After several decades as national head nurse of the Health Ministry Ministry of Health (MOH), Dr. Shosh Riba retired on June 30th and will be replaced by Dr. Shoshi Goldberg, currently the head of nursing at Sheba Medical Center, the largest medical center in the Middle East. Sheba nurses under her leadership perform research, improve outcomes, and improve safety in patient care. After years of stagnation at the MOH, Goldberg has a unique opportunity to make changes at the national level.
Some particular opportunities and challenges include increasing nursing recruitment and quality in Israel, developing and expanding the advanced practice nursing professions, such as nurse practitioners (NPs), developing policy to recognize and credential immigrant nurses and advanced practice nurses and improving the image of our profession in Israel.
According to 2014 Ministry data, there are more than 50,000 licensed nurses, yet 26% do not work in the health sector. Much publicity is given to the growing shortage of physicians in Israel, even though current levels are at the Organization for Economic Cooperation and Development (OECD) country average. Yet little to no publicity reflects that Israel has one of the lowest nurses-per-capita ratios in the developed world with 4.9 nurses per 1000 population compared to an OECD average of 9.1 (OECD, 2013). Furthermore, Israel and the Slovak Republic were the only countries to decrease the number of nurses per capita between 2000-2013, during which time the Israeli population increased by nearly 20%. Previous policy increased the number of nursing schools nationally, yet Israel has the second-to-lowest nursing school graduate rate per capita of all OECD countries (after Mexico).
Improving the quality of nurses and nursing in Israel is also essential. The lack of funding for nursing research leaves Israel lagging in nursing science development, which has been shown internationally to improve quality of patient care, efficiency, innovation, and health cost savings. Without funding, academic nursing remains stagnated. There are also shortages of doctoral-prepared nurses, and even fewer tenured professors.
Israeli nurses do not have a Nurse Practice Act to define and protect their profession, leaving nurses as mere para-professionals. In most developed countries, nurses enjoy full professional status. In fact, nursing is only mentioned as a byline of the Physician Practice Act as a physician subordinate along with medics and assistants.
Even the term “nurse” is not protected, and many non-licensed professionals utilize the term with no legal recourse – and the consumer does not know how the “nurse” is qualified. Additionally, oftentimes Israeli nurses do not perform the same range of activities as their counterparts in Western Europe, the US, or Canada – leaving a gap in care that must be filled by overburdened physicians.
The recent introduction of nurse practitioners (NPs) to the Israeli health system was a step in the right direction.
Advancing nursing practice in the form of NPs and other high-level professionals has been shown internationally to increase the attractiveness of the profession, raise the ceiling of professional development and potential, and to improve quality of care, health shortages, and accessibility for the population. The current state of Israeli NP development, however, does not appear to have a national plan, international academic standards, or integration plan.
Israeli NP programs are not objectively equivalent to those of developed countries, and remain similar to programs in developing countries with poor resources. For example, NPs in developed countries study in two- to three-year full-time clinical graduate programs with hundreds of clinical practice hours with specific skill acquisition requirements. There is a requirement for a three- to four-unit course on advanced physical assessment skills with extensive practice hours. The current MOH surgical NP students, who just finished a six-month part-time theory course, had a 1½ hour lecture on advanced physical assessment theory. That’s it.
Many NPs who finished one of the few Ministry courses, struggle to practice in their roles fully and to establish their unique profession in their workplace. Many continue to work only as nurses because of various bureaucratic or workplace barriers that, until now, have no solutions.
NP programs must graduate to open-market, accessible graduate academic programs in academic institutions, with the MOH Division of Nursing as the standard-bearer and regulator of the profession, clinical courses, practice requirements, and credentialing/ licensing processes. As the 55th country to recognize NP as a profession, Israel has many international models in the developed world by which to model the development of this essential profession.
Recent French immigrants have received much publicity regarding complex bureaucratic barriers facing physicians and dentists immigrating to Israel. Little to no publicity has been given regarding the even more complex process facing immigrant nurses from Western countries.
There are hundreds of immigrant nurses in Israel who are not yet credentialed as Israeli nurses, as it is a daunting process. This includes several examinations and courses, a high-level Hebrew language course, and Hebrew language exam that even physicians are not required to take. The process for nurses is even more difficult than the one for physicians and dentists.
In the 14 years between 2002 and today, the credentialing and licensing processes have become harder and more complicated, and consequently there are more immigrant nurses (from the US, Canada, France, etc.) who cannot work in Israel. Considering the aforementioned shortages, these collective nurses represent a wasted resource in a resource-starved professional field.
There are also dozens of experienced advanced practice nurses, such as NPs and nurse anesthetists, who have no process by which to be recognized through the Ministry Division of Nursing. This problem exists despite a 2013 law passed by the Knesset requiring a process to be developed for accrediting foreign-trained NPs. Implementing this policy through recognition of foreign-trained NPs can improve the integration of Israeli NPs into the health system through education and role modeling.
What struck me when I met Dr. Shoshi Goldberg for the first time was that she was a good listener. She was modest, down to earth, and she emanated an intelligence and keen understanding of the issues at hand. She thinks before she acts, she learns before she decides – rare qualities indeed.
Goldberg is entering the Ministry at this critical juncture, when the development of national health policies for nursing, nurses, and NPs can have a tremendous impact on Israel’s collective health system and our population’s access to healthcare. Goldberg is uniquely qualified to elevate the nursing profession, given her vast experience, openness to change, and her leadership qualities.
The stars are aligned in favor of Israeli nurses, and Goldberg will lead the way towards a brighter future for nurses and healthcare in Israel.
The writer has a doctorate in nursing policy, leadership, and management from Yale University. She is an Israeli nurse, (US) nurse practitioner and an expert on nurse practitioner policy in Israel. She is the director of EMA Care LLC, providing case management and medical concierge services in Israel.