Nurse Practitioner Caryn Scheinberg Andrews, who immigrated to Israel from Baltimore, Maryland in 2011 and is a lecturer in the Hadassah-Hebrew University Henrietta Szold School of Nursing, is on a personal mission: to fortify Israel’s health delivery capacity by helping to create a cadre of advanced practice nurses.

Her study, co-authored with Eliana Marcus Aaron of Yale University, entitled “Integration of Advanced Practice Providers into the Israeli Healthcare System,” was published in the February 2016 issue of Israel Journal of Health Policy Research. She has spoken about this topic at the International Conference on Health Policy in Jerusalem (2014) and most recently gave a presentation on the topic at a Sigma Theta Tau International nursing conference in Cape Town, South Africa.

Dr. Andrews (PhD, RN, CRNP) found that while in many countries, such as the United States, nurse practitioners have well-established roles, the profession of nurse practitioner in Israel is still in its infancy. This is despite the fact that quality of care often improves when NPs are involved and that having advanced practice nurses work in underserved areas is very helpful in counteracting the shortage of physicians–a very large problem in Israel. Dr. Andrews notes that “with a mandatory physician retirement of 67–70 years old, Israel’s Ministry of Health predicts critical shortages within 15 years.”

In addition, Dr. Andrews relates, Israel also suffers from a significant, growing nursing shortage. According to Dr. Andrew’s research, many international organizations have studied the impact of having NPs in various health care settings and report that “care provided by both physician and non-physician providers is equivalent, safe, cost-effective, and produces high levels of patient satisfaction.”

Dr. Andrews, who teaches advanced health assessment, advanced women’s health, and advanced oncology nursing, is certified as both a family and hemato-oncology nurse practitioner. The NP, she says, “provides a unique dimension of healthcare. By incorporating education into patient visits and working with patients and families as partners in healthcare, outcomes of nurse practitioner primary care with adults and children have been reported to be equal to or better than care provided by physicians alone, with less patient healthcare utilization and a more cost-effective bottom line.” Further, she reports, “indirect costs savings are even more substantial, as evidence shows that NPs reduce unnecessary emergency room visits, 30-day readmission rate, and waiting time for healthcare visits.”

And yet, there are many obstacles to growing the NP profession in Israel. As Dr. Andrews brings out:
• Israeli NPs are restricted in prescribing medication and in practicing independently.
• Israeli NP programs focus on institution-based practice.
• NP education is delivered directly through the Ministry of Health, rather than at an independent academic setting.
• NP education is a post-master’s certificate with six months of part-time didactic education, followed by a residency.
• Israeli NP programs are currently sub specialty-specific, as guided by physician shortages in the field, limiting graduates’ professional mobility.

Dr. Andrews explains that “the addition of advanced practice nurses to the nursing profession raises the economic and practice ceiling for nurses, which has the potential to attract more recruits to the larger nursing profession. In addition, as a quarter of Israeli nurses are not currently working in the healthcare sector, improving the attraction to the profession may motivate some of these nurses to return to the healthcare workforce.”

Emphasizing that integrating NPs into the healthcare workforce is “the most expeditious, evidence-based approach of alleviating the physician shortage in Israel,” Dr. Andrews recommends that NP programs continue to expand, become transparent, shift to publicly available academic programs, and effectively include all stakeholders and foreign-trained NPs in the rapid advancement of this profession.”

Nurse Aliyah
Another special project that Dr. Andrews has taken on deals with “Nurse Aliyah” (immigration to Israel). She has been working with new nurse immigrants and potential immigrants, helping to ease their way into a nursing career in Israel. When she immigrated to Israel, Dr. Andrews recalls, “I recognized what a difficult process it was to obtain a nursing license–despite being a fully capable professional nurse with years of experience. The task of getting a nursing license in Israel is arduous, time-consuming, costly, and may take years. Nurses are deskilled when they apply for jobs, starting at the bottom despite years of experience and education.” She now has a group of over 400 nurses in various stages of the Aliyah and licensing process.

