Caring in crisis

Paul De Raeve, Secretary General of the European Federation of Nurses Associations (EFN), discusses the impact of austerity budgets on nurses and nursing…

Since the onset of the global financial crisis in early 2008, EFN has been vigilantly observing the effects on nurses and nursing in Europe. The effects are obvious: an actual reduction in nurses' posts; pay cuts and salary freezes; higher Eastern European recruitment rates for cheaper jobs; compromises in quality of care and patient safety. Over half of the nursing associations report pay cuts up to 25 per cent and rising unemployment for nurses; over a third of EFN members report concerns about quality of care and patient safety; and over one-fifth of EFN members report downgrading of nursing and substitution of nurses with unskilled workers. This has resulted in nurses working even harder than before to maintain quality standards, thus being asked to provide more for less. Nursing is a primarily female dominated profession and women are hardest hit. Nurses face the dilemma of providing quality care in an environment obsessed with cost with real implications for patient safety.

Today's healthcare challenges in the EU are widely recognised. Elderly care and chronic diseases are increasing the social demands for more efficient healthcare systems. There is an imbalance between takers and providers in terms of healthcare delivery as the demographic change still shows an ageing population and workforce. These factors, together with the difficult financial circumstances, add even more pressure on EU health systems, leading to unfair cuts in health budgets.

Nevertheless, many efforts are being made at EU level in an attempt to tackle these issues: the use of ICT technologies is being boosted; innovative healthcare delivery are demanded for the management of chronic diseases; quality of care and patient safety continue to be emphasised as core principles in EU health policy documents. Despite this, nurses across Europe struggle to maintain the high standards of care they are educated to uphold. Increasingly it feels like a losing battle.

Posts for nurses
Nursing posts have been cut in some countries and other measures are also being taken:

• Bulgaria (200 posts cut);
• Ireland (2,800 posts cut);
• Romania, and the UK (300 posts cut);
• Cyprus, Greece and Portugal experience a freeze in recruitment;
• Hungary (increase in vacant posts);
• Czech Republic (general decrease in number of nurses;
• Finland (prevalence of nurses leaving the profession);
• Germany (reduction of nursing posts in hospitals, problems financing care in nursing homes);
• Poland (gap between the working conditions of nurses and physicians: one shift for a physician = one month for a nurse);
• Austria and Portugal (removal of specialist nurses);
• Lithuania and Romania (overall cuts and freezing of posts);
• Spain (hospital beds not being used because of a lack of personnel).

The staff reduction increases the workload for remaining nurses and strains the quality and safety of care provided to patients. As a consequence, motivation is low, stress levels are high and the working environment is deteriorating, leading many nurses to change profession or emigrate.

Salaries
While some countries report little to no impact on nurses' salaries (Belgium, Croatia, Germany, Norway, Sweden), others are reporting extremely low salaries for nurses, ranging from €100-500/month (Bulgaria, Hungary, Lithuania, Moldova and Montenegro). Many countries report a decrease in salaries and attribute this to increases in everyday taxes (Portugal, Romania), freezing of salaries (UK), and all-round cost-cutting measures (Spain). Moreover, these trends seem to particularly affect newly-employed staff (Cyprus) and pension schemes (UK). In the UK, there is a two year pay freeze for all NHS staff earning more than £21,000 per annum, while in Portugal, a special tax has been introduced on the amount above national minimum wage (€485).

Replacements
Cost-cutting measures include retired nurses not being replaced and increasing the nurses' workloads (Ireland, Portugal, Lithuania and Finland). The situation has provoked an increase in retirement age for nurses (UK). Croatia reports that there are no replacements for nurses on maternity leave while in some countries nursing posts are being filled by nursing assistants (Czech Republic, UK). There are indications that the number of specialist nurses are decreasing (Sweden) and that the hiring of non-qualified staff is compromising safety and quality (Luxemburg) with patients resorting to self-administering.

Unemployment
The cuts in posts are increasing the unemployment rate in the health sector. Cyprus, Denmark and Spain are among the countries reporting an increasing level of unemployment for nurses. In addition to this, the lack of posts force nurses to migrate to look for work. In Bulgaria, around 1,200 nurses leave the country every year. In Denmark and Portugal, it is mainly newly qualified nurses who are emigrating and in Iceland, an increasing number of nurses are leaving, mainly to Norway, for short periods of time (two to three weeks). Romania has also seen a lot of nurses leaving the country for better opportunities. By contrast, the number of nurses leaving Finland is reportedly decreasing and in Sweden the financial crisis seems to have made nurses less mobile, meaning they are staying in Sweden but finding it hard to secure permanent employment. Most Eastern European countries still report a steady outflow of nurses.

