Forming an Affiliation Between Two Culturally Different Academic Institutions of Nursing Studies.

INTRODUCTION: This article describes the association of two culturally different institutions opening a joint Bachelor of Science in Nursing (BSN) program for ultra-Orthodox Jewish (Haredi) women in order to enable them to find jobs due to changes in their society and increasing global demand for nurses in the labor market. The objective of this description is to illustrate the efforts and changes needed to facilitate the affiliation of two culturally and ideologically different organizations and the implications and conclusions of such a program.
METHODS: The study is based on interviews with past administrators, a review of the literature, and supporting institution documents.
CONCLUSIONS: A joint nursing academic program was founded by two culturally different educational institutions for the ultra-Orthodox Jewish women population. Creating a culturally sensitive nursing academic program helped ultra-Orthodox women acquire an academic profession which enabled their integration into the academic professional's work world and add more nurses to the labor market.The authors reviewed the efforts and changes needed to facilitate the affiliation of two culturally and ideologically different organizations based on the Bolman and Deal four frames model.

New trends in Israeli society led nursing leadership to decide on the academization of the nursing profession. The decision of the Israeli Ministry of Health(MOH) to close down all non-academic nursing education programs, and the complementary move of the Israeli Council for Higher Education (CHE) to transfer the education of nurses from schools with non-academic programs to academic colleges and universities, were triggers for all nursing schools to find a way to affiliate to a college or university in order to open academic programs. The Israeli CHE suggested an affiliation should be made between the Ruppin Academic Center and the Tessler Academic School of Nursing. Initiating change in an organization is always a challenge; however, launching an affiliation of two culturally and ideologically different systems is even more challenging and requires unique strategies.

In this case study, three tools were utilized: (1) literature review; (2) document analysis from the Tessler Academic School of Nursing archive, and (3) interviews. These included rabbis, nursing school administrators who took part in establishing the ultra-Orthodox nursing school, and representatives of the Tessler Academic School of Nursing management who took part in the process. Seven interviewees were identified by -Dr. Ester Strauss, the Tessler Nursing school's Director and her assistant; both have been involved with the school since it's founding. The study was approved by the Ethics Committee of the Faculty of Social and Community Sciences at the Ruppin Academic Center. All interviewees signed a consent form to participate in the interview and gave consent to utilizing their full name in future publications. Interviews were conducted using a semi-structured questionnaire.

Bolman and Deal (1991) offer a strategic tool for analyzing organizations through multiple perspectives or frames. The goal of this article is to review the efforts and changes needed to facilitate the affiliation of two culturally and ideologically different organizations in order to open a joint academic nursing program for the Haredi population based on the Bolman and Deal four frames model: Structural, Humanistic, Political and Symbolic.

Organizational Backgrounds

Two culturally different educational institutions founded a joint nursing academic program for the ultra-Orthodox Jewish women population. A short description of the two organizations follows in order to help readers understand the profound differences between them.

The Ruppin Academic Center – A Liberal Secular Institution

The Ruppin Academic Center was established in 1949 and is considered a liberal secular institution. One of the themes the center emphasizes is entrepreneurship and social involvement, as manifested in contribution to the community, volunteering in social projects, raising national issues on the public agenda, and making higher education accessible to excluded populations (https://www.ruppin.ac.il/en/About-Ruppin). In promoting this theme, The Ruppin Academic Center strived to make higher education accessible to the ultra-Orthodox community (Figure 1).

Figure 1.

Ruppin Academic Center’s Goals and Vision.

The Sanz Medical Center-Laniado Hospital and the Tessler Academic School of Nursing – A Jewish Ultra-Orthodox Institution for Women

The Sanz Medical Center-Laniado Hospital was founded in 1976 by the Klausenberg rabbi of the Sanz Chassidic dynasty. During World War II, the rabbi was sent to the Auschwitz concentration camp, together with his wife, eleven children, and tens of thousands of Hungarian Jews. His wife, children and many other family members perished in the gas chambers. The rabbi was shot in the hand; he then vowed that if God granted him life and healed his injured hand, and if he managed to survive the concentration camp, he would build a hospital staffed by doctors and nurses who believed in God and who would know that in healing a patient, they were doing the greatest mitzvah (good deed) in the Torah (H. Spitzer,[1] personal communication, December 12, 2018).

Hence, the Sanz Medical Center-Laniado Hospital–conforms to Jewish law in every detail (http://www.en.laniado.org.il/index.php?option=com_content&view=article&id=91&Itemid=88).

