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<p>The vast majority of European countries are struggling to embrace nursing as a profession and as a science. There are still not enough nurses with bachelor’s degrees and advanced practical skills, and clinical specialisations for nurses are being developed at the master’s level. Attention should be paid to recognising nurses as an equal healthcare workforce who need to be empowered to advance their profession and be provided with professional development opportunities. Changes needed include improving pay and working conditions, providing opportunities to improve skills and professional recognition, empowering nurses to deliver care, and harnessing the power of technology to better support nurses. The declining interest in nursing education and the often stereotypical and condescending view of the role and work of nurses on the healthcare team should be a warning signal to all who are working on healthcare reform.</p>
</abstract>

The vast majority of European countries are struggling to embrace nursing as a profession and as a science. There are still not enough nurses with bachelor’s degrees and advanced practical skills, and clinical specialisations for nurses are being developed at the master’s level. Attention should be paid to recognising nurses as an equal healthcare workforce who need to be empowered to advance their profession and be provided with professional development opportunities. Changes needed include improving pay and working conditions, providing opportunities to improve skills and professional recognition, empowering nurses to deliver care, and harnessing the power of technology to better support nurses. The declining interest in nursing education and the often stereotypical and condescending view of the role and work of nurses on the healthcare team should be a warning signal to all who are working on healthcare reform.

