The Ticking Time Bomb in the European Union Has Exploded: The Importance of European Council Recommendations on the Healthcare Workforce

The global nursing shortage was a well-recognized issue before the COVID-19 pandemic. In 2020, the first State of the World’s Nursing [1] demonstrated that the global nursing workforce was 27.9 million and estimated a global shortfall of 5.9 million nurses. Following the devastation of the pandemic, staff shortages have increased in many parts of the world. Some studies cite that up to 30% of nurses are considering retiring or leaving their profession [2]. Increased workloads, burnout, exhaustion, and lack of recognition and compensation contribute to these worrying trends. These issues are not new, but the pandemic has increased its focus and created a burning platform to address the looming crisis critically.

The International Council of Nurses frames this as a global health emergency [3]. Addressing the issues leading to the nursing shortage is critically important, and looking for evidence-based recommendations for supporting the workforce is essential. Relying on commitment and interventions at the individual level are unlikely to promote change, and bold interventions at the level of the organization and society are needed. A focus on improving recruitment, retention and engagement is urgently needed. While evidence-based strategies have been identified, including nurse-topatient ratios, skill–mix optimization, mentorship and team-based initiatives, these issues are complex and multifaceted [4].

Contextual analysis is necessary in the face of geopolitical instability, as social, political, and economic factors significantly impact how workforce issues are perceived and addressed. Using the method of a case study, and the European Union and Europe as a case site, we explore key issues and a path forward to address the healthcare workforce crisis with a particular emphasis on the nursing sector [5]. We revisit the policy backdrop in this sphere and reflect upon the numerous initiatives undertaken over the last decade that, regrettably, failed to garner sufficient traction in effectively addressing the persisting challenges. Then, we draw attention to the pivotal policy window on the horizon—the imminent Belgium EU Presidency—offering an opportune moment for proactive measures. Finally, we advocate for resolute Council conclusions, underscoring three pivotal areas necessitating decisive action: recruitment within the nursing profession, establishing safe staffing levels for nurses, and targeted investment in domestically trained nursing personnel.

The European Union (EU) is a supranational political and economic union of 27 member states located primarily in Europe. Health budget cuts and cost-saving measures introduced during the 2009 financial crisis continue to significantly impact the nursing profession with reduced staffing levels, wage cuts, and challenging working environments. Meanwhile, since 2009, the demand for healthcare has continued to rise. Dangerously low levels of nurse understaffing have been a significant problem in healthcare systems for many decades, but the COVID-19 pandemic aggravated the problem. COVID-19 injured the nursing profession, with frontline nurses now massively resigning due to exhaustion, unsafe working conditions, and unacceptable low salaries given general care nurses’ lifesaving responsibilities [4]. Consequently, nurses are moving from full-time to part-time jobs or leaving the nursing profession, not even waiting for the date of their pension entitlements. Now we see an increased outflow of nurses in all EU Member States with the EU Institutions’ inaction hiding behind the principle of subsidiarity: it is the member states’ responsibility.

The political response and rhetoric by EU Institutions and Member States to tackle the challenges have yet to translate into any tangible action to develop and implement solutions to protect the status of the nursing profession and the reimbursement of nurses within the healthcare systems. The EU has adopted new legislation and initiatives (COM Decision C(2021) 6712, 2021) to fortify its readiness and response to potential future health threats. This is intended to enhance the EU Health Union by bolstering capacity within Member States and improving coordination at the EU level. However, for a more comprehensive and practical approach, particularly regarding the capacity of the health workforce, a legislative focus at both the EU and country level to ensure bettercoordinated action across various fields needs to be a priority. The healthcare workforce needs to form the cornerstone of EU decision- making, pivotal in realizing the ambition to establish a European Health Union. To truly reflect the societal importance of health within the EU’s political ecosystem, the healthcare workforce must be further elevated politically and become a top priority for the upcoming Commission (EU Elections June 2024).

Given the broad impact of nurse shortages on the entire healthcare system, encompassing increased costs (such as bed and unit closures, longer waiting times, and increased reliance on temporary staff) and consequential effects on patient health outcomes—leading some patients to seek care in other EU countries—the European Commission, Council, and European Parliament must priorities an examination of the organization of healthcare systems across all EU countries. Addressing this issue should be a political imperative, considering that the scarcity of nurses is a prevailing reality in most EU member states, posing a significant risk of collapse for European healthcare systems.

