Setting the European and

International scene for the future

of nursing

Prof. Walter SERMEUSLeuven Institute For Healthcare Policy KU Leuven

Belgium

Overview

• Understanding 40 years in nursing education in Europe

• Where are we now

• Preparing the future

Developments in European Professional

Qualifications Directive

1977

9 countries

2005

25 countries

2013

27 countries

Directive 77/452/EEC

Aim: free movement of

People

How: mutual recognition

of formal qualifications of

nurses responsible for

general care

Directive 77/452/EEC – June 27, 1977

• Deriving from Treaty of Rome (1957) – 6 countries

o Free movement of people

• Directives 77/452-453-454/EEC

o Mutual recognition of formal qualifications of nurses responsible for

general care

o Minimum education and training

• 3 years – 4600 hrs practice & theory, entry after 10y of general

education

o Advisory committee on Training in nursing

• Directive 89/595/EEC

o Minimum content of the programme

• Theoretical instruction: 1/3

• Clinical instruction: 1/2

Developments in European Professional

Qualifications Directive

1977

9 countries

2005

25 countries

2013

27 countries

Directive 77/452/EEC

Aim: free movement of

People

How: mutual recognition

of formal qualifications of

nurses responsible for

general care

Directive 2005/36/EC

Bologna Declaration 1999

+ Aim: Harmonization

How: from practice discipline

To a profession

WHO Munich Declaration 2000

ILO – ISCO 88 to 08

Bologna declaration – June 19,1999

• Action lines – 46 European countries involved:

o The adoption of a system of easily readable and comparable degrees

for each discipline.

o The adoption of a system essentially based on two cycles:

undergraduate (Degree or Bachelor) and postgraduate (Master and

Doctorate).

o The establishment of a system of credits (European Credit Transfer

System [ECTS]) based on student workload

o The adoption of a Diploma Supplement

o The promotion of mobility of educators and students

o The promotion of an education quality control system

• Tuning project:

o Tuning of Educational Structures and Programs on the basis of

Diversity and Autonomy

Change in the (perception & definition) of the

of nurses

• A lot of support from WHO

o Munich Declaration (2000): 48 Health Ministers signed

their intent to improve the position of nursing and

midwifery within Europe

o WHO LEMON LEarning Material On Nursing

• Support from member states

o Bulgaria (FR, BE), Poland (UK, SE, IE, FR), Croatia

(FI), Lithuania (DK), Latvia (SE, NO, FI), Hungary (CA)

o Implementation of the Bologna Process

http://apps.who.int/iris/handle/10665/108181

ISCO-88: International Standard Classification

of Occupations - ILO Code 223

• Nursing and midwifery professionals apply medical

concepts and principles relating to the delivery of babies

and to nursing of the ill, injured or disabled, and of mothers

and their newborn babies.

• Tasks performed usually include: helping medical doctors

in the practical application of preventive and curative

measures and dealing with emergencies in their absence;

providing professional nursing services, care and advice

for the sick, injured, physically and mentally disabled and

others in need of such care, and directing auxiliary nursing

staff; delivering or assisting in the delivery of babies, and

instructing mothers in baby care. Supervision of other

workers may be included

Source: http://www.ilo.org

ISCO-08: International Standard Classification

of Occupations - ILO Code 222

• Nursing and midwifery professionals provide treatment and

care services for people who are physically or mentally ill,

disabled or infirm, and others in need of care due to

potential risks to health including before, during and after

childbirth. They assume responsibility for the planning,

management and evaluation of the care of patients,

including the supervision of other health care workers,

working autonomously or in teams with medical doctors

and others in the practical application of preventive and

curative measures.

• Tasks performed usually include: assessing, planning,

providing and evaluating nursing and midwifery care …

Source: http://www.ilo.org

Developments in European Professional

Qualifications Directive

1977

9 countries

2005

25 countries

2013

27 countries

Directive 77/452/EEC

Aim: free movement of

People

How: mutual recognition

of formal qualifications of

nurses responsible for

general care

Directive 2005/36/EC

Bologna Declaration 1999

+ Aim: Harmonization

How: from practice discipline

To a profession

WHO Munich Declaration 2000

ILO – ISCO 88 to 08

Directive 2013/55/EU

+ Aim: Quality & Patient

Safety

Directive 2013/55/EU

• Free movement - minimal requirements

o Higher education Institutions - completion of general

education of 12 year

• vocational training programme - general education of at least 10

years

• Harmonisation - Integration of Bologna into the directive

o More convergence & common understanding

o …. than standardisation & uniformity

• Quality and patient safety

o Introduction of a list of competencies

o Professional card

o Language requirements

Directive 2013/55/EU on the recognition of

professional qualifications

• Art. 31 Admission to training for nurses responsible for general care

shall be contingent upon either:

o completion of general education of 12 years, as attested by a

diploma, certificate … and giving access to universities or to higher

education institutions of a level recognised as equivalent;

o or(b)completion of general education of at least 10 years, as

attested by a diploma, certificate ... and giving access to a

vocational school or vocational training programme for nursing.’;

• At least 3Y of study; at least 4 600 hours of theoretical and clinical

training; at least 1/3 theoretical training; at least 2300h of clinical

training

Eight core competenciesa) competence to independently diagnose the nursing care

b) competence to work together effectively with other actors in the health

sector

c) competence to empower individuals, families and groups towards

healthy lifestyles and self-care

d) competence to independently initiate life-preserving immediate

measures and to carry out measures in crises and disaster situations

e) competence to independently give advice to, instruct and support

persons needing care;

f) competence to independently assure the quality of, and to evaluate,

nursing care

g) competence to comprehensively communicate professionally and to

cooperate with members of other professions in the health sector

h) competence to analyse the care quality to improve his own

professional practice as a nurse responsible for general care.’;

