Integration of advanced practice providers into the Israeli healthcare system

APN professions were established based on the needs of the medical system in times of war and physician shortage, and societal need in times of economic instability. Throughout the world, APNs have worked as non-physician health-care providers, effectively reducing physician shortages. There is a large body of evidence suggesting APNs provide effective, safe, equivalent, quality care in a wide variety of fields [11, 16].

According to the International Council of Nurses (ICN) and the International Federation of Nurse Anesthetists, there are currently four widely accepted APN professions including NPs, CRNAs, CNMs, and CNSs [58, 59]. The specific credentialing processes, roles, and practice of APNs are customized to each state and country. A master's degree in nursing is required or recommended in the majority of developed countries, excluding nurse midwives, and the American Association of Colleges of Nursing (AACN) has established a goal in the US of requiring doctoral level studies for new entry-level APNs [50, 51, 60, 61].

Notwithstanding the variability of preparation level, analogous themes are found in APN professional roles world-wide. Mantzoukas & Watkinson (2007) performed an international evaluation of the literature and identified 7 common, generic themes in APN roles internationally, as well as a common professional goal. Generic features include use of knowledge in practice, critical thinking/ analytic skills, clinical judgment and decision making skills, professional leadership and clinical inquiry, coaching and mentoring skills, research skills, and changing or improving clinical practice (p.32). In their assessment, the common professional goal was the attainment of professional autonomy [62].

The U.S. National Council of State Boards of Nursing defines Advanced Practice Nurses (APNs) as “registered nurses educated at Masters or post-Masters level [practicing] in a specific role and patient population. APRNs [Advanced Practice Registered Nurses, an alternative name to APNs] are prepared by education and certification to assess, diagnose, and manage patient problems, order diagnostic tests, and prescribe medications” [63]. The American Association of Colleges of Nursing defines APNs as nurses who meet specific criteria noted in Fig. 1 [64]. Due to the historic diversity in academic standards for APN professions, the APRN Consensus Model was introduced in the US as a “gold standard” for APN education. The core principles of standardized education and credentialing include requirements for three core courses: Advanced pathophysiology, advanced pharmacology, and advanced physical assessment [64].

APNs must specialize in at least one of six population foci: family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women’s health/gender-related or psychiatric/mental health [64] (p. 6). Sub-specialization occurs in the clinical setting, and promotes flexible career movement. For example, a family nurse practitioner can sub-specialize in geriatrics or pain management [64]. Global standardization of APN education is also underway through international European collaborations and the ICN [58].

Internationally, NPs are licensed clinicians that blend nursing and medicine into their clinical practice. Early in NP education, the university was established as the optimal academic setting. By 1989, 90 % of US-based NP programs were at the graduate level as a Master’s or post-Master’s certificate [65]. Each academic program requires hundreds of clinical practicum hours, beyond the clinical hours required for the undergraduate nursing degree, which must be completed in addition to didactic classroom instruction. NPs must also maintain a RN license, pass national certification exams, and maintain an additional NP license. Recertification is obtained through proof of Continuing Medical Education (CME) credits and active clinical practice.

NP education is based on expanding nursing knowledge to include advanced pathophysiology, diagnosis of disease, disease management, pharmacology, leadership, health policy, and education while incorporating the nursing paradigms of growth and development, health promotion, and disease prevention. The NP therefore provides a unique dimension of healthcare for chronic, complex, and acute situations [66]. By incorporating education into patient visits and working with patients and families as partners in healthcare, outcomes of NP primary care of adults and children have been reported to be equal or better to care provided by physicians alone, with less patient healthcare utilization and a more cost-effective bottom line [16, 67]. As early as the 1970s, studies (including systematic reviews, randomized clinical trials, and descriptive studies) evaluating the safety, outcomes, patient satisfaction, and other indicators show that NPs provide at least equivalent, cost-effective care for equivalent patient health conditions [68]. In the US, 40 % of primary care practices employ NPs [69]. Community-based NPs working in primary care can be found in countries across five continents (North America, Europe, Asia, Africa, Oceania) and is rapidly spreading due to efficacy of their work, impact on healthcare access, their work in underserved regions, and improved patient satisfaction ratings [70].

