Bologna process in European nursing education. Ten years later, lights and shadows

Abstract

More than 10 years after the Bologna declaration (1999), the Higher education landscape has changed, nursing education has not been exempt from adaptation in order to be competitive in a global market introducing changes that have an impact on both nursing profession and clinical practice. Worldwide and as well in Europe, we are living critical moments related to citizens' health. In those exceptional circumstances, the importance of nurses has become more relevant than ever. The International Council of Nurses (ICN) recognizes that this year had to be more than birthday of Florence Nightingale celebration. Governments, health systems, and society need to support the capacity, capability, and empowerment of the nursing profession to meet the growing demands and health needs in individuals and communities. The Qualifications Frameworks in the European Higher Education Area (QF-EHEA) has introduced important subjects in nursing curricula, but the pathway to change has not been like in all European countries. Integration of nursing education programs into the higher education system is intended to improve the status of the profession and to incorporate higher qualified graduates into the practice setting (European Commission/EACEA/Eurydice, 2018). Advanced nursing practice (ANP) with research-based thinking is needed to participate in decision-making and to refocus and help European health systems to cope with challenges for the benefit of their economies, patients, and societies. The Bologna Declaration had an impact on nursing education in most European countries, as a new structure has been implemented based on three levels of Bachelor, Master, and Doctoral Programs. Now, nurses are able to reach the highest academic levels and therefore they are more prepared for professional challenges. The outcome of the Bologna declaration has generated a consensus among European countries on nursing policies to achieve better and higher qualification of the nurse workforce. The policies focus at academic and research-oriented nurses with scientific backgrounds and implementation of evidence-based nursing to solve individual healthcare problems, empower people by structured therapeutic education on health promotion and disease prevention, and also improve the healthcare system. This change has contributed to sustainability of health care. European countries are at different stages of implementation of Advance Practice Nurses (APN) roles. Nurses respond to healthcare challenges with increase in their competences in complex care, prevention, self-care, long-term settings, community setting, and homecare with a focus on patient-centred care. New workforce policies and regulations result in increasing numbers of Master and Doctoral degree nurses across Europe, with the exception of Germany and Hungary. The higher qualified nurse's work is mainly in clinical settings as managers, APN, and in higher education institutions and universities as professors, teachers, and researchers. Generally, healthcare policymakers in Europe recognize the advanced role and higher qualification of these professional nurses but there is a lack of legal regulation frameworks to support their autonomy in the healthcare system. To date, only midwifes have a European Directive framework for practice. In some countries (e.g., Spain), governments favour educating clinical nurse specialists 2 two years with internship programs such as in mental health, paediatrics, geriatrics, community and family health, but there is a lack of specific positions for these nurses upon graduation (Siles González & Solano Ruiz, 2012). On the other hand, countries like Lithuania, UK, Denmark, and Poland have a more structured and official framework for ANP. There is a lack of harmonization of Masters degree programs in Europe and clinical nursing positions for APN varies among and within countries making difficult the mobility and collaboration among APN in Europe. In Denmark, Lithuania, Greece, Poland, and The Czech Republic, APN competencies are implemented in nursing positions in clinical settings and as in universities as teachers or assistant professors. Besides in these countries, nurses with doctoral degrees get better positions and salaries. In countries like Croatia, Austria, and Spain, APN have more complex responsibilities than generalist nurses, but in clinical settings they do not get better remunerations or benefits. Doctoral degree nurses play an important role in the academic setting, where a doctorate degree is a requirement to have a full professorship at the university. In general, salaries in healthcare settings are higher than in academics. Consequently, nurses with doctoral degrees working at the clinical areas are not willing to move into academic positions. These countries ought to have a more flexible workforce to allow the combination of clinical and academic roles (Palese & Watson, 2014). There is still an imbalance between an academic and a clinical career for nurses: How to enjoy and share the best of the both worlds? Nordic European countries like Denmark have implemented ‘Joint Positions’ to share and develop knowledge based on clinical and academic activity. This model has proven to be very effective, efficient, and has generated high levels of satisfaction in both settings. Most of the European