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EFN Members' Input to Tour de Table on "Nursing Education - DIR36"

EFN General Assembly, 15-16 April 2010, Bucarest, Romania

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Country	What are your views on the utility of the Directive? What opportunities/problems does the Directive raise for the Nursing Community (language/pension/movement issues)?	What do you think about the minimum requirements for nurse training, as set out in the Directive – considering current advances/changes in healthcare?	What are your views on the utility of Health Professional Cards?
Belgium
Bulgaria	The Directive 36\|2005 has already been implemented in the Bulgarian health legislation. The utility of the Directive benefits the mutual recognition of the professional qualification of nurses and midwives.It guarantees the minimum regulatory standarts for professional education and qualification of health professionals.We see it as a safe guard against downgrading the nurses' education. Bulgaria is a "sending " country of nurses to the other EU countries.We suffer from lack of nurses, but because of their poor salaries, they go abroad, relying on the Directive to receive formal recognition.It usually doesn't happen and they have to take courses or even an year education to be registered in the "receiving" country.At the same time we don't have any candidates nurses to work in Bulgaria - because of the language barrier, not only the poor salaries. We don't think the Direktive should be opened.	The requirements of the Directive must still be the minimum standart for the European nursing education.	We look positive to the project for the Health Professional Cards.If the system for HPC acts correctly, there will be clear professional and legal information for the cardholder. 3 years ago we started to issue HPC to our members. It is a very hard and complicated work to gather the necessary data. It is an obligation of the experts from our regional committees and from the National Quality Council with the help of qualified technical experts.We believe, that the HPC shows the legal and professional status of the cardholder, ensuring thr prerequisites for optimal patient safety.
Croatia
Cyprus	The utility of the Directive benefitted: the mobility of Nurses across borders; the quality / standards of nursing care and services because of mutual recognition, collaboration and communication among countries, i.e. in cases of malpractice and illegitimate acts; the professional esteem, image, standard, recognition; the advancement of the nurse profession through minimum standards of education and competency as well as obligation for continues professional development through lifelong learning. The Directive serves as common platform for the nurse profession which enhances understanding and communication among health care professionals, regarding education and practice / services. It enhances the accountability of nurses within the health care systems and other stakeholders related to health including governments and organizations. Concluding, the Directive as the minimum regulatory standard and mutual recognition of professional qualifications of nurses, safeguards the public and the public health from nurses either educated in Europe or outside Europe. It serves as a fair check point for third country applicants, especially at the point of entrance. Opportunities/problems (language/pension/movement issues) Opportunities: The Directive enhances nurses: mobility, professional recognition and accountability, accreditation of previous learning and experience, continues professional development, Enhances professional organizations, associations, services, unions, councils to pursue the full implementation of nurses’ activities and responsibilities in any setting according to the Directive. Problems: Mobility among nurse professionals in the EU member states; raises issues concerning multicultural nursing. Apart from language obstacles; one should keep in mind host country’s health beliefs, communication norms and generally the native viewpoint on health and illness. - It reduces the number of registrations (although it raises the quality). For i.e. third country applicants with less qualification than the minimum set by the Directive, previously they could work (and possibly learn) while now either they are not registered or they have to follow compensation education and practice to be eligible for practice. This could result in delays or dropouts from registration and worsen the problem of shortage of nurses in some countries. The philosophical query is that: Is it better without nurses at all or with nurses with even less qualification who may practice under supervision or in less advanced areas of nursing? - Post registration competency maintenance and development may not be monitored adequately in all member states or some competencies and skills may not be practiced by nurses in some countries. With the cross border mobility, nurses from a country with less developed skills can move to countries where nurses practice those skills. The nurse with the underdeveloped competencies and skills may threaten or cause harm to public (and the profession) in the host member state. (Note: with mutual recognition among member states, nurses with less developed skills or incompetency cannot be detected.) - The obligation of nurses to communicate in the native language of the host country may become an obstacle for nurses’ mobility (although they are safer for the public). Nurses who intend to practice elsewhere, they have to overcome the language barrier, then to become registered, and finally to practice. This may reduce the mobility. The language issue involves collaboration of other