The ‘Greying’ of Europe – Reflections on the state of nursing and nurse education in Europe
Article Outline
- Introduction
- The ‘decline’ of nursing
- Attempts to solve the decline in numbers – recruiting foreign nurses
- Attempts to solve the decline in numbers – a third level based education
- Ageing nursing faculty
- Attempts to solve the decline in numbers – recruiting the ‘right type’ of nurse
- Conclusion
- References
- Copyright
Introduction
By 2030 it is predicted that 25% of the European population will be over 65 and by 2050 the ratio of economically non-active to active people will stand at 1–2 (Giankouros, 2008, Commission of the European Communities, 2008) Belgium, the Czech Republic, Germany, Italy, Poland, and Russia will decline in population in the next 25
years, whilst those countries that will experience population increase, such as the UK, will do so because of net immigration rather than net births (House of Lords Select Committee on Economic Affairs, 2008). With these demographic changes in mind the European Commission has completed a major consultation exercise on the challenges posed by this European population demographic for the replenishment of the nursing workforce in the European Community area (Commission of the European Communities, 2008). However, this issue is not about numbers alone. It is also an issue of recruiting people ‘of the right type’ into the profession. By the right type we mean those who can put themselves in the shoes of patients and their family carers, who are aware of their reactions and emotions towards other people, and who are able to reflect on and learn from their mistakes and experiences.
In this analysis we reflect on the challenges posed to nurse education and nursing care delivery in the context of the ‘greying’ of European nursing. It is difficult to generalise about the European Union’s (EU’s) position because each member state has a different nursing tradition and the data available across the Union is patchy at best. However, there is no doubt that the age profile of nurses as this relates to recruitment and education within Europe could have a marked impact on the future of health services across the Union. We turn first to the impact of the ‘greying’ of nursing on the capacity of nurse education to educate new nurses.
The ‘decline’ of nursing
In some European countries such as the UK and Italy, the ‘greying’ of the population is already impacting on nursing. The age profile of professional nurses is now a middle aged one. Buchan and Seccombe (2005) report that 35% of UK nurses are aged between 40 and 49, 25% over 50 and only 1 in 10 nurses are aged under 30. In 2000, Wells et al. (2000) reported that over half of the qualified mental health nursing workforce in Ireland was over 40years of age. The Organisation for Economic Co-operation and Development (OECD) reports that a substantial proportion of the nursing workforce in Austria, Belgium, France, Germany, Italy, and the Netherlands are over 45; for example Belgium 35% and Austria 30% (Simoens et al., 2005).
The problem of health care services being dependent upon an increasingly middle aged nursing workforce is compounded by a shortage of nurses. The International Council on Nursing (ICN) reports a shortfall of more than 70,000 in five European countries (ICN, 2009). However, the level of shortage is highly variable between European countries. Thus Ireland has one of the highest nurse patient ratios in the OECD with 13,000 nurses per million population compared to Spain with 3000 per million of the population.
In the UK the shortages and difficulties in recruiting nurses, together with factors influencing them to stay or leave the profession, have been well-documented (e.g. Cowi et al., 2008, Garosa et al., 2008, Chen et al., 2008, Coomber and Barriball, 2007). According to Finlayson et al. (2002) there will be a predicted shortfall in the nursing workforce of 53,000 by 2010. However, work by Buchan and Seccombe (2005) has highlighted that shortages in the UK are unevenly distributed in relation to geography and specialty. This unevenness of distribution is reflected within the wider European context. For example, in Spain and the Slovak republic 5% of nurses are unemployed. However overall nursing unemployment is largely marginal in Europe and it is likely that in the longer-term, it will disappear as the density of professional nurses in the population declines as a consequence of retirement and relatively few younger people entering nursing.
Research into what motivates people to enter nursing (e.g. Miers et al., 2008, Mimura et al., 2009) suggests that altruism is the most frequently reason given by nurses. But financial factors are important too. In times of recession, such as the current one, numbers entering nursing tend to rise but the long-term trend in many countries is of fewer young people, wanting to enter the profession (Buchan, 2002, European Federation of Nurses’ Associations, 2004, Commission of the European Communities, 2008). For example, between 2003 and 2007 applications for nurse training in the UK fell by 26% and applications from men fell by 48% in the same period (Juson and Mullen, 2008). Possible reasons for this include decline in the numbers of young people available to enter the profession, greater availability of more attractive careers to the pool of young women available and a rise in demand for nursing care leading to a need to train more nurses than in the past (European Federation of Nurses’ Associations, 2004). A combination of increased career choices and a decline in the attractiveness of nursing as a career are particularly important contributors to this long-term decline. The UK provides perhaps the most prominent case study in this regard.