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<sec id="j_sjph-2023-0023_s_001"><label>1</label>
<div>INTRODUCTION</div>
<p>In recent years, numerous international initiatives, guidelines, research, reports, consultations and campaigns, including the International Year of Nurses 2020, have been conducted to improve the status of nurses, their level of competence, and their career development in healthcare systems (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_001">1</a>-<a ref-type="bibr" href="#j_sjph-2023-0023_ref_007">7</a>). The main objective was to send messages to influence and draw the attention of governments and their officials to invest in nursing practice and workforce development. Even in the face of the recent pandemic, government and health policy makers could not be convinced more directly to take seriously the role and status of nurses in the healthcare system and in society. The recent publication of The Health Policy Partnership states that we are in double crisis (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>). First, European health systems are in the midst of a crisis in the nursing workforce. Poor working conditions, low pay, high workloads and lack of career opportunities are affecting the well-being and satisfaction of nurses across Europe (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_007">7</a>). These working conditions have been shown to affect outcomes (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_008">8</a>) and intentions to stay in nursing (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_009">9</a>), using different study designs. The COVID-19 pandemic has exacerbated these challenges, causing nurses to leave their jobs or consider quitting in unprecedented numbers (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>). Second, Europe is facing a rapidly growing burden of noncommunicable diseases (NCDs), which are the leading cause of death in Europe and are responsible for some of the highest healthcare expenditures, requiring increasingly complex care (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_010">10</a>), most of which is provided by nurses. Over the past decade, an EU-funded Nursing Workforce Forecasting Study (RN4CAST) has examined nurses’ experiences in acute medical and surgical hospital care and the impact of workforce dynamics on outcomes and quality of care (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_002">2</a>). The results of a survey conducted in more than 38 countries, including countries outside Europe, provide us with important micro- and meso-level insights into direct care working conditions, norms, healthcare team relationships and career opportunities. The results highlight the importance of the number of patients per nurse and the importance of nurses’ level of education at the bedside. Both had a significant impact on monitoring patient outcomes (mortality within 30 days of hospitalization). Nurses’ work environment had significant effects on job satisfaction, professional development and staff retention (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_002">2</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_007">7</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_009">9</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_011">11</a>). The results confirmed previous findings and underscored the important role of nurses in safe patient care, paving the way for renewed discussion on the future direction of nursing in Europe (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_011">11</a>).</p>
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<sec id="j_sjph-2023-0023_s_002"><label>2</label>
<div>DISCOURSE</div>
<p>Why are there so many problems with nurses in Europe? We answer the question with a simplified application of the discourse technique, which helps to maintain or change social status by transforming power and attitudes. Discourse is socially influential and leads to important issues related to power (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_012">12</a>).</p>
<sec id="j_sjph-2023-0023_s_002_s_001"><label>2.1</label>
<div>Changing the understanding of nursing as a profession</div>
<p>The vast majority of European countries are struggling to embrace nursing as a profession and as a science. In some countries, there are still not enough bachelor’s degrees in nursing at the six levels of the European Qualifications Framework (EQF). Aiken and colleagues (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_013">13</a>) point out that at least 80% of all nursing staff should have a bachelor’s degree, as the RN4CAST survey clearly showed that treatment outcomes were better for patients treated by nurses with academic bachelor’s degrees (four-year degree) than those with professional bachelor’s degrees (three-year degree) or less. The fact is that countries that do not sufficiently support the development of bachelor’s, master’s, and PhD education in nursing and do not offer clinical jobs for advanced nurse practitioner (ANP), clinical nurse specialist (CNS), or minimally specialised nurse (SN) after bachelor’s education have problems retaining nurses in the profession and meeting the increasing demand for healthcare services that results from a long-lived society (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_002">2</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_006">6</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_009">9</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_014">14</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_015">15</a>). Policies in these countries are primarily aimed at solving problems related to physicians, but do not pay adequate attention to other professional profiles, especially nurse development providers. The study by Maier et al (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_014">14</a>) places most central and eastern European Union countries in the group of countries with the least developed advanced practical skills for nurses. The Slovenian RN4CAST study showed that professional development opportunities and educational opportunities are of crucial importance for respondents, which is a response to the hindrance of their professional development, followed by job satisfaction. Relationships with physicians and their behaviour toward nurses are also critical, as they influence nurses’ professional status, create their educational opportunities and promote the development of nursing as a profession and science (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_016">16</a>).</p>
</sec>
<sec id="j_sjph-2023-0023_s_002_s_002"><label>2.2</label>
<div>Create conducive working conditions</div>
<p>Creating an optimal working environment for nurses is an important task for managers and leaders, but also for national healthcare policy makers (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_016">16</a>). Policymakers must make systemic changes that prioritise nurses’ well-being. Changes needed include improving pay and working conditions, providing opportunities to improve skills and professional recognition, empowering nurses to deliver care, and harnessing the power of technology to better support nurses (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>). McHuge et al. (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_017">17</a>) clarify that pay is important for good nurse outcomes, but the work environment and staffing are even more important. There are also large differences within Europe, with salary levels in some western countries being up to three times higher than in eastern countries (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>). In the Slovenian example, salary was important, but not as much as career development opportunities and educational opportunities. Respondents felt that their career development was hindered (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_016">16</a>). Gender inequality and structural racism persist in the European healthcare sector and contribute to the nursing workforce shortage. There is a 20% gender pay gap in the European health sector. In addition, women in healthcare – and particularly in nursing – face other inequalities, such as difficulties in balancing childcare and work, higher health risks and lack of visibility of female managers (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>).</p>
<p>Relationships between nurses and physicians and between nurses and managers are also very important. Ineffective or non-existent collaboration leads to lower empowerment, increased burnout, lower job satisfaction and increased turnover among nurses (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_007">7</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_009">9</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_013">13</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_014">14</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_016">16</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_017">17</a>). Promoting nurses’ ownership, engagement and good interpersonal relationships in the workplace is essential for a positive work environment and quality patient care. National health policy must view nurses as equal health professionals and nursing as a profession and a science. Implementing health promotion measures in nurses’ workplace could be an important way to increase the capacity for work among nurses (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_018">18</a>).</p>
</sec>
<sec id="j_sjph-2023-0023_s_002_s_003"><label>2.3</label>
<div>Empowering nurses for new roles in the healthcare system</div>
<p>In Europe, opportunities for formal education or career development in nursing are very limited. There is also a lack of clarity about postgraduate education and educational requirements for advanced forms of healthcare work. For physicians, the European Directive mandates clinical specialisation, while it is not formally regulated for nurses. However, the health needs of the population are changing due to technological innovations, an increasing burden of disease and new organisational developments, and nurses need new technical skills, such as in the use of digital tools and artificial intelligence, as well as soft skills such as person-centred communication, interprofessional teamwork and sociocultural sensitivity (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>). Attention should be paid to recognising nurses as equal healthcare workers who need to be empowered to develop their profession and have professional development opportunities (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_015">15</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_016">16</a>). There is a need to improve the nursing work environment, support and promote continuing education, master’s and postgraduate education, and professional development for nurses, and to create an environment for solidarity among colleagues (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_016">16</a>).</p>
<p>The number of systematic reviews evaluating the clinical effectiveness and quality of care provided by nurses in advanced roles compared with generalist/physician practitioners has increased substantially in recent years. Results consistently show that task-shifting leads to equivalent or better quality of care (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_002">2</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_014">14</a>). Laurant et al. (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_019">19</a>) analysed 18 randomised trials. The analysis shows that for some persistent and urgent physical complaints and for chronic conditions, a postgraduate clinical nurse specialist (CNS) or advanced nurse practitioner (ANP), depending on the title of postgraduate formal education in the countries studied, are likely to provide equivalent or possibly better quality of care compared with primary care physicians, and are likely to achieve equivalent or better health outcomes for patients. This is a very important indication of how to make healthcare more accessible at the primary level while allowing nurses to develop their careers and continue their education in accredited master’s degree programmes, as recommended by the International Council of Nurses (ICN) and The Health Policy Partnership publication (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_003">3</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_004">4</a>). Nurses can also improve access to health care for children and adolescents, people with mental illness, etc. (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_020">20</a>). It is only necessary to open career opportunities for them by raising their educational level to the master’s level and clearly defining their competences in clinical work, which should be the subject of new study programmes.</p>
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<sec id="j_sjph-2023-0023_s_002_s_004"><label>2.4</label>
<div>Changes in education</div>
<p>Most countries have extended their bachelor’s degree programmes in nursing to four years because the RN4CAST study clearly showed that outcomes are better for patients cared for by nurses with a four-year bachelor’s degree (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_013">13</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_020">20</a>, <a ref-type="bibr" href="#j_sjph-2023-0023_ref_021">21</a>). Implementing the 4600-hour curriculum required by the European Directive is extremely difficult to achieve in three-year undergraduate programmes for nurses. With this approach, nursing students are among the most burdened group of students, which also affects their choice of studies and thus careers. In addition, research has shown that some of the competences acquired in undergraduate education are not applied whereas others are applied, while others are applied but not learned. An inventory of competences acquired in undergraduate education and applied in clinical practice could help clinically active nurses, nurse educators and healthcare managers identify areas for improvement (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_022">22</a>).</p>
<p>With the move to four-year bachelor’s degree programmes, the master’s degree will also be shortened to a minimum of one year at least or one and half years (60–90 ECTS). Master’s degree programmes must target different areas of clinical practice in nursing, which should be defined nationally as clinical specialization in nursing (CNS) for the secondary and tertiary levels and advanced nursing practice (ANP) at the primary level of the healthcare system. This transition requires the development of master’s degree programmes in various nursing specialties with at least 500 hours of clinical practice (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_003">3</a>). In addition, professional and multidisciplinary agreement, as well as political agreement, is required. In the Slovenian case, the application of expertise in the implementation of clinical specialization or advanced nursing competencies in nursing is not professionally acceptable, because the level of education required to acquire expertise is not comparable to the competences acquired in a master’s degree programme (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_023">23</a>). Therefore, professional organizations and faculties must strongly reject any attempts to implement advanced nursing practice without the recommended postgraduate education (<a ref-type="bibr" href="#j_sjph-2023-0023_ref_003">3</a>-<a ref-type="bibr" href="#j_sjph-2023-0023_ref_005">5</a>) at the primary level and clinical specialization in nursing practice at the secondary and tertiary levels of healthcare.</p>
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<sec id="j_sjph-2023-0023_s_003"><label>3</label>
<div>CONCLUSION</div>
<p>The fact is that the healthcare workforce will continue to grow in the future, but the pool of potential healthcare workers is shrinking. Nurses are expected to take on new tasks and roles, but we do not have enough of them and are losing too many. We need to adopt new and more challenging tasks and roles for them. Introducing new roles for nurses with master’s degrees, redistributing existing roles, increasing nurses’ education to implement patient-centred healthcare (palliative care teams, chronic disease teams, mental healthcare teams, oncology teams, etc), effective healthcare coordination, implementing evidence-based healthcare, and quality assurance are also needed. Changes are also needed in the numbers, proportions, skills, and formalisation of competences at the advanced care level. Many credible studies have shown this to be the case; it is up to us to change the division of labour in healthcare teams at all levels of the healthcare system and to enable physicians to deal in depth with the complex health cases that will become increasingly common in an ageing society. Advanced nursing practise and clinical specialisation in nursing with clear competences for independent practise will make nursing an attractive choice of study and career. The declining interest in nursing studies and the often stereotypical and condescending view of the role and work of nurses in the healthcare team should be a red flag for all those working on healthcare reform.</p>
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</div>

