State Involvement in Professional Nursing Development in Israel: Promotive or Restrictive

Nurses are the largest component of utilized human health resources both in Israel and throughout the world, providing the lion’s share of the population’s health care (International Council of Nurses, 2004; World Health Organization, 2000). As such, nurses' potential impact on the dynamics of the health care system as a whole, and on the health status of patients in particular, is substantial.

This article describes the role of the Israeli Ministry of Health’s Nursing Division in regulating the development of the nursing profession and the nursing care provided. First, factors influencing professional nursing in Israel and the development of the Ministry of Health’s Nursing Division are presented. Then, examples of the Nursing Division’s influence on nursing practice, the process of statutory authorization used to facilitate this influence, and future Nursing Division initiatives are discussed. The article concludes by noting that on balance, ministerial (governmental) involvement strengthens the nursing profession and the quality of nursing care provided, recognizing that this ministerial involvement may also restrict nurses’ private concerns.

Professional Nursing Development in Israel

Professional nursing development in Israel includes the continuous upgrading and expanding of the scope of nursing practice along with the provision of the necessary knowledge and skills needed for this growth. Professional development strengthens both the profession of nursing and the practice of the individual nurses who comprise the profession.

The state of Israel borders on the Mediterranean sea, between Egypt and Lebanon. To the west, lie Syria, Jordan and the West Bank of the Jordan. Israel's population is approximately six million people. The median population age is 29.2 years. Israel is experiencing a population growth of 1.8%, with the most rapid growth among the elderly who presently comprise 9.9% of the population. Cardiovascular diseases and cancer are the illnesses with the highest mortality rate. Infant mortality is 7.5%. The Physician/population ratio is 4.6 per 1000, and that of nurses is 5.9 per 1000 (Ministry of Health, 2003).

In Israel, the impetus for professional nursing development stems from three sources: nurses themselves, interested in pursuing particular career tracks; the private marketplace, motivated at least in part by considerations of profit; and governmental bodies, responsible for the overall welfare of society.

Nurses’ impact upon their own professional development is related to general trends in career choice. Nurses can advance by: climbing the managerial ladder, expanding clinical expertise while remaining at the bedside, and/or upgrading one’s organizational context, (e.g., moving from the position of charge nurse in an internal medicine unit to the same post in an intensive care unit). In Israel, working in an intensive care unit is considered more prestigious than working on a general unit.

The Israeli private marketplace is guided mainly by principles of cost/benefit ratio. This impacts upon professional nursing development by placing a priority on nursing positions that will facilitate the generation of monetary profit and by lobbying for government-approved education and authorization of qualified nursing personnel to fill these positions.

Nurses, who are indispensable for the operation of profitable, high tech operating theatres, are likely to be offered attractive salary and benefit packages. Nurses, on their part, will gravitate to positions of this nature.

In contrast to the self-interest that motivates individual nurses and the private marketplace, the government is motivated by the interests of the society as a whole. The government utilizes the resources at its disposal to navigate professional advancement in line with those interests. Resources are indeed shrinking and health costs rising in the international community of which Israel is a part. In addition, Israel faces two very specific economic challenges. The first is the high cost of the immigrant absorption and the second is the war on terror. With regard to immigrant absorption, Israel absorbed approximately 1,000,000 immigrants from the former Soviet Union alone in the last decade and a half (twenty percent of its previous population). It is worthy of note that many of these immigrants suffer from multiple chronic illnesses, a factor that contributes to national health care costs. With respect to the war on terror, repeated acts of terror that take a heavy toll in human lives also take a heavy financial toll in the loss of international tourism and investment. An additional burden on the economy as a result of the war on terror is the increase of the budget that must be set aside for defense.

Economic constraint has affected the ability of Israel to provide quality health care, especially to vulnerable populations such as the elderly, the poor, the mentally disabled, the chronically ill, and individuals living on the geographic periphery of the country. Providing health care for these vulnerable populations is relatively unattractive and unprofitable and often not a priority for the private sector. It is the responsibility of the public sector to find adequate solutions for the care of these populations. The Nursing Division of the Health Ministry has identified health care of vulnerable populations as a national priority and has addressed this priority by creating new nursing roles and expanding existing ones to meet these needs.

