Neutrality, conflict, and structural determinants of health in a Jerusalem emergency department.

BACKGROUND: Medical neutrality is a normative arrangement that differentiates a zone of medical treatment disconnected from the field of politics. While medical neutrality aims to ensure impartial healthcare for all and to shield the healthcare personnel from political demands, it can also divert attention away from conflicts and their effects on health inequity. This article analyzes how healthcare professionals understand and negotiate the depoliticized space of the emergency department (ED) through their views on neutrality. It also examines how medical staff use depoliticized concepts of culture to account for differences in the health status of patients from disadvantaged groups. These questions are examined in the context of the Israeli-Palestinian conflict. METHODS: Twenty-four in-depth, semi-structured interviews were conducted with healthcare personnel in a Jerusalem hospital's ED. All but one of the participants were Jewish. The interviews were analyzed using qualitative content analysis and Grounded Theory. RESULTS: The ED staff endorsed the perspective of medical neutrality as a nondiscriminatory approach to care. At the same time, some medical staff recognized the limits of medical neutrality in the context of the Israeli-Palestinian conflict and negotiated and challenged this concept. While participants identified unique health risks for Arab patients, they usually did not associate these risks with the effects of conflict and instead explained them in depoliticized terms of cultural and behavioral differences. Culture served as a non-controversial way of acknowledging and managing problems that have their roots in politics. CONCLUSIONS: The normative demand for neutrality works to exclude discussion of the conflict from clinical spaces. The normative exclusion of politics is a vital but under-appreciated aspect of how political conflict operates as a structural determinant of health. Healthcare personnel, especially in the ED, should be trained in structural competency. This training may challenge the neglect of issues that need to be solved at the political level and enhance health equity, social justice, and solidarity.

Social and structural determinants of emergency department use among Arab and Jewish patients in Jerusalem.

BACKGROUND: A growing body of research demonstrates that economic conditions and racial and ethnic disparities result in excessive overuse of emergency departments (EDs) by a small group of socioeconomically marginalized residents. Knowledge and understanding of these issues on the part of the healthcare team can promote equality by providing structurally competent care. This study aims to identify the major social and structural factors related to patterns of ED visits by Arab and Jewish patients in Israel, where access to health services is covered by universal national health insurance. METHODS: A cross-sectional study was conducted using questionnaires of ED patients in a tertiary care medical center in Jerusalem. The hospital is the largest of the three EDs in Jerusalem with over 90,000 adult patient visits a year. The sample was stratified by ethnicity, including 257 Jewish patients and 170 Arab patients. The outcome variable was repeat visits for the same reason to the ED within 30 days. RESULTS: There were differences between Jewish and Arab patients' social and structural characteristics, including health status, socioeconomic status, feeling of safety, and social support. There were also significant differences in some of the characteristics of health service utilization patterns, including ED repeat visits, language barriers when seeking healthcare in the community, and seeking information about medical rights. The variables associated with repeat visits were different between the two groups: among the Arab patients, repeat visits to the ED were associated with concerns about personal safety, whereas among the Jewish patients, they were associated with poverty. CONCLUSION: The study illustrates the gaps that exist between the Arab and Jewish population in Israel. The findings demonstrated significant differences between populations in both health status and access to health services. In addition, an association was found in each ethnic group between different structural factors and repeat ED requests. This study supports previous theories and findings of the relationship between structural and social factors and patterns of health services utilization.

Structural Competency in Conflict Zones: Challenging Depoliticization in Israel.

Structural competency is the trained ability to discern and acknowledge how health care outcomes are shaped by larger political, social, economic, policy, and legal forces and structures. Although structural competency has become an increasingly known framework for training and teaching, especially in the United States, it has usually not been used in nursing and nursing education. Moreover, very little is known about how to implement structural competency programs in conflict zones. Due to depoliticization that often prevails in both the higher education system and the health care system, the political conflict and the structural violence that significantly impact people's health are rarely discussed in these systems. This article examines the potential contribution of structural competency training programs for nurses and nursing students in conflict areas by analyzing a program that has emphasized the impact of the Israeli-Palestinian conflict on the health of Jerusalem's Palestinian residents. The article explains how this program has challenged the denial and silencing of conflict-related sociopolitical issues. At the same time, this program has created heated disagreements and friction. We suggest that structural competency training programs that are adapted to the political context in question may help nurses become organic intellectual leaders and agents of social change for those whose voices are not heard.

