Nursing in Israel: Life as a Kibbutz Nurse

Peggy Dryden, RN, MSN, MBA

Disclosures

September 09, 2002

Introduction

The third article in our series, "eLetters: Corresponding With Nurses," takes us to another politically charged country of the world -- Israel. We have been fortunate to hear from Nancy Yettra RN (Figure 1), who has lived on Kfar Blum kibbutz since 1986 and has spent several years as a kibbutz nurse. In this interview, Nancy shares her story.

Nancy Yettra outside the clinic.

We welcome your recommendations of other nurses we should interview for this series. We are looking for nurses doing unusual jobs or practicing in unusual situations or settings. Please contact the editor at nurse-editor@webmd.net.

Question: As an RN in Israel over years, how would you describe your role as a kibbutz nurse? How did it evolve during those years? How did the political environment affect your ability to fulfill your role?

Answer: Israel has always been an important part of my Jewish identity. I spent my childhood years in a West Los Angeles Reform Jewish community. In 1969, at 18 years old, I came to Israel to attend an "Ulpan", which is an intensive Hebrew study program. I returned to the United States to my studies at the University of California, Davis and completed 2 years of prenursing requirements. In 1971-1972, I visited Israel again. I decided to attend, for 1 year, the nursing school associated with HaSharon Hospital in Petach Tikva. After that year at HaSharon, I returned to the United States and completed my BSN in San Francisco in 1975.

I have lived in a variety of places, including Lincoln, Nebraska, where I started my career in emergency department (ED) nursing. I returned to California and worked in a variety of ED settings in the San Francisco Bay Area, and obtained certification as a Certified Emergency Nurse (CEN). I worked in the kibbutz clinic from 1989 to 1999, while more recently I have been employed in the ED of the Poriyya hospital near Tiberias.

When I began working at the kibbutz clinic in 1989, I didn't feel sufficiently acquainted with the Israeli medical system to want to jump into ED nursing right away. I had a young child and didn't want to work far from the kibbutz. Kibbutz nursing and ED nursing are very different. ED nursing involves patient contact of short duration and with little or no follow up. Kibbutz nursing is almost the exact opposite; it means knowing your patient population very well, in fact too well at times. The rewards of following up on the long-term care of various acute and chronic cases are of a different quality than those of the ED setting. Kibbutz nursing was quite an adjustment for me.

A kibbutz is a communal farm or settlement in Israel. Our kibbutz, located in Upper Galilee (Figure 2), is a community of about 500 people that includes members and their children, residents who rent apartments, and volunteers who are usually young people from all over the world who come to work and stay for short periods of time while traveling around our area of the world. The kibbutz nurse is responsible for the healthcare of the whole population and, in many ways, functions as a nurse practitioner (NP), although in Israel as of yet there is no such well-defined role.

Jordan River.

Our clinic (Figure 3) is a part of the Israeli medical health system that functions through various HMO-type organizations, the oldest of which is the Clalit Health Services, which is also the one with which most kibbutzim are associated. The clinic provides primary nursing and medical care for all age groups in a family medicine-based practice (Figure 4). The physician, who works closely with the nurse, receives patients 3 times a week for a total of about 7 hours weekly. The nurse's role includes perinatal care and well baby care, including immunizations, follow-up of chronically ill patients, and a broad range of health education topics.

Michalin Clinic.

Clinic treatment room.

Question: What is a typical day like being a nurse on the kibbutz? What kinds of health-related activities do you perform? How would an acute case be handled?

Answer: A typical day begins with the reception of patients invited for laboratory tests. This includes venipuncture for blood collection and preparing blood and other laboratory specimens to be sent off to the laboratory in Tiberias, about an hour away. (In the not too distant past, our laboratory test results would be received after quite a long time by mail, sometimes too late for them to be relevant. Today, things have improved dramatically, and we receive the test results by email and fax in a timely manner.)

Currently, the program also receives patients who have acute medical problems as well as school children before they go off to school. The kibbutz nurse follows a set of protocols or standing orders that the physician has signed. These protocols include diagnosing and treating urinary tract infections (UTIs), strep throats, and other common problems. In the case of something more urgent or not covered by the protocols, the nurse can consult by telephone with the physician or, as an alternative, send the patient to the town nearby for evaluation by a physician at the main clinic.

