (AACN 2007a).\n<\/p>\n As a result, recruitment of nursing and allied health professions stu- \ndents has become a major focus of practitioners, professional associations, and \nacademic institutions. In response, healthcare organizations (in addition to in- \ncreasing salaries) are developing innovative ways to recruit and retain nurses\n<\/p>\n 90 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 90\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n and allied health professionals. Such developments include opening or spon- \nsoring new schools, offering shorter and more flexible shifts, and providing \nchild care.\n<\/p>\n Alternative Therapies\n<\/p>\n Alternative therapies have gained more popularity, judging by the growing \nnumber of publications on this topic in the lay press and in academic literature. \nA turning point in this acceptance and increased respectability was the sentinel \nstudy of the prevalence of the use of alternative or unconventional therapies \n(Eisenberg et al. 1993). In the study, Eisenberg and colleagues concluded that \none in three adults relied on treatments and interventions that are not widely \ntaught at medical schools in the United States; examples of these alternative in- \nterventions included acupuncture and chiropractic and massage therapies. In a \nfollow-up study, Eisenberg and colleagues (1998) determined that, from 1990 \nto 1997, visits to alternative medicine practitioners increased by 47.3 percent. \nAnother study reported that 75 (60 percent) out of the 125 medical schools \nthat participated in the survey offered a course in complementary or alterna- \ntive medicine (Wetzel, Eisenberg, and Kaptchuk 1998). Additionally, con- \nsumers are demanding the use of alternative therapies, and hospitals have be- \ngun offering more of these services (Clement et al. 2006). As the use of \nalternative therapies continues to gain acceptance and to be integrated in med- \nical school curriculum, this specialty area may be more and more considered as \nan emerging healthcare profession.\n<\/p>\n Nonphysician Practitioners\n<\/p>\n With the advent of managed care, greater reliance has been placed on non- \nphysician practitioners. Collaborative practice models with nurse practition- \ners, physician assistants, pharmacists, and other therapists are appropriate to \nboth acute and long-term healthcare delivery. Strides have been made in the \ndirect reimbursement for some nonphysician healthcare provider services, \nwhich is an impetus for further collaboration in practice. The consolidation \nand integration of the healthcare delivery system have not, however, elimi- \nnated slack and duplication of services. Although the changes attributed to \nmanaged care have led to the promotion and use of less-costly sites for care \ndelivery, a larger impact on the division of labor among all healthcare profes- \nsionals, and thus on health professions, may yet occur.\n<\/p>\n Licensure and Certification\n<\/p>\n The use of nonphysician practitioners at various sites may be viewed as an op- \nportunity for the growth of nursing, pharmacy, allied health professions, and \nhealth administration. Alternatively, Hurley (1997) contends that it may lead \nto concerted efforts to repeal professional licensure and certification in health- \ncare. If policymakers jump on the bandwagon, this deregulation may lead to\n<\/p>\n 91C 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 91\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n not only the demise of some healthcare professions but also the proliferation of \nfunctionally trained, unlicensed personnel. The use of personnel who have less \neducation will have greater implications for the existence and growth of educa- \ntional programs in academic medical centers. The use of unlicensed support per- \nsonnel poses concerns about the intensity and quality of healthcare delivered. \nWhen fewer highly trained professionals are employed to oversee operations and \ncare delivery, the potential for adverse outcomes increases. Aiken, Sochalski, and \nAnderson (1996) found that, although the percentage of RNs increased over- \nall, fewer nurses per patient were available in the mid-1990s than in the 1980s \nto provide care for more acutely ill patients. The net effect was a relative increase \nin nonclinical personnel, which added stress for those who were expected to su- \npervise unlicensed staff and to care for sicker patients. This is a trend that con- \ntinues to affect the provision of healthcare (Aiken et al. 2002).