Israel's health system, like those worldwide, has limited resources, a shortage of qualified personnel, and an aging population. Due to these factors, the state of Israel strives to provide its citizens with more skilled and professional caregivers as well as better and more accessible services. As of 2013, the Public Health Regulations - Approval of Advanced Practice Nursing Degree Regulations have been enacted, which include a description of specialties, prerequisites for specialty, and the training processes necessary for Nurse Practitioner licensure. According to the Ministry of Health, the goal is to have 6% of nurses in Israel be Nurse Practitioners by 2030. In 2022, we can say that the “dream” has certainly “come true” in Israel, and that Nurse Practitioners are now effectively being implemented throughout the nation's healthcare system. The purpose of this article is to share the experience in developing the role, the necessary processes in its development and adoption, as well as challenges and successes encountered during its development and adoption. Moreover, the article will describe the differences between nursing roles in Advanced Practice in Israel and the United States, as well as the advantages and disadvantages of each.
Key Points
- •Israel's health system, like those worldwide, has limited resources, a shortage of qualified personnel, and an aging population.
- •Introducing a new role into an existing health system is challenging and requires strong leadership advocacy.
- •There are differences in the nurse practitioner’s role in Israel versus the United States that reflect differences in health systems and population needs.
Background
Nursing professional development can be divided into the following 3 main tracks: The classic hierarchical track, in which a nurse may advance from a staff nurse, to a team leader, to the head nurse in a department or clinic, and finally achieve the role of chief nurse of an organization. A nurse may also pursue promotion through the academic track, which involves studying for various academic degrees as follows: a bachelor's degree, a master's degree, and a doctoral degree, leading to a professorial degree. Additionally, nurses may pursue a clinical track that entails supervising a clinical issue within the department or clinic, coordinating a clinical subject throughout an institution, and achieving the status of nurse practitioner (NP).
Developing on all 3 tracks overlaps and complements each other, so that the nurse can work in different areas in the training service and institute, in the hospital at the bedside, in the field of administration or academics, or even combine them. Nevertheless, all nursing development tracks require the nurse to be motivated, acquire broader educational and professional knowledge, be appreciated by her colleagues, and gain professional experience.
1
Israel Ministry of Health, Nursing Division
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
https://www1.health.gov.il/nursing/work/toolkits/work-plan/
Date accessed: November 2, 2022
There are 2 important aspects of promoting nurses' professional development and knowledge acquisition. Improved quality of care and patient accessibility are the first and most important aspects.
2
The more skilled and professional caregivers we add in an area of limited resources, a shortage of skilled personnel, and an aging population,3
the better the service will be, as well as the more readily available it will be for patients.4
For example, there is a policy in Israel to shorten the waiting lists for operations. In other words, surgeons and their residents are in operating rooms more often, and patients who have undergone complex procedures fail to receive adequate care and attention after returning to crowded departments. The addition of a high-quality resource such as a surgical NP, who is qualified to provide medical care, allows the department to provide ongoing medical care, including postoperative medical admission, regular monitoring of patients' conditions following surgery, identifying deterioration, and providing immediate solution, such as starting antibiotic therapy, ordering pain management, and so on. As a NP assigned to a surgical practice, working there each morning permits continuity of care to be provided regardless of the high turnover of medical staff. The nurse gets to know the patient and meets him each morning, which allows her to recognize if his condition has changed. Further, the patient receives an immediate response and does not need to wait for surgeons, who are frequently engaged in a variety of tasks, consultations, and operations. As a result of the presence of a NP in the department, medical care can be provided in a continuous, accessible, safe, and high-quality manner. In addition, the impact of NPs on the development of nursing professions is an important dimension to consider. Currently, there is a constant shortage of nurses, and we are creating a role that has a professional horizon, prestige, and interest, which encourages young individuals to pursue a career in nursing. By doing so, we are able to influence the hiring of high-quality personnel for the profession.International Council of Nurses
Guidelines on advanced practice nursing 2020.
Guidelines on advanced practice nursing 2020.
https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf
Date accessed: November 2, 2022
5
,6
- Maier C.B.
- Aiken L.H.
- Busse R.