countries have lifelong learning education for nurses that allows to have adequate and up-to-date competencies and to reach to new advanced roles. It is interesting to known that in countries like Lithuania, Austria, UK, and Hungary it is mandatory for all nurses to update their knowledge, skills, and competences. For example, in Poland, according to the law and professional ethical code, nurses are required to provide evidence-based nursing practice. Most European countries, except Germany, offer specific educational programs in different areas of interest such as intensive care, emergencies, and oncology. These courses provide nurses with the opportunity to update or learn new clinical competences necessary for the standards and safety in their professional context. The main concern reported across Europe is the lack of nursing professionals in the labour market. Shortages of nurses have become problematic; in some countries, this shortage pre-existed the economic crisis of 2008 and now it is chronic. During the last years and after Bologna agreement, the situation has not improved for countries like Germany, Poland, The Czech Republic, and the UK. In countries such as Lithuania, Croatia, Spain, and Italy, the shortage has been aggravated when many nurses decided to migrate for stable employment and better working conditions and salaries. Main destinations have been the UK, Norway, Ireland, Germany, and Denmark. Those countries have benefited from the crisis by receiving well-trained and even experienced nurses from neighbouring countries. The global economic crisis started in 2008 and has had the highest impact on the nursing workforce in Lithuania, Spain, Portugal, and Italy, where migration of nurses has been significant (Galbany-Estragués & Nelson, 2018). In recent years, many nurses that went abroad have been willing to return, mainly for personal reasons. But upon return, many faced barriers and bureaucratic difficulties to obtain position in the healthcare system. For instance, in Spain due to inflexibility of the healthcare system and limited positions available, returned nurses had to wait many years for stable and suitable positions. Unfortunately, upon return several years later, they experienced the same situation that made them move to other countries. After the crisis, healthcare systems have invested in updating equipment, care centres, treatments, medical knowledge, and new technologies. In contrast, areas where nursing care is vital: health promotion, disease prevention, chronic diseases, and old-age care have not received a similar impulse of investment. In fact, the most forgotten areas have been long-term care (LTC) and nursing homes, an area where most European countries have their social and healthcare systems fragmented. Integrated care that bridges both social and healthcare systems continues to be a challenge in many countries. For instance, LTC in Eastern and Mediterranean countries is based on nurse aids or assistants; but the needs of their residents require more competent professionals. This reality is been demonstrated by the high ratio of resident deaths' during the recent COVID-19 outbreak in these institutions (WHO, 2020). The nursing workforce is a fundamental value for healthcare systems. It has been made evident worldwide in the response to COVID-19 pandemic. There is consensus among European countries that in the past 10 years degree nurses have improved the quality of nursing care. Nurses are more competent (knowledgeable, skilful, and critical thinkers) empowered, have higher self-esteem, assertiveness, and better communication strategies; therefore, they provide more comprehensive care and make complex decisions. European higher education institutions together with healthcare stakeholders must approach solutions to the shortages of nurses across countries. The ageing population and retirement of the active nursing workforce is a fact that requires analyses in order to establish an accurate nursing workforce planning in all healthcare settings including long-term care facilities and nursing homes. WHO estimates that there is a shortage of almost 6 million nurses worldwide. Therefore, governments must invest in nursing by increasing the number of well-prepared nurses, improving work conditions, and allowing nurse participation in decision-making at all levels including in policy and strategy (WHO, 2020). Nursing career must have the professional recognition and visibility it deserves, this has changed very little in the past years as there is still a need for upgrading its prestige. This fact concerns managers, society, mass- and social media, and the healthcare professionals. For both men and women and especially young people, nursing should be an attractive career with professional recognition, good working conditions, fair salary, opportunities for development, and active participation in decision-making. This editorial is based on European expert's views on the Bologna agreement impact of Nursing education and clinical practice. Lithuania, Natalja Fatkulina; Austria: Christa Them & Eva Schulc, Croatia: Robert Lovric; Denmark; Pia Riis Olsen; and Dorthe Boe Danbjørg; England: Rose Kane & Sophia Hunt; Germany: Gabrielle Meyer; Greece; Tziaferi Styliani; Hungary; Jozsef Betlehem; Italy: Alvisa Palese; Poland: Beata Dobrowolska; Czech Republic: Valerie Tothova; Iceland: Árún K. Sigurðardóttir. None.

Topics & Concepts