\n<\/p>\n Recruitment and Retention\n<\/p>\n Recruitment and retention of healthcare professionals are important in the \nface of continuing shortages in key healthcare professions, including nursing \nand allied health professions. The American Hospital Association (2007) re- \nported an average hospital nurse vacancy rate of 8.1 percent. The RN vacancy \nrate is projected to be 20 percent by 2020 (Buerhaus, Staiger, and Auerbach \n2000; Heinrich 2001). This vacancy rate is related to an RN shortage, which \nis estimated to be in the range of 340,000 to 1 million nurses by 2020 (Auer- \nbach, Buerhaus, and Staiger 2007; HRSA 2006b). Nearly 17 percent of RNs \nwere not employed in nursing in 2004, which was a 26.2 percent increase over \nthe 1992 rate (HRSA 2006a). Letvak (2002) predicted that one in five nurses \nplanned to leave the profession and turnover costs could be up to two times \na nurse\u2019s salary. Fifty-five percent of nurses reported their intention to retire \nbetween 2011 and 2020 in a survey released in 2006 (AACN 2007b), which \nwould further contribute to the RN shortage. Similarly, the American Hospi- \ntal Association (2007) reported vacancy rates among allied health profession- \nals (e.g., occupational and physical therapists, laboratory technologists, imag- \ning technicians) that range from 6 percent to 11 percent of needed positions. \nThese shortages require current professionals to treat more patients and to \nwork longer hours. Such conditions can contribute to emergency department \ndiversions, increased patient wait times, and decreased patient safety.\n<\/p>\n In response, healthcare organizations need to develop and execute re- \ncruitment and retention programs. These programs require senior manage- \nment support and dedicated financial and human resources. Such programs \nshould focus on building a culture of retention. While salary is an important \naspect of employee recruitment and retention, other aspects of work are \nalso influential, such as leadership support, ability to contribute to the organ- \nization and provide quality care to patients, degree of autonomy, engaging \nin positive relationships with direct supervisors and peers, good working\n<\/p>\n 92 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 92\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n conditions, and ability to maintain a work\u2013life balance. Additional tools for \nretaining employees include conducting employee-engagement surveys, pro- \nviding mentoring, and making training programs available.\n<\/p>\n One innovative way to differentiate a hospital from its competitors, \nwhich helps in recruitment and retention, is to achieve Magnet status. In \n1993, the American Nurses Credentialing Center\u2019s Magnet Recognition Pro- \ngram was developed as a way to specifically recognize excellence in nursing \nservices at the institutional level and to benchmark best practices to be dissem- \ninated throughout the industry. Hospitals that apply for and achieve Magnet \nstatus have created and demonstrated a professional practice environment that \nensures quality outcomes. These hospitals are recognized for their best prac- \ntices in nursing care, improved patient outcomes, and increased workplace sat- \nisfaction. The actual evaluation process is based on nine Magnet standards, the \ncompletion of an intensive written application, and a two-day site visit by a \nteam of nurse scholars. Hospitals that do not wish to engage in the applica- \ntion process can benefit greatly from using Magnet strategies to create a cul- \nture based on excellence in nursing and patient care (Pieper 2003). For more \ninformation on Magnet status, see www.nursecredentialing.org\/magnet.\n<\/p>\n Entrepreneurship\n<\/p>\n Given the bureaucratic nature of organizations, the regulation of the health- \ncare industry, and additional constraints by payers and managed care, many \nhealthcare professionals are choosing to pursue opportunities on their own. \nThe service economy coupled with knowledge-based professions may encour- \nage pursuit of new and different ventures for individuals who have the person- \nality, skills, and tenacity to go into business for themselves. An entrepreneur \nmust have a mix of management skills and the means to depart from a tradi- \ntional career path to practice on one\u2019s own.\n<\/p>\n White and Begun (1998) characterize the entrepreneurial personality \ntraits of a profession in terms of its willingness to take the risks associated with \nundertaking new ventures. Each profession may be categorized either as de- \nfending the status quo, which therefore entails little risk (defender professions), \nor as looking for new and different opportunities with greater risk (prospector \nprofessions). White and Begun view the more entrepreneurial professions as \nmore diversified in terms of processes and services delivered. The accrediting \nbodies of such entrepreneurial professions encourage educational innovation \nthat may extend to nontraditional careers. Each of the healthcare professions \nhas, to greater or lesser extents, defender and prospector aspects.