Nurses in advanced roles in primary care: policy levers for implementation.
https://www.oecd-ilibrary.org/docserver/a8756593-en.pdf?expires=1667372638&id=id&accname=guest&checksum=F697D5C338A91FD5206466A133172567
Date: 2017
Date accessed: November 2, 2022
National Level Process
The questions that arise, how can nurses be promoted to advanced roles at the national level? What is the first step? To engage in professional development at the national level, there are a number of preconditions that must be met, or as we put it, “all the stars must align in the heavens” for us to achieve our vision.
Initial, fundamental conditions include the support of the Ministry of Health's management (the Minister of Health, the Director General of the Ministry of Health, and the National Head Nurse), as well as their understanding that nurses are a key resource that provide a significant contribution to the health care system. However, merely appreciating nurses and their contributions is not sufficient. In order to establish advanced roles such as this, we must push to change our professional limits, break the glass ceiling, or in other words, move away from the traditional hierarchy within which only physicians can give medical orders and determine medical care. To create “new order” in such a big, traditional system, strong leadership is necessary as well as strong faith in the nurses' abilities. It would be extremely difficult to shift the boundaries of the profession without the backing and steadfastness of the Ministry's management. In essence, “shifting the boundaries of the profession” means giving NPs the authority to make medical decisions and perform medical procedures that were previously restricted to physicians only, such as: examination and evaluating the condition of the patient, referral for diagnostic tests and consultations, assessment and defining the medical condition of the patient, and establishing a medical treatment plan, including recording of orders for drugs and medical procedures. With the formalization of a range of authorities in conjunction with the job definition, the nurse can influence the advancement of care, allowing for high quality and readily available care within the department or clinic.
7
Israel Ministry of Health Director General & Nursing Division Guidelines
Public health order concerning determination of recognized Nurse Practitioner roles in all fields. 2013-2022.
Public health order concerning determination of recognized Nurse Practitioner roles in all fields. 2013-2022.
https://www1.health.gov.il/nursing/work/toolkits/regulations/
Date accessed: November 2, 2022
The second condition is established academization of nursing. Without advanced academic abilities, nurses cannot engage in professional development. Professional development requires the ability to read and analyze studies, work according to established evidence, and articulate a professional position and support it with empirical evidence at the high professional level, which is required of every caregiver who makes medical decisions. In the Israel's academic system, all nursing training is conducted in universities and colleges; therefore, there are many nurses in the country who have masters and doctoral degrees, as well as many professors. Considering academic ability, nursing in Israel is a completely academic profession, allowing the advancement to the degree of NP.
1
Israel Ministry of Health, Nursing Division
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
https://www1.health.gov.il/nursing/work/toolkits/work-plan/
Date accessed: November 2, 2022
Due to the fact that these 2 conditions have been fulfilled in Israel (full academic training and strong leadership that believes in the abilities of nurses), the Public Health Regulations and Approval of Advanced Practice Nursing Degree Regulations were enacted in 2013 following years of preparation. These regulations provide a definition of specialties, prerequisites for specialty, training requirements for licensing, as well as rules for licensing NPs. Six nursing specialties were initially included in the regulations. In the past 9 years, 5 additional specialties have been added, bringing the total number to 11. Ten of the nursing specialties are clinical, while one is aimed at senior management, a Policy and Administration Specialist. As of today, 6 specialties are already in full practice, 4 are in the advanced development stage (in the training process), and a new specialty will be developed in the near future.
1
Israel Ministry of Health, Nursing Division
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
https://www1.health.gov.il/nursing/work/toolkits/work-plan/
Date accessed: November 2, 2022
As noted above, the clinical fields chosen for development are those in which the Ministry of Health identified gaps that had to be closed and the medical care provided to citizens was needed to be strengthened, such as in geriatrics, surgery, and neonatology , and in fields where nurses have been recognized for their significant contribution, such as palliative care, diabetes, pain control, and rehabilitation, where they have a positive impact on quality of life, disease management, treatment compliance, and management of symptoms.
1
Israel Ministry of Health, Nursing Division
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
https://www1.health.gov.il/nursing/work/toolkits/work-plan/
Date accessed: November 2, 2022
Various processes have been undertaken for each of the clinical fields, including definitions of the role and scope of authority, reaching agreements with the professional associations of the physicians in those fields, formalizing authorities through a regulatory process, developing and implementing a curriculum, developing and administering licensing examinations, and promoting the use of the specialty in practice, including any necessary updates. It is an innovative role in the health system and nurses in Israel are mainly employed under collective agreements. Consequently, a process has been undertaken to define the employment conditions and hierarchy, supervisors, and interactions with others.