RN4CAST: Effect of nurse staffing on

patient mortality

14

Aiken et al. 2014 The Lancet

MEAN EUROPE: 1.3%, RANGE: 0.0%-7.2%, N=300

MEAN ONE COUNTRY: 1.2%, RANGE: 0.3%-3,0%, N=59

0,00%

1,00%

2,00%

3,00%

4,00%

5,00%

6,00%

7,00%

8,00%

1 7

13

19

25

31

37

43

49

55

61

67

73

79

85

91

97

10

3

10

9

11

5

12

1

12

7

13

3

13

9

14

5

15

1

15

7

16

3

16

9

17

5

18

1

18

7

19

3

19

9

20

5

21

1

21

7

22

3

22

9

23

5

24

1

24

7

25

3

25

9

26

5

27

1

27

7

28

3

28

9

29

5

30-day inpatient general surgery mortality per hospital Nh = 300 Hospitals, Np=422730 patients

(9 European countries: BE, UK, FI, IE, NL, NO, ES, SE, CH)“One country” hospitals are marked in red

Aiken LH et al…. Sermeus W, Nurse staffing and education and hospital mortality in nine European countries:

a retrospective observational study, The Lancet 26 February 2014

Lowest staffing

BE hospital

Ave staffing

BE hospitalHighest staffing

BE hospital

9/1000 deaths difference

Lowest QL

BE hospital

ave

BE hospital

highest

BE hospital

5,5/1000 deaths difference

Overview

• Understanding 40 years in nursing education in Europe

• Where are we now

• Preparing the future

Nursing Education Level in EU/EEA 2016

Requirements for entry into the profession

University Training

U/HE Training

HE / Vocational Training

(Own compilation of data)

9

22

Safe nurse staffing ratios in Europe

Advanced Practice Nursing Roles

• Nurse Practitioners or other Advanced Practice Nurses

(NP/APN), working at the interface of the nursing and

medical profession

• Expanding Scope of Practice:

o Task-shifting (a concept referred to as ‘substitution’)

whereby nurses take up activities formerly in the domain

of physicians to alleviate shortages and/or improve

access;

o New clinical areas (‘supplementation’) that have been

largely unexplored, such as new roles as case managers,

liaison roles, eHealth monitoring and lifestyle advice.

Task shifting from MD to RN (NP/APN)

Maier C., Aiken L. European Journal of Public Healh, 2015

Extent of task shifting from physicians to nurses by seven

clinical activities and educational requirements

Maier C., Aiken L. European Journal of Public Healh, 2015

Overview

• Understanding 40 years in nursing education in Europe

• Where are we now

• Preparing the future

Overall strategies on nursing education

• The IOM future of nursing Report USA (2010)

o Future of nursing : education (2010)

o Progress report 2013

o Progress report 2015

The Future of Nursing (2010)

• Remove scope-of-practice barriers

• expand opportunities for nurses to lead and diffuse

collaborative improvement efforts

• Implement nurse residency programs

• Increase the proportion of nurses with a baccalaureate

degree to 80 percent by 2020

• double the number of nurses with a doctorate by 2020

• ensure that nurses engage in lifelong learning

• prepare and enable nurses to lead change to advance health

• Build an infrastructure for the collection and analysis of inter-

professional health care workforce data

2006

2015

0

5

10

15

20

25

30

0 10 20 30 40 50 60 70 80 90

% BSNs in Hospitals

2006

2015

Moving Toward 80% BSNs

Hospital Workforce

Source: Center for Health Outcomes and Policy Research, University of Pennsylvania

%

Ho

sp

ita

ls

Overall strategies on nursing education

• The IOM future of nursing Report USA (2010)

o Future of nursing : education (2010)

o Progress report 2013

o Progress report 2015

• WHO-Europe: European strategic directions for

strengthening nursing and midwifery towards Health

2020 goals (Sept 2015)

o Scaling up and transforming education and training

o Workforce planning and optimizing skill mix

o Ensuring positive work environments

o Promoting evidence-based practice and innovation

WHO-Europe – strategy

Scaling up and transforming education

1. Standardize the initial education of nurses and midwives

at degree level to get the best outcomes for patients and

populations.

2. Develop education and regulation that enables and

ensures that nurses’ and midwives’ core competencies

are in line with the basic principles of Health 2020.

3. Strengthen continuing professional development and

career development.

Overall strategy for Education Health

Professionals

Flexner-report 1910 Lancet-report 2010 (Frenk et al.)

Recommentations from the Lancet report (1)

o Transformative learning

Lancet-report 2010

(Frenk et al.)

Recommentations from the Lancet report (2)

o Interdependence in education

Lancet-report 2010

(Frenk et al.)

Conclusions

• There is a general shift to free movement to quality and

patient safety

• The dominant model is a Bachelor degree as the minimum

requirement for entry into the profession in line with the

changing perception of nurses

• There is no “European nurse”: convergence & common

understanding rather than standardisation & uniformity

• Investments in Advanced Practice Nursing Roles (on

master level) and doctoral training (leadership, teaching,

research)

Thank you for your

attention