The aim of this article is to help nurses around the world understand Israel’s new nursing reality. Nursing in Israel is in the process of making important decisions regarding the role of registered nurses (RNs). In response to the many changes occurring in the Israeli healthcare system, a number of current issues are being debated. These issues include the financing of human and material resources, educational opportunities for nurses, changing healthcare roles, and use of technology to provide optimum healthcare today and for the future. The essence of each of these discussions will be presented below.

Israel's Shifting Reality

Since its inception in 1948 the Israeli government has been perceived being as responsible for shaping the healthcare system and providing healthcare services to the population. Since its inception in 1948 the Israeli government has been perceived being as responsible for shaping the healthcare system and providing healthcare services to the population. Healthcare is considered a basic right of all citizens. Over the years the government has established hospitals and community-based clinics and has been perceived by the public as seeking to advance the greater good. In addition, the government has been almost exclusively responsible for nursing education. However, in the 1980's, a significant healthcare crisis in Israel began to change this state of affairs. Manifestations of this crisis included a large deficit of the major sick fund (Clalit Health Maintenance Organization) and a lengthy strike held by physicians and nurses in protest of their unsatisfactory employment conditions and salaries.

Consequently, the Netanyahu Commission, a governmental inquiry commission headed by a former Supreme Court Justice, was appointed in 1988. The commission proposed a general reform of the healthcare system and submitted three main recommendations:

• The passage of a national health insurance law
• The transformation of government-owned and health-fund-owned hospitals into economic corporations (trusts)
• The changing of the Ministry of Health focus from providing healthcare services and health education to determining and supervising policy and standards (Ministry of Health, 2003)

The passage of the National Health Insurance Law, which was enacted in 1994, was the only significant recommendation implemented as a result of the commission's deliberations. The rest of its recommendations have been rejected by the various Health Ministers over the years (Rosen & Bin-Nun, 2006).

Israel's healthcare system is undergoing constant change in ways similar to healthcare systems in developed Western countries. Current patients are becoming more sophisticated and adopting approaches characterized by 'informed consumerism.' They are influenced by the media, particularly electronic media, including the Internet. In addition, the decision-making processes have become more transparent. Reasons for admission to hospitals are also changing as patient conditions are becoming more complex and treatment protocols are more complicated than ever before. Hospitals are attempting to become more ‘user friendly' and are trying to create a hotel-like atmosphere. Competition between service providers is increasing. Medicine and medical care are undergoing dramatic transformations. The Israeli medical community is restructuring and expanding itself in order to provide services to a growing population that includes a larger proportion of complex and unstable patients (Alexander & Kroposki, 2001).

Responses to Israel's Shifting Times

The Israeli healthcare system desperately needs more nurses. This section will describe responses to these changing conditions. These responses include increasing financial support from the Ministries of Health and Finance, providing more education for more nurses while maintaining a focus on the nurse-patient relationship, expanding nursing roles, and supporting nurses in the use of technologies.

Increasing Financial Support

The Israeli healthcare system desperately needs more nurses. As in most countries nurses constitute a large proportion of all healthcare workers in Israel , and they provide the largest amount of healthcare to the population. Yet according to data published by the Israeli Ministry of Health in 2009, the number of nurses in Israel in proportion to the population has dropped in recent years and is lower than in other western countries. In 2009 there were 5.51 nurses per one thousand people. In 2020 this number is expected to further decline to 4.82 nurses per one thousand people. In addition, a sharp rise in the demand for nurses is anticipated over the next few years (Nirel et al., 2010). A Health Ministry report (Even, 2010) noted that there has been an 8% drop in the number of doctors since 2000. There are 25,542 doctors in Israel today, or 3.36 doctors for every 1,000 people. This ratio is higher than in other industrialized nations, where the average stands at 3.1 doctors for every 1,000 citizens. However, Israel's ratio is expected to drop to 3.09 doctors per 1,000 people by 2015, and to 2.69 per 1,000 people by 2025, unless urgent steps are taken. While the number of medical students in Israel has remained largely unchanged, the number of doctors immigrating to Israel has dropped significantly. Given these forecasts and the fact that doctors need to undergo a seven-year residency in Israel, the ministry fears that Israel will experience an acute shortage of doctors in coming years (Even).