Characteristics and Motivational Factors of Whole Blood and Convalescent Plasma Donors during the SARS-CoV-2 Pandemic in Israel.

Demands for whole blood (WB) and COVID-19 convalescent plasma (CCP) donations during the SARS-CoV-2 (COVID-19) pandemic presented unprecedented challenges for blood services throughout the world. This study aims to understand the motivating factors that drive WB and CCP donations in the context of the pandemic. This cross-sectional study is based on data extracted from surveys of the two volunteer donor cohorts. The findings reveal that when compared to CCP donors, WB donors were more likely to view donation as a form of social engagement (97.7% vs. 87.1%, p < 0.01), advantageous in the workplace (46.4% vs. 28.6%, p < 0.01), advantageous in their social network (58.6% vs. 47.0%, p = 0.01), and view their donation in the context of positive self-satisfaction (99% vs. 95.1%, p = 0.01). The average age of CCP donors was 7.1 years younger than those who donated WB (p < 0.01). Motivational factors were also analyzed by sex and religiosity. In conclusion, whereas both donor groups showed a high motivation to partake in these life-saving commitments, WB donors were more likely to be motivated by factors that, when better-understood and implemented in policies concerning plasma donations, may help to increase these donations.

Medical neutrality and structural competency in conflict zones: Israeli healthcare professionals' reaction to political violence.

ABSTRACTThis article explores the meaning, manifestations, and ramifications of medical neutrality in conflict zones. We analyse how Israeli healthcare institutions and leaders responded to the escalation of the Israeli-Palestinian conflict in May 2021 and how they represented the role of the healthcare system in society and during conflict. Based on content analysis of documents, we found that healthcare institutions and leaders called for cessation of violence between Jewish and Palestinian citizens of Israel, describing the Israeli healthcare system as a neutral space of coexistence. However, they largely overlooked the military campaign that was simultaneously taking place between Israel and Gaza, which was considered a controversial and 'political' issue. This depoliticised standpoint and boundary work enabled a limited acknowledgement of violence, while disregarding the larger causes of conflict. We suggest that a structurally competent medicine must explicitly recognise political conflict as a determinant of health. Healthcare professionals should be trained in structural competency to challenge the depoliticising effects of medical neutrality, with the aim of enhancing peace, health equity, and social justice. Concomitantly, the conceptual framework of structural competency should be broadened to include conflict-related issues and address the needs of the victims of severe structural violence in conflict areas.

Biomedicine and the treatment of difference in a Jerusalem emergency department.

Biomedicine has played a key role in the dissemination of modern social norms, such as the emphasis on individual autonomy and the distinction between science and religion. This study examines the way the mostly-Jewish members of the medical staff at an emergency department of a Jerusalem hospital perceive Jewish ultra-Orthodox and Arab patients' behaviors vis-à-vis the existing biomedical norms. We analyzed participants' perceptions in terms of the social constructs they reveal, their meanings, and their implications. Semi-structured in-depth interviews were conducted with 24 staff members and were analyzed using content analysis. The staff described challenges in treating Arab and ultra-Orthodox patients, which they related to both groups' embeddedness in traditional "cultures" and collective identities. According to the participants, in both cases, the patients' cultural affiliations constrained their sense of individual autonomy and rationality. However, in the comparative analysis, two differences emerged. First, while both groups were perceived to diverge from modern norms of individual autonomy, in the case of Arab patients, these characteristics were presented as disruptive and potentially threatening to the hospital staff. By contrast, in the case of ultra-Orthodox patients, adherence to traditional and collective values was more likely to be represented as a risk to the patient, rather than to the staff. Second, staff were more likely to provide accommodations for ultra-Orthodox patients than for Arab patients. These accommodations were often described in the frame of "cultural competency." We suggest that divergences in how staff understood and responded to perceived cultural differences of each group reflect unequal impacts of structural determinants of health, including of political conflict. We recommend moving beyond the conceptual framework of cultural competency to strengthen the staff's structural competency, cultural and structural humility, and critical consciousness.

Holocaust and Genocide Studies in Nursing Education: Nurse Practitioners as Critical Intellectuals.