Prior to the 2nd World War in the UK, there were relatively few career choices for young women – primarily teaching, social work or nursing. From the end of the 2nd World War there were increased employment opportunities for women, including in higher status professions such as law and medicine, although it was not until the 1960s that career choice became an option for most women. These increased career options went hand in hand with opportunities for women to take a university degree. Consequently, in the 1960s there were calls from nurse educators that nursing would need to offer women a university education if it was to attract them; thus, for example, in 1963 O’Connell (1963) argued that nurse education should be moved from the hospital training schools into the universities on the grounds that young women of the right type would not be attracted into nursing unless it was also a university subject. Indeed, from the 1960s the proportion of the UK undergraduate university population who are women has risen to the point where the 2005/06 Higher Education Initial Participation Rate figures for 17–30years old showed a 7.2% participation gap, in favour of women – a gap which appears to continue to widen (DIUS, 2008).
Aside from increasing career opportunities and participation in higher education, there has arisen since at least the 1970s an increasing reluctance by British career women to undertake work involved with bodily functions, or what we might call the ‘dirty work’ of nursing. Wolf (1996) has argued that those who undertake dirty work are soiled by association and Clarke (1999) points out that many nurses believe that increased social status is incompatible with these tasks.
As result of these developments, recruiting sufficient numbers of nurses of the right type has become an increasing problem and a policy concern in the UK. Particularly from the 1960s approaches to address the issue (recruitment of overseas nurses, and moving nurse education into the universities) were first developed and continue to be the principal mechanisms by which European policy makers address the recruitment problem. We consider these policy responses and the problems we believe they raise in relation to improving the recruitment situation.
Attempts to solve the decline in numbers – recruiting foreign nurses
One solution developed in the UK was to recruit nurses from other countries. Since the 1990s there has been a steady rise of immigrants recruited into nursing since the early 1990s, with a fivefold increase between 1990 and 2001. In 2001–2002 Buchan (2002) points out that 15,000 of 30,000 new nursing registrants in the UK were from overseas. Only a small proportion of these non-national nurses were recruited from other European countries with the majority recruited from outside the Europe. Between 2005 and 2008 30,000 new entrants onto the UK register came from outside the EU, principally from the Philippines, South Africa and Australia.
The UK is not alone in Europe in experiencing this increasing growth in foreign registrations. Ireland too has seen a rapid growth in the number of non-national nursing registrants. Thus in 2000, 14% of registrants were non-EU. In 2006, this had risen to 57%, most of whom were from India and the Philippines (Royal College of Surgeons in Ireland, 2008).
Within the EU as a whole there has been increasing concern that this growing dependence on non-EU registrants is not only undesirable in terms of addressing recruitment shortfalls, but is also unethical as it exploits the poverty of the ‘third’ world and exacerbates nursing shortages in these countries (International Council of Nurses, 2003). As a result EU members have agreed ethical guidelines to the recruitment of non-EU nurses, (e.g. Standing Committee of Nurses of the EU, 2004). Other initiatives, such as the establishment Health Worker Migration Policy Advisory Council, chaired by the former President of Ireland, Mary Robinson, (Robinson and Clarke, 2008) are attempts to develop world-wide solutions which support poorer countries to retain their nurses whilst respecting the rights of individuals to improve their economic prospects through migration.
It is the last issue of improving one’s personal economic lot combined with the point of origin of many of these nursing registrants that may exacerbate the crisis in nurse recruitment in the EU in the long-term, since it is likely to impact negatively on the decisions of young Europeans considering a career in nursing. High levels of recruitment from overseas will attract public criticism because a high proportion of the nurses that patients encounter in hospitals do not reflect the population from which the patients themselves are drawn. This is already an important issue in the United States (Ludwick and Silva, 2000, Xu and Davidhizar, 2004). The outcome is that nursing will, in our view, increasingly be associated in the European public mind with fear of ‘the other’ rather than an integrated societal profession. Nursing will decline further in social status through its association with immigrant groups.
At the start of this analysis we comment on the importance of ensuring not only an adequate number of recruits, but also recruiting people of the ‘right type’ into nursing. Whilst many overseas nurses are people of the right type, because nursing is seen in poorer countries as a route to improving ones economic status it is perhaps inevitable that many economic migrants will be uninterested in nursing values. In the United States there is not only considerable discussion about cultural competence and misunderstanding between American nurses and non-American patients (Brush et al., 2004), but there is an increasing body of literature on conflict between nurses from different ethnic backgrounds arising from a clash between cultural backgrounds and values and differing standards of nurse education they have received. In some cases such conflict has led to patient harm (Kawi, 2009).