organizations, legislations, and Ministries. For i.e. an employer has to recruit applicant nurses from EU or third countries. If they do not know the language they have to engage in other business and at the same time learn Greek. Once they prove language efficiency, they become registered by the N&M Council in Cyprus, and finally be able to practice nursing. The implementation of the Directive must enforce simplification of these processes as well, most probably by other law amendments. Another issue is that the language provision is beneficiary to countries with most spoken languages and discriminatory to countries with less spoken languages (eg Greek). - Pension problems are dealt through other common regulations and recommendations as a result of social dialogue among stakeholders of members states. This provision is covered by article (7). - If an applicant from a third country becomes registered in one member state because of false evaluation, this applicant can be eligible to practice in all other member states. Therefore, the implementation of the Directive must be well established to all member states. - To come to a more transparent process or even a clearer provision regarding Branch nurses recognition and practice (articles 14 and 15).	Despite the advancements in healthcare and in education, the Directive still deals with the minimum requirements. Thus, the number hours and the % of theory: practice must remain. (It is easy to translate hours to ECTS, no need to change). Also theory must be defined as teaching hours and not as students’ effort. Practice also must remain in hours and define the overall competencies to be achieved (as midwifery program). Though, it could be suggested that: - “Research methodology”, “quality” and “risk” management could be added to article 31 (2). - The word “training” to be amended with the word “education” throughout article 31. - In article 31 (4), the word “trainee” nurse to be amended with “student” nurse and “teachers” of nursing with “educators” or “educationalists” , and to add “evidence-based” before the words professional knowledge. - General secondary education of 10 years to become 12 years (article 31 (1)). This amendment will identify that nurse education is a higher or university level education. - Annex V could provide the minimum regulated responsibilities and activities of the nurses (as midwives)	HPC will make mobility safer for the public and the profession. It will speed up the information exchange as well as career monitoring of nurses. Information to be provided by competent authority to include: Qualification, legal status, penalties, liabilities, registration details. Personal data protection measures Furthermore, HPC can be very useful provided that they carry all necessary information for HPs, that can be decoded in all EU MS. Caution is needed for delicate personal data and data access and publicity. However information on malpractices, qualifications, and CPD are also necessary to be available to the host country association and/ or regulatory body.
Czech Republic	1. In the Czech Rep., Dir. 36 set a clear request for the duration and content of nursing education, which was then embedded in the Czech national legislation. The education of general nurses in the Czech Republic moved to universities and colleges, the education is compatible with the EU. We perceive as very positive, that the age of the graduates is about 21years and they are more mature when they enter the workforce. Nurses are now more active as teachers of nursing students and in the management of the nursing schools. The mobility of Czech nurses is increasing, more nurses seek employment abroad without any qualification recognition problems. Nurses educated before the new legislation came into effect are in a more difficult position. They have extensive practical experience, they participate in the CPD, but there aren´t any “bridging courses” to upgrade their education without going through the whole 3 year training. That increases the costs, nurses have to study and work at the same time for a long time, and after they complete their study, their salary remains the same.	2. We agree with reviewing the necessary subjects in nursing education, with regard to the prior education of the students and the current needs in nursing. The changes should be based on the needs analysis from the individual MS.	3. Theoretically, it is a good idea, but it is not promoted among the health care workers. Considering the financial crisis, maybe some of the existing platforms could be used (something like the Europass diploma?)
Denmark	The criteria set out in the directive for the nursing education now constitutes a safeguard against downgrading nursing education. It has taken The Danish Nurses Organization 100 years to raise the nursing education to its present level, and DNO, therefore, has no interest in opening the directive. With the increasing lack of nurses, we must not open up for substandard nursing education or new categories of auxiliary staff. As regards opening the annex about the nursing education, the risk may be less, since it focuses on content, not length or level of theoretical and clinical education. If we must compromise, that might be a viable solution.	The requirements set out in the directive must still be the absolute minimum standard for European nursing education, taking into consideration the current medical and technological development. To secure a high level of patient safety it is essential not to downgrade education for nurses as surveys clearly shows that higher level of education causes higher level of care and fewer unintended incidents	The Health Professional Card is a visionary project. With huge administrative, technical,legal and security related difficulties.