According to the American Association of Nurse Anesthetists, CRNAs are defined as certified and licensed medical professionals who administer every type of anesthesia in every setting where anesthesia is administered. CRNAs are the primary providers of anesthesia care in rural US, and the main providers of anesthesia in the US military. They provide anesthesia services for every type of surgery and invasive procedure. CRNAs, at a minimum, have a Master’s degree, and they practice with a high degree of autonomy. They are required to be RNs, have acute care experience prior to applying to CRNA programs, and must maintain certification and licensure as CRNAs. They are re-certified through proof of CMEs and professional practice requirements [71, 72].

Nurse anesthetists have worked for nearly 150 years, pre-dating anesthesiologists by decades [72]. In 1906, Alice Magaw published the first study of nurse anesthesiology, which reviewed 14,000 cases with no fatalities attributable to anesthesia, a profound statistic at that time [73]. More recently, a Center for Medical and Medicaid Services (CMS) landmark study of 500,000 patient chart reviews showed that CRNAs provide equivalent anesthesia services to anesthesiologists with no increased complications or deaths [74]. An economic assessment in 2010 showed that independent CRNAs provide significantly more cost-effective care than supervised CRNAs or anesthesiologists alone [75].

In a review of the literature (CINAHL, MEDLINE, SCOPUS, PUBMED, Google SCHOLAR) published in 1990–2014, we were unable to find negative research about CRNAs. In a large Cochrane comparative review of over 1.5 million anesthesia cases administered by anesthesiologists, independent non-physician anesthesia providers (NPAs) such as CRNAs, and supervised NPAs, no conclusions were drawn about any difference in morbidity or mortality between the groups reviewed [76‐78]. The International Federation of Nurse Anesthetists, representing 40 country members, acknowledges country-based variability in the autonomy, scope of practice, supervisory requirements (if any), licensure, education, and regulation of CRNAs [59]. To date, there have been no descriptive studies found regarding levels of autonomy of nurse anesthetists per country (as per our literature review described above).

According to the American Academy of Physician Assistants (AAPA), PAs are defined as certified and licensed medical professionals who practice medicine on healthcare teams with physician supervision. PAs perform medical histories, physical exams, diagnose and treat illnesses, order and interpret tests, develop treatment plans, write prescriptions and other activities [79]. Additionally, PAs can work as first assistants in surgery and perform many procedures that were previously considered physician-exclusive. According to the AAPA, PA duties “depend on the setting in which they work, their level of experience, their specialty, [and] State laws” [79]. PAs are educated in medical model clinical graduate programs, and most have a master’s degree. Previous experience in healthcare and prerequisite courses similar to medical school entry are required for entry into most PA programs.

The PA profession developed in the 1960s when experienced, post-Korean War paramedics returned to the US and needed to find suitable employment [80]. The development of NP and PA professions were within the same time period, so underlying societal and economic factors were similar for both professions. The educational development of the PA began as a post-Bachelor’s certificate program, and was not originally based in academic study. Moreover, they were not originally considered “professionals” (i.e. not possessing a unique body of knowledge), but specifically physician-extenders, created by physicians themselves.

Nursing, in comparison, has been considered a profession for decades based on academic education and extensive research. Nurses holding PhDs and other doctoral degrees in nursing are highly regarded in the academic world. The NP role evolved as an advancement of the nursing profession. There are over a hundred journals dedicated to nursing and APN research. There are fewer than ten dedicated journals for PAs. The PA profession is evolving and now has a growing body of unique PA-based research. PAs with doctoral degrees remain a rarity, and much of their education is still provided by physicians.

In a study of 118 US acute care hospitals, PAs and NPs were found to have little difference in their respective roles and in reimbursement for services [81]. Likewise, a survey of 246 US-based trauma centers reported that 33 % are already utilizing NPs and PAs in their trauma service, while an additional 19 % plan to incorporate PA and NP surgical sub-specialties in the future [82].