As the nursing workforce in many EU countries is in a crisis, the European Commission has a vital role in better preparing the European healthcare systems for future health emergencies. However, operating within its current political responsibilities, the Commission must address multiple critical facets [6], which we list here and elaborate on next:
• Ensure the development of a sufficient nursing workforce through strategic planning, education, and training without compromising educational standards, as outlined in Directive 2013/55/EU.
• Diminish dropouts during the 4-year EU education cycle for nursing students by advocating and investing in mentorship programs.
• Implement the WHO Global Code of Practice on the International Recruitment of Health Personnel [7], considering the limitations of extensive recruitment of nurses from regions such as India, the Philippines, and African nations, which alone cannot fully mitigate shortages of domestically trained nurses.
• Define and enforce safe staffing levels to sustain highquality patient care standards across the EU; and,
• Acknowledge the pivotal role that nurses’ salary and overall well-being play in effective retention by prioritizing strategies that effectively support and maintain the workforce.

The European Commission Green Paper on the EU Workforce for Health [8] led to the European Parliament’s written declaration on the EU Workforce for Health [9]. The European Parliament Declaration called on the European Commission and the governments of the Member States to take appropriate measures to:
• Ensure that there are sufficient comparable data for EUwide health workforce planning.
• Establish effective and sustainable recruitment and retention strategies in the health sector.
• Ensure that all health professionals have access to continuing professional development (CPD) and that professional qualifications meet agreed criteria; and
• Promote the role of health professionals in identifying and implementing strategies that facilitate professional and knowledge mobility while recognizing health professionals’ contributions to achieving optimal health outcomes.

Following the successful political lobby of the European Federation of Nurses Associations (EFN), alongside other health professions stakeholders, in the European Parliament, the Council conclusions in December 2010 re-launched the EU Health Workforce file. The 2010 Council Conclusions invited Member States to:
• Strengthen collaboration and exchange of good practice, including the collection of high-quality and comparable data, to better support the development of Member States’ health workforce policies for the future, contributing to equal access to care for all, with particular attention to forecasting future health workforce needs and effective health workforce planning throughout the European Union.
• Raise awareness of the importance of attractive working environments, working conditions and professional development opportunities in motivating the health workforce and guaranteeing the quality and safety of the care provided.
• Stimulate training and education of the health workforce to promote the quality and safety of care further and consider how to make the best use of EU tools for financing this, without prejudice to the future financial framework. and,
• Adhere to the WHO Global Code of Practice on international recruitment.

Furthermore, the Council invited Member States and the Commission to:
• Develop an action plan providing options to support the development of Member States’ health workforce policies, recognizing the competencies of Member States, in particular in the areas of the assessment of competence profiles, the improvement of planning methodologies taking into account identified health needs, CPD and recruitment and retention strategies, and to tackle the critical challenges for the health workforce throughout the EU in the medium and long-term perspectives.
• involve in the development of this action plan, patient representatives, and health professionals, as well as other relevant stakeholders from the health sector; and,
• Take into account in the development of this action plan the potential contribution of different policy areas, in particular, education, labor, social affairs and the internal market.

Moreover, importantly, at that time, the Council invited the European Commission to:
• Encourage cooperation between Member States and lend support to the development of the action plan by 2012.
• Include training and education of the health workforce as a priority area and consider how to make the best use of EU tools for financing this. and,
• Ensure that the 2011 workplan of the Health Programme can include a joint action providing a platform for cooperation between Member States on forecasting health workforce needs and health workforce planning in close cooperation with Eurostat, OECD and WHO.

It is critical to note that the Council Conclusions of 2010 did not lead to any improvements in the healthcare sector during the last 14 years. This is despite the Commission responding with the Action Plan on the EU Workforce for Health in 2012 and the Joint Action Health Workforce Planning and Forecasting (EUHWF) mid- 2013, extended to 2022 (Heroes). Instead, due to the COVID-19 pandemic, the shortage of nurses and doctors aggravated: the COVID-19 crisis exposed a lack of policy coordination and funding to tackle nurse shortages. It is disappointing and striking to realize that the EU and its Member States did not implement the policies that would have made Europe’s health workforce more resilient.

