Health policy and Management, Yezreel Valley College, Israel
Received date: June 15, 2018; Accepted date: July 9, 2018; Published date: July 16, 2018
Citation: Haron Y (2018) Policy and Research in the Israel Ministry of Health's Nursing Division. Health Syst Policy Res Vol. 5 No.2:71
Copyright: © 2018 Haron Y. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
The Israel Ministry of Health Nursing Division, headed by the Government Nursing Officer, plays a pivotal role in promoting the nursing profession and influencing national health policy. In terms of nursing, the Division is authorized to set, upgrade, and audit professional standards; create new specialties; formulate, oversee and accredit educational programs, and register nurses. In terms of broad policy, it has a voice in shaping general health priorities and resource allocation. To expand evidencebased policy, it has established a Research Department, which will examine health policy decisions in light of scientific evidence. This article describes and analyzes the research department's contribution to the promotion of nursing policy in the Israel healthcare governance.
The Israel Ministry of Health (MoH) Nursing Division (ND), headed by the Government Nursing Officer (GNO), plays a pivotal role in promoting the nursing profession and influencing national health policy. In terms of nursing, the Division is authorized to set, upgrade, and audit professional standards; establish new nursing specialties; structure, oversee and accredit educational programs, and award licenses for practice. In terms of broad policy, it has a voice in shaping general health priorities and allocating resources. The Government’s Nursing Officer (GNO)'s responsibility is to assist the government in achieving the country’s health goals through expert advice, professional networks of influence, and in-depth professional understanding.
According to the WHO Report , an important role of the GNO is to advise the government on policy and participate in setting the health agenda. This includes providing advice on the capacity, capability, and skill mix of the nursing and midwifery workforce, recommending professional regulation and policy for their professional practice, and advising on educational program standards, accreditation, and funding. Additionally, the GNO plays an operational role in planning and delivery of health systems and services. Based on the literature review, the GCNO's roles may be categorized under leadership and influence, advising on policy, planning and delivery of health systems and services, and health-status improvement programs.
The Structure and Function of the Nursing Division
Israeli Public Health Regulations (1979, 1983)  designate the GCNO as an appointee of the MoH Director-General, responsible for health policy, with regard to the nursing profession. Since 1994, the ND, with the GNO at its helm, has been an integral part of the MoH, directly answerable to the Director General and is included in the Ministry's central policymaking body, reflecting national recognition of nursing as the largest, most vital health profession. The GNO’s role in Israel is comprehensive, encompassing functions related to both nursing and general health policy. Specifically, these include participating with other senior Ministry members in shaping general health policy, providing expert advice on nursing-related issues, developing the profession, setting educational and practical standards, managing budgets, assuring nursing staff quality, and officially representing the nursing profession nationally and internationally.
To meet these goals, the ND set up five executive units of collaborative work: Evidence-based policy research; Professional Development; Testing; Credentialing and Licensure; Professional Guidelines and Quality Assurance. Of the three models suggested by Splane and Splane on the GNO's role (in this case, together with the ND), the “executive model” most closely reflects the Israeli case . The research department identifies new healthcare needs to be met by nursing and the specific related professions. The evidence gathered is used to inform the powers-that-be of these needs, and to translate them into actual policy (examples follow below). Analysis use of data and information to identify trends and support decision-making, and the ability to recognize the necessity for new research evidence, in order to support informed decision-making, are essential to evidence-based policy.
Healthcare in Israel
Israel, a Middle-Eastern country with a population of 8 million, 80% Jews and the remainder mostly Arabs, has been a member of the Organization for Economic Cooperation and Development (OECD) since 2010. Many of the Jews are first- or second-generation immigrants from different countries, each with a distinct culture and tradition. The population is aging-the elderly now comprising 13%-putting increasing pressure on healthcare . Although geographically small, Israel has the highest standard of living in the region and one of the longest life expectancies in the world. Education is free from ages 3-18 and literacy rate is 97% . At the same time, there are large gaps between rich and poor in terms of income, education, housing, and access to services such as healthcare. In 1994, universal health insurance became available through the National Health Insurance Law . Citizens choose from four competing National Health Maintenance Organizations (HMOs) providing ambulatory and in patient care. The law authorizes the MoH to supervise and audit the HMOs, and provide supplemental care for the needy, disabled, traumatized, elderly, and peripheral citizens, geographically or culturally. The MoH owns and operates a national network of geriatric, psychiatric, rehabilitative, and public-health facilities providing consumers with basic services at little or no expense [7,8]. The ND is responsible for maintaining high professional standards and culturally-sensitive competency for nursing care administered within the framework of these special public services, as well as all services offered by the four national HMOs.