ESNO	The directive is the only one adressing the nurses competencieswhile it is a durective for free movement of professional and services and not health issues.. It adresses only the general care and the specialties , and above all all additional education and practice beyond the level of general care is not recognized.One of the consequence is when it comes to the implementation of the general rules applied for the recognition of qualification for post-registered specialties the additional education simply disappears. When it says that the level immediately below the one requested in the hosting country, it comes to the fact that one year of additional education is just withdrawn and by the way ignored. In the annexes, some countries have listed specialties with post-registered education at a level that is below the general nursing education what is a non sense.	It gives only minimal criteria for recognition of equivalence and not a real set of standards of education and practice. The minimum level required doesn't meet the criteria for being recognized as a bachelor level according to Bologna concept.The educational requirements should be explicitely ECTS with instead of hours having the minimum of 180 ECTS for being recognized as a full bachelor level.	waht is the need for Professional cards if it doesn't correspond to an actual level of education? A European accreditation system for Nursing programs would be more efficient.
Estonia
Finland	The Finnish Nursing programme is a 3.5 - 4 year programme at a Polytechnic level. The FNA does not recommend the opening of the directive. Directive now perceived to be the minimum standard of nursing education. We agree many countries that opening the annex the risk may be less, since it focuses on content, not length or level of theoretical and clinical education. With the increasing lack of nurses, we must not open up for substandard nursing education or new categories of assisting staff. Neither decrease the education requirements or standards and thereby the cost. In addition, do we need to control the amount of professionals that are moving within EU?	The directive needs to be as the absolute minimum standard for European nursing education. This standard helps us to keep a high level of patient safety, similarly for the rest of the health care clinicians and the health care system as whole. The directive absolutely needs to be updated and include the use of new information technologies. The importance of nursing needs to base on the best available scientific evidence.	The Health Professional Card is an interesting idea in general. But do we need to have a new systems because we have for example a European accreditation system for Nursing, If the HPC offered protection against criminal or professional misbehaviour and each country could be sure that the health professional is who they say they are and have the appropriate qualifications, then it would be a positive outcome. Finally, the HPC should include information on the legal status of the cardholder
Former Yougoslav Republic of Macedonia
France
Germany
Greece
Hungary
Iceland	The Icelandic Nursing programme is a 4 year programme at a University level. As a minimum standard the levels set in the Directive are solid and are used when evaluating applications for registration from nurses from abroad. The INA does not recommend the opening of the directive as it may result in a situation where we as Nurses associations have little or in worst case scenario no influence. The INA finds it unlikely that the annex 5.2.1 can be opened without opening up for changes in the Directive itself. The atmosphere in the health care systems to day is somewhat changed and the recession would at least in Iceland be a huge influence on the educational demands set forward in the annex. It is the INA opinion that changes of the annex could easily be economically driven and the results be downgrading rather then improvement.	The minimum standard for Nursing education in Europe must not be set down. These standards serve as a safeguard for patients as well as for the rest of the health care work force and the health care system as a whole. Patient safety has been shown to be linked with educational levels of nurses and therefore the INA would not support any downgrading of the educational levels.	Today every Nurse holds a document stating her or his right to practice Nursing. The administration of these documents is likely to be bigger or just about the same as the administration of a plastic card. The card thoug is more solid and hopefully not easily forged. Frogery though is a fact and the issue here should be to minimize publication, papers and administration and to insure updated information about the nurses rights to practice nursing. The INA sees the issue of such a card not to be a priority and a waste of time and money. The INA suggests that a European database for registered nurses would be more effective instrument. It is easy to update information, it cuts out the nessecity of issuing papers or plastic cards and the nurse can walk in to the relevant institution in a given country in Europe with a valdi passport and have her or his rights conformed. Some counties allready have their databases open for the public.