Dr. Andrews is also working on a qualitative study concerning nurse olim (immigrants to Israel) with Dr. Yaffa Zisk Rony, head of the Advanced Practice Nursing (APN) master’s degree program in the Szold School of Nursing. They are documenting the experience of nurse olim as they struggle to integrate professionally into the health care system. Their goal is to provide evidence to Israel’s policymakers that change is crucial.

Advocating for Cancer Screening
A prolific researcher who has been the recipient of a six-year research grant from the Ministry of Absorption New Scientist Program, Dr. Andrews is also working on a study with Szold Faculty Member Dr. Anita Noble (funded by the Israel Cancer Association) to examine the cancer screening practices, knowledge, and attitudes of Anglo, Israeli, and Arabic men and women. Pilot data suggest that men’s awareness of their need to be tested to see if they carry the BRCA genetic mutation is lower than that of women’s, which puts them more at risk for contracting breast cancer.

Palliative Care
Dr. Andrews is also just completing a study with Prof. Freda Dekeyser, head of Hadassah’s new PhD nursing degree program, which compares the competency and comfort level of Israeli oncology nurses versus intensive care unit nurses in implementing palliative care for their patients. As she explains, “Palliative care is a treatment approach whose goal is to improve quality of life and relieve the suffering of patients and their families, as their loved one faces the end of life.” Other research has revealed that ICU nurses, who come from a culture of “save life at any cost” often experience a sense of failure when moving from curative treatments to palliative care and, therefore, are resistant to making the transition. While the National Cancer Center Network has proposed guidelines which suggest that palliative care be a part of all cancer treatment–on a trajectory from cure to end of life, obstacles still remain. From the results of this study, Dr. Andrews and Prof. Dekeyser recommend that efforts be made to educate all nurses about palliative care and that further research be conducted to determine how to better introduce palliative care into the hospital setting and raise the comfort level of nurses to take the initiative to offer this element of care to their patients.

Religiosity and Modesty
Dr. Andrews has also explored the relationship of religion, modesty, and use of the health care system among Jewish women, both religious and secular, in the United States and Israel. She researched the question, “Do religiosity and modesty play a role in health care utilization among Jewish women?”

In her study, she found that not all Jewish women have issues with going to a health care provider of the opposite gender; that women’s attitudes were individual and it is not correct to assume that very religious Jewish women are less likely to have health care screenings such as mammography because they are too modest to get undressed in front of the health care provider. Her findings caution health care providers not to generalize about modesty among religious women. Rather, she says, “the results of this study suggest that Jewish women express modesty in different ways: some express modesty as behavior, some as the way they dress, and some in their interaction with others.” Some individuals who feel vulnerable, she explains, “express modesty by being very shy with other people–family, friends, neighbors–or in business interactions. The shy, timid person, appears to be more at risk for not seeking the health care she needs.”

The real issue, identified by this research, Dr. Andrews says, “is the need to ascertain each woman’s individual means of manifesting modesty.” She is continuing to explore the relationship between modesty and religiosity with men and women of different cultures in Israel.

In looking back on her journey–from building a successful NP career in the United States to starting over as a nurse in Israel–Dr. Andrews is appreciative of the fact that Dr. Miri Rom, Director and Associate Dean of the Szold School of Nursing, and her colleagues on the nursing faculty “took her in.” As she says: “They helped me to regrow myself into a researcher, teacher, and health policy advocate. “They are a wonderful new family for me and my family.”

Whether advocating for sensitivity that would improve the patient’s experience with the health care system, policy and educational changes that will bring more quality nurses into advanced practice nursing or removal of the obstacles that foreign nurses face in navigating the complex road to a satisfying nursing career in Israel, Dr. Andrews is happy to call herself a “worker bee researcher”–as well as an educator who is proud that her lab coat says “Nurse Practitioner.”