It is very important to note that all specialty programs have very high prerequisites, and include the following: A master's degree or higher degree, a post-basic course (which is a year-long training program in the field of expertise), and many years of relevant experience. As for the specialty program itself, it consists of 700-1240 study hours, of which 400-700 are clinical practicum hours under the supervision of a specialist physician. Upon completion of the course, a two-phase licensing examination is administered (written and oral).
8
Differences Between Models of Advanced Practice Nurse
The United States advanced practice registered nurse (APRN) model has existed for many years and is an integral part of the American health care system, they are often the primary care providers
9
for the majority of the population.10
,American Academy of Nurse Practitioners
https://www.aanpcert.org/
Date accessed: November 2, 2022
11
The role in Israel, on the other hand, is still in its infancy, and its implementation presents many challenges, including colleagues' fears of a change in the boundaries between professions and nurses' ability to influence and promote quality care and availability. Nevertheless, since Israel is a small country with highly centralized nursing policy and management leading by the Nursing Division, the ability to carry out national processes is more straightforward, and it is expected that the profession will be fully assimilated within a short period of time. As a matter of fact, in the State of Israel, all issues relating to professional licensing, professional development, and professional guidelines are governed by one regulatory body that is part of the Ministry of Health. Consequently, the Nursing Division operates under the direct guidance of the Minister of Health and the Director General of the Ministry of Health, jointly promoting the assimilation of APRNs into all the health care systems in the state of Israel. All areas of expertise are developed in a uniform manner, including the prerequisites for admission to studies, uniform standards for the duration and quality of training programs, requirements for compliance with the specialty program, and national licensing examinations. Israeli nursing license does not restrict specialist nurses to any particular geographical area or organization. In contrast, licensing requirements in the United States are determined by each state, and each state has its own licensing procedures.12
American Nurses Credentialing Center
https://www.nursingworld.org/ancc/
Date accessed: November 2, 2022
The Israeli Ministry of Health has decided to develop a unique specialization model for each clinical field, similar to the medical model (e.g. diabetic care, geriatric care, neonatal care, pain control, etc). In this model, it is possible to specialize in clinical fields at a high level, but it is more difficult to move from one field to another. The United States, on the other hand, has few main areas of APRNs, including Adult NPs, Family NPs, Psychiatric Mental Health NPs, and Certified Nurse Midwives.
4
As a result of each of these areas of specialization, there is a variety of opportunities for professional growth, for example, in the area of expertise of the adult, you may work in many different hospitalization and community-based scenarios.International Council of Nurses
Guidelines on advanced practice nursing 2020.
Guidelines on advanced practice nursing 2020.
https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf
Date accessed: November 2, 2022
NPs in Israel and in the United States are considered senior health care providers in the health system, but their scope of practice differs from that in the United States. In the United States the scope of practice is different from state to state. On the other hand, in Israel the scope of practice differs from specialty to specialty, but it is based on a number of leading principles that are applicable across all disciplines, for example, across all fields, practice involves the making of medical decisions, including the assessment, diagnosis, and treatment of illnesses and injuries, and the decision and titration of drug treatments. The NPs provide a holistic approach to the patient's needs (medical and non-medical) and their areas of practice are nationwide. An APRN treats and diagnoses illnesses, makes health advice to the public, manages chronic diseases, and engages in continuous education to keep abreast of any technological, methodological, or other advances in the field.
2
,4
,International Council of Nurses
Guidelines on advanced practice nursing 2020.
Guidelines on advanced practice nursing 2020.
https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf
Date accessed: November 2, 2022
8
For NP training, both countries require applicants to possess a Master's degree, and licensure is required for all registered nurses, but Israel requires at least 2 years of clinical experience in the specialty area, as well as a post-basic course in the specialty area. Because of these high requirements, it is difficult to recruit candidates for the NP program and the number of nurses undergoing training each year is delayed.
4
,International Council of Nurses
Guidelines on advanced practice nursing 2020.