NPs and PAs combined represent 29 % of primary care providers in the US [83]. As of 2010, 52 % of US-based NPs and 43.4 % of PAs were working in primary care, totaling over 86,000 primary care providers [12]. APPs, including PAs and NPs, are predicted to provide a larger share of US primary care with the implementation of the Patient Protection and Affordable Care Act (PPACA) [84, 85].

In Europe, where APPs have been introduced more recently (with the exception of Great Britain), many countries are struggling with gaps in primary care coverage. A study evaluating gaps in primary, preventative, and coordination of healthcare in eight European countries (Austria, Belgium, Spain, England, Finland. Germany, The Netherlands, and Wales), shows that despite physician reluctance to delegate patient care duties to NPs, Dutch models of NP-inclusive primary care have shown positive results. Primary care NPs improved clinical outcomes, self-management skills, quality of life factors, and patient compliance with health plan [86] (p. 82). Furthermore, the study suggests that while patient populations remain suspicious of economic-based motivations of changing healthcare paradigms, they have high levels of trust in nurses working in advanced practice (p. 82). A British study found that primary care NPs provided at least equivalent care to patients requiring “same day” visits for acute episodic conditions [15].

There is no consensus international standardization for APN role recognition and definition [50]. Although we found consistency in education, separation of the APN role from the RN, and ability to perform previously exclusively medical functions, there is wide variability by country in the actual function and independence of the APN, particularly the NP [61]. The ICN lists country-specific definitions for the advanced practice roles. Many international studies utilize the ICN definition of NPs or APNs [9, 70, 87, 88]. In other international literature, NPs are also linked with PAs [81‐83, 89]. Both professions have been shown to contribute towards solving physician shortages [80, 90].

More than 100 countries now recognize and differentiate APNs from RNs. The PA profession is recognized in some form in 6 countries. The educational requirements for APN professions internationally include graduate education as a pre-requisite for practice. Globally, all APNs must have a local RN license as prerequisite for an APN license. The educational requirement for PAs as of 2014 includes a clinical graduate degree [79]. Table 2 is a comparative analysis of various APP roles, educational requirements, and the number of countries accepting the roles.

Most countries reported that APNs practice autonomously (without physician supervision or co-signature) or in collaboration with physicians [58]. PAs generally require physician supervision. There are currently over 205,000 NPs [65], over 50,000 CRNAs [91], and over 95,000 PAs [92] reported in the US alone. In the US, NPs provide over 900 million patient visits annually [65]. CRNAs provide 65 % of all anesthesia services in the US, with over 40 million anesthetics provided annually [91, 93]. No data was available for number of PA visits provided.

To sum up, as seen in Table 2, scope of practice in each respective country has some similarities, and includes many essential, independent functions that were previously considered exclusively physician "scope of practice". Internationally, there is not necessarily a relationship between scope of practice and independence in practice. Even within the US, levels of independent practice varies by state [94]. The IOM landmark report “The Future of Nursing” recommends expanding APN practice and encouraging independent practice [11]. To date, 20 US states plus the District of Columbia allow for completely independent NP practice, 30 states have partial independence, often requiring a collaborative agreement with a medical provider [94].

This paper has reviewed the acute problem of physician and nursing shortages and the role of APPs in addressing these shortages internationally. In Israel, one benefit to APP utilization would be the ability to provide healthcare to underserved areas, such as the geographic periphery. Areas of specialization-specific shortages such as trauma centers, understaffed hospital units, surgical suites, and primary care settings would likewise benefit from APPs [28, 46]. APNs have been providing primary care in remote regions worldwide, including Canada, Australia, and the US, even before the professions were officially recognized [119, 120]. International research demonstrates that APNs can alleviate both geographic and specialization-based physician shortages, expand healthcare accessibility, and improve the quality of healthcare provision [11, 16]. PAs are also an evidence-based viable solution to physician shortages [80, 121].

The anesthesiology shortages are worsening as medical students are less interested in entering the field [122]. The larger impact of this provider gap affects many areas of healthcare in Israel. For example, a patient requiring hip surgery who must wait many weeks for surgery may have higher levels of mortality, morbidity, and require more extensive rehabilitation due to postponed treatment [123].