Evidence-based Policy in Post-Generic Program Development
Israeli nursing practice is multi-leveled. Registered nurses (RNs) hold a diploma, post-basic certification or degree. Each level's scope of practice is different (BA, MA or PhD). To broaden the scope of practice, the Professional development department designs and oversees educational programs, focusing on a set of expanded competencies for safe, quality practice throughout. Although not yet formally approved academically (by the Israel Council of Higher Education), these are advanced, highlyregarded certificate programs available only to nurses with a BA. Each function stipulates the relevant patient population and designates the time frame for execution. These courses are open to a pre-determined number (consistent with the workforce needs of national healthcare) of academically-educated RNs wishing to specialize and recommended by their employers . Examples of post-generic programs are: community health, mental health, intensive care, oncology, midwifery, and emergency care.
If nurses do not perform nursing functions, other professional stakeholders often move in to fill the vacuum [10,11]. For example: although RNs in Israel are fully qualified to serve as breastfeeding counselors, over time and due to lack of motivation and inadequate encouragement from management, they were unsuccessful in claiming this arena in the country's maternity units. It is remarkable that whereas in community mother-and-child clinics, nurses have maintained this role and take great pride in it-in the hospital setting, non-nurse providers have taken over. Nursing thus lost an important part of the maternal-child domain and care became more fragmented.
After the needs were identified by the ND Research Unit, the Professional Development Unit designed a unique post-basic certification breast feeding counseling program, operational since 2010, within the scope generic nursing preparation. Postbasic training is not compulsory for qualifying as a breastfeeding counselor. Nevertheless, the ND designated it a post-basic specialty and course graduates are required to pass a national certification examination. This step lent the role greater stature, enhanced knowledge and competency. Additionally, the Professional Guidelines Unit stipulated that every woman after childbirth is entitled to breastfeeding counseling by an appropriately knowledgeable and experienced RN.
The association between research and policy is found at multiple levels. In Israel, Public Health Nurses (PHNs) currently face many professional challenges due to new health issues, greater public awareness of health rights, including participation in policymaking, and the impetus for equality on the health indicators of various populations. The extent and variety of practice areas currently included in the PHN role require skilled, professional staff. Thus, in 2015, the Research Unit conducted a national study to gain a detailed, up-to-date account of the current PHN job description and practice areas, and to map community needs and the required services that can be provided by nurses with public health clinical training. Data were collected in interviews with stakeholders, on the required community services that PHNs provided. Additionally, PHN focus groups discussed role development, requisite training and scope expansion. A PHN structured national survey (n=824), the first to focus on Israeli PHN practice areas and activities. Represented the quantitative part. It identified areas of practice where further training might be required. It informed policymakers of the professional activities to which patients are entitled and which PHNs are able to perform; of the current scope of PHN work; and of future service requirements. By analyzing the current versus the desirable situation, policymakers and other stakeholders gain comprehensive, up-to-date information for developing clinical expertise in public-health nursing and the scope of services expected of PHNs in an era of health-system challenges.
Evidence-based Policy in Advanced Practice Nurses Development
Increased demand for broader, more sophisticated nursing care in certain areas, and the shortage of physicians in these fields, created an opportunity for the establishment of the nurse practitioner role (APN), a major ND milestone in the past decade. This development posed a legal complexity as it required that the MoH Director General add a new directive to the Physician Regulations . Palliative care was the first specialty to receive approval, in 2009 . Two years later, the directive was expanded to include the geriatric nurse practitioner (GNP). The prioritization of this specialty resulted partially from a survey conducted by the Research Unit among senior nursing students. One significant finding was the assertion by 60% of the students that they would seriously consider geriatrics as a clinical field of choice if an advanced practice option were available . A critical piece of data since Israel, like other countries, suffers from an acute shortage of nurses in geriatrics.
In developing the new GNP role, it was obvious to the MoH ND that its success depended on the attitudes of gerontological physicians and nurses. Moreover, future NP development in other clinical areas would be affected by the impact of the implementation of the GNP role, which was relatively new in Israel. Based on previous research [15-18], there was clearly a need for a better understanding of the obstacles to, and facilitators of, implementing the NP role with long-term sustainability. The Research Unit consequently conducted a study in collaboration with the MoH Geriatric Division to examine how gerontological physicians and nurses related to the extent and effect of GNP practice on health care quality, before fully introducing it into the healthcare system .