Quality of care and patient safety
The quality of care is being compromised due to reduced staff, low motivation, increased workload and poor quality materials (Bulgaria, Moldova and Portugal). In Finland and Ireland longer waiting times and overcrowding have led to decreased patient satisfaction. The closure of wards and hospital facilities is an increasing risk to patient safety and impacts on the quality of care. Luxembourg has experienced problems in quality and safety since the beginning of 2011 due to added costs for home care patients while Romania is reporting a lack of material and medicine in hospitals. In Sweden, the lack of specialist nurses is affecting the quality particularly in psychiatry, elderly, medicinal, surgical, ambulance and primary care. Finally, a rise in nursing errors has been reported in Austria.

Nursing education
Due to the increasing demands in the healthcare sector, countries are now bringing in new models of competences for nurses (Austria, Hungary), adding advanced roles for nurses (Finland, Sweden), and increasing the number of nurse prescribers and specialists nurses (Ireland). Some countries report an increase in nursing students (Cyprus, Finland) while others are struggling to fill vacant posts due to a lack of qualified applicants. Data shows that the tasks, skills and competencies of nurses do not match with the current education and training programmes in most European countries. There is thus a significant gap between nursing theory and nursing practice, leading in some cases to difficulties when new graduates perform their daily work.

Developments at national level
Most countries have seen, or expect to see, some sort of reform on healthcare services. The UK is dealing with a major reform aiming to increase patient choice, reduce bureaucracy and give clinicians more freedom in the commissioning of services for their local communities. In Bulgaria, changes are expected in the field of home and social care, while Denmark expects its new government to focus more on prevention and chronic diseases, and is anticipating problems with unemployment and expensive medicine. In Cyprus, a new ambulant service has been designed for nurses who will also benefit from continuous professional development. In Greece we see limited supplies in hospitals due to the country situation. Some countries report a shortage of hospital beds (Iceland, Malta) and Poland is experiencing problems due to the privatisation of healthcare services. Spain, with a regional deficit of €20bn in the healthcare system, is expecting negative trends to spread. In many countries, healthcare reforms have been introduced (Former Yugoslav Republic of Macedonia – FYROM, Hungary, Ireland and Montenegro) but the precise impact on nurses and nursing has yet to be determined. Fortunately, some countries report that they have been able to successfully counteract the adverse effects of the crisis (Norway).

In order to address these difficulties nurses are turning to their governments for protecting the nursing profession. Certain initiatives could pave the way for improvements for the profession:

• Alternative ways of delivering of care;
• Extending the roles and responsibilities for nurses;
• Including nurses in the relevant political decision-making;
• Engaging nurses in the planning for policies that affect them;
• Strategies to attract young people into the nursing profession;
• Coordination of EU data collection on healthcare workforce.

Conclusion
The impact of the financial crisis on nurses and nursing has been cuts in posts and salary, leading to a decrease in the rate and level of healthcare services provided, which is affecting the quality and safety of care. Not only is there a shortage of nurses and reduction of new posts, the healthcare sector is facing new challenges that demand new and advanced roles for nurses. In terms of quality and safety, nurses agree that conditions are jeopardising patient safety. The increase in working hours lead to fatigue and decreased motivation, making the staff unfit for practice.

Several EU initiatives focusing on patient safety and quality of care have been launched attempting to make recommendations for what appears to be a dwindling workforce. The clear link between the working conditions of the health workforce and quality and safety means that more focus should be put on resolving these problems at EU level.In terms of education, new initiatives should aim for the creation of new posts to accommodate new tasks and skills learnt.

The current challenges facing Europe demand a reform in health systems. Several e-health initiatives looking for innovative solutions to respond to the healthcare challenges have started. e-Health is seen as a tool to decrease the economic pressure and work burden while improving the quality of healthcare. A highly skilled workforce is, however, still needed. What would happen if there are no more nurses to employ these new services, if retiring nurses are not replaced?

Nurses go abroad looking for job opportunities and better working conditions. Some countries employ strong recruitment campaigns leading to shortages in other countries. Some countries are supporting the entry of lower skilled professionals with less education into the profession faster and with fewer costs. Such practices must be avoided when promoting quality and safety. The review of the EU Professional Qualifications Directive has an important role to play in ensuring minimum training requirements and adequate levels of education. Further, the main aim of the directive being to ensure the free movement of professionals, a mapping of the health workforce is essential for planning for future needs. There is an urgent need to sustain a highly skilled nursing workforce effectively providing care through the use of new technologies. In the currently increasingly demanding situation, it is complicated for nurses to acquire more responsibilities, when even providing basic care is challenging. More efforts must be made at all levels to tackle this situation and to support the capacity of the nursing profession to provide more and better care.