\n<\/p>\n Workforce Diversity\n<\/p>\n Each of the healthcare professions must continue to monitor and encourage \ndiversity in its membership because the demographic shifts that the United \nStates is going through will have an impact on the workforce composition in\n<\/p>\n 93C 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 93\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n the coming decades. Although workforce diversity is a broad concept, it fo- \ncuses on our differences in gender, age, and race; these aspects not only re- \nflect the population that healthcare serves but also the people who provide the \nservices. Some professions are dominated by one gender or the other, which \nis illustrated by the predominantly female field of nursing or the historically \npredominantly male field of health administration. The health administration \nprofession, however, has made strides in recent years as more female adminis- \ntrators have entered the field. Labor shortages and employee turnover are \ncommon in the healthcare professions. Consequently, healthcare executives \nmust balance the needs of new entrants into the profession and those already \nin the profession.\n<\/p>\n Changes in the ethnic and racial composition of the workforce are pro- \nportional to the changes in the size and age of the population (D\u2019Aunno, \nAlexander, and Laughlin 1996). Because many healthcare professionals are \nracial\/ethnic minorities, a concerted effort needs to be made to recruit and \nretain them because the diversity of the members of a profession should re- \nflect the diversity of the members of the population.\n<\/p>\n Summary\n<\/p>\n Healthcare professionals are a large segment of the U.S. labor force. Histori- \ncally, the development of healthcare professionals is related to the following \ntrends:\n<\/p>\n \u2022 Supply and demand \n\u2022 Increased use of technology \n\u2022 Changes in disease and illness \n\u2022 The impact of healthcare financing and delivery\n<\/p>\n The healthcare workforce is very diverse. The different levels of education, \nscopes of practice, and practice settings contribute to the complexity of manag- \ning this workforce. The coming decades will be characterized by some reforms \nwithin the healthcare professions because of increasing pressures to finance and \ndeliver healthcare with higher-quality, lower-cost, and measurable outcomes.\n<\/p>\n 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\n<\/p>\n 1. Describe the process of profes- \nsionalization. What is the difference \nbetween a profession and an \noccupation?\n<\/p>\n 2. Describe the major types of healthcare \nprofessionals (excluding physicians and \ndentists) and their roles, training, licensure \nrequirements, and practice settings.\n<\/p>\n Discussion Questions\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 94\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n References\n<\/p>\n Aiken, L. H., S. P. Clarke, D. M. Sloane, J. Sochalski, and J. H. Silber. 2002. \u201cHospital \nNurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction.\u201d \nJAMA 288 (16): 1987\u201393.\n<\/p>\n Aiken, L. H., J. Sochalski, and G. F. Anderson. 1996. \u201cDownsizing the Hospital Nursing \nWorkforce.\u2019\u2019 Health Affairs 15 (4): 88\u201392.\n<\/p>\n American Association of Colleges of Nursing (AACN). 2007a. \u201cEnrollment Growth Slows \nat U.S. Nursing Colleges and Universities in 2007 Despite Calls for More Regis- \ntered Nurses.\u201d [Online news release; retrieved 1\/31\/08.] www.aacn.nche.edu\/ \nMedia\/NewsReleases\/2007\/enrl.htm.\n<\/p>\n \u2014\u2014\u2014. 2007b. \u201cNursing Shortage.\u201d [Online news release; retrieved 1\/29\/08.] www.aacn \n.nche.edu\/Media\/FactSheets\/NursingShortage.htm.\n<\/p>\n American College of Physician Executives (ACPE). 2007. [Online information; retrieved \n2\/4\/08.] www.acpe.org\/Footer\/AboutACPE.aspx.\n<\/p>\n 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\n<\/p>\n 3. Describe and apply the issues of human \nresources management and systems \ndevelopment to healthcare professionals.\n<\/p>\n 4. How has managed care affected the \nhealthcare professions?\n<\/p>\n 5. Who are nonphysician practitioners who \nprovide primary care? What is their role \nin the delivery of health services?\n<\/p>\n Experiential Exercise\n<\/p>\n The purpose of this exercise is to give you an \nopportunity to explore one healthcare pro- \nfession in detail.