Developing the Nursing Division of the Ministry of Health

The Nursing Division was established by the Ministry’s top leadership in 1994, as part of the general reform of the Israeli health care system. The reform was based on conclusions reached by the Netanyahu Commission (Netanyahu Report, 1990), which recommended major changes, on a national scale, in three health care domains:

• Health insurance (the enactment into law of a new National Health Insurance Act, providing for a universal insurance plan)
• Hospital administration (conversion of hospitals into economically solvent corporations)
• Ministerial responsibility (converting the Ministry of Health from a direct service provider to a body whose main responsibility would be establishing and auditing adherence to professional standards)

The establishment of the Nursing Division was part of the reorganization of the Ministry of Health. The decision to create a separate entity responsible for nursing was based upon the recognition of nursing as a distinct autonomous profession in the forefront of health care. From the time of its inception, the Division has represented the nursing profession in the Ministry’s policy-making process. Health policy within the Ministry is determined in a multidisciplinary manner. All health professions are represented in the deliberations, and decisions are made in light of how resources can be used most effectively for the public good.

The Division’s domain of responsibility vis-à-vis nursing is to establish and oversee national nursing policy on an ongoing basis. The division’s specific goals are as follows:

• To set and consistently upgrade professional standards of practice
• To expand the scope of practice and create new and more autonomous job descriptions
• To structure and oversee nursing education on the generic (entry level) and post generic levels in line with professional development

The Nursing Division regulates nursing as it accomplishes these goals.

To meet these goals, the Division has set up three executive departments, which work, in full cooperation with one another: Professional Development, Professional Guidelines, and Licensure and Accreditation.

The policy of the Nursing Division is to be actively involved in delineating new nursing domains and designating the concomitant bodies of knowledge nurses need to master in order to practice within these domains. New nursing domains are identified by carefully studying the changing needs of the population, health trends, and the progress being made in health technology. The latter opens up new opportunities to improve health and well-being, opportunities that can be utilized by nurses in providing nursing care. The Department for Professional Development crafts the new nursing domains. The Department of Professional Guidelines, in turn, sets guidelines for practice. The respective bodies of knowledge and skills are integrated into the educational programs designed by the department of Professional Development and accredited by the Department of Licensure and Accreditation.

The Nursing Division includes in its decision-making process nationally renowned experts in nursing and other health fields both from within the governmental framework and outside of it. Prominent stakeholders, such as medical and nursing directors of community and institutional health facilities, heads of private medical centers, and major insurers, are invited to address policy issues. Critical decisions are customarily made at formal conferences in which all stakeholders participate.

The Nursing Division at Work: Developing the Nursing Profession

The Nursing Division closely follows national and international trends in health care utilization. These trends often form the basis for establishing professional advancement. Two major trends that have, of late, had a significant impact on the nursing profession in Israel are movement into the "gray areas" of practice, and the change of the focal point of health care from hospital-based to community-based care. Each will be discussed in turn.

The First Trend: Movement into the Gray Areas of Practice

The network of therapeutic services available to the health consumer in Israel, as in other developed countries the world over, includes a broad spectrum of providers: doctors, nurses, occupational therapists, social workers, physiotherapists, technicians, and others. Each profession possesses its own unique operational turf, but also shares territory with the other professions. The recent trend in Israel is for professionals to cross over into shared territory, initially without statutory authorization. This trend of ‘frontier crossing’ (or if you will, moving into the "gray areas"), although occurring among all the health professions, consists predominantly of nurses moving into professional boundaries of physicians. (Riba, 2000). Nurses often welcome expanded nursing practice as it upgrades their professional profile, despite the questionable legality. The medical functions incorporated into nursing often include facets of clinical decision making which enhance the nurses’ ability to give quality comprehensive care. An example of a medical function recently added to nursing practice is the authority delegated to nurses to administer narcotics via an epidural catheter in providing palliative care.

Socioeconomic and political developments have been instrumental in formation of the gray areas. These developments include rapid changes in medical technology, rapid developments in information technology, a shift of the public’s perception of health, and the rising cost of operating the health care system.

Rapid changes in medical technology have introduced new, sophisticated procedures that can be performed as safely and proficiently by nurses as by physicians. Physicians, who zealously hold on to functions they view as prestigious and challenging, opt to delegate the performance of less glamorous functions to nurses, either for lack of time or lack of interest (Riba, 2000; English, 1997).

