With increasingly depleted workforces across Europe, Paul De Raeve from the European Federation of Nursing Associations posits the urgency to address the registered nurse shortage, and the consequences of political inertia.
Based on the requirements within the European Pillar of Social Rights, efforts to increase the availability of qualified professional nurses can secure timely and accessible healthcare to European populations, if adequately prioritised. The COVID-19 crisis has exposed a lack of policy coordination and funding in the area of workforce planning, along with an absent future-proofing effort for the nursing workforce. It is both disappointing and striking to realise that the European Union (EU) and its Member States did not implement the policies that would have made Europe’s health service more resilient.
The COVID-19 pandemic has shown that our European health services were not resilient enough: the healthcare and public health systems must learn from this very difficult lesson. On an EU-wide basis, policies must be developed, rapidly funded, and implemented to secure enough nurses and to expand their roles, increasingly required within evolving health services; the safe provision of professional nursing care is paramount to achieve optimal patient care, at every level of healthcare delivery. The EU must require Member States to invest in building a resilient nursing workforce to protect Europeans, and this is most effective by requiring evidence-based measurement tools to determine sufficient and safe registered nurse staffing and funding for the implementation of staffing adjustments.
The short and long-term resilience of the EU health service depends upon having a reliable workforce of available nurses, compared to the frontline needs, to guarantee quality and safety. Resilience can only be achieved if the EU educates and trains enough nurses in line with Directive 2013/55/EU (Article 31) and if those general care nurses can apply their care responsibilities in safer working conditions.
COVID-19 brutally exposed the structural weakness of the EU healthcare systems, revealing the risk of becoming a ticking time bomb for quality and safety: collapsing healthcare systems in the EU will be the result if nurses keep leaving frontline jobs due to exhaustion, unsafe working conditions and unacceptable low salaries.
EU hiding itself behind subsidiarity
The European Federation of Nurses Associations (EFN) engaged in the EU Health Workforce Agenda in 2008 through the Green Paper on the EU Workforce for Health (De Raeve, 2011). In 2010, EFN moved the health workforce up the political agenda of the European Parliament, launching a written declaration (n°40/2010) that was presented to the European Parliament. The key points of this declaration were to ensure that there is sufficient comparable data for EU-wide health workforce planning and that effective and sustainable recruitment and retention strategies in the health sector are established. On these two key points, nothing happened as the EU institutions hide behind subsidiarity.
Health professionals need to have access to continuing professional development (Directive 2013/55/EU); their present and future professional qualifications must meet agreed criteria. The declaration promotes the role of health professionals in identifying and implementing strategies that facilitate professional and knowledge mobility; concurrently, it recognises health professionals’ contribution to achieving optimal health outcomes. The Council Conclusions provided a pathway for the 2011 and 2012 EU Presidencies to create several policy initiatives on the EU workforce, among which the Action Plan on EU Workforce for Health in 2012 and the Joint Action on EU Health Workforce in mid-2013, which was renewed in 2022. The same captains, the same soldiers, but no changes to frontline nurses’ ratios, instead, a worsening situation described by WHO as “the ticking time bomb”. All these efforts on planning the workforce at the government level have led to nice ideas, deliverables, and research careers, but nothing for frontline nurses.
However, the EU institutions could do better to address the registered nurse shortage in the EU. Millions have been spent, without any visible change frontline. In contrast, the registered nurse shortage is getting worse and worse, until the last final option remains: frontline nurses leaving frontline nursing care. The lack of workforce policy support led to nurses now leaving bedside nursing care. For many young and experienced nurses, ‘enough is enough’, and as such general care nurses leaving nursing, even leaving the register. Nurses in the EU, and Europe more generally, are leaving the workforce at an unprecedented pace which will lead to healthcare systems in the EU collapsing. Patients will suffer from a lack of registered nurses and lesser qualified and even unqualified workers taking over their tasks. This is a very risky workforce policy development leading to downgrading quality and safety, with potentially serious consequences for patients. Fewer nurses mean units will need to merge, and hospitals will need to close down. These developments will impact the medical profession, being a wake-up call.
Accurate definition of data collection for nurses
This silent resignation will become the next public health pandemic in the European region. EFN has continuously emphasised that the use of International Labour Organisation (ILO) data that relies on the International Standard Classification of Occupations (ISCO) 08-code is not appropriate for planning nurses’ needs. We are losing our frontline nurses while civil servants and researchers are planning and forecasting with ILO data that does not make sense! Using the ISCO 08-code for nursing care leads to inaccurate data collection, inappropriate comparison of the nursing workforce and, finally, unrealistic planning for the future. It is impossible to plan with unreliable, inflated, data.
However, for many years now EFN has been in discussion with the WHO, EUROSTAT, and ILO, to change the definition of the nursing profession and the related occupations as described in the ILO’s International Standard Classification of Occupations (ISCO-08).