Ireland	The current nursing programme in Ireland is a 4 year honours degree. The criteria for nursing education set out in the Directive although now perceived to be the minimum standard in Ireland still serves us well in registering nurses trained outside the country. The INMO would like to see the Directive reflect the current educational standards however the INMO does believe that opening the Directive in the current economic climate is not in nurses’ best interest. We believe that there is no impetus by Government to increase the nursing education requirements and thereby the cost. The INMO believes that opening up the Directive provides for two options: 1. To increase the education requirements and standards in the Directive and perhaps reduce the numbers of registered nurses, but increase the number of health care assistants or bring in second level nurses. 2. To decrease the education requirements and standards and thereby the cost.	Directive 36 is related to the Internal Market and free movement and the INMO cannot foresee the EU increasing the difficulties for professionals to move between countries by increasing the standards except for options already stated. There have been discussions with the regulatory bodies about opening the annex to Directive 36 and if it improved the content to reflect the current nursing curricula then it may be a positive outcome. However, the INMO would like to know the EC’s rationale for focussing on the Annex.	If the Health Professional cards offered protection against forgery, fraud, criminal or professional misconduct and each country could be sure that the professional is who they say they are and have the appropriate qualifications then it would be a positive outcome.
Italy
Latvia
Lithuania
Luxembourg
Malta
Netherlands
Norway	DIR 36 safeguards quality of nursing practice in terms of qualifications required and suitability. It has enabled a positioning of nursing education in the HE degree structure. Previously, in Norway, clinical practice did not count as academic study, but has gained this status through the Directive. The DIR 36 has put a pressure on the authorities in terms of content of the national curriculum and it has been beneficial to nursing education, enabling an economical and efficient study plan. It is a foundation for a system in which patient safety and quality are better secured and integrated. It also provides guidelines for regulative bodies and enables mobility. As far as language requirements are concerned - it is an issue that these are not part of the Directive, but up to the individual employer, this has caused difficulties in Norway. In terms of pension, the Norwegian pension scheme differs greatly from most other European countries and the Directive does not really represent any challenges for us at present concerning pension issues.	The changes concerning task shifting and skill mix are not being sufficiently addressed in the Directive. Decreased bed rest/time, home-based care, efficiency of care are some of the elements of modern healthcare not addressed properly in the DIR 36, along with a lack of focus on prevention rather than treatment. Ehealth and developments in IT and financial systems are changing so rapidly and again the DIR 36 is not keeping up with these developments	HPC - in general we are positive, as it would facilitate administrative routines regarding the control of qualifications and legal status, provide easy access to information which in any case needs to be documented and thus ensuring those prerequisites which need to be present for optimal patient safety. The card should contain information regarding the national regulation authority, professional qualifications, educational institution, preferrably also information on professional experience. Furthermore, it should contain information on the legal status of the cardholder (authorisation), potential pending sanctions (warnings, temporary withdrawal of authorisation etc). We would be reluctant to include further information in the card.
Poland
Portugal	1. In this analysis it is important to considerer the purpose and main objective of DIR 36: the mobility and free circulation of nurses, through the recognition of their professional qualifications. 2. And it is because qualifications presume and require the education requirements (to acess and the education itself) and the professional experience recognition, that we focus in education; We must articulate and put in dialogue the DIR 36, the Bologna Process and the ongoing discussions on European Qualifications Framework. 3. In Portugal, nursing education is at High Education level since 1988 and complies with the Directive – in Portugal, the “re-publication” of 2005 was only transposed in 2009. But, in what concerns to nursing education requirements, they are fulfilled – we have 12 years in secondary education, 4 years degree Nursing programme, with 240 ECTS and the Bologna Process was implemented in all country. 4. The DIR 36 bounds the nursing education to a, at least, 50% of practical training and we think that is not in agreement with an intellectual and scientific profession; as well the 3 years or a number of hours is dissonant with the usual language of the Bologna Process. 5. We face a paradox, of an old Directive, with more than 30 years, ruling nowadays. It would be important to make a revision and harmonization, coming closer to professional regulation, specially the regulation of the access to the profession. 6. In Portugal we have two professional titles: nurse and specialist nurse; and we register them all. We have around 59000 nurses, 8000 specialists among us. And less than 3000 are foreigners. We recently changed the law and now language is a requirement. Probably because our language is difficult to learn, we don’t have a lot of foreigners; but, eventually, we all agree that language is essential to nursing care delivery. 7. The title attribution that we do and the professional recognition we are compelled to do, facing the DIR 36, create concerns about patient safety and nursing quality care, and the compensation mechanisms and the choice that the applicant can make (between an exam or practical period) may became unfair between national and foreign nurses. Probably, it is not the automatic recognition that erases difficulties and equity questions – but the differences between national realities.	See question 1.	We believe that they would be quite useful provided that they reflect the "current professional status" of the professional and that they are "valid and useful" both the in the nation of origin and in the EU. This requires a lot of work that has already been done in other European projects (HPCB; HProCard) that have showed that, although difficult, it is possible to achieve consensus on a number of issues and that the biggest challenge is to create (and maintain) an european infrastructure that would read the cards.