While planning the opening of the Sanz Medical Center-Laniado Hospital, the founders understood that a nursing school was needed. The Klausenberg rabbi believed the educational background of Haredi women made them particularly capable of nursing patients and the vulnerable (D. Halamisch,[2] personal communication, February 11, 2019). Therefore, in 1977, with the help of the MOH, the hospital opened a Jewish ultra-Orthodox nursing school. At that time, there were no nursing schools in Israel dedicated to training ultra- Orthodox nurses, making the Tessler Academic School of Nursing the first of its kind (G. Leader,[3] personal communication, December 25, 2018).

The Bolman and Deal Leadership and Management Effectiveness Model

The Bolman and Deal Model was used in order to enable the authors to attain the differences between the world views of two different organizations and describe how the affiliation of these two were managed. A basic assumption of the Bolman and Deal Model is that individuals see life in different ways since they are rooted in different world views. People tend to view their experiences through a system of preconceptions which impede their own effectiveness (Bolman & Deal, 1991). Four organizational frames were suggested: Structural, Human Resource, Political and Symbolic, which enable understanding of how people and organizations think and work.

The is mainly task oriented which focuses on the “how” of change. It coordinates activities by developing rules, policies and managing hierarchies. It concentrates on strategy, setting goals, clarifying tasks and responsibilities, and creating standard operating procedures.

The differences between the Sanz Medical Center and the Ruppin Academic Center were very noticeable. The Ruppin Academic Center is secular and liberal; the Sanz Medical Center is an ultra-Orthodox institution. Indeed, these two institutions have extremely opposite worldviews. On the one hand, the Tessler Academic School of Nursing had to maintain its strict religious standards. On the other hand, the Ruppin Academic Center had to make the necessary accommodations, while at the same time, upholding CHE standards (Table 1). The necessary modifications included structural and administrative modifications and nursing study program and academic staff adjustments (Y. Shachnovich,[4] personal communication, December 17, 2019).

Table 1.

Academic Program's Credits and Courses Accommodation Between The Ruppin Academic Center and The Tessler Academic School of Nursing.

Institution credits	Ruppin Academic Center	Tessler Academic School of Nursing
4	Nursing Ethics	Jewish Nursing Ethics
4	2 Optional Courses	Nursing Practice from the Perspective of Jewish Law
1	Professional Aspects of Nursing	Nursing in the Mirror of Judaism

Structural and Administrative Modifications

The structural changes included expanding the computer classroom and connecting it to the Ruppin Academic Center's library, and renovating the simulation classroom. Students were considered mutual students of both institutions. The Tessler Academic School of Nursing administrative staff had to be connected to the same software as the Ruppin Academic Center administrative staff for purposes of student registration and recording of all student information. In addition, the Ruppin Academic Center staff had to instruct the Tessler Academic School of Nursing staff on the use of different software programs (e.g., the Ruppin Academic Center Michlol, Ruppinet and Moodle networks).

The computerization changes needed at the Tessler Academic School of Nursing constituted a complicated cultural challenge to overcome. A significant number of Haredi student nurses do not have access to computers at home. The use of an unfiltered internet is forbidden by ultra-Orthodox rabbis. Only people who need the internet for purposes of their livelihood are allowed to use a "filtered" version of the internet (Golan & Mishol-Shauli, 2018). Since the nursing students needed the internet for much of their course work, a filtered version of the internet had to be specifically set up for them. Implementation of protective technology required constantly searching for the proper balance between offering an environment that would advance the students' knowledge while maintaining the standards required by Haredi culture.

The Nursing Study Program and Academic Staff Adjustments

The nursing program had to be adapted to the ultra-Orthodox students. Nursing programs in Israel are generally based on the core program of the Israeli MOH, with each institution adding courses as approved by the CHE. The program at the Ruppin Academic Center was changed, nine credits were converted to special courses for the ultra-Orthodox student nurses (e.g. Jewish Nursing Ethics and Nursing Practice from the Perspective of Jewish Law).

To ensure that all courses were on the same level, the lecturers of parallel courses had to have equivalent degrees. For example, if the genetics lecturer at the Ruppin Academic Center had a PhD, the Tessler Academic School of Nursing also had to find a genetics lecturer with a PhD. The Tessler Academic School of Nursing had to adopt all the Ruppin Academic Center's course syllabi and all exams had to be identical and taken at the same time. The lecturers at both institutions collaborated to plan and rebuild their courses (Y. Shachnovich, personal communication, December 17, 2019). In addition, the Ruppin Academic Center had a special unit for promoting teaching that prepared training programs and tools for improving the quality of teaching at the end of each semester. Lecturers from The Tessler Academic School of Nursing also participated in this unit.

