A year ago when I selected Israel as AONE’s academic trip abroad, I had no idea what to expect, nor that my role at AONE at the time would be changing from president to CEO. By selecting Israel, I hoped the AONE delegation, led by AONE Board President Joan Shinkus Clark, could return with knowledge of several areas critical for US nurse leaders. Among the areas I hoped to explore: emergency preparedness, treating victims of violence in Israeli communities, and Israeli nurse leaders’ initiatives to keep themselves and their staff resilient. Additionally, I hoped to learn how nurse leaders in Israel partner with their academic colleagues in preparing the current and future generation of nurses for the growing demand of health care needs as their population ages.
As the new CEO for AONE, I felt an obligation to assess the benefits of international travel for our member- ship and AONE. While each delegate pays his or her own way, AONE absorbs the travel expense for the CEO and board president. During the trip, I was convinced that international travel is a must for our organization if we are to fulfill our mission, “To shape health care through innovative and expert nursing leadership,” and our vision, “Global nursing leadership–one voice advancing health.” According to the World Health Organization, which uses factors such as life expectancy and distribution of care to rate health care in countries around the world, Israel is ranked 28th while the United States is ranked 37th. Not a huge difference in performance, but each country’s health care is delivered in very different systems, which provided a rich opportunity for learning.
As I sit in my kitchen sipping on my Aroma brand coffee purchased in Jerusalem, I taste the hint of cardamom spice and once again I am back in Israel. We arrived in Tel Aviv September 13, 2016 and gathered as a delegation for the first time at dinner where we were introduced to our guide, Moshe Nov. It was hard to imagine that 12 people, many meeting for the first time, would have such an instant connection. Some people say there are no accidents in life— or that it was “bashert,” which is Yiddish for “it was meant to be.” Two of the 11 delegates had traveled to Israel before, but for all of us, it was a visit we will always remember.
The first lesson I learned was that participating in a delegation is similar to a running a marathon, both physically and mentally (I have never done this but have a good imagination). Delegates managed a nonstop itinerary for 7 days and evenings, in addition to what our guide Moshe squeezed in. He wanted us to have an experience of a lifetime and repeatedly told us the importance of meeting people, tasting local foods, and visiting sites not listed in our itinerary. Moshe accomplished this mission with enthusiasm!
Insights in Context
In order to understand the significance of our visits to both Israeli and Palestinian hospitals, it is important to share a brief history of the area, much of which I learned from Moshe first thing every morning. He would start the day by saying “talk or no talk?” Of course, we were all hungry to learn as much as we could during our 9- day visit, so we were unanimous in asking him to talk.
Israel is a country that has been locked in conflict with its Palestinian and Arab neighbors over ownership of land considered holy by many Jews, Christians, and Muslims. After the Nazi Holocaust, Israel became a Jewish state in 1948. Hundreds of thousands of Palestinian Arabs were displaced in the fighting in 1948, and wars continued in 1967 and 1973. The Palestinians in the West Bank and eastern Jerusalem have been living under Israeli occupation since 1967. To date, nearly 500,000 Jews remain settled in the West Bank, which is why, per our guide, Moshe, the solution isn’t so easy. In 2005, Israel evacuated its settlers from the Gaza Strip, ending almost 4 decades of Israeli military presence. Israel continues to control Gaza’s sea front and air space. In 2007, the militant Islamic group Hamas reinforced its power in the Gaza Strip, resulting in Israel intensifying its economic blockade of the strip. Palestinians are allowed to travel—mostly for health care—outside of the Gaza Strip only after receiving security clearance because of the ongoing terrorist attacks against Israeli citizens. According to Moshe, the Palestinians from the Gaza Strip are not allowed to work in Israel. Sadly, the unemployment rate in the Gaza Strip is approximately 60% and, Moshe noted, a breeding ground for discontent and potential terrorist activity.
Israel has socialized medicine and is organized into 4 health maintenance organizations (HMOs). In addition to the basic coverage, which includes in vitro fertilization treatments and medications, additional tiers of packages are available for those willing to pay out of pocket. These packages offer more provider and service choices outside of an HMO’s network. Sound familiar? Depending on whom you ask, the overall feeling is that this system works well for most Israelis, who do not pay any out of pocket expenses for the basic plan. The tax paid by Israeli residents is based on income, so on average about 3% to 4% of one’s salary goes to health care for the country. A growing concern is over the increasing number of ultra-Orthodox Jews, which Moshe estimated was close to 20% of the population, who do not pay taxes; the majority of them do not work. Another concern for Israelis is the growing expense of the military, which is around 5.2% of the gross national product, compared to the US, which is around 3.4%.
