Diversity-sensitive measures in German hospitals – attitudes, implementation, and barriers according to administration managers

While 93.7% of administration managers stated that their hospital sufficiently addressed the needs of their patients, only 69.6% considered a diversity-sensitive orientation necessary. In contrast to that, 72.3% of respondents thought that it was important for staff to take part in training courses pertaining to diversity issues. A future, more diversity-sensitive orientation of hospitals in general was perceived as important by 77.7% of respondents, while only 53.6% reported the existence of corresponding plans for their own hospital. The majority of respondents considered sensitivity to diversity an important factor for patient satisfaction (83.0%) and staff satisfaction (75.9%). It was also regarded an important factor for effective treatment by 78.6%. In contrast, only 46.4% considered a diversity-sensitive approach as an important resource to increase the numbers of patients.

On an organizational level, more than half of the hospitals surveyed reported to address diversity ideationally e.g., in their mission statement (57.1%) or as a consideration in their quality management efforts (59.8%), for example when handling patient complaints (Table 2). For both statements, around 10.7% of administration managers reported that inclusion of diversity aspects was currently in planning. In contrast, less than a quarter of hospitals had implemented concrete measures on a structural level. 15.2% of hospitals had designated or hired a diversity commissioner and 4.5% were planning to designate such a position. Another 15.2% of administration managers reported to have implemented working groups addressing diversity, while 10.7% were planning to do so. About one fifth of hospitals offered or planned to offer regular training courses and consultations for staff that were meant to enhance sensitivity to diversity (22.3%, resp. 19.6%). While 22.3% of respondents reported specifically addressing diversity in their public relation work, 14.3% were planning to do so.

In our study, almost 50% of administration managers reported to ensure that their staff has a minimum proportion of male or female employees or of staff with physical or mental disabilities. 27.7 and 24.1%, respectively, considered it important to have a minimum proportion of older-aged employees or of employees with a migrant background.

In terms of personnel policies, results were inconsistent (Table 3). While the majority of respondents stated that they intended to keep personnel diverse concerning a number of dimensions, this is only partially reflected in specific actions. In terms of recruiting diverse staff, 50.9% of hospitals targeted health personnel from other countries for recruitment, while only 33.0% published vacancies in ways to specifically reach people with disabilities. Specific services, e.g., mentoring programs, to facilitate the integration of new employees with special needs were reported by 41.1% of respondents. Specific leadership training to increase the proportion of women in leadership positions was offered by 38.4% of hospitals. While the majority of hospitals provide German courses for employees (58.2%), only 27.7% offer training courses in other languages.

In terms of work-life balance, results also indicated no clear trend. Many or most respondents stated they offered flexible working hours (91.7%), additional (potentially unpaid) leave days for special demands, e.g., childcare or caring for ill relatives (66.1%), and the possibility of working from home (59.8%). Fewer hospitals offered job sharing (49.1%) and corporate childcare (39.3%).

When dealing with diverse patient groups, one major aspect to be considered is language. While 64.3% of administration managers reported to provide consent forms in different languages, other special forms and information leaflets in different languages were only provided by 47.3% (Table 4). Only a small number of hospitals offered meal plans/menus in languages other than German (12.5%). Overall, written materials were most commonly available in English (24.3%), Turkish (20.0%), Russian (17.3%), Arabic (8.7%) and Polish (7.0%). Admission and exit interviews were also available in different languages in 59.8% of all surveyed hospitals, while 57.1% of respondents stated to offer treatments and therapies in different languages. Specific consultations, such as social counseling or nutrition counseling, were available in different languages in 39.3% of hospitals, while 11.6% offered corresponding non-German language trainings, seminars, or presentations. Most commonly, these services were available in English (29.2%), Russian (22.9%), Turkish (14.5%), Arabic (13.1%) and Polish (9.2%).