Given the nursing staff shortage, particularly in psychiatry, as well as the insurance reform and deinstitutionalization policies executed in mental-health services in Israel, an urgent need arose to reassess the professional role of RNs in psychiatry. The ND Research Unit decided to conduct a more thorough examination of the suitability of specific training in psychiatry for the current practice areas and functions of psychiatric nurses, and to identify practice areas where advanced training might be required. A countrywide sample of nurses with post-basic training in State psychiatric hospitals identified areas of practice for further training: psychotherapy intervention (60% of respondents); consultation for the elderly (60%); care prescriptions (64%); community drug-treatment management (69%), and referral to professionals and community resources (56%). Nurses reported gaps in the continuity of care and community rehabilitation activities . These findings have implications for training in an era of greater focus on chronic mental illness in the community. Furthermore, the study findings contribute significantly to the articulation of the role of advanced nurses in mental-health services.
Social Periphery and Health Gaps
Resources are shrinking, and health costs are rising in the international community, including in Israel . Economic constraints have affected Israel’s ability to provide high-quality healthcare, especially to vulnerable populations such as the elderly, the poor, the mentally disabled, and the chronically ill needing disproportionately more intensive care, as well as to individuals living in the country's peripheral areas .
About 20% of Israel’s families and 33% of children are defined as underprivileged, while 23% of the elderly live in poverty . There are considerable disparities between different regions, especially between the country’s center and periphery on such health indicators as life expectancy, general mortality, chronic illness, and infant mortality. At the end of 2010, as part of its overall work plan for 2011-2015, the MoH published objectives on reducing inequality in healthcare. One of the objectives was: reduction of the impact of cultural differences on the use and quality of health services in peripheral areas, in terms of improving availability of services, and effective intervention activities to reduce healthcare inequality.
The ND identified healthcare for the Bedouin population in southern Israel as a national priority, by collaborating with nursing leaders from the four HMOs to create new nursing roles and expand existing ones in order to meet these needs together with other health professionals. Like all Israeli citizens, the Bedouin are covered by National Health Insurance and receive mother-and-child preventive care services, including prenatal care, at local MoH-operated clinics. However, many Bedouin women do not use the service, mainly because they perceive themselves as culturally estranged from the health providers. This is a cause for concern as the lack of prenatal care in the Bedouin community is associated with adverse perinatal outcomes. Specifically, it is an independent risk factor for preterm delivery, low birth weight and perinatal mortality . In light of this, the GNO/ND, in its regulatory capacity and with the collaboration of all its Units, encouraged the partial transfer of some highly competent, experienced RNs from hospitals and community health centers in metropolitan Tel Aviv to locations in southern Israel heavily populated by Bedouin. The nurses received in-service training focusing on culturally-sensitive health promotion and prevention specific to this ethnic group. Earning appropriate compensation for the need to relocate, the nurses administered and managed care in local village schools and family clinics for two years; an additional clinic was established in a major southern city composed mostly of Bedouin residents.
The project research was an evaluation study which assessed the consequences of the program. Additionally, according to policy to reduce healthcare disparities, the ND Research Unit together with the MoH Strategic Planning Administration Department embarked on a comprehensive study to map nursing services by district, including Mother-and-Child Clinics, primary community services, and emergency services to learn how to implement the policy of reducing regional healthcare inequality in nursing as well.
This article describes the use of research evidence in health policymaking in ND to meet MoH policy goals to develop the profession for the benefit of the health and wellbeing of the country's residents. It demonstrates how the Research Unit together with other ND Units responds to the healthcare scene and participates in its policymaking process, as we strive to ensure that health-related public policies are based on the best scientific data available. Consequently, new nursing roles have been created and vulnerable populations are receiving culturally-sensitive healthcare attention.
Policymaking processes include participation in research roundtables, workshops, and planning meetings to provide opportunities, shape research priorities, and identify policy issues and needs. Furthermore, a new type of studies “online consultation with the public” may increase the patient’s engagement in healthcare and health-policy issues in order to meet health challenges. Engaging patients in health-policy research renders research more accountable and transparent, provides new insights and ensures that research and policy are relevant to patient concerns.
Indeed, research for evidence-based policy requires the engagement of diverse stakeholders and multiple disciplines, in order to address the complex implementation challenges they face. Research for evidence-based policy is often at its most useful when implementers play a part in the identification, design and performance phases of a study. Because of this, fostering collaborative ties between key stakeholders involved in generating policy, managing programs, and research is so important. One way to support collaboration between researchers and implementers is integrating research into policy and programmatic decision-making processes from the outset rather than conducting it in isolation from the implementation process.23075