In order to close the gap between what we have and what we need, it will be necessary to expand nurse education programs to prepare an additional 850 nurses each year, complementing the 1,100 nurses currently completing their education each year (Linder-Ganz, 2009). In light of this shortage of nurses the Ministry of Finance is embarking on a program aimed at increasing the number of nurses. One of the major strategies to increase the number of nurses is to encourage professionals who already hold academic degrees in other disciplines to switch to a career in nursing. In an unusual step in an era beset by budget cuts, the Ministry of Health has recently invested a total of $ US 10.5 million: $ US 3.7 million in the form of 200 additional student nurse positions and $ US 6.6 million in the form of scholarships. Both of these avenues are aimed at individuals with academic degrees in other disciplines, with the intention of recruiting them into the discipline of nursing. In addition, the ministry is investing over two hundred and fifty thousand dollars in a public relations campaign to encourage these professionals to change to a career in nursing. The Ministry of Finance is willing to increase the budget allocated for this purpose if there is more demand for this career change than anticipated.

Enhancing Educational Opportunities

Promotions in the workplace are usually predicated on the acquisition of at least one degree in nursing. The dynamic shifts within the Israeli healthcare system have created a new reality whereby nurses require more extensive medical and scientific background. In light of this need the Ministry of Finance is embarking on a program aimed at enhancing the professional status of nurses to enable nurses to utilize the sophisticated equipment and processes for which they are responsible in both supervisory and operational capacities (Alexander & Kroposki, 2001; Zalmanovitch, 2002).

Nurse education programs in Israel are not uniform. Previously educational programs were divided into the following levels: practical nurse, registered nurse, and registered nurse with an academic degree. About six years ago a decision was made to cease providing practical nurse education in Israel. Consequently all nurses who now complete a nursing education graduate with the qualifications of a registered nurse. At the end of their educational program all nursing students must pass a standard government licensing exam that authorizes them to work as nurses. After passing the exam, and in the course of their work, nurses may choose from a large array of advanced courses which provide additional knowledge and authority in different fields, including obstetrics, emergency care, dialysis, and intensive care to name a few. Today, an increasing number of nurses acquire advanced degrees in nursing and related professions, thus enhancing the scholarly base of professional nursing. Promotions in the workplace are usually predicated on the acquisition of at least one degree in nursing. Currently in Israel nurses may hold various academic degrees, ranging from a baccalaureate degree, through a master's degree, and concluding with a PhD degree in nursing (DeKeyser & Kahana, 2006; Ehrenfeld et al., 2007). ...the nursing profession is undergoing significant transformation without losing sight of the main focus of nursing, namely promoting nurses' personal relationships with their patients.

To keep up with the changing environment in Israel the nursing profession is undergoing significant transformation without losing sight of the main focus of nursing, namely promoting nurses' personal relationships with their patients. The nursing profession is working to clarify its essence, as well as to enhance the educational preparation and the authority of registered nurses. Because the definition of professional nursing in Israel is based on the Public Health Regulations of 1988, it fails to reflect the progress that has occurred in the profession, and the increased expertise gradually acquired over the years by its practitioners. At present, it is difficult to define the legal authority of RNs, as well as the range of nursing/medical actions that they are legally permitted to perform, based on the current regulations (Levy, 2008; Yakov, Shilo, & Shor, 2010).

Expanding Nursing Roles

This section will discuss the expansion of nursing roles in other nations and the expansion of nursing roles in Israel. It will also describe the reactions of various professional groups to these expanded roles.

