International Women’s Day: women in health innovating for change

The theme for International Women’s Day 2019 – “Think equal, build smart, innovate for change” – underscores the important role that women and girls have in building more inclusive systems, efficient services and sustainable infrastructure to accelerate the achievement of the Sustainable Development Goals.

In the WHO European Region, women make up the majority of the health workforce, having surpassed the 50–50 gender breakdown for physicians and other segments of the health workforce. Indeed, health systems in the Region simply could not function without the contribution of millions of female health workers.

However, gender inequalities still persist, and female employees face significant barriers in terms of achieving leadership positions, accessing income equality and overcoming gender stereotypes about the sorts of health-care roles women generally fill.

Moreover, the burden of informal and/or unpaid health care falls disproportionately on women in the Region, with women performing 3 times more unpaid work than men.

Despite these remaining challenges, women leaders in the health sector are a particularly powerful force innovating for change by helping to build strong health systems and finding solutions to improve the lives of the people they serve.

Tikva, a nurse from Israel, is among the pioneering nurse practitioners in palliative care in her country. Her story illustrates how one brave and committed innovator can have a far-reaching impact.

As Shoshy Goldberg, Chief Nursing Officer in Israel, says, “Nurse practitioners like Tikva are leaders with vision who provide health services that encompass clinical expertise, empathy and caring. They create an environment of safety, quality care and collaboration with doctors, and also empower patients to be active participants in their own care.”

Tikva’s story

I have been a nurse for more than 30 years now. I started working as a nurse in the oncology ward while I was a medical student, studying to become a physician. This encounter with nursing made me fall in love with the profession. I realized that I had a passion for the care of patients, for physical and hands-on work. It became clear to me that I would be a much better nurse than physician.

Forging a new path in palliative care

Since graduating in 1991, I have held clinical, educational and managerial roles in the nursing profession. But frankly, I disliked managerial roles and was not very good at them. I had to find out the hard way that I’m not meant to be a manager.

I also discovered that, as an oncology nurse, I cared deeply about working with cancer patients who could no longer benefit from treatment. I often faced the question of how to prepare and communicate with these patients, which led me to take a basic course in palliative care. I wanted to better understand how to support these patients and ease their suffering.

After the basic course in Israel, it was by chance that I came across and enrolled in a 200-hour WHO course in palliative care in Kerala, India, and this was my introduction to what has today become my primary area of work.

I then got a master’s degree in palliative care from the United Kingdom – the degree was not available in Israel – and went on to do a doctorate in nursing related to advance directives. These directives tell health-care providers and family about the medical care a person would or would not want if the person became terminally ill and was unable to speak for themselves.

When I started working for the Sheba Medical Centre in 2010, I was one of the pioneering nurse practitioners in palliative care and worked in both adult and paediatric hospices. We started the palliative care service in 2013 as a very small team – in addition to me, there were 4 part-time physicians, none of whom were specialized in palliative care, and 1 other nurse. We also had the support of the psychology service in the oncology centre.

It started as a pilot project for patients with pancreatic or lung cancer, but it quickly grew and spread throughout and then beyond the oncology ward to more general wards, such as the internal medicine and surgical wards where many cancer patients are hospitalized in acute events or when they deteriorate.

Our colleagues working on these general wards had neither the knowledge of symptom management and relief nor the understanding of how to properly communicate with a patient whose condition is changing, usually for the worse, to prepare them and their family for a decline in their condition – or even the end of life.

We were quickly embraced by the teams from the general wards, probably because we gave them answers to very profound questions and filled an important gap.

Today, we are a much larger team, including 7 nurses, 6 of whom are nurse practitioners in palliative care. We also now have 5 physicians, 2 of whom are specialized in palliative care, another who specializes in pain, a psychiatrist and a family physician. We have psychologists, social workers, a dietitian and a chaplain.

Palliative care is provided through interdisciplinary collaboration. We have really grown a lot in these 6 years and we have helped our colleagues understand the value and importance of palliative care.

Our work in oncology is very tailored to the individual; we provide very specific care to every patient. On a day-to-day basis, I do consultations with patients most of the day, and these can last from 30 minutes to more than 2 hours.

An important part of our work is also educating the teams of health professionals that we collaborate with – nurses, social workers and physicians alike. In some ways, I think that this is the most profound work that we do in the field, and providing basic palliative care needs to be part of every physician and nurse’s practice in the future.

I must say that I really see a change in the culture of the practice. Young physicians should learn their discipline alongside a better understanding of the palliative care concept. Physicians are gradually becoming more open to the discussion with patients about their wishes, about their preferences and fears. I don’t think we have reached the point where we are satisfied yet, but I can look back and see that something very meaningful has occurred in these 6 years.

Sheba Medical Centre was just accredited as a centre for specialization in palliative care medicine, and I am thrilled about that, because it means we will be learning new things and opening new areas of cooperation with other non-oncology specialties.

A leader – but also a listener

A nurse leader does not have to be someone who sits behind a desk or manages a large team. You can be leader out on the front lines of care, too. I think that every nurse leader, especially one working with palliative care, needs to be very empathetic with patients and colleagues alike, very gentle in the way we offer help. We need be very good listeners, much more than talkers. We need to be very attentive to the dynamic of our communication with the patient.

Finally, I think we need to be humble – humble enough to be critical of our own work, as well as to take criticism from others and view it as important feedback. This is vital in palliative care, which is a multidisciplinary environment.

I feel fortunate to be doing this work – I view it as both my duty and a pleasure.