Attempts to solve the decline in numbers – a third level based education
In the early 1990s nurse education in the UK moved from a hospital based training into the universities, through what was known as the Project 2000 initiative. This was an attempt primarily to halt the steady decline in recruitment to nursing through improving its social status. This was an attempt too, to increase the general standard of nurse education to that enjoyed by an elite group of nurses who had been trained on small scale nursing degree courses established in the 1970s in some of the best UK universities. Studies of the careers of graduates from these small university programmes showed that they achieved very high standards of academic and clinical achievement and that, contrary to the expectations of their critics, these graduate nurses stayed longer in clinically based nursing than nurses from the hospital based programmes (Howard and Brooking, 1987).
All EU countries have attempted to encourage young people to enter nursing. Whilst these campaigns have been successful in some countries, such as Ireland, their impact has been reduced because of high student attrition from training programmes and an increasing number of students who, on graduating, decide not to enter the profession (Sochalski, 2002). Within the UK meeting recruitment targets is a major challenge for the universities and has done little to improve attrition rates, compared to those experienced prior to the move into the universities. In the 1960s wastage from nursing was around 34%; according to the Nursing Standard more than a quarter of the UK nursing students dropped out of their courses in 2006, wasting an estimated £98m (http://news.bbc.co.uk/1/hi/health/7337259.stm). Financial penalties for UK universities which do not meet recruitment or attrition targets provide a powerful incentive to compromise admission and assessment standards. In Ireland, which unlike the UK, is an all degree pre-registration programme, attrition rates on nursing courses stand at around 20% and again are the highest for any third level programme.
The example of Ireland highlights a key problem in addressing the nursing shortage through education within the European context. Despite the Bologna Declaration (1999), there is no uniform approach to the education of nurses within Europe. Ireland is the only country that has fully embraced pre-registration education at degree level. The UK has two levels of educational preparation for entry onto the UK register – diploma and degree. France and Germany remain firmly wedded to a hospital based non-degree training, whilst smaller countries such as Hungary have adopted a more vocational college based approach (Jackson et al., 2009). There are initiatives to agree common standards for nurse education, consequent upon the Bologna Declaration (1999), such as the Tuning Project (2000) which aims to develop similar although not necessarily the same model of education across 16 participating European countries (Zabalegui et al., 2006). However, achieving a consensus is proving to be a slow process and in the current economic downturn prospects for wide spread adoption and so greater conformity are questionable. Last year the European Federation of Nurses’ Association called upon the European Commission to facilitate ‘cooperation, collaboration and financial support to implement change’ (EFN, 2008). The clear implication of such a call is that this is effectively lacking between member states at present.
Ageing nursing faculty
Despite attempts to encourage more young people to enter nursing and standardize nursing qualifications and training within Europe, there is another constraint, which, if not addressed, will hamper educational initiatives and attempts to recruit more students onto nursing programmes. This constraint is the ageing and retirement of nursing faculty across the Union.
The profile of nursing faculty in Europe remains largely unexplored. In part this may be a result of its complexity, because as previously mentioned, member states have different approaches to the delivery of nurse education and so there is no uniformity between member states on the qualifications required to be a nurse educator. However, according to Spitzer and Perrenoud (2006), many nursing faculties in European universities are experiencing difficulty recruiting academic staff who are appropriately qualified because of unattractive conditions of employment. The literature on this issue is more extant within the United States, a context which, like Europe, is facing a ‘greying’ of its nursing faculty; and may provide a pointer to what may be happening within Europe.
There is an increasing shortage of nurse educators to teach nursing in the United States (Bartfay and Howse, 2007). The American Association of Colleges of Nursing (2005) reported that nursing schools turned away more than 5000 applicants because of shortages of nurse teachers in 2001. The average age of a nurse educator in the United States is 51, though those doctorally qualified are older at 56 (Joint Commission on Accreditation of Healthcare Organizations, 2002). The Joint Commission on Accreditation of Healthcare Organizations (2002) has reported that it is increasingly difficult to recruit suitably qualified younger faculty because these are drawn from the general nursing population which is affected by the same workforce issues as affects the rest profession and is further compounded by poor working conditions in terms of remuneration and workload. The crisis is such that President Obama, in March 2009, hosted a health care summit at the White House specifically to explore how to improve working conditions and so attract more American citizens into nursing; by implication the working conditions of those charged with the education of these students will also need to be addressed.
It seems to us that the position of European nursing faculty is likely to be no different to that found in North America within a context of nursing shortages. Its impact is also likely to be similar, in that as faculty numbers diminish, workloads for those left will increase, leading to a career as a nursing academic losing its attraction. Furthermore, such faculty shortages are also likely to increase competition between European educational establishments for those faculty that are available, leading to wealthier Union member states denuding poorer regions of their most able nursing faculty (Ketefian and McKenna, 2005). This is particularly likely to be exacerbated within a European context because of the lack of uniformity in relation to the qualifications required to become a member of nursing faculty and career opportunities between member states (EFN, 2007).