Rapid developments in the field of information technology have empowered consumers with considerable knowledge and an increased awareness of their options as consumers, and also have demystified the medical profession and medical care.

The media have literally brought sophisticated medical knowledge to the fingertips of a growing body of consumers and have made both the decision-making process, and the decisions made by policy makers on all levels, common public knowledge (Curtin, 1996; Harrington & Ritsatakis, 1995). These developments have both encouraged consumers to be more active and discriminating partners in their health care and increased consumer willingness to accept nurses, along with physicians, as potential primary health care providers.

The shift of the public’s perception of health has moved from a dichotomous entity to a perception of health on an "ease" to "dis-ease" continuum. The presence or absence of specific illness is no longer considered to be the sole measure of health. Individuals strive to remove barriers to optimal living, including both illnesses and phenomena such as depression, loneliness, and dependence, related or unrelated to specific illness. The developed world has been blessed with a substantial increase in life expectancy. This is still a mixed blessing since society has not succeeded in concomitantly increasing quality of life. The prevalence and incidence of chronic illness increases with age and often brings in its wake pain, disability, fear, poverty, and social isolation. Individuals suffering from chronic illness seek relief from the ravages of the illness to the degree possible, while at the same time seeking optimal quality of life. Nurses, educated in the tradition of caring and enhancing overall functional level and life satisfaction, strive to empower individuals for effective coping and enriched quality of life. For all of these reasons, nurses are typically well-suited for narrowing the "quantity versus quality" of life gap.

Rising costs of operating the health care system have spurred competition for client and resource markets as well as exploration of avenues for cutting costs without sacrificing quality of care. Again, nurses are advantageous professionals in that they can often provide health care services as safely and proficiently as their professional counterparts while remaining less expensive to employ.

The Nursing Division has taken advantage of these technological and societal developments and of the willingness of physicians to delegate medical functions to nurses. The Division has set into motion the statutory process necessary for legalizing the delegation of these activities to nursing.

The Second Trend: Movement From Hospital-Focused to Community Focused Care

Rising costs of health care have provided the impetus for two major changes in hospital admission and discharge policy. These changes include setting consistently higher levels of acuity as criteria for inpatient admission and shortening the period of hospitalization.

With respect to the State of Israel, if one compares the number of hospital inpatient days per 1000 people in 1975 with those in 2001, one finds a decrease of 28% in the number of hospitalization days in general hospitals and a remarkable decrease of 69% in psychiatric hospitalization (Ministry of Health, 2002). These statistics, which reflect an ongoing trend, are the result of fewer (yet more acute) admissions, as well as shorter periods of hospitalization. Fewer physicians and nurses (and more technicians) are employed in hospitals, and more of those remaining on staff are highly specialized. Individuals are often released from hospitals in semi-stable conditions, leaving doctors and nurses with little opportunity for developing therapeutic relationships with their patients during the hospitalization period.

As in other parts of the developed world, Israeli community care services are restructuring and expanding in order to accommodate a larger and more clinically unstable population of patients (Coulter & Mays, 1997; Pearson & Jones, 1997; Pringle & Heath, 1997).

Often, care during the post-hospitalization period is provided at the client’s bedside in the home, with all the technical accouterments necessary to make possible the providing of quality critical and palliative care. The chronically ill, except in the most complex cases, are being cared for solely in their homes (Coulter & Mays, 1997;Pearson & Jones, 1997; Pringle & Heath, 1997). In addition, as part of the national health care reform spurred by the work of the Netanyahu Commission (Netanyahu Report, 1990), mentally disabled individuals who previously resided in psychiatric institutions on a permanent basis have been transferred from these facilities into the community, sometimes in the framework of hostels or halfway houses.

Nurses, with a long tradition of caring, compassion, and sensitivity to quality of life issues, are well suited to provide the initial and ongoing treatment for vulnerable groups. They are often the primary health care providers in the community. They are usually the ones who make home visits and painstakingly follow the patient's often slow progress. Patients have increasingly greater expectations from their nurses (Light & Connelly, 1991).

It is no longer adequate for nurses to be capable only of performing technical skills and following doctors’ orders.

