Nursing Practice and Nursing
Education in current and future
health care
Prof. Walter SERMEUSLeuven Institute For Healthcare Policy KU Leuven
WHO CC Human Resources in Health Research & Policy
Belgium
How to improve nurse’s education
Health workforce is key to the sustainability of
health systems• Challenges:
o Ageing of population and health workers
o Increase of chronic and multi-morbidity
o Economic crisis
• Leading to:
o shortages of professional skills
o Regional imbalances of health professionals
• Policy responses:
o (inflow) Increased recruitment & training
o (Labour market) Organisational changes in
care delivery
o (outflow) Improved retention, pay, working
conditions
WHOOECD
EU
How are these elements related?
Dubois et al., BMC HSR, 2012; Sousa et al., WHO Bulletin, 2013
Recruitment Organization & care delivery Retention
Patient care quality &
safety
Health & job
satisfaction
Do we have data? RN4CAST, 2009-11
Dubois et al., BMC HSR, 2012; Sousa et al., WHO Bulletin, 2013
Recruitment Organization & care delivery Retention
Patient care quality &
safety
Health & job
satisfaction
Qualification level
Skill-mixNurse Staffing Levels
Work Environment
Job Satisfaction – Intention To LeaveQuality & Patient Safety
What do we know?
Dubois et al., BMC HSR, 2012; Sousa et al., WHO Bulletin, 2013
Recruitment Organization & care delivery Retention
Patient care quality &
safety
Health & job
satisfaction
Nurse Staffing Levels
Work Environment
Job Satisfaction – Intention To LeaveQuality & Patient Safety
51
56
52
0
20
60
32
100
22
100
59
10
0102030405060708090
100
% Bachelor trained nursing staff
What do we know?
Dubois et al., BMC HSR, 2012; Sousa et al., WHO Bulletin, 2013
Recruitment Organization & care delivery Retention
Patient care quality &
safety
Health & job
satisfaction
Work Environment
Job Satisfaction – Intention To LeaveQuality & Patient Safety
51
56
52
0
20
60
32
100
22
100
59
10
0102030405060708090
100
% Bachelor trained nursing staff
Ireland 7.0 5.4-8.9
the Netherlands: 7.0 5.1-8.1
Sweden: 7.6 5.4-10.6
Finland: 8.3 5.3-15.6
Greece: 9.86.3-15.5
Germany: 13.0 7.5-19.2
Spain: 12.4 9.4-17.9
Belgium: 10.7 6.2-16.2
England: 8.65.6-11.5
USA5.3
Portugal: 7.7
Italy: 9,57,1 - 13,7
Cyprus: 6.6
Patient to Nurse ratios
What do we know?
Dubois et al., BMC HSR, 2012; Sousa et al., WHO Bulletin, 2013
Recruitment Organization & care delivery Retention
Patient care quality &
safety
Health & job
satisfaction
Quality & Patient Safety
51
56
52
0
20
60
32
100
22
100
59
10
0102030405060708090
100
% Bachelor trained nursing staff
Ireland 7.0 5.4-8.9
the Netherlands: 7.0 5.1-8.1
Sweden: 7.6 5.4-10.6
Finland: 8.3 5.3-15.6
Greece: 9.86.3-15.5
Germany: 13.0 7.5-19.2
Spain: 12.4 9.4-17.9
Belgium: 10.7 6.2-16.2
England: 8.65.6-11.5
USA5.3
Portugal: 7.7
Italy: 9,57,1 - 13,7
Cyprus: 6.6
Patient to Nurse ratios
0% 20% 40% 60% 80% 100%
Belgium
Switzerland
Germany
Spain
Finland
Greece
Ireland
Netherlands
Norway
Poland
Sweden
England
Total
poor
mixed
better
Nursing work environment
What do we know?
Dubois et al., BMC HSR, 2012; Sousa et al., WHO Bulletin, 2013
Recruitment Organization & care delivery Retention
Patient care quality &
safety
Health & job
satisfaction
Quality & Patient Safety
51
56
52
0
20
60
32
100
22
100
59
10
0102030405060708090
100
% Bachelor trained nursing staff
Ireland 7.0 5.4-8.9
the Netherlands: 7.0 5.1-8.1
Sweden: 7.6 5.4-10.6
Finland: 8.3 5.3-15.6
Greece: 9.86.3-15.5
Germany: 13.0 7.5-19.2
Spain: 12.4 9.4-17.9
Belgium: 10.7 6.2-16.2
England: 8.65.6-11.5
USA5.3
Portugal: 7.7
Italy: 9,57,1 - 13,7
Cyprus: 6.6
Patient to Nurse ratios
What do we know?