Since most lecturers were not ultra-Orthodox, they underwent special preparation to adjust their teaching style and common terms to fit the "modesty" value: a mark of sexual purity and respectable womanhood (Geller et al., 2020), before the beginning of classes, so as not to offend students by their language or the examples they brought into the class (i.e, intimate pictures of both genders, unfiltered movies with non-modest content). Because of the need to be sensitive to modesty requirements, the Ruppin Academic Center's lecturers received a letter on this topic, discussed it with the Tessler Academic School of Nursing staff members, and attended a special workshop on the subject of cultural sensitivity and ultra-Orthodox society. To assure modest content: respectful and non-offending religious values (i.e. totally dressed human images, non-vulgar nor sexual language), all teaching materials were reviewed before being used in the classroom.

Before beginning their clinical studies in the different departments, all students attended a workshop to prepare them for exposure to the different departments and diverse populations. At the workshop, lectures were given by a rabbi and an ultra-Orthodox nurse working at the hospital. The nurse came from the same cultural background and understood the values and needs of Haredi students and the cultural difficulties they were likely to face. The Haredi nurse was able to give students tools to help them adapt to and cope with cultural difficulties. Whenever problems or special issues arose, the administration and academic staff of both institutions met to discuss and resolve barriers and challenges.

The focuses on people's needs. It assumes that an organization should meet human needs and customize itself to the employees to give them power and opportunities in order to enable them to perform their jobs well (Lyon et al., 2014). This includes addressing their needs for human contact, personal growth, and job satisfaction. Interaction between the worker and the organization must be positive in order to achieve mutual achievement and success.

The human resource frame was the basis of the affiliation which occurred between the Ruppin Academic Center and The Tessler Academic School of Nursing. The affiliation addressed the need of the Haredi population for livelihood and receiving a profession through means which were acceptable to this population and meeting their special needs, aligned with the Ruppin Academic Center vision which strives to make higher education accessible to excluded populations; in this case the Haredi population.

What Makes This Population Unique and What Are Their Special Needs?

The ultra-Orthodox Jewish (Haredi) population in Israel constitutes of 8-11.5% of the total population. This group is characterized by strict adherence to Jewish laws and values, with life revolving around the Torah. Members of the Haredi community tend to live in distinct geographical areas and communities that are socially isolated from the secular population. Their unique lifestyle is marked by modesty, absolute separation between men and women, high birthrates, and consultation with rabbinic leaders regarding many aspects of their lives (Kulik, 2016).

Haredi Education in Israel

The educational values of the Haredi community are based on the notion that nothing is superior to Torah study. This worldview has an impact on the decision-making processes of all Haredi young people and on their academic and vocational choices (Malhi, 2015). The Haredi educational system is marked by gender separation. In contrast to the boys, secular subjects are an integral part of the curriculum for girls and women in Haredi society (Malhi, 2015). In addition, they are taught the rules of modesty as practiced in ultra-Orthodox society, including a dress code, modest speech and behavior, and conforming to a modest way of life (Simhi et al., 2020). All pictures, movies and study materials must also be modest. To preserve all of the above, the Haredi community established special learning settings. An ultra-Orthodox nursing school is expected to meet the same requirements, especially in the context of studying sensitive materials. The educational programs at such a nursing school must be tailored to the Haredi way of life.

To launch a combined program, the Ruppin Academic Center administration and academic staff had to incorporate therapeutic listening, openness, sincere desire to understand the needs of both sides, and cultural sensitivity (I. German,[5] personal communication, December 19, 2019). Cultural sensitivity implies being mindful of cultural differences that can affect values, behavior and learning (Stafford et al., 1997) and may require accommodations.

Since all events in the ultra-Orthodox community must be gender separated, ceremonies in which the Tessler Academic School of Nursing student nurses participated were held on the Tessler Academic Nursing School campus with the participation of the Ruppin Academic Center staff. Other events that included the Ruppin Academic Center nursing students were held on the Ruppin Academic Center campus, and the Tessler Academic Nursing School staff were invited and usually took part in these events. The Ruppin Academic Center staff ordered refreshments with the appropriate kosher approval for the ultra-Orthodox staff to make them feel comfortable and enable them to engage in eating at these celebrations.

The views organizations as areas of scarce resources where influence and power affect the allocation of resources among interest groups and organizations. Aspects of this frame include games of power, conflict management, self-interest, competition, and negotiation (Lyon et al., 2014).

The academization of nursing education in Israel is an example of the above. The academization of nursing expanded and programs for teaching nursing moved to the universities (Bartal, 2015). On September 6, 2003, the MOH decided to close all non-academic nursing education programs. In a complementary move, the CHE transferred the education of nurses from schools with non-academic programs to academic colleges and universities (Israeli CHE, 2005). This caused resources to move from the MOH to the CHE.

