Nurse practitioners (NPs) provide medical treatment to patients based on their training and according to criteria approved by the Director General of the Ministry of Health. NPs’ authorities are broader than those of non-practitioner nurses, and they are required to complete more extensive training. In 2009, Israel launched a training program for NPs with a specialization in palliative care, and in 2010 the first graduates of that program became licensed. Since then, the following areas of expertise were added: diabetes, premature infants, surgery, nursing policy and administration, pain, and rehabilitation. The trend in Western countries is to expand the numbers of specialty nurses, not only in hospitals but in the community as well.
Introducing a new role into a health system is a complex and dynamic process. It takes considerable time and requires a significant investment of resources and collaboration on the part of all stakeholders. The contribution of NPs has already been examined in the literature, and found to be conducive to preventing hospitalizations and achieving better treatment results. Patients have also been found to be highly satisfied with NPs.
The present report addresses nurses specializing in geriatrics and palliative care. NPs in palliative care work in both inpatient and ambulatory settings. Palliative care includes caring for patients nearing the end of their lives, providing balanced pharmaceutical treatment to alleviate and control symptoms, and providing counselling and guidance to the patients and their families. These nurses serve as a backbone for the patients and their families – they coordinate all treatments and at the same time conduct ongoing dialogue with all members of the healthcare staff.
Geriatric NPs provide comprehensive medical care for senior citizens. Starting in 2013, they were employed in geriatric inpatient settings, and in 2020, the Ministry of Health expanded their employment to also include general hospitals and the provision of geriatric counseling. Most recently, in 2022, they began working in the community as well.
Demographic changes, primarily the rise in chronic and complex morbidity, pose serious challenges to the Israeli health system, such as the need for efficient operations. NPs can help in addressing these challenges. Therefore, the Nursing Administration at the Ministry of Health asked the Myers-Joint-Brookdale Institute to conduct a study examining the NP’s role and contribution.
The study’s main objective is to examine the perceptions of the NPs regarding the contribution of NPs to the health system and the potential development of their role in palliative and geriatric care. The study’s secondary objectives are as follows:
- Examine the unique contribution of NPs specializing in palliative and geriatric care to the healthcare system and assess their contribution to the community (or the setting where their contribution may be optimal).
- Examine the state of the art in the world with regard to the work of NPs in these areas, including the settings where they are employed, their roles, and their authorities.
- Examine how it would be most appropriate to develop the roles of NPs in these areas in community care settings, from the perspectives of both healthcare policymakers and the nurses in the field.
The study combined quantitative and qualitative methods, as follows:
- Twenty-six semi-structured in-depth interviews were conducted with NPs specialized in geriatrics and palliative care, as well as with professionals working with them or who take part in shaping the policy on the NPs. The interviews were conducted face-to-face or over the phone from January 2019 to July 2021.
- An online self-report survey of 89 geriatric (29) and palliative (60) NPs was conducted. The survey forms were emailed to the nurses from June to October 2020.
- A comprehensive review of the literature was conducted to examine the global state of the art, including a review of the settings and authorities of NPs in various countries.
The study received the approval of the Ethics Committee of the Myers-JDC-Brookdale Institute and the Nursing Administration at the Ministry of Health.
Background characteristics: Most of the NPs are women (84%), born in Israel (69%) and Jewish (64%). About half (53%) have 1-4 years’ experience as practitioners, and 71% are employed fulltime.
Organizational climate: The NPs feel that both their supervisors and patients evaluate their work and that they are considered professional authorities.
Academic activities: Half (51%) of the nurses reported frequent studies in the course of their duties; 27% reported considerable integration of research in their work; and 72% reported considerable integration of teaching in their work.
Contribution to the health system: The nurses felt they made a contribution to four types of beneficiaries: the patients, the family members, other professionals, and the health system in general. It was also found that specialization contributed to the nurses themselves by providing them occupational horizons, preventing burnout, and enabling them to care for the specific population in which they were interested in caring.
Professional identity and autonomy: Geriatric NPs feel they belong to the medical sector rather to the nursing sectors more than do palliative care NPs. It was found that NPs were more autonomous in their activities than non-practitioner nurses. Nevertheless, the NPs did not always manage to benefit from full autonomy in the field.
Challenges: (1) The NP’s status needs to be further established vis-à-vis both medical staff and patients; (2) There is a need for ongoing practical and theoretical training; (3) The lack of available NP positions should be addressed; (4) Overload (including emotional overload) and difficulty implementing palliative care in the health system has to be addressed.
Professional training: More than half (58%) of the nurses were satisfied with their training course; 71% felt there was some content missing.
The profession’s future: Most (76%) NPs believed the NP role will expand in five years’ time; 88% of respondents would recommend other nurses to join the profession.
Developing the NP’s community role: According to the participants, they have the potential to make considerable contribution to community medicine – in maintaining treatment continuity and preventing hospitalization as well as providing home care for people with special needs, whom physicians do not have enough time to treat. They believe that in order to develop their role, their knowledge and authorities must be expanded, and their integration in patient medical care should be deepened.
Discussion and Conclusions
The role of NPs in Israel is new. This study contributed to the understanding of the role of NPs in geriatric and palliative care, the implementation of this role and the potential development of these roles.
The combination of the patient-centered and aging-in-place approaches clearly point to the need to further develop and expand the NP profession in the community. It is therefore highly important to identify areas that require intervention where the contribution of NPs can be optimal. It appears that integrating geriatric NPs – particularly in treating homebound, complex, and dementia patients can contribute to optimizing the monitoring and caring for these populations and contribute to optimal treatment plans.
We recommend considering the following action items:
- The definition of the NP role needs to be further clarified and its authorities be more accurately articulated in laws and regulations
- NPs’ professional training must be adjusted to the role requirements, with emphasis on their community work, and a mechanism for continuous knowledge updates needs to be developed
- The relations and trust between the medical establishment and MPs should be strengthened through dialogues and joint professional meetings, as in symposiums and peer consulting forums
- The NP role should be better positioned through a variety of branding activities
- Emotional support for palliative care NPs should be considered
These steps will improve the unique status of the NPs in the health system and contribute to increasing their number, and at the same time, to reducing the opposition of the medical establishment to expanding their authorities. These two outcomes are highly significant given the aging of the population, the growing implementation of the aging-in-place principle, and the increased demand for geriatric and palliative care.
To conclude, the NP role is an emerging and growing role that has significant and broad contributions. We therefore recommend that its development and implementation be further monitored, and that the integration of NPs in additional specialty areas be considered, with an emphasis on community work and on their essential role in the health system.