Guidelines on advanced practice nursing 2020.
https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf
Date accessed: November 2, 2022
8
NP employment is the last but most significant difference between the 2 countries. While in the United States, it is a free market where NPs can be employed as the main caregiver instead of physicians,
13
the employment mechanism in Israel is public based, and the nurses have a collective employment arrangement.NPs are not included in the standard ratio between the number of nurses and the number of patients established by the state (different in each description). Therefore, their employment is based on an additional standard and requires significant financial resources. But in order for the health care organizations to invest in the employment of NPs in addition to their existing health care staff, they must be convinced that this investment is worthwhile. Obviously, organizations with the appropriate resources can make this type of investment (Table 1).
1
,Israel Ministry of Health, Nursing Division
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
https://www1.health.gov.il/nursing/work/toolkits/work-plan/
Date accessed: November 2, 2022
4
,International Council of Nurses
Guidelines on advanced practice nursing 2020.
Guidelines on advanced practice nursing 2020.
https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf
Date accessed: November 2, 2022
6
,- Maier C.B.
- Aiken L.H.
- Busse R.
Nurses in advanced roles in primary care: policy levers for implementation.
https://www.oecd-ilibrary.org/docserver/a8756593-en.pdf?expires=1667372638&id=id&accname=guest&checksum=F697D5C338A91FD5206466A133172567
Date: 2017
Date accessed: November 2, 2022
14
Table 1Summary of the Main Differences
| Country | United States | Israel |
|---|---|---|
| Licensing | Determined by each state | Central |
| Regulatory body | By state + central | Central |
| Prerequisites for admission to studies | Admission requirements for the Master's | 2 y experience Post basic curse Admission requirements for the Master's |
| Training program | Master/DNP | Master/post master diploma (1 y) |
| Specialization model | Unified fields (adult/pediatric/psych etc.) | Medical model (by clinical specialty) |
| Scope of practice | Senior health provider Scope determined by each state Full prescribing authority | Senior health provider Central scope determined Limited prescribing authority |
| Employment | Free market | Collective employment arrangement |
DNP, Doctor of Nursing Practice.
Results
Israel is constantly approaching the objective to reach 6% NPs out of all nurses in Israel by 2030. The number of clinical NPs in Israel is growing every year as we expand the number of specialties and training tracks available to them.
Family NP is the newest field that we have added to the community health services practice. A key aspect of primary health care in Israel is the excellent services provided by the 4 healthcare organizations (health maintenance organizations). Furthermore, every citizen is insured by law, so that they are eligible for medical services provided by one of the health maintenance organizations in their community. By working in a primary clinic as a partner in the team alongside family physicians, NPs will be able to expand caregiver resources in the community, providing a quality response to patients who primarily present in minor acute situations, such as upper respiratory tract infections and urinary tract infections, managing chronic and elderly patients, and promoting health for healthy and ill individuals.
15
As a result, family physicians that are faced with a heavy caseload (which has increased during the COVID-19 pandemic) will be able to focus on more complex cases and provide a solution when necessary.Recently, the role of the Psychiatric NP (PNP) has been defined in Israel, and it is this days' challenge for the ministry to determine how to implement it. There is an understanding that by fostering the development of NPs' roles and authority within the mental health care system, improvements in the quality of mental health care can be achieved. And in addition to providing care to patients of all ages, the PNP can contribute to addressing the needs of patients in the community. It is intended that PNPs will reinforce a holistic approach that acknowledges the emotional balance in addition to their physical and social rehabilitation, while promoting health of the individual, thereby improving the outcome of complex mental health cases.
16
,17
Under the new model of PNP, chronically and acutely ill patients will be the first population to be addressed and treated. In particular, the resources should be directed at the first phase of the program in underserved communities where the number of psychiatric services is inadequate and nursing staff is scarce. For those populations, the ability to provide mental health treatments by PNPs will make a very big impact on the quality of service delivered.
Conclusion
Although the adoption of the role in the health care system is relatively new, all processes associated with its implementation are backed by research, and despite the function's relatively recent arrival in the health system, its impact on quality care, availability of care, continuity of care, and therapeutic outputs can already be observed. For example, maintaining disease balance parameters and treatment compliance, preventing deterioration and the need for hospitalization, balancing symptoms and ensuring patient satisfaction, and teams and nurses themselves. Additionally, since the NP position has been adopted in Israel's health care system, more and more young people are entering the profession, knowing that they wish to become NPs in the near future.