There is therefore, a need to ‘map’ nursing faculty in terms of its age profile, turn over and working conditions. Such a mapping exercise is needed to assess the capacity of educational establishments in member states to train sufficient numbers of nurses. It would also assess the degree to which working conditions and career pathways of nurse educators need to be improved in order to support nurse education to the level required to educate sufficient numbers of nurses.
Attempts to solve the decline in numbers – recruiting the ‘right type’ of nurse
We now turn to the other main challenge for all nurse education systems, which is preparing students who are recruited to be fit for practice. By fit for practice we mean that they have good nursing skills. However, this alone is not enough. They also need to be ‘thinking’ nurses who can give clear reasons for their nursing actions, and be motivated to keep themselves up to date throughout their career. The Tuning Project is an attempt to establish a set of agreed competencies between member states that nursing students should be able to achieve. If successful the implication is that the EU will move towards one generic nursing qualification supported by a clear blueprint of the competencies that all nurses should possess; these would include cultural competence and a set of shared values in an increasingly culturally diverse and, in some countries such as the UK, an increasingly culturally fragmented society. However, this ‘blue print’ must address the process of nurse education and not just its outcomes.
Research in the UK has demonstrated the need for a blueprint of nursing education, albeit it a ‘national’ one, if the right type of nurses are to be retained. For example, a study of Scottish undergraduate nurse education by Norman et al. (2002) found that reluctance of clinically based mentors to fail poor students threatened the ability of continuous clinical assessment alone to discriminate between students with different abilities. Norman et al. (2002) concluded that a mixed method approach to competence assessment was needed and advocated the introduction and validation of a single continuous competence assessment measure nationally for use by mentors. This recommendation has not been taken up and consequently, whilst the universities pay heed to the general outcome frameworks for nurse registration set by the UK Nursing and Midwifery Council, different universities continue with different schemes for assessing clinical competence. This may contribute to lack of confidence on the part of service managers that newly qualified nurses have the practical skills required. Similar concerns have been articulated by managers in Ireland about newly qualified Irish nurses. A series of hygiene scandals in the UK involving nurses have led to newspapers accusing university educated nurses as being ‘too posh to wash’ – that is too theoretical and not sufficiently practical to give direct physical care to patients.
In our view, this is unfair. The problem is not university education as such, indeed university education is essential if nurses are to be educated to be thinking nurses who can give an account of their actions rather than simply trained to deliver nursing care. The blame for declining nursing standards (if they are indeed declining) does not rest with university education per se, but with the quality of support offered to student nurses in clinical practice within a system of education where there are perverse financial incentives for universities to retain students at all costs. These incentives are not unique to the UK, or Ireland for that matter. If nurse education is to address shortages in a European context then clinical mentors and assessors need support and, we would suggest, a framework of assessment to guide European faculties in their approach to clinical competence assessment.
Conclusion
All the indications are that over the medium to long-term most EU states will face substantial nursing shortages. Variation between member states is likely to be only be one of degree reflective of differences in pay and conditions, the local status associated with the profession (particularly as this relates to educational qualifications and level of responsibilities) national labour market conditions, the nature of the work nurses are expected to undertake locally and the local financial context.
Because of ‘pull’ factors within the EU, the nursing shortage needs to be addressed at a Union wide level if tensions and conflicts between member states are to be avoided. Nursing needs to be made a more attractive career option than it is now if it is to compete successfully with the other career opportunities open to women in particular. Transferring nursing into the university sector should be encouraged within member states, with the minimum qualification set at degree level. To set it at anything else propagates a message, as in the UK example, that nursing is a sub-standard academic subject which will accept recruits who do not have the abilities required for a modern nursing career.
There is a strong economic case for supporting nurse education, not only because there are now so many medical roles which are undertaken by well educated nurses – prescribing for patients, minor surgery, delivering psychological therapies are just some examples; but also because there will be a need to replenish nursing faculty with high quality educators and researchers. The speed and level that this needs to be achieved can only be gauged through a proper examination of the European career structures for nursing faculty.
In addition there needs to be an agreed structure across the EU not only in terms of competence outcomes but how competence should be assessed. We do not mean that local autonomy should be entirely abandoned, but in a context of workforce mobility the European public needs to have confidence that its nurses are trained to a shared minimum standard that they have been properly assessed and also that nurses in Europe subscribe to a set of shared values rooted in a European cultural context.
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PII: S0260-6917(09)00136-1
doi:10.1016/j.nedt.2009.07.003
© 2009 Elsevier Ltd. All rights reserved.