It is key that EFN and ICN get more reliable data for more accurate workforce visualisation, and that the ILO data collection and review of the ISCO classification remains open to revision. EFN and ICN have been in close contact with ILO and have already written twice to them on this topic. The lobby work of ICN and EFN strengthens as a result of these fruitful collaborations. EFN members play a key role in these negotiations, by checking the number of nurses reported by their governments in the WHO State of the World’s Nursing report, and by pointing out any discrepancies in the data. These localised actions further support EFN and ICN in this effort for more accurate data collection.
Importantly, EFN members remain concerned that a task-based approach in delivering nursing care would lead to thinking about nursing care as a production line with discrete tasks assigned to workers with specific skills to complete a task. However, this approach does not recognise the overall responsibility and accountability for care delivery, the complexity of clinical decision making and multiple and interrelated variable factors influencing health and the safety and quality of outcomes of care. The assessment, planning and evaluation of care (Article 31 Directive 2013/55/EU) are as critical as the implementation of care: together they account for the process of nursing care for which general care nurses are both educated and regulated to deliver.
The task-based approach to ILO definitions, combined with the absence of reference to educational preparation, regulation and decision-making responsibilities are the main fundamental flaws in the ILO definitions.
European Global Health Strategy
Given the impact of the COVID-19 pandemic on the global nursing workforce and the scale of nursing shortages that the world is now facing (Sustain and Retain, ICN 2022), EFN strongly believes it is important to review the data definitions and provide further guidance to countries to ensure that the nursing workforce recruitment, retention and future planning is based on a more precise understanding of the size and composition of the nursing workforce.
The massive resignation of frontline nurses leads to the political and professional discussion on developing and implanting patient-nurse ratios in national and European legislation. The challenges inherent in nursing lobbying and in solving the registered nurse shortage relate to not having an agreed nurse/patient ratio at the EU level. The challenge lay with reaching a consensus at the EU level regarding different workforce plans and strategies and doing so in a way that will be beneficial to all EFN members. For instance, in Finland, there were some severe cases of missed care and so in 2020, there was a law introduced to set minimum staffing requirements in elderly care facilities.
However, given the registered nurse shortage in Finland, it is not possible to meet this law and so its implementation has been postponed for a year. Recently in Malta, three cases with negative patient outcomes were reported because there were not enough nurses to provide safe care. Unfortunately, these Maltese nurses were put in front of the Court, while instead, the low implemented nurse-patient ratio should be in Court, not the nurses.
The blame for poor care is gradually shifted to nurses when the shortage is not something within their control. At the EU level, this is a complex issue because nurses have different competencies in different countries which each have different numbers of other health professionals. Therefore, it will be key to look into the ways and methodologies for calculating minimum nurse-to-patient ratios in the different EU countries.
The EFN policy statement on safe staffing is a starting point for sharing experiences among the different countries. There is available evidence showing this is a public health and patient safety issue and more needs to be done at the EU level to protect nurses, guarantee quality and safety, and secure access to healthcare. It is paramount to collect all the available evidence from the different countries to make them readily available to policymakers at the EU level.
Therefore, it is key to holding the pen on the global health strategy. A new EU Global Health Strategy is being shaped, with a European Commission communication to be released before the end of 2022. The Strategy will steer the European community’s action points up until 2030. Different speakers at Gastein, such as the Commission’s DG SANTE Director General Sandra Gallina, and the young Gasteiners, together with the European Health Parliament members, made it very clear: the health workforce needs to be our top political priority in the Global Health Strategy.
Indeed, as Dr Ilona Kickbusch rightly summarised: “This is really a historic meeting… Twenty years ago was the very first time there was any talk of a European global health strategy”, and it took place as a dialogue between Commissioner Burn, the first Commissioner for Health, and many health stakeholders, including EFN. But Ilona Kickbusch also recalled: “But then it disappeared” till 2010 and it needs a COVID-19 pandemic to be picked up again! Two decades down the road led to many frontline nurses leaving the profession.
The WHO European Region registered nurse ‘time bomb’
The registered nurse shortage in the health workforce is the most critical silent crisis threatening progress on global health agendas worldwide, and the EU strategy is no exception. Sandra Gallina clearly said in Gastein: “The health workforce is at the end of its tether,” and continued saying: “That is the crude reality. They are very tired. There is a crisis…
“We need to stop being in this reactive mode. I am fed up that we in health are forced into reaction mode all the time. We wait for something to hit us in the head, and only then do we react.”
Hans Kluge is on the same page by adding health workforce to his political priorities. Rightly so! Indeed, health ministers come and find the WHO Regional Director indicating they have sleepless nights because they have no nurses. The most recent WHO report ‘Health and care workforce in Europe: time to act’, identifies ten actions to strengthen the workforce and raises questions on what impact these recommendations will have on solving the shortage of nurses. The report repeats the many demands of EFN and health stakeholders to recruit, and more importantly retain, nurses.