In order to provide the gamut of care necessary in the wake of the great expansion that has taken place in community care in Israel (as in other parts of the world), broader skills and more professional independence for nurses are needed (World Health Organization, 1996). This is especially true in the fields of support, counseling, patient education and advocacy, adherence promotion, and symptom and case management (Coulter & Mays, 1997; Light & Connelly, 1991, Pearson & Jones, 1997; Pringle & Heath, 1997; Simpson, 1996; Thomas, 1992). Nurses, on their part, have been eager to expand their professional scope of activity and authority (Ehrenfeld & Ecklering, 1995). They have done so by developing new nursing functions, and assuming responsibility for some medical functions via the statutory process described in the next section.

An example of a role undergoing expansion in Israel is that of the primary health community practitioner. New functions are in the process of being added to the professional repertoire of these nurses. These functions include comprehensive care for common infections (including prescription rights), symptom control and palliative care for chronic conditions (also including prescription rights), and case management. In addition to these functions, the domains of patient education and advocacy, family support, and crisis intervention are being expanded. The Nursing Division is also developing the role of the rural community nurse specialist. This nurse specialist is authorized to provide emergency services, such as critical, initial doses of cardiac and respiratory medications in the absence of a physician.

Development of these new roles and the expansion of others go hand in hand with nursing education. The Nursing Division has designed post generic courses of study in community health, oncology, and geriatrics, to provide nurses with the bodies of knowledge necessary for safe and effective advanced practice. These courses expand upon the knowledge base comprising generic registered nursing programs by sharpening clinical judgment through the study and application of clinical guidelines to complex patient situations. Post generic courses are open to a pre-designated number (in line with national health needs) of academically prepared registered nurses who wish to specialize in specific nursing domains and who are funded accordingly. These courses are continuously being updated as nursing roles are expanded. The Division also updates the components of the generic program as necessary for safe performance of nursing functions practiced by nurses prepared at the generic level.

Thus, the Nursing Division has facilitated the movement of professional nursing into both gray areas of practice and into the community through the process of statutory authorization. This process is illustrated below.

The Process of Statutory Authorization for Expanded Nursing Practice

As previously stated, nurses move into the professional territory of physicians initially without statutory authorization. This occurs when nurses perceive themselves as performing certain medical functions better than, or as well as, their physician counterparts, especially in situations where physicians are less available.

The statutory process for the approval of the delegation of medical functions to other health professionals is spelled out in section 59 (1) of the Physician’s Ordinance (1976). The Health Ministry’s Director General, by virtue of the legal powers vested within him by the said ordinance, can approve functions for delegation. With the approval of the Director General, the function is brought before a special committee chaired by the Head Nurse of Israel (an appointee of the Director General) who also plays a major role in determining the committee’s agenda. Presenting the function before the committee, which is composed of senior nursing and medical personnel, entails precise delineation of the function, the knowledge base that must be mastered for safe and effective practice, the relevant professional guidelines, and the parameters for evaluating quality assurance. The Director General of the Health Ministry ultimately decides whether to legally endorse or deny the transfer of professional authority.

The specific criteria this committee applies to the consideration of these requests are as follows:

• physician performance of the procedure that has resulted in problems of accessibility and availability
• nurses’ performance of the procedure that has not diminished the quality of care
• nurses’ performance of the procedure that has added value to the provision of the health procedure by incorporating additional aspects of health care, such as counseling and psychosocial support

The act of endorsing requests for delegation by the committee determines which new functions will accrue to the nursing profession. The Nursing Division determines which functions are appropriate for the generic level of practice, and which require specific post generic domains of expertise. In turn, the accumulation of authorized, delegated functions provides the basis for formally creating new domains of expertise. This is a slow evolutionary process. Nursing education on the generic and post generic level incorporates the knowledge bases necessary for assuming the responsibility for delegated functions. A case in point is the recent expansion of the post generic program in mental health nursing to incorporate the knowledge and skills necessary to execute a newly delegated function: deciding when to give a client an emergency dose of psychotropic medication and when to refer him or her to an acute care facility for further treatment.

Nurse Staffing: A Look to the Future

The increasing scope and intricacy of nursing practice in Israel necessitates rethinking the optimal ratio of nurses to varied patient populations as well as the optimal nursing staff mix, i.e., the proportion of academically prepared registered nurses, licensed practical nurses, and nurses’ aides. The Ministry of Health has set up a special committee consisting of senior nurses, health managers, economists, human resource experts, and nurse educators to study the current utilization of human resources and recommend the necessary changes.