Expansion of nursing roles in other nations. Recently in other countries, due to the dearth of ‘human resources' in the medical profession, nurses' responsibilities and authority have been undergoing expansion. This has led to development of the ‘nurse specialist.' In the United States (US) these specialists are called Advanced Practice Nurses (APNs). Advanced Practice Nurses include nurse practitioners, clinical nurse specialists, nurse midwives, and nurse anesthetists. The process of granting additional authority to APNs was initiated in the US as early as the 1960s. In 1991 the U.S. Pew Health Professions Commission declared that the goal of improving healthcare, particularly in the community, can be achieved by expanding the authority of nurse practitioners (Pew Health Professions Commission, 1998). The global definition of a nurse practitioner is that of a registered nurse who works in a team consisting of different professionals and who has broad authority in the assessment and management of care, including prescribing of medication; referral for various tests, such as computed tomography (CT) scans; and referral to other therapists as necessary (Brodsky & Van Dijk, 2008). A study in Australia found that 95% of consumers of eligible nurse practitioner services evaluated the quality of care provided by nurse practitioners as very good or excellent (Allnutt et al., 2010).

Expansion of nursing roles in Israel. The severe shortage of doctors in Israel has led to the delegation of authority to registered nurses, creating a shift in the authority and responsibility of all RNs (Atias, 2010). Responsibilities previously belonging to doctors have been transferred to RNs by authority of the Director General of the Ministry of Health. On May 15, 2001, the Director General determined, by virtue of his authority, that sixty-one operations previously defined as ‘medical practice' would hence be defined to also be ‘nursing practice' in that they could be performed by registered nurses through a well-defined process of authorization. The activities transferred from doctors to nurses included lifesaving activities and the administration of medication, among others. Yet most of these were activities that nurses had already been performing in practice (Riba, 2001). In 2007 the Director General published a circular (the official vehicle for publicizing formal instructions) expanding the authority of nurses in fields such as psychiatry, geriatrics, primary care, rehabilitation, diabetes, and obstetrics. This circular stipulated that registered nurses from these groups could perform the expanded responsibilities only after they had passed a knowledge test. These responsibilities had not been previously included in nurses' education at any educational level. Now advanced studies are being made available for nurses interested in expanding their expertise and accepting further responsibilities (Director General Circular, 2007).

On July 23, 2009, an amendment regarding the authority to prescribe medications was added to the Pharmacists' Ordinance. This amended ordinance gave authorized registered nurses the authority to renew a prescription for a patient receiving chronic care if the medication had been previously prescribed by a doctor and if the medication was included on a given list of groups of preparations. Authorization to prescribe these medications is given on a personal basis to nurses who have a minimum of 5 years seniority and who have received the required education (Circular of the Director General, 2010). RNs who hold an academic degree and who have received an appropriate one-year educational program, will be able to renew prescriptions for a wide range of medications, including those for the treatment of cholesterol, hypertension, diabetes, psychiatric disorders, and also eye disorders if they are in the form of eye drops.

In 2009, in response to the dearth of human resources and the overburdening of the medical profession in Israel, the Director General of the Ministry of Health decided, by virtue of his authority, to recognize clinical nursing expertise in palliative care. The title of Clinical Nurse Specialist (CNS) can now be awarded to RNs who complete a structured, educational program in this field. To be titled a CNS nurses need to hold an academic degree and to have: taken a recognized, advanced course in oncology; taken a recognized, advanced course in the care of geriatric patients with specific attention to palliative care; and demonstrated eight years of experience in palliative care. Nurses with such qualifications can stabilize and change existing palliative care orders, including those involving dosages and methods of care provision, for palliative care patients in their homes or at palliative care clinics, and also for oncology patients receiving care in the community (Nursing Administration Circular, 2011).

Reactions to expanded roles of nurses. The institution of the new roles largely depends on their acceptance by healthcare workers. In various western countries in which nursing authority has been expanded, physicians' views of this expansion and their recognition of nurse expertise in different spheres has been investigated. These studies have identified that, in general there have been no physician objections to expanding nurses' roles. However, a certain level of skepticism was discerned regarding the expansion of nurses' roles to perform specific medical activities, for example making patient diagnoses and prescribing patient medications, and regarding nurses' professional capabilities (Brodsky & Van Dijk, 2008). Rashid (2010) has divided these skeptical views into three categories: some physicians feel threatened both professionally and financially; some are concerned that nurses are incapable of completing the necessary education and bearing the responsibilities involved; and some are troubled by structural and organizational problems inherent in changing the physician/nurse balance of authority.

