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A Comparison of Advanced Nurses in the Israeli and Canadian Health Systems Aaron Ludman ID: XXXXXXXXX Hebrew University in Jerusalem School of Nursing Asaf Harofeh Hospital

Final Project Scientific Writing (91679) Dr. Nomi Warbeloff January 31, 2012

A Comparison of Advanced Nurses in the Israeli and Canadian Health Systems

Table of Contents Introduction....3 What is an advanced nurse?....3-4 The Israeli and Canadian Health Care Systems.4 The advanced nurse model in Canada ...5-6 Advanced Nurses in Israel..........6-7 Objections to the Israel Advanced Nurse...7 Adopting the Canadian Model in Israel......7-8 Conclusion..8 Bibliography.9-11

A Comparison of Advanced Nurses in the Israeli and Canadian Health Systems

Introduction: Although not a new concept, in recent years we are witnessing the globalization, expansion and redefinition of the advanced nurse. These nurses, upon completion of their training, are being given greater responsibilities of patient management and care (Buchman & Calman, 2004, Hooker, 2006). The Israeli socialized medicine health care system is stressed and overworked. A report by the Ministry of Health has found a steady decrease in the number of physicians in Israel (2007 ,' .) The doctor shortage, which in part can be pinpointed to physician burnout, inadequate financial compensation, and emigration to other countries, has had a negative impact on many aspects of the Israeli health system. It has led to a critical shortage of hospital beds, at times a decline in the quality of medical care, and has been seen as the cause of violence of patients and their families towards medical staff (2011 , ;, , , Israeli Medical Association, 2011). In spite of this, Israel has done little to employ, train or even recognize advanced nurses. This article explores the definition of the advanced nurse, their roles and their integration within the Israeli health system. It compares it to the integration of the Canadian advanced nurse.

What is an advanced nurse? In 1965, Medicare and Medicaid insurance programs in the United States expanded their scope of coverage, and began covering children, the elderly, people with disabilities and low-income women. As a result of this new expansion of coverage, together with the increasing number of physicians leaving primary care medicine and moving to specializations, the doctor-patient ratio decreased, and many areas had no physician coverage at all. Due to this new demand and lack of availability of physicians, nurses who were already collaborating with doctors stepped in to fill the gap (OBrien, 2003). Later that year the first advanced nurse program was created by Loretta Ford, focusing on health promotion, disease prevention and the health of children and families (OBrien, 2003).

A Comparison of Advanced Nurses in the Israeli and Canadian Health Systems

Today, nurses who have undergone specialized training and advanced higher education (a masters or doctorate degree), and who have acquired the expert knowledge base and decision-making skills are being classified and certified as advanced or specialist nursing practitioners (Buchman & Calman, 2004; Hooker, 2006; International Council of Nurses, n.d.). Although the roles and responsibilities of the advanced nurse differ in each country and region, these advanced nurses are often given responsibilities as clinical consultants, advanced patient educators, and deal with coordination of patient care, often initiating diagnostic tests, prescribing treatments and performing therapeutic procedures (Pearson, Nay, Ward, Lenten, & Lewis, 2004; Shah, Bruttomesso, Sullivan, & Lattanzio, 1997; Williamson & Harris, 2000). Throughout the world there exist many different labels for the advanced nurse, with the most common being: Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Nurse Consultant (NC), Clinical Registered Nurse Anesthetist (CRNA) and Certified Nurse Midwife (CNM) (Ball, 2005; Lloyd Jones, 2005). Although each have their own unique areas of expertise, advanced nurses all share in common advanced clinical training and secondary degrees, as well as in-depth nursing knowledge and expertise (Ball, 2005, Canadian Nurses Association, 2008).

The Israeli and Canadian Health Care Systems Health care in Israel and Canada have many similarities. Both countries work on universal health care models, or organized health systems that provide coverage for all members of society (Damelin, n.d.; Health Canada, 2010; World Health Organization, 2008). Both in Israel and in Canada, all citizens are entitled to basic health care as part of their standard benefits package, regardless of financial status. While in Canada health care is administered by each of the provinces and territories, in Israel medical services are provided by four national health insurance companies known as Kupot Cholim. Both Israel and Canada are dealing with societies whose health care needs are evolving. Both systems suffer from a shortage of professionals,

A Comparison of Advanced Nurses in the Israeli and Canadian Health Systems

and are dealing with rising costs and an aging population (2007 , ; , Canadian Nurses Association, 2008; Worster, Sarco, Thrasher, Fernandes, & Chemeris, 2005).