Romania
Slovak Republic
Slovenia
Spain	Utility: • Ensuring the free movement of professionals within EU. • To allow an adequate and effective exchange of information between competent authorities. • Allows the host countries to establish a minimum to ensure professional qualification. Problems: • Lack of criteria for assessing the language skills of the professionals • How to establish the balance between the rights that Directive provides to the professionals and the duties of the competent authority to ensure patient safety? • How to control the amount of professionals that are moving within EU, so as not to sharpen the shortage of nurses in an specific country in favour of other?	Must be updated to include the use of new information technologies and communication, the research process and the importance of nursing based on the best available scientific evidence. Should be including the use of technologies in national health system (e.g. e-health), promoting health research. Take in account the changes made by Bologna Process in nursing higher education.	It facilitates the access to the information available about the nurse is moving, expediting its recognition of qualifications and reducing the time required to weigh out their incorporation.
Sweden	We don´t see the directive as an obstacle more like a floor. The criteria in the directive for the nursing education are a safeguard against downgrading nursing education and that is important for the health professions and the quality and safety for the patent. We don´t have any interest in to open the directive. The opportunities is the Internal Market and free movement for the health professions and that fact at the directive make sure of that the educations level not get lower than the directive say. The problem is that the directive addresses only to the general care and not the specialties professions. As regards opening the annex about the nursing education we agree with Denmark, the risk may be less, since it focuses on content, not length or level of theoretical and clinical education. If we must compromise, that might be a viable solution.	Also in this we see the directive as the absolute minimum standard for European nursing education. Here is very important not to downgrade nurse’s education so we can keep a high level of patient safety. We can´t see any obstacle for the members in EU to have an education level that is adapt to the health care in the members own country.	The Health Professional Card is an interesting project. But we can´t see the utility with The Health Professional Card compare with the system we have today, for example examination certificate or registered.
Switzerland	Opportunity: Dir36 supports stabilizing our education system and to avoid cheap and low level training Problems: if Dir36 is considered as norme and not as minimum; it might prevent university training as being standard.	It might help to put forward Swiss nursing- Our hazard: By some players nursing is more seen in the Kopenhangen system than in the Bologna one.	They are being useful in our view, if card is European and nursing (EFN) is involved in developing and supervising system
United Kingdom	UK Educators recognise the benefits of directive 36 in enabling mobility of nurses whilst maintaining a minimum standard of nursing qualification by nurses within the EU. The development of new Member States and Accession countries towards this standard and the measurement of overseas programmes against can prove a useful legislative mechanism for NNAs, regulators and employers alike. It is clear that to open the directive, should this subsequently mean removal of it as a minimum baseline, would not be desirable (risking “…throwing the baby out with the bathwater”).	From a UK perspective there is a tension in respect of content and level of programmes undertaken by nurses which creates idiosyncrasy. This could be addressed through reviewing the annexe in a constructive way (provided the existence of the directive itself is not put at risk) which would seek to resolve the following: 1. The consideration of some mechanism for safe practice – to include language competence and understanding of the scope of practice within country of destination 2. Post qualification mandatory updating and requirements for continuing professional development. 3. A minimum educational level of competence for nursing at qualification rather than a focus upon hours of learning. (In the UK this is now acknowledged as a Bachelor of Arts university degree). 4. Increased freedom for universities in respect of the learning periods to include simulation and use of technological advance as key elements of practice learning, and student centred focus to theoretical education 5. Evaluating the relationship between ECTS and the current mechanism of hours and consideration of the application of Europass Diploma	Health professional cards could be an effective means for making the necessary adjunct in the annexe recordable for individuals and this should be considered as part of such an evaluation. This should be available for all learners as they work towards qualified practice – so consider including health care assistants as well as qualified workforce.