Although the committee is still in the middle of its work, several points are already in consensus. First, nursing care in all venues must be based primarily upon academically prepared registered professional nurses. Second, the existing ratio of registered nurses to licensed practical nurses needs to be rapidly increased, both in the community and for in-patient facilities. Subsequently, licensed practical nurses are to be phased out, and where necessary, trained nurses’ aides will provide unskilled care. Third, nurse staffing formulas for community care must include more registered nurses (preferably academically prepared) than the formulas for institutional care, as nurses tend to be more independent in their practice in the community.

The committee has also decided upon the parameters it will use to determine specific staffing ratios and mixes. In the community, the parameter is the number of nurses per 1000 population. In primary care ambulatory clinics, the parameter is the ratio of nurses to physicians. For in-patient facilities, the parameter is the number of nurses to a bed.

Discussion

The Health Ministry, specifically the Nursing Division, navigates nurses’ and nursing’s professional development. The Nursing Division also takes into account the needs of the marketplace and considers development of nursing skills in line with new technological developments. The Division utilizes both delegation of existing practice (mainly from physicians), and creation of new domains of practice to expand the horizons of the profession in line with developing trends in health. These practice domains are in the field of diagnosis and treatment, technological knowledge, management, and psychosocial support. New areas of specialization are formed and established ones are updated in line with the increase of delegated and created professional functions. This process is always paralleled by the provision of the necessary educational frameworks, (generic and post generic). Ministerial involvement benefits society, but also benefits nurses who are eager to expand their professional repertoire.

On the other hand, the Israeli government does navigate professional development and holds veto power with respect to policy making. The government, in the final analysis, delineates the domains, appropriates the government funds, administers the examinations, and awards the professional diplomas. No other body is authorized to perform these functions. As a result, nurses or private concerns may not always get their first choice of priorities and may need to accept second choice alternatives. Ministerial involvement is in this sense restrictive

Given the intense involvement of the Nursing Division in nurses’ professional development, the important question in the final analysis is: Given the balance, does ministerial involvement essentially promote the nursing profession and the quality of nursing care or restrict development that might take place if the private marketplace and individual nurses’ career choices were the dominant determinants of nursing career development? This article makes a strong case for the former. Nursing resources are directed to where they will make the greatest difference in promoting public health and safety. On the whole, the Nursing Division has capitalized on national health trends to open up many opportunities for nurses, and the nursing profession in Israel is flourishing.

Authors

Shoshana Riba, PhD, MA, RN
Email: shoshy.riba@moh.health.gov.il

Dr. Shoshana Riba serves as National Head Nurse and Director of the Nursing Division of the Israeli Ministry of Health. In this capacity, she is responsible for making and overseeing all policy related to nursing education, practice guidelines, and professional development. Dr. Riba is a member of the National Advisory Board on Health Affairs to the Minister of Health. In addition, she is a consultant to foreign government ministries as well as international organizations (including the World Health Organization) on matters concerning the nursing profession. She has led national and international workshops in nursing leadership and in the establishment and implementation of health policy for health professionals in senior level management. Her previous positions include Director of the Wolfson School of Nursing and lecturer in health services management at the University of Tel Aviv.

Chaya Greenberger, PhD, MSN, RN
Email: chaya.greenberger@moh.health.gov.il

Dr. Chaya Greenberger is currently the Director of the Department of Testing at the Nursing Division of the Ministry of Health. In this capacity, she oversees all licensure examinations on the generic and post generic levels and is involved in the policy making of the division. She is a family nurse practitioner and has worked in the field of community health with chronically ill clients, as well as in the field of acute geriatric care, both as a nurse and an instructor. Dr. Greenberger directed the Shaare Zedek school of nursing for many years. She lectures in the master's program in Social Work at the Hebrew University and is a member of several professional organizations.

Hiba Reches, MA, RN
Email: hiba.reches@moh.health.gov.il

Hiba Reches is Director of the Department of Nursing Licensure of the Israeli Ministry of Health’s Nursing Division. In this capacity, she is responsible for the content and quality of the generic nursing education, including setting performance standards and updating programs on a regular basis. Ms. Reches was the first editor of the professional journal Oncology Nursing in Israel. She has both coordinated nursing curricula and taught various nursing courses at the Tel Aviv University.