In a debate at the Ben Meir Annual Scientific Conference of General Practitioners in Israel in April 2008, most attendees did agree it was necessary to expand nurses' therapeutic authority in defined circumstances and situations. The field of preventive medicine, in which nurses currently function independently, was cited as one of these situations (Lahad et al., 2008).

Nurses themselves have greeted this transfer of medical responsibilities to nurses in an inconsistent manner. In contrast to the more positive reactions to increase nurse authority in the United Kingdom and the US, the Israeli Medical Association has objected to any expansion of nurse authority. It has even petitioned the Supreme Court against the 2007 decision of the Director General of the Ministry of Health to expand nurses' authority to perform an array of procedures. These petitions pertained mainly to the initiation or cessation of medication and the adjustment of medication dosages. The Association claimed that the Director General does not have the authority to make such a decision (Israeli Medical Association, 2008). The decision of the Supreme Court stressed the importance of negotiations between the Nurses' Association, the Ministry of Health, and the Medical Association. The Supreme Court has approved most circumstances of expansion of authority authorized by the Director General, with the exception of the introduction of nasogastric tubes by swallowing and the administration of Pethidine to laboring women, which the Court believed warranted further consideration (Supreme Court Verdict, 2008).

Nurses themselves have greeted this transfer of medical responsibilities to nurses in an inconsistent manner. Some nurses were insulted, believing they were being assigned “what they don't want to do" and fearing the introduction of legal suits due to negligence (Brodsky & Van Dijk, 2008). Other nurses perceived the expansion of their authority as a step forward for the nursing profession. The Israeli Nursing Committee, too, remains ambivalent. On the one hand, it supports the awarding of further authority to nurses; yet on the other hand it is worried about the growing burden on nurses and the continuing shortage of nurses (Balik, 2009).

Using Technology to Meet Changing Demands

Side by side with this expansion of authority, Israel is experiencing extensive technological growth. This rapid growth has had a dramatic effect both on the provision of healthcare services and on nursing education. The prevalence of affordable personal computers and the continuing development of computer programs have contributed to an explosion of information technologies in healthcare. Electronic medical records, which have replaced traditional paper documents, facilitate faster and more accurate practice by RNs. Developments in digital technology have enhanced the option of providing nursing and medical services via the telephone, leading to a closer relationship between medical/nursing service providers and recipients in the absence of physical proximity. Dramatic improvements in accessibility of clinical information from various locations and time zones have also led to improved outcomes and management of care, as well as helping healthcare consumers access online information previously available only to doctors and nurses (Alexander & Kroposki, 2001; Heller, Oros, & Durney-Crowley, 2005).

Although this advanced technology, now encountered on a daily basis, may lead to a more complicated nursing work routine due to insufficient knowledge regarding computerized systems, it has the potential to reduce workloads, improve quality of care, and prevent mistakes due to the enhanced quality assurance processes offered by this technology. Zuzelo et al. (2008) examined the barriers to introducing computerized systems in nursing. They identified the essential role of nurse managers in developing computerized technologies and determining how these technologies can best be used. They emphasized that nurse managers need to assume responsibility for changing work procedures. It is also important that nurse managers adapt these processes to new circumstances so as to prevent incidents and errors in patient care which have resulted from the use of these advanced technologies. These authors also recommended both the development of programs to teach nurses how to work with these new technologies and the development of flowcharts to help nurses cope if these technological systems happen to break down.