Nursing School Challenges
We visited several Israeli nursing schools and one Palestinian school. Similar to the US, funding is a major concern. Israel changed to all BSN entry to practice back in the 1990s and in 1996 stopped its practical nursing programs. Ella Koren, PhD, MA, RN, who has been the director of nursing at the Ziva Tal Academic Nursing School at Sheba Medical Center since 2011, shared many of her challenges and successes. In less than 5 years, under her leadership, the school has doubled enrollment and was able to secure funds for pro- gram expansion and resources. Upon her arrival, Koren recognized a huge gap in both student and faculty knowledge as it related to financial management of resources. By introducing basic financial fundamentals, she was able to save money and reinvest funds into the school.
A major concern, she said, is clinical placements for Ziva Tal Academic’s students. The hospital has been running at 92%–100% occupancy; staff nurses are tired and not enthusiastic about adding the bur- den of educating students to their workloads. She mentioned several efforts to recognize the staff nurses for their contribution to the students’ education, such as naming a Preceptor of the Year. One interesting note: the nursing schools take on the responsibility of creating post-graduation specialty certifications such as critical care, oncology, obstetrics, and others. In addition, the schools provide continuing education courses for all nurses, such as those focusing on geriatrics, palliative care, and multicultural health services. In the US, specialty clinical training falls on the shoulders of the hospitals.
Lessons in Emergency Preparedness
We traveled from Tel Aviv to Haifa to learn about emergency preparedness at the Rambam Medical Center and the Sammy Ofer Fortified Underground Emergency Hospital, which in the largest of its kind in the world. Rambam Medical Center is the referral hospital for the Israeli Defense Forces Northern Command, the US Navy Sixth Fleet, and the UN Peacekeeping Forces posted in the region. Within 72 hours, the medical center is able to convert its under- ground parking facility into a fully functional hospital with a capacity of 2,000 beds.
Israel performs ongoing emergency drills, and each hospital is graded on how it responds. Israel is about the size of New Jersey, so these drills are similar in scale to those performed in many US regions and states. Rambam Medical Center emphasizes the inclu- sion of all community resources in the drills, such as police and other agencies. The medical center has trained more than 3,500 professionals from more than 61 countries on trauma emergency and mass casualty situations; Rambam staff encouraged us to share this information with our stateside colleagues. Nurse lead- ers are reminded almost daily that terrorist attacks and mass casualty situations can occur anywhere—no one is immune. These events are no longer a question of “if ” but “when.”
While I could write a small book on each place that we visited, I especially want to share how nurse leaders in Israel—no matter their religious beliefs— are all working together for the health and wellbeing of the patients they serve. Many readers may be thinking, isn’t that what we do as nurses? And the answer is yes, but just imagine ongoing terrorist attacks within your community and being asked to care not only for the victims of the attack, but also the terrorists. Both Islamic and Jewish nurse leaders spoke about the importance of working together to improve timely access to care for all patients, especially those located in the West Bank and Gaza Strip. Suleiman Turkman, chief nursing officer at the Al-Makassed Islamic Charitable Hospital, said it could take days, weeks, or even a month for people to receive life-saving treat- ments.
Each nurse leader spoke about the challenges of the political environment and how nurses can be, and must be, leaders in influencing positive change for their communities. Julie Benbenishty, RN, MNS, trauma coordinator and researcher at the Hadassah Ein Karem hospital, spoke about the importance of nurses as leaders and researchers to collaborate on topics with international scope, such as the legal and ethical issues of providing care to terrorists, treating “undesirable” patients (such as those who are disre- spectful of caregivers from another ethnic group), the therapeutic relationship between nurses and patients, and disparities of care. She worries about the effec- tiveness of healing environments in such a highly charged political situation, and notes little research has been published on the topic and its implications for nursing practice. Benbenishty is a beacon of hope, and the words “not possible” are not in her vocabulary. She expressed interest in collaborating with AONE on future research topics that would provide global benefit and stressed the importance of nurses as peacemakers, noting that nurse leaders can collectively and internationally make a positive impact. It’s con- nections like these that underline the importance of AONE international trips, to help in creating our vision of global nursing leadership and to galvanize support for our international colleagues who, like us, are focused on leading staff to provide the best care possible.
Maureen Swick, RN, MSN, PhD, NEA-BC, chief executive officer of AONE
senior vice president and chief nursing officer of the American Hospital Association.