As Belgium takes up the EU Presidency in 2024, focusing on the EU Workforce for Health, this window of opportunity should lead to concrete policy initiatives at the EU level. Any initiative should build on the developed EFN Workforce Matrix 3+1, providing clarity on the three categories of nursing care: General Care Nurse (Directive 2013/55/EU), Specialist Nurse, and Advanced Practice Nurse (APN), and have critical principles for the development of Healthcare Assistants (HCAs) [10].

Advanced practice nurses (APN) represent one of the most rapidly growing workforce innovations in healthcare, essential for building trust in healthcare systems and improving access to care. The development of APNs is claimed to strengthen the accessibility, safety, efficiency, and quality of health care [11]. APNs have been shown to positively impact health service organization, delivery, and healthcare management. Besides improving healthcare quality, implementing, and integrating APNs in health systems reduces clinician-related costs and improves nurse recruitment and retention by providing nurses with career development pathways. The need for developments in APNs is pressing, given the current and future pandemic context stretching health systems and increasing health needs globally. Within the pandemic context of tighter health budgets and rising demand for high-quality and safe care, the implementation and integration of APNs are central to making the best use of scarce resources and improving outcomes.

However, notwithstanding the investments of the OECD, WHO, EUROSTAT and ILO in trying to collect comparative quantitative data, incomparable data sets and methodologies prevent designing nursing workforce policies and establishing an evidence-based workforce science [12]. The categories for the nursing profession used in the OECD-WHO-Eurostat Joint Questionnaire to collect data at the national level are still based on the ISCO-08 code. Using the ISCO 08-code for nursing care leads to inaccurate data collection, inappropriate comparison of the nursing workforce and, consequently, unrealistic planning for the future. The ISCO-08 code mismatches occupations and qualifications, creating confusion about the terminology and leading to unreliable data collection to plan and forecast the EU health workforce. Regrettably, the ILO is not planning to make any changes before 2028.

The outcome document of a 2010 ministerial meeting – titled “Investing in Europe’s health workforce of tomorrow” – called on the bloc’s member states to “invest in sufficient, motivated and well-skilled health professionals in order to protect the viability and accessibility of health systems.” EU health ministers have not convened to discuss the health workforce crisis since 2010, when Belgium last held the presidency of the EU Council. While the EU has held multiple consultations and launched Joint Actions EU projects on health worker migration, skills, empowerment, and workforce planning and forecasting in the years since that meeting, the bloc’s health workforce remains chronically underfunded, even after the Recovery and Resilience Plan was put in place during the COVID-19 pandemic.

Belgium will assume the Presidency of the Council of the European Union in January 2024. As one of its primary objectives, it will priorities tackling the health workforce crisis at the EU level for the upcoming years and the next European Commission, considering that the EU Elections will take place in June 2024.

As the primary headache for health ministers in the EU and the WHO European region is the growing shortages of nurses and doctors and knowing that in 2010 the EU Institutions voted on EU Workforce recommendations, we find ourselves in a dire situation needing careful handling to avoid healthcare systems in the EU and Europe collapsing. Ministers know the alarming numbers of nurses fleeing to other sectors due to poor working conditions, low pay, and threats to their physical and mental health exacerbated by the strains of the COVID-19 pandemic. The World Health Organization (WHO) called Europe’s health workforce crisis a “ticking time bomb”, but EFN members’ evidence shows the “bomb already exploded” [13]. Now it is time to identify the collateral damage caused by the lack of EU actions, given a shortfall of 1.8 million health professionals (mainly nurses and doctors), which is projected to double to 4 million by 2030 [14].

Therefore, we suggest focusing on policy priorities that can have a real impact within the EU member states. With this in mind, we recommend that the 2024 Council Conclusions primarily focus on two priorities: education and safe staffing levels.

2024 Council Recommendation 1: Get more Nursing Students with more supportive Clinical Outplacements

The foremost strategy to alleviate the nursing shortage in the EU is a substantial investment in domestic nursing education and training programs. Governments must focus on creating domestic nurses to compensate those retiring, reducing their working hours, or leaving the nursing profession. Domestic production becomes the critical factor for workforce and healthcare systems sustainability.