The advanced nurse model in Canada In the early 1970s, the Canadian health system was experiencing a shortage of family physicians and first introduced the primary health care advanced nurse. Despite the positive feedback, the Canadian advanced nursing program came to a halt, and it wasnt until the end of 1999 to the beginning of 2000, when health care reform saw the re-introduction of the advanced nurse in an attempt to improve access to health services in Canada (Canadian Nurses Association, 2008; Faith et al., 2010). The advanced nurse in Canada focuses on clinical management with direct patient care, but also involves a supportive and consultative role in patient treatment. Advanced nurses combine education, clinical expertise, leadership skills and an understanding of the health system to make them key players in the Canadian health system (Canadian Nurses Association, 2008). In Canada, the minimal education requirement for the advanced nurse (both the CNS and NP advanced nurse models) is a masters degree in nursing. In addition, the advanced nurse must achieve clinical knowledge and expertise, and be committed to lifelong learning. This combination of these attributes gives the advanced nurse the competency required to carry out his or her tasks in the Canadian health system. In addition, the advanced nurse should be committed to a leadership role within continuing education (Canadian Nurses Association, 2008; Thrasher, & PurcStephenson, 2008; Worster et al., 2005). The Canadian advanced nurses competence can be split into four categories: clinical, research, leadership and consultation. Although separate, these overlap to create a superior practitioner. The advanced nurse provides expertise in a specialized area, while implementing a holistic approach. He or she develops assessment tools, interprets data from multiple sources, and coordinates and manages a wide range of patient responses to potential health problems. Advanced nurses are leaders in the community and in the workplace and identify and implement research-based

A Comparison of Advanced Nurses in the Israeli and Canadian Health Systems

innovations. They serve as mentors and coaches for other members of the health team, and work in partnership with the patient, and consult, refer, and collaborate with other health-care providers (Canadian Nurses Association, 2008; Worster et al., 2005). The impact of advanced nurses on the Canadian health system can be seen at many different levels. Cunningham (2004, p. 219) found that advanced nurses enrich health care by adding value to the delivery of health-care services. Advanced nurses help promote evidence based care, improve quality of health care, decrease the number of hospital admissions and emergency department visits, decrease the number of re-admissions and shorten the length of hospitalizations, saving money for the institutions and the provincial health care systems. In addition, patients hospitalized are less likely to develop complications such as urinary tract infections, skin ulcers and pneumonia (DeGrasse & Nicklin, 2001; Kleinpell, 2007; Sangster-Gormley, 2007).

Advanced Nurses in Israel In the year 2000, during a lecture and discussion group for senior Israeli nursing staff, the idea of the advanced nurse was first raised in Israel. The consensus at the conference was that there was a need for the advanced nurse in Israel, resulting in an outline of how the advanced nurse model in Israel should look (Brodsky & Van Dijk, 2008; Riba, 2004). On May 14, 2009, Professor Avi Israeli, the Director-General of the Ministry of Health, signed an injunction recognizing the grandfathering in of palliative care nurses as advanced care nurses, and effectively creating the first advanced nurse in Israel (Livneh, 2011). While this was a major accomplishment, and took many years to achieve, it changed very little in practice. For over two decades Israeli palliative care nurses had already been working in an advanced nurse capacity, changing palliative care orders, including dosage and method of administration of medications. Additionally, although the first advanced nurses have been recognized, they were grandfathered in (their professional work in palliative care was acknowledged before the injunction). There currently exists no training program for the palliative care

