The upgraded Israeli nurse

The director general of the Health Ministry, Prof. Avi Yisraeli, is planning to draw up a list of medicines for chronically ill and "terminal" patients, for which nurses will be allowed to write prescriptions. This follows an amendment to the pharmacy directives passed last week in committee, in preparation for a vote in the Knesset.

The amendment is strongly opposed by doctors, who say that patients will pay a high price and their lives could be endangered. Nurses, on the other hand, see the move as a victory in their struggle for a better status among medical personnel - an upgrading from mere mediators between doctors and patients, and the granting to them of a right which has traditionally been that of the physicians alone.

The process of upgrading the status of nurses in Israel is being led by the director of the ministry's nursing division, Dr. Shoshana Riba, and entails improving the profession's academic status and changing the image of nurses from people who focus their efforts on the patient's basic needs to those who have freedom of action to maintain patients' quality of life.

For several years now, the health authorities in Israel, particularly the Israel Medical Association (IMA), have been warning of a shortage of doctors, that Israel is lagging behind developed countries in this respect and that there could be a real crisis in several years. The shortage is already being felt in the peripheral areas.

There are long lines in the health maintenance organizations' clinics; doctors complain they are collapsing under the heavy workload; patients' "quality time" with physicians is growing shorter and this is especially salient at a time when preventive medicine is considered so important - after all, a doctor who has more time can notice if his patient is showing early signs of disease and prescribe medication which will prevent deterioration and greater expenses in the future. The warning signs can be seen not only in the periphery, however. Residents of the center of the country are also exposed to the distress caused by a severe lack of experts in various medical fields, such as anesthetists, nephrologists and specialists in internal medicine.

Some IMA members feel that the state, instead of opening new avenues for training doctors, is taking the easy way out by giving some of their authority to nurses, who will be glad to have their status upgraded even if they do not get more money for writing prescriptions. "There is no doubt that the amendment to the law is a very bad thing," said IMA president Dr. Yoram Blachar. "It will severely undermine the relationship between the patient and his doctor," he told Haaretz.

The amendment to the law that was approved by the Knesset's Labor, Welfare and Health Committee was, in its original form, much broader. It spoke of granting greater freedom of action to nurses in writing prescriptions such as antibiotics for people with throat infections. IMA deputy chairman Dr. Shlomo Birkenfeld and MK Rachel Adatto (Kadima) were incensed and, following a prolonged argument with the ministry, reached a compromise that they call "the lesser of the evils" - granting limited authority to nurses to write prescriptions, and only in cases of ongoing treatment when terminally ill patients require analgesics or chronically ill patients need their medications filled for the coming three months. In all cases, the nurses need to have been working in their profession for at least five years and to have received special training and a permit from the ministry.

The IMA heads feel that these directives have somewhat sweetened the bitter pill, and enable the doctor to determine the patient's condition in the initial stages and track his medical state through various measures such as physical examinations, deciding on a diagnosis and discussing the patient's condition with him. According to the amendment, the doctor will meet with the patient once every six months to examine whether the medications are suited to his current medical condition.

Nevertheless, doctors are severely critical of the relative freedom of action that nurses will enjoy after taking over what was their sole prerogative. "Nurses who want to write prescriptions for patients should take the trouble to study medicine for seven years, then to undergo another few years of specialization and after more than a decade of studying and specializing be allowed to write prescriptions for whomsoever they wish, not merely chronically ill patients," says Blachar. "This attempt will not succeed and it will be to the detriment of the patients. The dam has been breached and the question now is: What's next?"

Adatto, who is a doctor by profession and served for 15 years as deputy director of the Shaare Zedek medical center in Jerusalem before being elected to the Knesset, was a vociferous opponent of the move. "One must not regard this matter lightly," she says. "I studied medicine for many long years and I wrote prescriptions with fear in my heart, and only after I had cross-examined patients to find out whether they were taking other medications because of contraindications; I examined whether there were background diseases and what their medical histories were. When writing a prescription, a great deal of consideration and thorough thinking must be given to the matter, because we are dealing with peoples' lives."