We have shown that the literature supports the notion that adding APNs to healthcare teams could reduce the delays to point-of-care and extend the effective reach of Israeli physicians. Physician time may be better utilized by focusing on complex patient care, leaving routine healthcare to NPs. Additionally, evidence-based research demonstrates that APNs provide value-added services (i.e. supplemental services) beyond filling existing gaps in physician staffing (i.e. substitution services), since they are experts in health promotion, patient education, and disease prevention, and are considered more user-friendly according to patient satisfaction surveys [9, 124, 125]. NPs also spend more time explaining health conditions thus, patient self-management is improved and patient satisfaction rates are higher [15, 86]. Thus, APNs add a dimension of care otherwise not provided.

Even though many countries have determined that APP roles are indispensable within their healthcare systems, barriers remain in the recognition and integration of these roles in the Israeli healthcare system. One of the most significant barriers, is a lack of title protection for the term “nurse”, “nurse practitioner”, “nurse expert”, “nurse specialist” and a clear Hebrew translation of NP or APN. Israeli healthcare professionals, especially those who trained abroad, oftentimes utilize the English term “nurse practitioner”. Few Israeli-trained healthcare providers have an accurate understanding of what an NP or APN is. To further complicate matters, the MOH Division of Nursing created the term “clinical nurse specialist” and “expert nurse” to be used interchangeably for both NP and CNS roles in Israel [126]. This discrepancy in names has caused confusion. In Israel, for example, any nurse can be called a “specialist” by taking a post-basic course, yet being a “specialist” is not the same as an Israeli “clinical nurse specialist” [127]. Moreover, neither of these terms is protected or exclusive to specific role designations. World-wide, title protection and definition remains a pertinent issue.

A critical analysis of the 2013 MOH committee report on “Physician Assistant”, which documents policy development for APP professions, reveals several weaknesses. First, there were no APPs represented on the panel, nor were any consulted for expert opinion. Second, none of the numerous international APP organizations were consulted regarding professional designation, education, and scope of practice. Third, the MOH report was not data-based, nor based on scientific evidence from the existing body of literature regarding the integration and utilization of APPs globally. Fourth, the MOH panel recommendations for education standards of Israel’s proposed APPs were not based on international criteria and standards. For example, the panel suggested that paramedics could be educated to become anesthesiology “assistants” and “physician assistants” with one year of training [46]. In contradistinction, current international education standards for APPs require or recommend a minimum of a clinical master’s degree, as seen in Table 2. Accordingly, the validity of the findings and the recommendations of the report are questionable.

While the MOH report recognizes the need for APPs [46], only small groups of nurses have received NP education to date. Likewise, courses offered are not consistent in length and breadth to current NP education in other developed countries. In fact, considering the short, part-time course, MOH programs appear more congruent with NP education in developing countries where resources are more limited [61]. The MOH has adopted a 50-year-old model of NP education rather than using a contemporary, mature, evidence-based model, such as the APRN Consensus Model, which is accepted throughout the world and supported by the OECD and other international bodies. The rationale for this is unclear.

The APRN Consensus Model is predicated on the medical model of education: Generalist NP education followed by clinical specialization. Advanced specialization is attained after meeting post-generalist qualification levels. Physicians choosing to sub-specialize do so through clinical residencies and fellowships. Among NPs, for example, an experienced oncology nurse must earn a generalist NP degree in family, adult, or pediatric medicine. After graduation and board certification, one can choose to do a specialty clinical rotation in oncology before working as an oncology NP independently.

Before the introduction of the APRN Consensus Model in the US, there was academic variation with a trend towards NP sub-specialization, leading to differences in standards, education, scope of practice, and regulation by school, region, state, and specialty. Since the implementation of the Consensus Model and similar models internationally, APN education, regulation, and practice has become more uniform. There are many advantages to allowing more generalized and uniform NP education including job flexibility, improved community-hospital care coordination, and lowered APN education expenses. Israel could benefit from following an established model, such as the APRN Consensus Model, which would give structure and guidance for the new NP profession.