1
Israel Ministry of Health, Nursing Division
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.
https://www1.health.gov.il/nursing/work/toolkits/work-plan/
Date accessed: November 2, 2022
References
- Annual report and work plans for years 2009 2022. between the years 2009-2019, hard copy reports. Between the years 2020-2022.(Available at:)https://www1.health.gov.il/nursing/work/toolkits/work-plan/(in Hebrew)Date accessed: November 2, 2022
- Broadening the scope of nursing practice.N Engl J Med. 2011; 364: 193-196
- Substitution of doctors by nurses in primary care.Cochrane Database Syst Rev. 2004; : CD001271
- Guidelines on advanced practice nursing 2020.(Available at:)https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdfDate accessed: November 2, 2022
- The Nursing Division of the Israeli Health Ministry moves nursing into the forefront of health care.Pol Polit Nurs Pract. 2014; 15: 49-57
- Nurses in advanced roles in primary care: policy levers for implementation.(Available at:)https://www.oecd-ilibrary.org/docserver/a8756593-en.pdf?expires=1667372638&id=id&accname=guest&checksum=F697D5C338A91FD5206466A133172567Date: 2017Date accessed: November 2, 2022
- Public health order concerning determination of recognized Nurse Practitioner roles in all fields. 2013-2022.(Available at:)https://www1.health.gov.il/nursing/work/toolkits/regulations/(in Hebrew)Date accessed: November 2, 2022
- Public health regulation 2013: approval of the degree of expert nurse.(Available at:) (in Hebrew)
- Defining nurse practitioner scope of practice: expanding primary care services.Internet J Adv Nurs Pract. 1997; 1
- (Available at:)https://www.aanpcert.org/Date accessed: November 2, 2022
- How nurse practitioners obtained provider status: lessons for pharmacists.Am J Health-System Pharm. 2003; 60: 2301-2307
- (Available at:)https://www.nursingworld.org/ancc/Date accessed: November 2, 2022
- Patient satisfaction with primary care: does type of practitioner matter?.Med Care. 2004; : 579-590
- Gerontological Nurse Practitioners (GNPs) for the first time in Israel: physicians’ and nurses’ attitudes.J Am Assoc Nurse Pract. 2016; 28: 415-422
- Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors.BMJ. 2002; 324: 819-823
- Development of psychiatric–mental health nurse practitioner competencies: opportunities for the 21st century.J Am Psychiatr Nurses Assoc. 2004; 10: 129-138
- The future of the psychiatric mental health clinical nurse specialist: evolution or extinction.Nurs Clin. 2012; 47: 295-304
Biography
Hilla Fighel, PhD, RN, is an expert in Nursing Policy and Management and director of the Professional Development Department at the Ministry of Health's Nursing Division, Israel. Fighel is responsible for developing advanced roles for nurses and adopting them in Israel's healthcare system. The duty includes responsibility for developing all clinical advanced practice registered nurse functions. Fighel is also responsible for leading the national program for expertise in policy and administration for training of the senior nursing staff for senior management functions in health organizations at the national level. She can be reached at [email protected] Tmira Hefetz, MPA, RN, LLB, is a director of Nursing, Gehha Mental Medical Center, Clalit Health Services, Israel. Hefetz is responsible for 166 patients and in charge of 125 nurses. Hefetz also is the deputy CEO of the National Ethics Committee of Nursing in Israel. Under this role, she is part of the policy makers in guiding nursing behavior, addressing challenges in daily work of nurses across all clinical disciplines. She can be reached at [email protected]
Article info
Publication history
Published online: December 16, 2022
Footnotes
Note: H.F. responsible for developing advanced roles for nurses and adopting them in Israel’s healthcare system. The duty includes responsibility for developing all clinical advanced practice registered nurse functions. Also responsible for leading the national program for expertise in policy and administration for training of the senior nursing staff for senior management functions in health organizations at the national level. T.H. responsible for 166 patients and in charge of 125 nurses. Tmira also is the deputy CEO of the national ethics committee of nursing in Israel. Under this role, she is part of the policy makers in guiding nursing behavior, addressing challenges in daily work of nurses across all clinical disciplines.
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2022 by Elsevier Inc. All rights reserved.