By strengthening nurse education and training programs, we can nurture a robust pipeline of skilled nursing professionals wellequipped to meet the healthcare needs of our communities. This includes channeling resources into nursing schools, promoting research in nursing education, and enhancing the appeal of the nursing profession to potential students. Moreover, we must examine why people do not enter nursing education and why nursing students drop out halfway through their degree programmes.

A significant challenge is the low interest in nursing as a profession. For example, the number of applications to study nursing across the UK fell by almost 20%. In the UK, some 33,570 individuals applied to study nursing this Autumn 2023 – more than 7,600 less than the same time in 2022 (-18.5%). A similar trend can be seen across EU Member States. The number of students in EU nursing education programmes declined in 2023 by 40% (compared to 2019). One of the critical reasons people are not entering nursing training is the lack of tuition and maintenance support.

Furthermore, nursing students across the EU report excessive practice hours, a lack of educators and mentors, and requirements to undertake tasks beyond the scope of their clinical placements. These issues lead to students leaving their studies or deciding not to seek employment within the nursing profession upon graduation. Nursing students experience an increasing mismatch between their expectations and the reality of practice. Although the issue of nursing student attrition has never been more pressing, political recommendations have never been made to address this issue.

Therefore, preventing dropouts by promoting and investing in mentorship for nursing students is essential. Policy initiatives should support nursing students in finishing their nursing education by ensuring adequate practical supervision and guidance. In addition, nursing students need clear career prospects, while primary and secondary care providers must implement career pathways to support nurse development following initial nursing education.

The EU and Europe should design their workforce policies in line with other countries, and specifically look to what the US is legislatively putting in place to educate and train more nurses and grow their nursing workforce. This is unique as the Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, plans to award more than $100 million, which is in addition to the annual $300 Million in funding for nursing workforce development programs that focus on all aspects of workforce demand (education, practice, recruitment, and retention). These investments will address the increasing demand for registered nurses, nurse practitioners, certified nurse midwives, and faculty staff. Political supporters recognize that the nursing workforce is essential to improving health outcomes and healthcare delivery across settings – including hospitals, nursing homes, and community care. In this way, the Biden-Harris Administration has shown its commitment to supporting nurses.

Given this US context, as a best practice example, the Belgium EU Presidency should develop a Council recommendation towards the Member States to:
• Ensure sufficient nursing students for EU-wide health workforce planning.
• Establish effective and sustainable recruitment strategies to attract recruits to nursing education.
• Ensure that nursing students’ curricula are compliant with Directive 2023/55/EU and that professional qualifications meet the agreed criteria.
• Recognize the importance of nursing students’ working environments, working conditions and professional development opportunities to stay in the nursing profession. and
• Stimulate nursing students’ training and education to further promote the quality and safety of care and consider how to make the best use of EU tools for financing this without prejudice to the future financial framework.

Importantly, the Council could invite the Member States and the European Commission to:
• Develop an action plan providing options to recruit more nursing students, taking into account recruitment needs.
• Involve in the development of this action plan the nursing profession representatives, as well as nursing teachers and regulators.
• Take into account the potential contribution of other policy areas, in particular, education, labor, social affairs and the internal market.
• Encourage cooperation between Member States and lend support to the development of the action plan by 2025. and,
• Develop an EU Action plan for Nursing student mentorship.

2024 Council Recommendation 2: Safe Staffing Levels

The mounting research evidence shows that increased nurse staffing with an appropriate skill mix positively affects patient outcomes and mortality rates and improves job satisfaction and nurse retention [15-19]. Evidence-based methods to determine the most appropriate staffing levels and skill mix are available, for example, the Framework for Safe Nurse Staffing and Skill Mix (Department of Health, 2018). It is widely acknowledged that ensuring optimal nurse staffing is essential to providing safe, highquality care.

Efforts to increase the availability of qualified professional nurses can also secure trust in the healthcare systems. By building a resilient nursing workforce, EU member states can protect European citizens by ensuring safe nursing staffing. Trust and resilience can only be achieved if the EU educates and trains enough nurses in line with Directive 2013/55/EU (Article 31) and if those general care nurses can apply their care responsibilities in safer working conditions. The momentum for legislated nurse staffing ratios is growing, with some states in countries like the USA and Australia already implementing minimum ratios and reporting positive impacts. However, Europe still has substantial room for progress on comprehensive legislation, supportive methodologies, and accountability guidance to enable safe nurse staffing ratios. The main barriers are political reluctance, decentralized systems, nursing shortages, and cost concerns.