During last week's discussion in the Knesset committee, she was in the minority and voted against the proposal while her colleagues voted enthusiastically in favor. Everyone had her or his own reasons: MK Orli Levy (Yisrael Beiteinu) believes that this will solve the problem of many chronically ill people in peripheral areas who have to wait long hours in a clinic to see a doctor simply to get a prescription. MK Moshe Matalon (also Yisrael Beiteinu) is of the opinion that the amendment would eliminate unnecessary bureaucracy when getting a prescription, while the committee chairman, Haim Katz, (Likud), described the decision as "a revolution in the treatment of the chronically ill," and stressed that the considerations had been to the point.

Adatto however, described the decision as an underhand opportunistic move, and said that such a far-reaching professional decision should have been preceded by a far more thorough and serious discussion, and not have been part of the Economic Arrangements Law, as happened in this case.

Adatto also holds a degree in law and specialized in an office that deals with medical negligence. "I was cautious enough as a doctor when writing prescriptions, but my legal training in medical negligence made me even more cautious," she says. "I still do not understand the issue of responsibility in situations like this. If I, as a doctor, write a prescription for a patient and three months later the patient gets a prescription from a nurse - who is responsible if the patient suffers damage?"

Riba told Haaretz that in a situation like the one Adatto described, the nurse would be held responsible. She said that this was yet another step toward improving the service to patients, and is accepted practice in the western world. "In 43 states in the United States and in a long list of other western countries, including Scandinavia, Britain and Australia, it is accepted practice for nurses to write prescriptions from a list, as will be the case when the amendment is applied in the Health Ministry. Many studies have been conducted in those countries and they have shown that this is effective and good. It will shorten lines in the clinics, improve the feeling of the chronically ill toward the health services, lessen the distress of patients in the peripheral areas and improve the connection between nurses and patients because the chronically ill will be placed in organized follow-up programs [run by] the nurses."

The head of Israel's nurses union, Ilana Cohen, is convinced that there is nothing wrong with the amendment. "One must put ego considerations aside, rise above petty considerations and look only at the good of the patient, and the new law will make this possible," she says. "We have no intention of competing with anyone, certainly not to take away the doctors' income. The nurses are the ones who keep up relationships between patients and the health system. In many cases, nurses also carry out visits to patients' homes, many more than the doctors. It is natural that if a nurse takes care of a chronically ill patient who requires regular medication for treating his blood pressure or diabetes, she should write a prescription for him if his medicines have run out."

Israel, however, is not merely suffering from a shortage of doctors - there is an even worse shortage of nurses. Up-to-date Health Ministry data reveals that in 2008, the number of nurses in Israel continued to drop. In 2007, there were 5.8 nurses for every 1,000 Israelis, and the number decreased to 5.6 in 2008. By contrast, in most western countries there are more than seven nurses per 1,000 people. The Health Ministry is convinced that opening additional training frameworks for nurses, improving the profession's academic status and granting wider freedom of action to those serving in the profession will all improve the situation. "The Finance Ministry is very interested in advancing the nurses and developing the nursing profession, and is allocating a great deal of money for this," says Riba.

She says that three new nursing frameworks were recently opened in Safed, Jerusalem and the Jezreel Valley, and these will be joined by another three, so that in three years' time, some 400 nurses will graduate. In addition, there are plans to retrain unemployed academics to work in nursing, in a shortened two-and-a-half-year course, instead of four.

A veteran nurse who works in a community clinic in one of the southern towns recently heard about the doctors' fears over amending the law. "I can't really understand what they are talking about," she said. "We have been doing this for years already, without waiting for a new law, or the Knesset, because there is nothing else we can do - that is how it works. In cases of chronic illness, when there is not always a free doctor in the vicinity and we know the patient and his medical history, we write out prescriptions and go into the doctor's office for a second, get him to sign, and give the patient the prescription. The law is a mere technical matter which takes care of the existing situation," she says.