BACKGROUND: In most nursing schools, Holocaust and genocide studies are not part of the curriculum. However, studying past horrors involving health care professionals is essential for forming a clear moral compass to navigate future nursing practice. This article analyzes a unique Holocaust and genocide curriculum for graduate nurse practitioner students and its effects on participants. METHOD: The students wrote reflective accounts, which were analyzed using qualitative content analysis. RESULTS: The studies had a profound effect on the students, who adopted a critical perspective and became more sensitive to wrongdoing and social suffering, more involved in current ethical and social issues, and more willing to engage in social advocacy. The course strengthened the moral responsibility of the students, transforming them into critical intellectuals. CONCLUSION: Holocaust and genocide studies enhance nurses' humanistic approach and help them confront dogma, challenge social denial, and resist oppression, discrimination, and structural racism. [J Nurs Educ. 2022;61(11):624-632.].

Ultra-Orthodox Nursing Students' Cultural Challenges Inside and Outside Their Community during the COVID-19 Pandemic.

In line with findings that nurses from minority groups have an important role in making health services accessible to their community, our study aimed to identify the challenges ultra-Orthodox Jewish nurses faced during COVID-19 in their encounters with patients and health staff from other communities, as well as their own community. The ultra-Orthodox community is a highly religious group that maintains isolation from general society, a phenomenon that affected its member experiences during COVID-19. Our research followed sequential explanatory mixed methods. The quantitative phase included a questionnaire completed by 235 female students (111 ultra-Orthodox and 124 non-ultra-Orthodox), followed by a qualitative phase, which included six focus-groups (n = 15). The quantitative analysis showed that the ultra-Orthodox students felt a higher sense of responsibility toward their community. They used their authority and knowledge to guide their community during the pandemic. The qualitative analysis identified two themes expressed as challenges ultra-Orthodox nursing students encountered within their community and with other sections of Israeli society. Our research shows the important role that transcultural nurses play in mediating updated health information otherwise inaccessible to their community, especially in times of crises. It is important to address dilemmas this group faces inside and outside their respective communities.

Social and structural determinants and their associations with patient experience in the emergency department.

BACKGROUND: Improving patient experience and satisfaction in the emergency department (ED) is challenging but beneficial. Previous studies have shown an association between social and structural factors and patient satisfaction. This study examined the structural and social factors related to the ED patient experience among Jewish and Arab patients in a Jerusalem hospital. METHODS: A cross-sectional study was conducted among ED patients in a Jerusalem hospital. Data were collected via questionnaires. The sample included 257 Jewish patients and 170 Arab patients. The outcome variable was a positive or negative ED experience. RESULTS: Jewish and Arab patients had different factors related to ED experience. Cultural differences, including a language barrier and access to information, were associated with a negative experience among Arab patients. Among Jewish patients, frequent use of community health services was associated with a negative ED patient experience. CONCLUSION: This study shows an association between social and structural factors and patient experience, illustrating gaps for and vulnerability of different ethnic groups that affect their experience with healthcare services. Understanding these issues and implementing solutions formulated at the institutional and national levels can promote equity by providing structurally competent care.

Does volunteering change attitudes towards people with disabilities? A qualitative study of the experience of orthodox Jewish nursing students.

BACKGROUND: People with disabilities identify negative staff attitudes and behaviors as barriers to accessing health services. Studies show that nursing education activities specific to people with disabilities improves nursing care. This study explores the experience of orthodox Jewish nursing students volunteering with people with disabilities, how their attitudes towards this population changed. DESIGN: A qualitative design was used. This research is part of an extensive ongoing study of orthodox and ultra-orthodox (Haredi) students volunteering with people with disabilities. METHODS: Data from 13 semi-structured interviews, conducted between July and September 2017, with 14 male students (two students chose to be interviewed together) and four people with disabilities were analyzed using thematic analysis. RESULTS: Volunteering enhanced students' awareness of the needs of people with disabilities, changed their attitude towards this population and enhanced their confidence as nurses. The individuals with disabilities valued the help they received as well as the opportunity to change the students' prior notions and stigmas regarding disability. CONCLUSIONS: Projects such as ours could improve the attitude of nursing staff towards individuals with disabilities and improve nursing care. We recommend involving people with disabilities in designing such projects.

Teaching the Holocaust in Nursing Schools: The Perspective of the Victims and Survivors.