Unlike the APRN Consensus Model, the Israeli NP model consists of independently developed sub-specialty clinical programs described above. Consequently, Israeli NP sub-specialists cannot work in other clinical areas and there is little job flexibility. Thus Israeli NPs have a limited scope of practice and limited professional mobility compared to their international colleagues.

The determining factor regarding international utilization of NP models similar to the Israeli one is whether it is a developing or developed country, i.e. whether or not the country has the education and resources to support the new role adequately, as recommended by the ICN standards for APNs. Israel is universally considered a developed country and therefore appropriate resources must be allocated to ensure appropriate education and standards for this new role. Singapore, which developed the APN profession in recent years requires a Master’s Degree, 2 years of advanced education, hundreds of clinical hours, and nursing-exclusive APN educators [128]. Israel’s NP education is primarily provided by physicians and with standards that differ from international standards. For example, the “advanced physical assessment” course for the current surgical NP students was scheduled to be a 1.5-h long lecture. The APRN Consensus Model values advanced physical assessment as part of a core curriculum – as an individual semester-long course with clinical components [64].

In Israel, the critical shortage of nurses has an impact on the advancement of nursing. Ganz and Toren (2014) report that nurses in Israel describe poor work environments attributed to poor staffing and resource allocation [37]. In fact, a major critique for developing APNs in Israel has been that the nursing pool from whom APNs can be recruited and trained, is relatively small and may be negatively impacted through APN recruitment [46, 129]. The OECD [9] disagrees with this sentiment, stating that “the development of more advanced roles for nurses is often seen as a way to increase the attractiveness of the nursing profession and retention rates by enhancing career prospects [emphasis added]” (p. 9).

In the OECD survey results, Poland, Cyprus, Ireland, and the Czech Republic agreed that APN role development increased the recruitment and retention of nursing professionals. Additionally, “improving career prospects for nurses” may result in less emigration of these healthcare professionals to more lucrative careers abroad [9] (p. 19), thus decreasing the international “brain drain” phenomenon. A review of nursing retention strategies reinforced the concepts that encouraging nursing autonomy and promoting independent practitioners were key factors in improving clinical practice environments and retention [130] (p. 88).

A recent OECD report shows that from 2000–2013 Israeli nursing ratios decreased while physician ratios remained unchanged [31]. This data shows that the national plan to address physician shortages has been partially successful thus far. The lack of a national plan to improve nursing shortages is likewise reflected in the deteriorating numbers.

While hundreds of evidence-based studies show that APPs provide high quality, equivalent healthcare when practicing independently, significant barriers continue to exist internationally, and even within different US states [94]. Although more independent practice is evolving, this is a process that will likely take several years. In assessing historical integration processes from other countries, independent practice evolved over years with the maturing relationship between physicians and APPs. Maturity appears to be an important factor in determining the success of new APP roles.

Tens of foreign-trained and licensed APPs who have immigrated to Israel, are currently unable to practice. Foreign-trained APPs represent a significant, underutilized resource in Israel. Many of these healthcare professionals continue to work abroad in order to maintain their licenses and certifications, and to provide incomes for their families. This illustrates another example of the “brain drain” phenomenon reported in the literature [4]. Many other foreign-trained APPs living in Israel are underemployed or begin new professions.

There is tremendous potential for APP utilization in Israel. Many gaps in the healthcare system can be filled by APPs. Nurturing these professions during their infancy will ensure their successful integration into the Israeli healthcare system. It is essential to not only review Israeli health policy barriers and needs, but to also understand international historical trends with regards to successful integration of these professions. Israel can proactively smooth the way for APPs by anticipating concerns and developing policies to support both professionals and stakeholders in moving Israeli healthcare into the future.

APNs promotes another level of differentiated nursing practice; advanced practice. In creating new position structures, there are opportunities for professional growth, increased salaries, and improved professional image; key factors in Israeli nursing recruitment [131, 132]. We believe that the addition of APNs 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.

We advocate that there may be advantages to grouping the roles of APN and PA into a single title of APP because of similar academic training, international role definitions, similarities of policy and regulation, and barriers to practice. While this may not be advantageous in countries with established professional roles, it may be particularly beneficial in small healthcare systems such as in Israel, where nursing self-perception is sub-optimal [133] and professional recruitment is difficult [131]. The title is not meant to diminish the nursing profession in anyway, but to raise the professional and cultural ceiling by widening the scope of shared professional practice. This title is much preferred to the title of the MOH commission that utilized the terms “physician assistants” and physician extenders in reference to APNs [46].