Although there is no universally accepted standard for safe nurse staffing levels, with optimal levels likely depending on factors like patient acuity and care environment, the momentum for safe staffing policies has been growing globally. For example, in the USA, the American Nurses Association (ANA) recommends a nurse-to-patient ratio of 1:2 in ICUs, 1:3 in intermediary units, and 1:5 in medical-surgical units. California was the first US state to implement minimum staffing ratios in 2004. As of 2023, eight further US states (Oregon, New York, Massachusetts, Pennsylvania, Georgia, Maine, Illinois, and New Jersey) are pursuing laws that mandate minimum nurse-to-patient ratios in attempts to improve patient outcomes and increase nurse job satisfaction. Similarly, Victoria, Australia, has legislated minimum nurse-patient ratios in public acute hospitals since 2001 [20].

In Europe, however, examining the nurse-patient ratio legislation landscape across the 35 countries represented through the EFN [13] reveals lack of progress regarding comprehensive, mandatory nurse-patient ratio laws. Out of the 35 countries, 11 indicated some existing legislation or frameworks related to nursing ratios and staffing levels. These 11 countries are Austria, Belgium, Cyprus, Czech Republic, Estonia, Finland, Germany, Portugal, Romania, Slovakia, and Wales. Though these countries have taken some steps toward legislating nurse staffing levels, a deeper analysis shows that the existing legislation is often limited in scope or enforceability [13]. The countries lacking legislation also indicated they lack established national methods to systematically determine appropriate nurse staffing levels and skill mix. Of those countries that indicated having some method of determining nursing staffing level and skill mix, only Austria, Belgium, Cyprus, Finland, Germany, Ireland, Portugal, Serbia, and Slovakia stated that their staffing level calculation methods, whether ratios or minimal numbers, are approved by their governments.

As nurses continue advocating, sharing best practices, and demonstrating the patient safety benefits of legislated ratios, Europe will eventually reach a tipping point where nurse-patient ratios are the enforced standard rather than the exception. However, there is an immense need and opportunity for progress to achieve this vision. The current situation in most countries reflects staffing requirements that remain predominantly at minimum levels rather than safe staffing levels.

When it comes to investment in safe staffing levels, the EU should look at staffing ratios.

For nearly two decades, only one US state -- California -- governs the number of patients assigned to a nurse. Recently, Oregon became the second state. Advocates of nurse-to-patient ratios are hopeful that other states will follow. These legislative developments represent the significant efforts to improve healthcare safety in acute care hospitals in the US, including evidence-based initiatives to reduce healthcare-associated infections, medication errors, and patient falls [21]. Some healthcare leaders argue that ratios are a one-size-fits-all response to a dynamic system and claim that new technologies transforming care delivery will make ratios out of step with health system realities. We would argue the opposite: the digital transformation will need highly qualified nurses on the frontline to succeed.

Furthermore, standards are not one-size-fits-all but tailored to the units and nurses’ workload. It is argued that staffing ratios could improve hospital recruitment, retention, and patient outcomes [22]. Research shows that better nurse staffing is associated with better patient outcomes, increased patient satisfaction, decreased hospital-acquired conditions, decreased length of patient stay, decreased chances for patient readmission, and decreased patient mortality.

As of 2019, 14 US States have laws or regulations representing one of the following approaches: (a) mandated nurse-to-patient ratios for all hospital units; (b) mandated staffing committees; and/or (c) mandated public reporting by hospitals of nurse staffing levels. These laws and regulations were passed by State senators and representatives to protect patients and ensure safe care. In 1999, California became the first US state to mandate minimum nurse-to-patient staffing, taking effect in 2004. In August 2023, Oregon Gov. Tina Kotek (D) signed into law a comprehensive “safe staffing” bill that mandated minimum nurse-to-patient staffing requirements across most hospitals for nearly a dozen types of hospital units in the state. The law also charged the Oregon Health Authority with investigating complaints about hospitals that failed to enforce these requirements.