Nurses today are required to function effectively within environments rich in innovative technologies, while continuing to provide empathic care to patients and families. Alexander and Kroposki (2001) have recommended the establishment of multidisciplinary teams to evaluate the processes of working with innovative technologies for the purposes of quality assurance. They have also emphasized the importance of involving nurses in developing and utilizing new technologies. This is particularly important in light of the significant roles of nurses in healthcare systems and in the health conditions of specific patients. Nurses today are required to function effectively within environments rich in innovative technologies, while continuing to provide empathic care to patients and families.

Nursing education programs in Israel are responsible for integrating new technologies into basic nursing courses. Nursing students must know, before they begin their practical (clinical) work, how to use these tools; they must also have the critical thinking skills necessary to ask what else can be done to improve these advanced technologies.

Conclusion

In the state of affairs described above nurses need to strengthen professional values and skills that are, and will continue to be needed to promote wellness and prevent illness using evidence-based care (Heller et al., 2005; Savrin, 2009). The advanced level of care expected from contemporary healthcare organizations demands that nurses ensure continuity of care and provide holistic care, focusing not only on the physical aspects of patient care, but also on the social, political, and economic factors (International Council of Nurses, 2008).

Nursing leaders and policy designers need to clarify the nature of these changes for nursing managers, who in turn can convey the message to nurses in the field. In response to the many changes occurring within the Israeli healthcare system, current issues being debated include financing of human and material resources, educational opportunities for nurses, changing healthcare roles, and using technology to provide optimum healthcare today and for the future. Nursing leaders and managers must play a major part in addressing these issues and determining national policy concerning programs that will address the most appropriate utilization of new skills and technologies throughout the nation. Nursing leaders and policy designers need to clarify the nature of these changes for nursing managers, who in turn can convey the message to nurses in the field. In the existing legal state of affairs in Israel this is especially important, given both the absence of nursing law and the fact that regulations do not provide an unequivocal clarification of nurse authority. Nursing leaders need to promote strict descriptions of the responsibilities given to nurses while continuing to fight for more nursing positions.

At the same time, nursing leaders must formulate plans to enhance cooperation with physicians through the creation of interdisciplinary committees whose deliberations will help to reach compromises with regard to the interests of the different healthcare sectors. They must also prepare additional nurses, expand nurses' roles, develop advanced courses of study, and enhance the use of new technologies among nurses to provide a healthy work environment, quality nursing care, and desired patient outcomes.

Authors

Merav Ben Natan, RN, PhD
E-mail: meraav@hy.health.gov.il

Dr. Ben Natan is the Director of the Pat Matthews Academic School of Nursing, at the Hillel Yaffe Medical Center, in Hadera, Israel. She is also an instructor in the Department of Nursing at Tel Aviv University. Dr. Ben Natan's primary research interest focuses on the image of nursing as a profession. She received her BA and MA from the Tel Aviv University, School of Nursing, and her PhD at the Haifa University, Faculty of Health Professions, both in Israel.

Meir Oren, MD, MSc, MPH
E-mail: oren@hy.health.gov.il

Dr. Oren is the Chief Executive Officer and Medical Director of the Hillel Yaffe Medical Center in Hadera, Israel, and Professor at the Faculty of Medicine, the Technion, in Haifa, Israel. He is chairman and member of many joint committees dealing with emergency preparedness and actively engaged in a wide range of national-level activities concerning policy and healthcare services in Israel. Professor Oren's primary interests are in the broad aspects of preparedness for non-conventional terrorism. His particular interests include chemical, biological, radiological, and nuclear assessments as well as warfare scenarios at the national level and in particular at the healthcare system level. Professor Oren earned all of his degrees at the Tel Aviv University, Sackler School of Medicine in Israel.

Nursing Administration Circular. (2007). Instruction for implementing nursing operations defined in Director General circular number 9/07 from May 17, 2007. Retrieved November 22, 2010 from
www.health.gov.il/download/forms/ND-70int.pdf.  [Hebrew]

Nursing Administration Circular. (2009). Expert nurse in palliative care . Jerusalem : Ministry of Health . Retrieved November 5, 2010 from
www.health.gov.il/download/forms/ND-79int.pdf. [Hebrew]