In recent years, there has been increased recognition of the significance and relevance of Holocaust studies to nurses. However, these studies are rarely integrated in the nursing curriculum, and even when they are, the focus is usually on healthcare personnel who collaborated with the Nazi regime. This article aims to bridge this gap by analyzing a comprehensive requisite curriculum on the Holocaust for graduate nursing students. We emphasize the work of Jewish healthcare professionals during the Holocaust and the dilemmas they faced, as well as the trauma and resilience of Holocaust survivors, their treatment today, and implications for treating other patients. This article examines how studying these issues affected the graduate students. It analyzes the reflective accounts written by the students, using qualitative content analysis and Grounded Theory. The findings suggest that students received tools to act professionally and empathetically while demonstrating greater sensitivity to the patients' identity, past experiences, trauma, and how the hospital as a "total institution" affects them. Many of the students developed conscious leadership. The program used a personalized pedagogical approach that contributed to experiential learning but was also emotionally challenging for the participants. We recommend including Holocaust studies as a requisite component in nursing programs worldwide.

An analysis of social determinants of health and structural competency training in global emergency medicine fellowship programs in the United States.

BACKGROUND: Clinicians must be aware of the structural forces that affect their patients to appropriately address their unique health care needs. This study aimed to assess the participation of global emergency medicine (GEM) fellowship programs in formal social determinants of health (SDH) and structural competency (SC) training to evaluate the existence and procedures of such programs. METHODS: A cross-sectional study conducted with a short, online survey with questions regarding the presence of curriculum focused on SDH, SC, educational metrics, and the desire for further formal training in this domain was sent to all 25 GEM fellowship directors through the Global Emergency Medicine Fellowship Consortium (GEMFC) email listserv. RESULTS: Eighty percent (20/25) of GEM fellowship directors responded to the survey. All (20/20) of participating fellowship programs included SDH and SC training in their didactic curriculum, and eight of 20 (40%) programs offered similar training for faculty. Additionally, 19 of 20 (95%) of respondents indicated interest in an open-source tool for emergency medicine (EM) fellowship training in SDH and SC. CONCLUSIONS: While multiple GEM programs offer formal training on SDH and SC, gaps exist regarding similar training for faculty. Additionally, there is a lack of metrics to determine fellows' comfort with the content of this training. As a majority of GEMFC programs requested, an open-source tool would allow a uniform curriculum and measurement of EM fellowship training in SDH and SC.

The TOLERance Model for Promoting Structural Competency in Nursing.

BACKGROUND: Structural competency is the trained ability to recognize how social, political, economic, and legal structures shape diseases and symptoms. Although structural competency has become an increasingly accepted framework for training and teaching, it usually has not addressed nursing students and has not included marginalized patients as trainers. METHOD: This article analyzes a structural competency training model for nursing students that includes five components: Theory, Observations, Learning from patients, Engagement, and Research (the TOLERance model). RESULTS: The TOLERance model increases the understanding of the interrelation between the individual clinical level and the sociopolitical structural level. It encourages nursing students to actively engage in social, political, and policy issues that affect their patients' health and to advocate for policy change. CONCLUSION: The moral and professional commitment of nurses to their patients demands that they do not ignore the structural forces that are detrimental to their patients' health. The TOLERance model provides nursing students with skills and competencies that help them to fulfill this commitment. [J Nurs Educ. 2020;59(8):425-432.].

Lessons learned from an evaluation of referrals to the emergency department.

BACKGROUND: Emergency department (ED) crowding is an international phenomenon dependent on input, throughput, and output factors. This study aims to determine whether patterns of potentially unnecessary referrals from either primary care physicians (PCPs) or urgent care centers (UCCs) can be identified, thereby to reduce ED visits by patients who could be treated elsewhere. Literature from the United States reports up to 35% unnecessary referrals from UCCs. METHODS: A retrospective cohort study was conducted of patients referred to an ED in Jerusalem by either their PCP or a group of UCCs with a full range of laboratory tests and basic imaging capabilities between January 2017 and December 2017. The data were analyzed to identify referrals involving diagnoses, specialist consultations, and examinations unavailable in the PCP's office or UCC (e.g., ultrasound, CT, echocardiogram, or stress test); these referrals were considered necessary for completion of the patient work-up. If patients were evaluated by an ED physician and sent home after an examination or laboratory test available at least in the UCC, the referrals were considered potentially unnecessary. RESULTS: Significantly more referrals were made by PCPs than UCCs (1712 vs. 280, p < 0.001). Significant differences were observed for orthopedics, general surgery, and obstetrics/gynecology referrals (p = 0.039, p < 0.001, p = 0.003). A higher percentage of patients referred by PCPs had potentially unnecessary visits compared to patients referred by UCCs (13.9% vs. 7.9%, p = 0.005). CONCLUSION: A robust UCC system may help further reduce potentially unnecessary visits (including complex patients) to the ED.