A Comparison of Advanced Nurses in the Israeli and Canadian Health Systems

advanced nurse and all palliative care advanced nurses received their training abroad (Livneh, 2011; ;9002 ,, Ben Natan, & Oren, 2011). Additionally, the advanced nurse model has only been approved for palliative care, which although important, is only a small fraction of the potential capabilities of the advanced nurse. Objections to the Israel Advanced Nurse A study done by Brodsky and Van Dijk (2008) found that a relatively high number of both physicians and nurses agreed on the importance of initiating an advanced nurse program in Israel. Although nurses viewed the importance and need of these changes more favorably then physicians, 72% of physicians saw the introduction of the advanced nurse as important to the Israeli health system. In contrast to the more positive reactions from Israeli nurses and physicians, and positive international reactions to the increase of nurses authority, the Israel Medical Association has objected to any expansion of nursess authority. The Israel Medical Association has objected so much so that they petitioned to the Supreme Court against any expansion of these authorities. The Israel Medical Association (IMA) claims that the Director General of the Ministry of Health does not have the authority to make such changes. In addition the IMA claims that nurses are more likely than physicians to make mistakes when choosing the correct drug and dosage, that expanding the authority of nurses will hurt the physicians ability to be the patients case manager, that Israeli doctors, unlike in other health systems, are readily available, and that advanced nurses in the long run will not save the Ministry of Health money (Israel Medical Association, 2008; Livneh, 2011). Adopting the Canadian Model in Israel The Supreme Court ruled that the expansion of nursess authority by the Ministry of Health was permissible (except for two protocols that the court ruled should be further considered before allowed), but stressed the importance of negotiations between the Israel Medical Association, the Nurses Authority and the Ministry of Health (Supreme Court verdict, 2008, as cited in Livneh, 2011).

A Comparison of Advanced Nurses in the Israeli and Canadian Health Systems

Reaching an understanding and agreement on the boundaries, scope of practice and the role of the advanced nurse will help promote the successful integration of the advanced nurse into the Israeli health system. Advanced nurses must be supported at all levels of the health system if they are to operate effectively and benefit both patients and other members of the health team (Brodsky, and Van Dijk, 2008; Canadian Nurses Association, 2008). Furthermore, education will be the key to the proper development of the advanced nurse in Israel. Well-defined university tracks in Israeli universities must be established, and the curriculum must be based on the agreed upon scope of practice, while emphasizing the unique aspects of the Israeli health system , and providing communication tools to educate the public about the importance of the advanced nurse, and their role in the Israeli health system. In addition there must be support for professional development and lifelong learning, allowing national funding for research by Israeli advanced nurses. Last but not least, there must be interprofessional education and organizations that foster teamwork. Nurses, advanced nurses and physicians must realize that all three professions play a unique and important part, and that each profession brings something to compliment the other (Canadian Nurses Association, 2008; .)9002 ,,

Conclusion Although disputed, it is time to fully integrate the advanced nurse into the Israeli health care system. This can be done by partially adopting the Canadian model, whose health care system is very similar to Israels. What will help to make or break the integration of the advanced nurse will be the cooperation between the Israeli Ministry of Health, the Israel Medical Association and the Nurses Authority. As the national Chief Nursing Officer and Director of the Nursing Division has remarked: the questions here are so vast and important that they could easily fill a dissertation (Dr. S. Riba, personal communication, January 26, 2012). The Israeli Medical Association must realize that with a continually developing health care system it is time to leave old prejudices and perceptions behind, and move on in developing a stronger, better health care system.