Although many hospitals reported offering consultations or treatments in languages other than German, only 23.2% regularly used professional language interpreters, while 52.7% used professionals in some cases. Most hospitals frequently used medical personnel (69.6%) or patients’ friends and relatives (46.4%) for translation. To a lesser degree, hospitals relied on non-medical personnel (18.8%) or other patients (3.6%). Another way of overcoming language barriers in health care delivery is the use of language-independent materials that mostly rely on photos, pictures and pictograms instead of text to convey information. Only a minority of administration managers reported to use such, most of which provided language-independent signs and guideposts (38.4%) or information leaflets and similar materials (32.1%). Fewer hospitals had language-independent therapy plans (7.1%) or menus (8.0%) available.

Other aspects of diversity that have been associated with different needs and expectations are cultural and gender aspects. Addressing these aspects in therapeutic and non-therapeutic settings is another important component of diversity-sensitive health care. While 57.1% of respondents stated that they offered a culturally sensitive menu selection, most hospitals did not provide other known services that cater to needs and expectations informed by gender or culture (Table 5). While 41.1% of hospitals offered the option to be treated by staff of the same sex, only 17.0% reported to offer group therapies for men and women separately. Diversity-sensitive learning opportunities were provided in 36.6% of hospitals and 38.4% offered the possibility to choose between different therapeutic alternatives. In terms of non-therapeutical services and resources, 45.5% of hospitals reported to provide neutrally decorated prayer rooms. While foreign language TV stations were available in 28.6% of hospitals, only 11.6% provided foreign language newspapers or magazines. Only one hospital offered flexible opening hours of the cafeteria, which could be used for example by Muslims adhering to fasting rules during Ramadan.

Administration managers reported financial concerns as well as problems in establishing corresponding organizational structures and measures as main barriers to implementing diversity-sensitive care (Table 6). A lack of financial resources was reported by most of the respondents (54.5%), with 49.1% also reporting a lack of incentives from the respective funding organizations. Organizational difficulties were perceived by 45.5% of hospitals, while 35.7% saw a lack of information on how to implement diversity-sensitive measures as an important barrier that made the implementation of diversity-sensitive care difficult. Fewer respondents reported a lack of perceived necessity of such measures among decision makers (28.6%) and/or a lack of motivation among staff members to implement them. Only 20 hospitals (17.8%) – varying in ownership and size – reported no barriers in implementing diversity-sensitive measures, while 8.0% reported not intending to implement any diversity-sensitive measures at all.

According to our knowledge, this study is the first to provide information on the sensitivity and responsiveness of German hospitals to the diversity of patients and staff on an organizational level. In addition, we identified several important barriers to implementing respective strategies and measures. These findings can inform future research focusing on the development and implementation of suitable concepts for diversity sensitive health care. Our study also has several limitations that need to be mentioned. For our study we relied on information provided by hospital administration managers. This only allows for a subjective account of how facilities are responding to diversity, which would need to be corroborated by standardized assessments. Therefore, in our study, information pertaining to the perception or motivation of employees and other decision makers, on which we also have no further information with respect to their age or sex, could be biased. The findings could either over- or underestimate the true level of diversity sensitivity in the facilities. For example, while almost all of the respondents stated their hospital addresses the needs of their patients, patients themselves could have a different impression. In addition, responses to other items concerning the implemented measures suggest, that the level of diversity awareness may be lower than perceived by the respondents. In contrast, specific measures taken by hospital staff without consultation of administration managers or measures not included in our questionnaire may have led to an underestimation of diversity sensitivity. To address the latter aspect, we included several open questions to identify such measures, which did not yield any valuable results. A more detailed, stratified analysis by the size or ownership of the hospitals, which would have been beneficial for the interpretation of the findings, was not possible due to the small sample size. Compared to other official statistics, hospitals from non-profit organizations were widely overrepresented in our sample. The low response rate and the structure of our sample indicate that our findings may not be representative for all hospitals in Germany. Similarly, administration managers with no interest in the topic or working at hospitals with no implemented measures to address diversity may be underrepresented, which may have led to an overestimation of diversity sensitivity in our study. This would suggest an even stronger necessity to increase awareness of the importance and the potential benefits of diversity-sensitive and responsive health care among hospital managers and other involved decision makers.