\n<\/p>\n From all of the healthcare professions, \nselect one for analysis. Table 4.1 provides a \nstarting point for selection. Describe the fol- \nlowing characteristics of the profession you \nselected:\n<\/p>\n \u2022 Knowledge base \n\u2022 Collective goals \n\u2022 Training \n\u2022 Licensure (this varies by state) \n\u2022 Number of professionals in practice by\n<\/p>\n 1. Vertical differentiation (position, \nexperience, education level)\n<\/p>\n 2. Horizontal differentiation \n(geography, practice setting, \nspecialty)\n<\/p>\n \u2022 History and evolution of the profession \n\u2022 Professional associations and their roles \n\u2022 Competitor professions \n\u2022 Current strategic issues that face the\n<\/p>\n profession and the profession\u2019s position \non these issues\n<\/p>\n To get started on this exercise, you \nmay wish to go to the websites of profes- \nsional organizations and various state licens- \ning boards. You may also interview members \nof the profession as well as leaders in the \nfield.\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 95\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n American Hospital Association. 2007. \u201cThe 2007 State of America\u2019s Hospitals\u2014Taking \nthe Pulse: Findings from the 2007 AHA Survey of Hospital Leaders July 2007.\u201d \n[Online information; retrieved 1\/31\/08.] www.aha.org\/aha\/content\/2007\/ \nPowerPoint\/StateofHospitalsChartPack2007.ppt.\n<\/p>\n American Nurses Association (ANA). 2008. \u201cThe Nursing Process: A Common Thread \nAmongst All Nurses.\u201d [Online article; retrieved 2\/6\/08.] www. \nnursingworld.org\/EspeciallyForYou\/StudentNurses\/Thenursingprocess.aspx.\n<\/p>\n Association of American Medical Colleges (AAMC). 2007. \u201cCombined Degree Pro- \ngrams.\u201d [Online article; retrieved 7\/16\/07.] http:\/services.aamc.org\/currdir\/ \nsection3\/degree2.cfm.\n<\/p>\n Association of Schools of Allied Health Professions (ASAHP). 2007. [Online information; \nretrieved 2\/4\/08.] www.asahp.org\/history.htm.\n<\/p>\n Auerbach, D. I., P. I. Buerhaus, and D. O. Staiger, 2007. \u201cBetter Late than Never: Work- \nforce Supply Implications of Later Entry into Nursing.\u201d Health Affairs 26 (1): \n178\u201385.\n<\/p>\n Begun, J. W., and K. R. White. 2008. \u201cPositioning Nursing for Leadership in a Complex \nHealthcare System.\u2019\u2019 In On the Edge: Nursing in the Age of Complexity, edited by \nC. Lindberg, S. Nash, and C. Lindberg. Allentown, NJ: Plexus Institute.\n<\/p>\n Buerhaus, P. I., D. O. Staiger, and D. I. Auerbach. 2000. \u201cImplications of a Rapidly Ag- \ning Registered Nurse Workforce.\u201d JAMA 283 (22): 2948\u201354.\n<\/p>\n Bureau of Labor Statistics (BLS). 2006. \u201cLicensed Practical and Licensed Vocational \nNurses, 2006.\u201d [Online information; retrieved 2\/5\/08.] www.bls.gov\/oco\/ \nocos102.htm.\n<\/p>\n \u2014\u2014\u2014. 2007. \u201cHealth Care.\u201d [Online information; retrieved 2\/6\/08.] www.bls.gov\/ \noco\/cg\/cgs035.htm.\n<\/p>\n Clement, J. P., H. Chen, D. Burke, D. G. Clement, and J. L. Zazzali. 2006. \u201cAre Con- \nsumers Reshaping Hospitals? Complementary and Alternative Medicine in US \nHospitals 1999\u20132003.\u201d Health Care Management Review 31 (2): 109\u201318.\n<\/p>\n Coile, R. C. 2001. \u201cMagnet Hospitals Use Culture, Not Wages, to Solve Nursing Short- \nage.\u201d Journal of Healthcare Management 46 (3): 224\u201328.\n<\/p>\n D\u2019Aunno, T., J. A. Alexander, and C. Laughlin. 1996. \u201cBusiness as Usual? Changes in \nHealth Care\u2019s Workforce and Organization of Work.\u201d Hospital & Health Services \nAdministration 41 (1): 3\u201318.\n<\/p>\n Dreyfus, H. L., and S. E. Dreyfus. 1996. \u201cThe Relationship of Theory and Practice in the \nAcquisition of Skill.\u2019\u2019 In Expertise in Nursing Practice: Caring, Clinical Judgment, \nand Ethics, edited by P. Benner, C. A. Tanner, and C. A. Chesla. New York: \nSpringer.\n<\/p>\n Eisenberg, D. M., R. B. Davis, S. L. Ettner, S. Appel, S. Wilkey, M. Van Rompay, and R. \nC. Kessler. 1998. \u201cRC Trends in Alternative Medicine Use in the United States, \n1990\u20131997: Results of a Follow-Up National Survey.\u201d New England Journal of \nMedicine 280 (18): 1569\u201375.\n<\/p>\n Eisenberg, D. M., R. D. Kessler, C. Foster, R. E. Norlock, D. R. Calkins, and T. L. Del- \nbanco. 1993. \u201cUnconventional Medicine in the United States.\u2019\u2019 New England \nJournal of Medicine 328 (24): 246\u201352.\n<\/p>\n Haddock, C. C., R. A. McLean, and R. C. Chapman. 2002. Careers in Healthcare Man- \nagement. Chicago: Health Administration Press.