The clinic in Kiryat Shemona provides specialty services such as a surgery clinic; OB/GYN services; dermatology; audiology; pediatrics; ophthalmology; physical therapy; occupational therapy; ear, nose, and throat; and rheumatology, as well as radiology and ultrasound facilities. Our kibbutz clinic has a fairly extensive pharmacy, and the nurse in effect acts as both NP and pharmacist for the cases that are within her treatment repertoire. We receive a monthly medication supply that consists of individual patients' chronic medications and a general clinic supply for our day-to-day use. We are also provided with pharmacy services from Kiryat Shemona on a daily basis as needed.

Throughout the morning, the kibbutz nurse is busy charting and dealing with test results that have arrived by email or fax. In addition, the nurse receives patients who come in to get their monthly medications, who may need wound care or other treatments, or who report back after having been to various imaging tests or medical specialists. A lot of our time is spent explaining to patients the recommendations of the specialists and the significance of their test results. Confidentiality issues arise in kibbutz nursing, as it is common for people to inquire about the health of other patients and, of course, this sometimes includes parents of adult children inquiring or friends and neighbors inquiring, all out of concern and caring. It is very important to maintain patient confidentiality in such a small community. Unfortunately, this isn't always understood by the people inquiring.

An important part of our day includes making house calls to patients who are unable to come into the clinic. Our kibbutz has a large population over the age of 80 years. There is also a small nursing home facility (Figure 5) on the kibbutz, with 18 beds, providing around-the-clock nursing care.

Beit Kassif Nursing Home.

A perinatal care and well-baby clinic are available as part of the national health service. The clinic is staffed full time by the kibbutz nurse, along with a pediatrician who arrives for well-baby check ups on an as-needed basis. (In the urban areas of Israel, the well-baby clinic is a service that is separate from the HMO clinics and is held in special government clinics.) The well-baby nurse is responsible for various developmental evaluations and routine immunizations of all children from birth to age 5 years. Visiting the 5 year olds in the familiar setting of their kindergarten is usually the best place to perform the 5-year developmental evaluation.

During the afternoon hours, the kibbutz nurse continues to receive patients and to finish up paperwork and order medications. Some days, the physician receives patients in the late afternoon, and one nurse will accompany the reception and also receive patients. The kibbutz clinic is open 6 days a week and open in the evening at least twice a week, allowing people who work outside the kibbutz access to health services.

The kibbutz clinic is staffed with 1 RN working a 30-hour work week, whose salary is paid by the HMO. The kibbutz, which has traditionally placed a great emphasis on health and education, provides for an additional full-time RN, helping to reduce burn out. (Our kibbutz provides for the extra 40-hour RN and pays her; the HMO pays me a salary for 30 hours only. My salary goes to the kibbutz, since I am a member. Every kibbutz determines for itself how many nurses it wants to work in the clinic. The HMO provides for a nurse according to the number of patients listed for that clinic. Some kibbutzim let that be the only nursing staff, while other kibbutzim have a lot more staff than we do.)

In addition, the kibbutz nurse provides extended services. Kibbutz nursing services cover the patient from "the cradle to the grave." These services include health education for all age groups on such topics as hygiene, diet, family planning, and preventing STDs. In addition, hospice care is provided for terminally ill patients. The kibbutz staff have worked closely with the Hospice of the Upper Galilee, founded by Nancy L. Caroline, MD, who wrote the paramedics bible, Emergency Care in the Streets.

As the nurse who is also a member of the kibbutz, I have served on various kibbutz committees such as the welfare committee, the community council, and the committee that helps members with discreet problems such as psychological support and counseling. While we do have the services of a social worker, she works only 1 day a week. Frequently, it falls to the nurse to fulfill the social work role as well. We also serve as advisors to the children's houses in regard to hygiene and diet for the various age groups.

Question: Could you describe how you handle services after hours and emergencies?

Response: Historically, the clinic nurses shared on-call duty after clinic hours and were reached by kibbutz members requiring emergent or urgent care by cell phone (and before the age of cell phones, by walkie talkie). Currently, the kibbutz contracts out to a company who provides medical coverage after clinic hours and on Saturdays and holidays. The 24-hour nurse on-call work was very expensive for the kibbutz and a huge factor in staff burn out.

In the case of an acute emergency, we have emergency supplies for most cases, including medications, oxygen, and a Club Car (a small utility vehicle) so that we can get to any place on the kibbutz where we are needed. We have at our disposal the services of a mobile intensive care unit (MICU) based in Kiryat Shemona, which is just 7 kilometers away. Paramedics from this unit usually are able to respond to a call within 5 or 10 minutes.