Staffing ratios have also been endorsed by members of Congress. In March, Rep. Jan Schakowsky (D-Ill.) and Sen. Sherrod Brown (D-Ohio) reintroduced a bill to enact minimum nurseto- patient staffing requirements nationally. Seven states — Connecticut, Illinois, Nevada, Ohio, Oregon, Texas, and Washington — have legislation for hospitals to implement staffing committees to develop staffing plans. Minnesota follows The Joint Commission standards with a chief nursing officer developing a staffing plan with other nurses [23].

These staffing committees allow clinical nurses a forum to participate in nurse staffing decision-making [23]. The common component in the staffing committee regulation is to have direct care “general care nurses” and leaders (e.g., nurse managers and chief nursing officers) develop nurse staffing plans [24].

Besides staffing ratios and committees, another approach requires hospitals to report and disclose staffing patterns to the public. This process makes data about hospital staffing comparable and readily available to consumers, nurses, and hospital administrators. Public reporting is envisioned to improve care delivery as providers identify underperforming areas, increase consumer trust in the health system, and support healthcare decision-making [25].

Furthermore, in September 2023, the U.S. Department of Health, and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), issued a proposed rule that seeks to establish comprehensive staffing requirements for nursing homes in the US, including, for the first time, national minimum nurse staffing standards, to ensure access to safe, high-quality care for the over 1.2 million residents living in nursing homes. This proposed rule builds on the President’s historic Action Plan for Nursing Home Reform launched in the 2022 State of the Union. Nursing homes would need to provide residents with a minimum of 0.55 hours of care from a registered nurse per resident per day and 2.45 hours of care from a nurse aide per resident per day, exceeding existing standards in nearly all states. CMS estimates that approximately three quarters (75%) of nursing homes would have to strengthen staffing in their facilities.

2024 Council Recommendation 3: International Recruitment is Not the Solution for Domestic Nursing Shortages

Nursing shortages are often approached by recruiting from abroad. However, this raises the question of recognizing the qualifications and skills obtained in non-EU countries. The minimum requirements under Directive 2013/55/EU, particularly the 4600 hours of theoretical education and clinical teaching, may not always be met. This is important because Article 31 of the Directive outlines necessary nursing competencies that must be fully exploitable in practice. While recognizing the importance of simplifying procedures for recognizing nurses’ professional qualifications acquired in countries outside the European Union, the degree of demand required of these professionals should be the same as that required of nurses who have undergone education and training in the European Union

EU legislative developments, therefore, must align with the WHO Global Code of Practice on the International Recruitment of Health Personnel [7] to prevent targeted recruitment from already fragile healthcare systems.

To guarantee the delivery of high-quality care and priorities patient safety, nursing professionals’ competencies must align with Directive 2013/55/EU, regulating the general care nurse at the EU level. Each country must, therefore, invest in solid national, government-led, and funded qualification paths based on the minimum qualification stated by the Directive 2013/55/ EU, including language requirements, to ensure sufficient language proficiency from a patient safety perspective. Due to the complexity of healthcare, a thorough evaluation process is necessary. Rushed recognition procedures could endanger both patients and the healthcare system. In cases of uncertainty about the equivalence of qualifications, competency assessments should be conducted to determine if the candidate meets the necessary standards.

Attracting qualified nurses from non-EU countries to help address the nursing shortages within the EU must be done without compromising on Directive 2013/55/EU competencies and be sensitive to the risk of brain drain. Some new registrants to EU regulatory bodies are from countries on the WHO’s health workforce support and safeguards list, breaching the ethical standard in the WHO’s Global Code of Practice on the International Recruitment of Health Personnel [7].

The case of Ukrainian nurse refugees seeking employment in EU Member States stands as an illustration of concern. Due to non-compliance of their diplomas with Directive 2013/55 EU, these nurses could not be employed as general care nurses but instead worked as assistant nurses. Regrettably, the EU missed an opportunity by failing to implement bridging courses funded by existing EU resources to facilitate the upgrading of Ukrainian nurses’ qualifications. This lack of support represents a significant oversight and a missed chance to invest in the nursing profession, hindering the potential contributions of skilled individuals seeking opportunities within the EU.

Despite these challenges, there is a critical need to recognize and appreciate the skills and qualifications of migrant health professionals, even in cases where official documentation might be lacking. It is imperative to assess and acknowledge their competencies swiftly, recognizing their value and the potential contributions they can make within the healthcare sector. Improving knowledge about qualifications and establishing efficient communication channels between national authorities responsible for qualifications within EU and non-EU countries, for instance, through systems like the IMI of Directive 2005/36, would significantly enhance understanding and trust in various qualifications. This, in turn, would expedite the recognition process, ensuring a more rapid integration of skilled professionals into the workforce.