\n<\/p>\n Hamric, A. B. 2005. Advanced Practice Nursing: An Integrative Approach, Third Edition, \nedited by A. B. Hamric, J. A. Spross, and C. M. Hanson, 95\u201396. St. Louis, MO: \nElsevier Saunders.\n<\/p>\n 96 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 96\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n Health Professions Education Extension Amendments of 1992, Section 701 PHS Act. \nWashington, DC: Government Printing Office.\n<\/p>\n Health Resources and Services Administration (HRSA). 2006a. \u201cThe Registered Nurse \nPopulation: Findings from the 2004 National Sample Survey of Registered \nNurses.\u201d [Online information; retrieved 1\/29\/08.] http:\/\/bhpr.hrsa.gov\/health- \nworkforce\/rnsurvey04.\n<\/p>\n \u2014\u2014\u2014. 2006b. \u201cWhat Is Behind HRSA\u2019s Projected Supply, Demand, and Shortage of \nRegistered Nurses?\u201d [Online information; retrieved 1\/29\/08.] \nhttp:\/\/bhpr.hrsa.gov\/healthworkforce\/reports\/behindrnprojections\/index.htm.\n<\/p>\n Heinrich, J. 2001. Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors. \nGAO Report to Health Subcommittee on Health: GAO-01-944, pages i\u201315. \nWashington, DC: Government Accountability Office.\n<\/p>\n Hurley, R. E. 1997. \u201cMoving Beyond Incremental Thinking.\u2019\u2019 Health Services Research 32 \n(5): 679\u201390.\n<\/p>\n Jones, C. B. 2001. \u201cThe Future Registered Nurse Workforce in Healthcare Delivery.\u2019\u2019 In \nThe Nursing Profession, edited by N. L. Chaska, 123\u201338. Thousand Oaks, CA: Sage \nPublications.\n<\/p>\n Kovner, C. T. 2002. \u201cCMS Study: Correlation Between Staffing and Quality.\u201d American \nJournal of Nursing 102 (9): 65\u201367.\n<\/p>\n Letvak, S. 2002. \u201cRetaining the Older Nurse.\u201d Journal of Nursing Administration 32: \n387\u201392.\n<\/p>\n Lynn, M. R., and R. W. Redman. 2005. \u201cFaces of the Nursing Shortage: Influences on \nStaff Nurses\u2019 Intentions to Leave Their Positions or Nursing.\u201d Journal of Nursing \nAdministration 35 (5): 264\u201370.\n<\/p>\n National Commission on Allied Health. 1995. Report of the National Commission on Al- \nlied Health. Rockville, MD: Health Resources and Services Administration.\n<\/p>\n National Council of State Boards of Nursing. 2006. [Online information; retrieved \n7\/16\/07.] www.ncsbn.org.\n<\/p>\n O\u2019Neil, E. H., and D. M. Hare (eds.). 1990. \u201cPerspectives on the Health Professions.\u2019\u2019 In \nPew Health Professions Programs. Durham, NC: Duke University.\n<\/p>\n Pieper, S. K. 2003. \u201cRetaining Staff the Magnet Way: Fostering a Culture of Professional \nExcellence.\u201d Healthcare Executive 18 (3): 12\u201317.\n<\/p>\n Wetzel, M. S., D. M. Eisenberg, and T. J. Kaptchuk. 1998. \u201cCourse Involving Comple- \nmentary and Alternative Medicine at US Medical Schools.\u201d JAMA 280 (9): \n784\u201387.\n<\/p>\n White, K. R., and J. W. Begun. 1998. \u201cNursing Entrepreneurship in an Era of Chaos and \nComplexity.\u2019\u2019 Nursing Administration Quarterly 22 (2): 40\u201347.\n<\/p>\n 97C 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\n<\/p>\n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 97\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n \n Fried_CH04.qxd 6\/11\/08 4:09 PM Page 98\n<\/p>\n EBSCOhost – printed on 2\/1\/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY. All use subject to https:\/\/www.ebsco.com\/terms-of-use<\/p>\n<\/p>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":" you have to do all\u00a0 1- EE2 Weeks 4 and 5. 2- look to Research topic ideas and pick one and do 2-DB5 Project Topic. 3-HCA 542 Research Project Requirements and Grading Guide 5 page. HCA 542, Knowledge Assessment\/ Do not exceed more than one page, double spaced, per question. This knowledge assessment is not […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":"","_joinchat":[]},"categories":[1],"tags":[],"_links":{"self":[{"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/posts\/155493"}],"collection":[{"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/comments?post=155493"}],"version-history":[{"count":0,"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/posts\/155493\/revisions"}],"wp:attachment":[{"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/media?parent=155493"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/categories?post=155493"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/qualityassignments.net\/wp-json\/wp\/v2\/tags?post=155493"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}

HCA 542 Human Resources Management<\/h2>\nResearch Project Guidelines and Grading Criteria<\/p>\n<\/p>\n

HCA 542 Human Resources Management<\/h2>\n
Research Project Guidelines and Grading Criteria<\/p>\n<\/p>\n