This mobile ICU is staffed with both a paramedic and a physician and it is equipped for any trauma or medical emergency. The MICU is part of the Red Magen David station -- the Israeli counterpart of the Red Cross. Red Magen David is also associated with the satellite ED in Kiryat Shemona, which is a part of the Sieff Hospital in Tzfat, a city about 45 minutes away. Because of our distance from the hospital, the MICU is an essential part of the emergency services in our area. In the case where an MICU is not necessary, we have access to a regular ambulance (Figure 6) that serves 4 kibbutzim and is staffed by kibbutz members who serve as ambulance drivers and emergency medical technicians on a part-time rotational basis. This ambulance has on board a semiautomatic defibrillator for our use as needed until an MICU can arrive.

Clinic and ambulance.

Question: Could you describe a few scenarios to illustrate your most harrowing and/or rewarding moments?

Answer: A couple of situations come to mind. First, in 1991, when the Gulf War broke out, Israel was being shelled by Iraq. The threat of chemical warfare was very real. In fact, the night the war broke out, we were awakened by a phone call from relatives in the United States who informed us that the shooting had started. The next night, when the Scud missiles started to fly, we also got a phone call from relatives in the United States who informed us that CNN was reporting that the missiles had fallen in Ramat Gan (near Tel Aviv and far from us) and that they were chemical in nature! Fortunately, the chemical part of this report proved to be false, but the war continued, and we spent a lot of time in our sealed rooms with gas masks; the stress level was very high during that time. As we were frequently unable to leave our sealed rooms, medical questions did arise. Luckily, we made it through that war with no real emergencies during the missile alerts.

Second, during Operation Accountability and Operation Grapes of Wrath, when the Hizbollah were shooting katyusha rockets toward us from over the hill in Lebanon, we had to sleep in the bomb shelters. (There are bomb shelters scattered all over the kibbutz. In time of war, a shelter (Figure 7) near the clinic serves as the clinic and field hospital.) During the Grapes of Wrath campaign, our living room window was shattered by a katyusha that fell nearby. (We were, thankfully, not at home.)

Shelter with playground on top.

In 1999, our area was again shelled and 3 people were injured nearby. It was early in the morning, and we had instructions to stay at home in our security rooms, but Israelis being Israelis, we went out to work anyway. I was called out to treat the injured until the emergency services from Kiryat Shemona could arrive. When I got to the scene, the dust and smoke and rubble was all around. The most seriously injured person had sustained chest and arm wounds from shrapnel. Fortunately, the wounds were not too deep, though he required surgery. I made do with field dressings and was about to start an IV when the MICU arrived and took over. The other 2 people had less serious injuries, though after seeing the damage to the area involved, I couldn't believe that they weren't killed or more seriously injured. This was really treatment under fire... at any time another katyusha could have made its way over the hill toward us again.

Question: How does the political situation affect your work?

Answer: It is important to note that Kfar Blum is situated in the finger of the Galilee or the Upper Galilee panhandle -- the very north of Israel, which is nestled between the Golan Heights and Syria on one side and the Naftali mountains and Lebanon on the other. While we are in a beautiful setting, it is at times also a dangerous one. At the present time, we are enjoying a period of relative quiet as opposed to the center of the country where the terrorist attacks are almost a daily event.

Question: There may be some nurse readers who are considering a position on a kibbutz. For nurses outside Israel considering a similar experience to yours on the kibbutz, what advice would you give them? What should they do to prepare for the experience? What are the pros/cons of such a position?

Answer: Most kibbutzim look for nurses who are fluent in Hebrew and who are familiar with the Israeli medical system, as well as being willing to work and live on kibbutz for a significant period of time. It takes quite a while to become accustomed to the way things work here. It may be possible to contact the TAKAM, the United Kibbutz Movement offices in Tel Aviv; they would know if any kibbutz is looking for a nurse. (TAKAM contact information can be found at http://www.ketura.org. il/vol1.html.) Getting an Israeli nursing license is often a bureaucratic nightmare, however. Even though I had sent all my licenses and credentials way ahead of my arriving in Israel, it took almost 6 months to get my official license from the Health ministry. I strongly recommend that anyone interested send the required paper work way ahead of time. Make copies (lots of copies) of any credentials that might be relevant, including letters from previous employers, as seniority -- counted as years of actual nursing work -- is a very important component of a nurse's salary here.

Thank you, Nancy, for telling your story. Readers interested in contacting Nancy Yettra may email her at nyettra@hotmail.com .

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