A Comparison of Advanced Nurses in the Israeli and Canadian Health Systems

Ball, J. (2005). Maxi nurses. Advanced and specialist nursing roles. Results from a survey of RCN members in advanced and specialist nursing roles. Cavendish, London: Royal College of Nursing. Retrieved: January 27, 2012. Retrieved from: http://www.rcn.org.uk/__data/assets/pdf_file/0006/78657/002756.pdf Ben Natan, M., Oren, M. (2011). The essence of nursing in the shifting reality of Israel today. The Online Journal of Issues in Nursing. 16(2). doi: 10.3912/OJIN.Vol16No02PPT04 Brodsky, E., Van Dijk, D. (2008). Advanced and Specialist Nursing Practice: Attitudes of Nurses and Physicians in Israel. Journal of Nursing Scholarship, 40 (2), 187-194. Buchan, J., & Calman, L. (2004). Skill-mix and policy change in the health workforce: Nurses in advanced roles. OECD Health Working Papers, 17. doi: JT00172012. Cunningham, R. (2004). Advanced practice nursing outcomes: A review of selected empirical literature. Oncology Nursing Forum, 31(2), 219-230. doi: 10.1188 /04.ONF.219-231 Damelin, B., (n.d.). Israels health care system- an overview. La-Briut. Retrieved: January 27, 2012. Retrieved from: http://www.la-briut.org.il/english/article/?id=5d4818ba4f9348515449e5720b25ea78 DeGrasse, C., & Nicklin, W. (2001). Advanced nursing practice: Old hat, new design. Canadian Journal of Nursing Leadership. 14(4), 7-12. Faith, D., Martin-Misener, R., Bryant-Lukosius, D., Kilpatrick, K., Kaasalainen, S., Carter, N., DiCenso, A. (2010). The primary healthcare nurse practitioner role in Canada. Nursing Leadership, 23, 88-113. Health Canada. (2010). Health care system (Medicare). Retrived: January 29, 2012 Retrieved from: http://www.hc-sc.gc.ca/ Hooker, R.S. (2006). Physician assistants and nurse practitioners: the United States experience. The Medical Journal of Australia, 185 (1), 4-7. Internatonal Council of Nurses. Nurse Practitioner/ Advanced Practice Nurse: Definition and Characteristics of the Role. n.d. Retrieved January 25, 2012, Retrieved from: http://icn-apnetwork.org/ Israel Medical Association. (2008). Expanding the authority of nurses, pharmacists, and para-medical prodessionals. Retrieved: January 29, 2012. Retrieved from: http://www.ima.org.il/mainsite/ViewCategory.aspx?CategoryId=844 Israeli Medical Association. (2011). The physician shortage in Israel. Retrieved

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January 26, 2012. Retrieved from: http://www.ima.org.il/eng/ViewCategory.aspx?CategoryId=6152 Kleinpell, R. M. (2007). APNs: Invisible champions? Nursing Management, 38(5), 18-22. Livneh, J. (2011). Development of Palliative Care in Israel and the Rising Status of the Clinical Nurse Specialist. Journal of Pediatric Hematology/Oncology, 33(2), S157-S158. doi: 10.1097/MPH.0b013e318230e22f Lloyd Jones, M. (2005). Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and metasynthesis. Journal of Advanced Nursing, 49, 191209. OBrien, J. (2003). How nurse practitioners obtained provider status: Lessons for Pharmacists. American Journal of Health-System Pharmacy. 60(22), 2301-2307. Pearson, A., Nay, R., Ward, C., Lenten, L. and Lewis, M. (2004). Nurse practitioner project: Phase 2 External evaluation. Bundoora Victoria, Australia: La Trobe University. Retrieved January 25, 2012. Retrieved from: http://www.health.vic.gov.au/__data/assets/pdf_file/0004/17608/finalreport13august.p df Riba, S. (2004). Developing the role of the clinical nurse specialist: Policy statement. Retrieved: January 29, 2012. Retrieved from: http://www.old.health.gov.il/pages/printer.asp?maincat=12&catId=175&PageId=2185 Sangster-Gormley, E. (2007). Nurse practitioner-sensitive outcomes. Halifax, Canada: College of Registered Nurses of Nova Scotia. Shah, H. S., Bruttomesso, K. A., Sullivan, D. T., and Lattanzio, J. (1997). An evaluation of the role and practices of the acute-care nurse practitioner. AACN Clinical Issues, 8 (1), 147-155. Thrasher, C., and Purc-Stephenson, R. (2008). Patient satisfaction with nurse practitioner care in emergency departments in Canada. Journal of the American Academy of Nurse Practitioners, 20 (5), 231-237. Williamson, T., and Harris, K. (2000). A new role in practice development. Nursing Standard, 14(35), 54-56. World Health Organiaztion. (2008). Universal health care (chapter 9). In Daily living conditions part 3, 94-106. Worster, A., Sarco, A., Thrasher, C., Fernandes, C., Chemeris, E. (2005). Understanding the role of nurse practitioners in Canada. Canadian Journal of Rural Medicine, 10 (2), 89-94.

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