In the wake of the Israeli MOH decision to close non-academic nursing programs, the Tessler Academic School of Nursing sought to affiliate with an academic institution accredited by the Israeli CHE. The school searched for an institution that would be willing to open a special BSN program of study on the Tessler Academic School of Nursing campus specifically geared to the lifestyle of ultra-Orthodox students. For many reasons this did not work out. For one thing, the universities demanded that a large part of the studies be held on their campuses, violating the principle of separation demanded by the Haredi population (Dr. Ester Strauss, personal communication, December 25, 2018). At that time, no academic setting existed that could meet the special needs of the Haredi population (Marcus et al., 2015) (Figure 2).

Figure 2.

Haredi Women's Lifestyle Requirements in the Academic Arena.

A government resolution to facilitate access to higher education for the Haredi population (Lupo, 2003) was the catalyst for the decision of the Israeli CHE to open its doors to the Haredi community. Indeed, the CHE set the integration of Haredi society into Israeli academia as one of its goals. In July 1999, the CHE began instituting academization for the Haredi population by establishing designated academic programs (Marcus et al., 2015). The CHE devoted efforts and resources toward making higher education accessible to the ultra-Orthodox Jewish population. Efforts were based on the principle of recognizing the unique characteristics of this specific population and integrating practices into academia while respecting the Haredi way of life. It was understood that in order to establish an appropriate learning environment for these students, all programs had to be gender separated (Novis-Deutch & Rubin, 2019). As a result, the CHE created an infrastructure in which universities and colleges ran duplicates of their programs in existing Haredi settings. From that point, the establishment of academic programs proceeded rapidly (Marcus et al., 2015). In 2012, the CHE proposed the Ruppin Academic Center open a joint BSN nursing program on the campus of the Sanz Medical Center. The administrators of both institutions met and decided to open such a program; the first class started in 2013 (Figure 3). This was a win-win situation where the Ruppin Academic Center received a special budget from the CHE to open a program for the Haredi population and the Sanz Medical Center also received part of the budget and was able to open a program which they had strived to open for many years.

Figure 3.

Time Line of the Tessler Academic School of Nursing's Affiliation. *Marcus et al. (2015).

The includes shared values and culture which constitute the institutional identity. The organization's collective history and culture may be communicated symbolically and includes development of the institutional vision and image projected to different populations (Lyon et al., 2014).

A symbolic leader is highly charismatic and sees beyond current realities to create opportunities. The leaders of all the foundations taking part in this affiliation had to have such characteristics in order to promote this program.

The population of the State of Israel is a cultural mosaic originating from immigration across the globe (Gonen et al., 2016). In order to cope with this background, the MOH had set the reduction of gaps and the creation of equality in health services as a major policy goal (Khatib & Hadid, 2019). In this context, it should be noted that of the poor Jewish families in Israel, one-fourth belong to the ultra-Orthodox Haredi population (Endeweld et al., 2018). In addition to this low socioeconomic status, Haredi society is marked by high birthrates and marriage at a very young age; these two factors have an impact on mental and physical health (Peles et al., 2018). Culturally competent nurses that will respect and deliver holistic family-centered treatment are needed to provide skilled nursing care for the Haredi population (DeVito, 2019). The ultra-Orthodox nurses educated in programs such as the one explained here can help address the special needs of this population. In the past two decades, Haredi society has undergone significant changes, with more and more women acquiring higher education and academic professions. In light of this, the roles of Haredi men and women are being re-examined (Kalagy & Braun-Lewensohn, 2019). In the past, most ultra-Orthodox women were employed in the fields of education, child care, and community services. As a result of the changes inside the Haredi society, nursing and computer programming have become additional employment options, as have small-scale entrepreneurship and communication. Thus, in recent years approximately 8,000 Haredi employees, mostly women, have entered the Israeli labor market (Raz & Tzruya, 2018).

In view of the increasing global demand for nurses, the academic nursing studies in this program have enabled Haredi women to find jobs (Liaw et al., 2017). Nursing also offers a wide range of work options (Ashkenazi et al., 2017), so that Haredi nurses in particular can customize the type and scope of their job according to their personal and family situations.

Graduates have expressed their gratitude towards this special program which enabled them to study nursing based on their beliefs and culture. They express their thanks for being able to make a dream come true and to be able to work and support their families. There is a new demand by these graduates to open more programs of this type, adapted to the Haredi population, for continuing nursing education.

Thanks to high cultural sensitivity, honest discussions and negotiations, the Ruppin Academic Center - a secular institution, successfully tackled the complex challenge of opening a BSN program for ultra-Orthodox nurses with a veteran ultra-Orthodox institution.