There is precedent for the APP title, as similar groupings exist, such as the title of “non-physician provider” used in the US and elsewhere. APP as a title may be especially applicable in settings that struggle with role perception or understanding, such as acute care settings. In primary care settings, where the focus is more health promotion oriented, the nursing model and APN title may be more appropriately utilized. In the US, PAs and NPs collaborate and work together. Many hospital practice sites employ PAs and NPs, with comparable job descriptions, pay, and scope of practice [81]. Though the training of each profession may differ, the combined effect of using both professions may be advantageous [102].

Since Israeli nurses have similar, unionized salaries in all work environments, nurses are unlikely to change jobs even when dissatisfied. Presently, there is little financial incentive for nurses to change jobs, and recruitment to areas of need is challenging. We recommend moving towards a model of offering financial incentives that has been successful thus far in improving physician recruitment to needed areas. Moreover, nursing should evolve towards free market wages to allow institutions to compensate nurses more freely, especially in areas of extreme shortage. This would also improve nursing work environment and patient safety, according to the reviewed literature [45].

As in all new projects, stakeholders must be identified before they can be engaged in understanding APP roles [88]. The MOH has not yet defined who those stakeholders are, and what the full extent of the APP roles will be. Furthermore, the MOH excluded vital stakeholders from the Committee for “Physician Assistant” [46], despite recommendations to do so from the 2010 physician and nursing manpower report [21]. For example, the Israeli Nursing Association (INA) was not part of the core committee for evaluating APP roles. The INA must be engaged in lobbying for the advancement of APN roles. Most importantly, the public, as the largest stakeholder in Israel, must be informed and educated about APPs and their successes internationally in order to promote confidence in the new healthcare providers.

Title protection and consensus is vital to ensure the security and quality control of the NP profession in Israel. It is crucial for the MOH to legally protect the title of “nurse” and “nurse practitioner” and eliminate all similar titles from national medical lexis. This will avoid role confusion and ensure that people have the stated qualifications when using the protected titles.

In Israel, general nursing education is delivered by academic institutions while the MOH Division of Nursing and the Council of Higher Education sets guidelines and monitors programs. Combining the role of education provider and regulator for NP programs, limits the MOH’s ability to objectively evaluate itself and its programs, and constitutes a conflict of interest. In the majority of countries, the providers and regulators of nursing education and clinical guidelines are rarely performed by the same organization. Moreover, in the current state, there is less opportunity to educate larger numbers of NPs, as the MOH has limited resources. Accordingly, most APP programs in developed countries are based in graduate academic settings.

We therefore recommend that NP education in Israel be consistent with international standards of developed countries. The MOH should be responsible for transparency in setting academic and clinical standards for NPs to qualify for licensure. The MOH must maintain its objective role as regulator for NP standards of practice, and overseer of NP licensure and certification. NP education must be delivered through graduate academic clinical programs in institutions offering a master’s degree in nursing. The Council for Higher Education should monitor NP academic program delivery, as they do for all academic degrees.

Foreign-trained APNs with years of experience could bring maturity into a profession currently in its infancy in Israel. We believe that these professionals should be integrated into the healthcare system, by facilitating a pathway for their recognition and licensure. Foreign-trained APNs can be utilized as role models and may expedite the integration of NPs into healthcare settings. Benner’s Novice to Expert theory of nursing supports the notion that experts develop over time with experience and education [134]. Expert nurses who take NP coursework - become novice NPs. Expert nurses are unable to teach NP clinical skills. Likewise, physicians, who are presently the primary educators of NPs in Israel, are unfamiliar with expert NP practice and roles. They are unable to teach NP role integration and the nursing-medical bridging required to become a proficient NP. Overall, clinical maturity of NPs in Israel is limited by not taking advantage of expert mentors such as experienced, foreign-trained NPs who already live in Israel.