Nursing Development should Now Become a Priority for Health Systems in Europe

Slovenian Journal of Public Health

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

RAZVOJ ZDRAVSTVENE NEGE NAJ POSTANE PREDNOSTNA NALOGA ZDRAVSTVENIH SISTEMOV V EVROPI

The vast majority of European countries are struggling to embrace nursing as a profession and as a science. There are still not enough nurses with bachelor’s...

Nursing Development should Now Become a Priority for Health Systems in Europe

Article Category: Invited editorial

Published Online: Oct 04, 2023

Page range: 162 - 166

Received: Aug 07, 2023

Accepted: Sep 18, 2023

DOI: https://doi.org/10.2478/sjph-2023-0023

Keywords
Nursing care, Work conditions, Profession development, ANP competences

© 2023 Brigita SKELA-SAVIČ, published by Sciendo

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Nursing Development should Now Become a Priority for Health Systems in Europe

Article Category: Invited editorial

Published Online: Oct 04, 2023

Page range: 162 - 166

Received: Aug 07, 2023

Accepted: Sep 18, 2023

DOI: https://doi.org/10.2478/sjph-2023-0023

KeywordsNursing care, Work conditions, Profession development, ANP competences

© 2023 Brigita SKELA-SAVIČ, published by Sciendo

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Keywords
Nursing care, Work conditions, Profession development, ANP competences