Dubois et al., BMC HSR, 2012; Sousa et al., WHO Bulletin, 2013
Recruitment Organization & care delivery Retention
Patient care quality &
safety
Health & job
satisfaction
51
56
52
0
20
60
32
100
22
100
59
10
0102030405060708090
100
% Bachelor trained nursing staff
Ireland 7.0 5.4-8.9
the Netherlands: 7.0 5.1-8.1
Sweden: 7.6 5.4-10.6
Finland: 8.3 5.3-15.6
Greece: 9.86.3-15.5
Germany: 13.0 7.5-19.2
Spain: 12.4 9.4-17.9
Belgium: 10.7 6.2-16.2
England: 8.65.6-11.5
USA5.3
Portugal: 7.7
Italy: 9,57,1 - 13,7
Cyprus: 6.6
Patient to Nurse ratios
Aiken et al., BMJ Q&S, 2016
RN4CAST: Effect of nurse staffing on
patient mortality
10
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
Significant effect
Aiken et al. 2014 The Lancet
Physicians’ density 2000-2014
Source: G. Lafortune, EUPHA, Vienna 2016
Based on 2016 OECD/Eurostat/WHO-Europe Joint Questionnaire.
6,3
5,1
4,44,3
4,1 4,14,0
3,9 3,83,7 3,7 3,7
3,53,4 3,4 3,4 3,3 3,3 3,3
3,2 3,13,0 3,0
2,9 2,8 2,8 2,8 2,7
2,3
4,4
4,1
3,6
3,12,9
2,2
1,8
0
1
2
3
4
5
6
7
2014 2000Per 1 000 population
16,5
14,1
13,1
12,0 11,9
11,2
10,610,0
9,6
8,6 8,4 8,2 8,0 8,0 7,97,6
6,46,2 6,2 6,1
5,8 5,8 5,75,2 5,2 5,0 4,8
4,4
3,2
17,6
16,9
15,3
5,9
5,1
4,0
1,9
0
2
4
6
8
10
12
14
16
18
2014 2000Per 1000 population
Nurses’ density 2000-2014
Source: G. Lafortune, EUPHA, Vienna 2016
Based on 2016 OECD/Eurostat/WHO-Europe Joint Questionnaire.
Physician/Nurse densities across OECD
countries
15
Physicians Low
Nurses High
Physicians Low
Nurses LowPhysicians High
Nurses Low
Physicians High
Nurses High
Inflow Nursing Graduates (per 100.000
population)
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7
Spain
Switzerland
United Kingdom
United States
Belgium
Norway
CH
BE
UK
ES
US
NO
Based on 2016 OECD/Eurostat/WHO-Europe Joint Questionnaire.
2010 20112008 2009 2012 2013 2014
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
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
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.
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
Master
level
Bachelor
level
PhD
level
Nursing Education Level in EU/EEA 2016
Requirements for entry into the profession
University Training
U/HE Training
HE / Vocational Training
Vocational Training
(Own compilation of data)
9
22
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.’;
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.
Master
level
Bachelor
level
PhD
level
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
Doctoral degree in nursing
Master
level
Bachelor
level
PhD
level
The IOM future of nursing Report USA (2010)
Overall strategy for Education Health
Professionals
Flexner-report 1910 Lancet-report 2010 (Frenk et al.)
Recommentations from the Lancet report (1)
Frenk et al., 2010
Shifts proposed in the Lancet report (2)
Frenk et al., 2010
www.JAHWF.eu)
Conclusions
• Highly positive: all nurses are trained at the Bachelor Level
• Health system: high physician density, low nurses’ density
• Shift in competencies will be required (chronic care
conditions, primary care, elderly care,…)
• Recommendations to develop further:
o Recruitment & retention efforts
o Advanced Practice Nursing Roles (on master level)
o Doctorates for teaching, innovation, leadership
o Transformational skills and competences
o Interprofessional education
Thank you for your
attention