Although a long-term goal for APP independence in Israel should exist, the reality is that a team approach linking physicians and APPs may be a more realistic and culturally competent short-term solution. Introducing APPs as team members is less threatening to physicians who are used to being the sole medical care providers. NPs working in teams may help reduce barriers to practice, improve designation of new professional boundaries, and facilitate the integration of new professions into healthcare settings [135]. In the Netherlands, a deliberately slow integration of NPs into primary care has led to physician support for primary care NPs. The evidence supported the shared team-based model with regard to beneficial interdisciplinary processes and patient outcomes [86] (p. 84).

The extreme shortage of anesthesiology services in Israel impacts many fields and has a high cost in terms of patient morbidity and mortality due to delayed surgeries. Considering the data reviewed, establishing the CRNA in Israel would be a relatively fast (2–3 years) way of improving accessibility to anesthesia services, especially in the periphery. CRNAs, as opposed to paramedics with a 1-year course (suggested by the 2013 MOH committee) [46], have the strongest, time-tested evidence-based practice in terms of patient safety, quality of care, longevity, and ability to work independently. CRNAs have been shown internationally to provide equivalent care to anesthesiologists. CRNAs in Israel will not replace anesthesiologists, but will extend the reach of anesthesiologists in Israel. One anesthesiologist could monitor several surgeries at once while CRNAs provide anesthesia services in the operating room, seeking physician consultation as needed. We therefore recommend that the MOH prioritize CRNA programs to improve patient accessibility to safe, quality anesthesia services as soon as possible.

Finally, the enormity of the worsening nursing shortage in Israel must be mitigated through an elimination of bureaucratic barriers, increasing the number of nurses in the healthcare workforce, and an improvement of the public’s professional nursing image, which NP development may help [131, 132]. The integration of APPs into the healthcare workforce is the most expeditious, evidence-based approach of alleviating the physician shortage in Israel. Since the NP role has already been initiated into the healthcare system, albeit on a very limited scale, it is reasonable to suggest that these 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.

Our investigation notes a gap in the literature regarding international comparative reports on APP professions. In a global world, with emigration being a commonplace phenomenon, increasing the clarity by understanding the processes and challenges by which healthcare professionals are recognized, educated, and integrated into their countries of choice may help to expedite the process towards licensing and gainful employment. No studies have evaluated foreign-trained APPs living in Israel. Future pilot studies could be initiated to assess the integration of foreign-trained APP immigrants to Israel. Other studies should include interviewing key policy makers as to their general attitudes towards APP integration into the Israeli healthcare system. It would also be useful to study how the training of APPs is financed in other countries and to consider the pros and cons of various options for how such training could be financed in Israel.

The economic impact of NPs in Israel also cannot be assessed as there are too few NPs currently working in Israel. In the US, NPs, PAs and CRNAs were found to be cost-effective providers, but this may be different in Israel where socialized medicine has produced lower overall salaries in the healthcare field. Future study of the health economics of NPs and other APPs in Israel is essential. Finally, patient health scores for those with chronic diseases could be assessed before and after the introduction of APPs into specific clinical settings; similarly, patient, nurse, and physician satisfaction of care could be reported as the new role is introduced.

As international economic comparative studies between APNs, PAs, and physicians may not apply to all countries – in depth analyses are needed in Israel to evaluate the cost-effectiveness of the new professions, including direct and indirect comparative cost. This is particularly vital as Israel, like all countries, must justify spending and budgets in healthcare and seek more resource-friendly options.

Even though international literature has shown consistent positive comparative quality and outcome results between APNs and physicians, these studies must be repeated in Israel to show the effectiveness of NP delivery of quality care. These studies will also strengthen the argument for supporting other APP professions and expanding current levels of practice.

Many European countries have started APN education programs in recent years [97], limiting the availability of research from those countries. Although we attempted to include as much relevant data from a wide range of countries, a majority of the literature originates from English-speaking countries, which has been acknowledged by other international researchers [9].

Authors respectfully acknowledge their status as Israeli RNs who remain unrecognized, foreign-trained, licensed, and certified nurse practitioners living in Israel.