Strategic actions to attract and retain health workers in rural and remote areas are too limited. As an emergency priority, the EU should immediately focus on supporting Member States to ensure adequate domestic training capacity, and to improve the retention of domestically educated nurses. This requires a commitment to support safe staffing levels and ensure Member States and employers are not ‘robbing Peter to pay Paul’. Dangerously low levels of registered nurse understaffing have been a major problem in many health systems during the pandemic and are the driver for the increased outflow of nurses. Improving the retention of nurses and the attractiveness of a career as a registered nurse, through the provision of fair pay and better conditions of employment, will be essential to keep experienced nurses in the profession. Therefore, WHO action five calls for working conditions that promote a healthy work-life balance and the workforce’s health and wellbeing (WHO, 2022, p.64). Actions 4, 5 and 6 are key to keeping nurses in the nursing profession and stopping the ongoing ‘silent resignation’ (WHO, 2022, p.63). But all these actions will not have any impact if there is no public investment in workforce education, development, and protection.
So, let’s hope Galina and Hans will convince health and finance ministers to find a solution to keep our current nurses in the profession and to bring new, young people into the nursing profession. This is the political priority; the rest is all nice to have! “The time to act on health and care workforce shortages is now” (WHO RC, Hans Kluge). European governments needed to invest more money in the workforce and invest it better. The report recommends developing policies that protect the health workforce by placing its interests and wellbeing at the centre of economic and social recovery from the pandemic.
In conclusion, the European Commission and WHO Europe need to focus in synergy on progress in Member States by linking workforce resilience to the EU Recovery and Resilience Facility, as they do for the digitalisation of the healthcare sector, with a threshold of 20%! The EU Recovery Plan, the EU’s post-pandemic economic aid program, should focus on the recruitment and retention of frontline nurses as they suffered most from the crisis. If many targets and milestones need to be met to unlock the billions, why not add the nurse-patient ratio to secure quality and safety to the program targets and milestones? Expenditures of these EU recovery funds should become conditional on the provision of optimal working conditions, including better pay for frontline nurses.
Failing to retain frontline nurses will render the EU and Europe ill-prepared for the years ahead. Investment in nurses’ recruitment and retention to reduce European labour and skills shortages further should be a key political and economic priority. Failing to do so would have severe social and economic consequences for the EU, Europe, and its Member States.
- EFN Position Statement on Consequences of nurses shortages in public health (EFN GA October 2020) https://efn.eu/wp-content/uploads/EFN-Policy-Statement-on-Consequences-Nurses-Shortages-in-Public-Health-Nov.2020.pdf
- Health and care workforce in Europe: time to act. Copenhagen: WHO Regional Office for Europe; 2022. Licence: CC BY-NC-SA 3.0 IGO.
- Aiken L et al. (2008) Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes, Journal of Nursing Administration, 38(5). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2586978/
- Aiken L et al. (2016) Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. www.qualitysafety.bmj.com/content/early/2016/11/03/bmjqs-2016-005567.full.pdf
- Aiken L et al. (2021) Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. https://www.thelancet.com/journals/lancet/article/piiS0140-6736(21)00768-6/fulltext
- EFN Workforce Matrix 3+1 http://www.efnweb.be/?page_id=8220
- EFN Workforce Matrix 3+1 Executive Summary http://www.efnweb.be/wp-content/uploads/EFN-Workforce-Matrix-31-Executive-Summary-May-2017.pdf
- The State of the World’s Nursing 2020 https://www.who.int/publications/i/item/9789240003279
- Directive 2013/55/EU of the European Parliament and of the Council of 20 November 2013 amending Directive 2005/36/EC on the recognition of professional qualifications and Regulation (EU) No 1024/2012 on administrative cooperation through the Internal Market Information System (‘the IMI Regulation’) EUR-Lex – 32013L0055 – EN – EUR-Lex (europa.eu)
- Sustain And Retain in 2022 and Beyond. The Global Nursing Workforce and the COVID-19 Pandemic. https://www.icn.ch/news/new-report-calls-global-action-plan-address-nursing-workforce-crisis-and-prevent-avoidable
- Evidence based Nurse Staffing. ICN Position statement https://www.icn.ch/sites/default/files/inline-files/PS_C_%20Evidence%20based%20safe%20nurse%20staffing_1.pdf
- Nurse Staffing Levels for Patient and Workforce Safety ICN and Saudi Patient Safety Centre 2019 https://www.icn.ch/sites/default/files/inline-files/WHITE%20PAPER%20on%20Nurse%20Staffing%20Levels%20For%20Patient%20Safety%20and%20Workforce%20Safety_1.pdf
Prof Dr Paul De Raeve, RN, MSc, MStat, PhD, FAAN
European Federation of Nursing Associations
This article is from issue 24 of Health Europa Quarterly. Click here to get your free subscription today.