We highlight the importance of subjecting third-country qualifications to rigorous scrutiny of Third Country Qualifications by Member States (MS) to ensure they meet the minimum training requirements outlined in Directive 2013/55/EU and the need for a clear position on language requirements in the recognition process.

We recommend that EU Member States establish standardized recognition processes for nursing qualifications obtained in third countries. These processes should priorities assessing whether the training aligns with the Directive 2013/55/EU minimum training requirements. This standardization will help create a level playing field and foster confidence in the quality of care provided by recognized health professionals. Member States that employ simplified or expedited recognition processes for qualifications that do not meet Directive 2013/55/EU requirements should review these processes and consider aligning them more closely with EU standards to ensure patient safety and the quality of care. (recital 19 of Directive 2005/36/EC).

Finally, recognizing the importance of effective communication between health professionals and patients, we encourage Member States to establish clear language requirements for health professionals seeking recognition. Language proficiency should be evaluated as part of the recognition process, ensuring that healthcare professionals can provide safe and effective care to patients.

Within this context, the Belgium EU Presidency should develop a Council recommendation towards the Member States to:
• Ensure that nursing education curricula are in compliance with Directive 2023/55/EU and that professional qualifications meet agreed EU criteria.
• Establish effective and sustainable strategies to develop safe staffing levels in the EU.
• Promote the role of APNs and facilitate professional and knowledge mobility.
• Consider how to make the best use of EU tools for financing this without prejudice to the future financial framework.
• Establish and legislate safe nurse staffing levels to ensure the safety of patients and nurses.
• Develop proper and legitimate agreements to protect nurses when faced with missed nursing care due to nursing shortages.

Moreover, importantly, the Council could invite the Member States and the European Commission to:
• Develop an action plan providing options to implement the EFN Workforce Matrix 3+1 to improve workforce planning methodologies taking into account the national recruitment needs.
• Involve in the development of this action plan the nursing profession representatives, as well as nursing teachers and regulators.
• Take into account in the development of this action plan the potential contribution of other policy areas, in particular, education, labor, social affairs and the internal market. and,
• Encourage cooperation between Member States and lend support to developing the action plan by 2025.

Although we focused on two main workforce policy priorities, the Council Conclusions developed by the EU Belgium Presidency in 2024 should include a recommendation on Violence against nurses, Work-life Balance, better pay, and digitalization.

As violence against nurses has grown into epidemic proportions [26], Council Conclusions on the health workforce must refer to violence against frontline healthcare professionals. The nature of nurses’ work makes them vulnerable to physical workplace violence and verbal abuse. Member states across the EU and Europe should mobilize to provide better care for all nurses who are victims of violence and abuse. Initiatives to support nurses should consider legal sanctions against perpetrators of violence. The EU Victims’ Rights Directive (EC 2012/29/EU) and strategy (EC COM/2020/258) offer better protection and empowerment of women. It is vital that nurses feel free to express themselves and report violent incidents at work in national databases.

Furthermore, the lack of work-life balance is one of the main reasons for nurses leaving the profession; therefore, this should be referenced in the Council Conclusions. A better balance can be reached by no longer mandating overtime, short notice calling in, and even cancelling vacation time. This is why many nurses turn to agency work for a more flexible schedule, better working conditions, and better benefits and career opportunities. Agency nurses have more control over their work schedule and can choose shifts that fit their lifestyle. This flexibility is particularly beneficial for nurses who have family and education commitments.

Competitive wages and benefits are significant in fostering nurses’ motivation and job retention. Wages should reflect the nurses’ skills, effort, responsibilities, and difficult working conditions in which they have to operate. The EU should focus on supporting EU Member States to improve recruitment and retention of domestically educated nurses. Improving the attractiveness of nursing as a career by providing fair pay and better conditions of employment will be essential to keep experienced nurses in the profession and attract youngsters to the nursing profession.

Finally, having a greater systemic understanding of digital solutions will improve digital literacy. Nurses will be able to perform in a more time-efficient way and better organize their dayto- day work; reduce administrative workload and improve recordkeeping; make better-informed and evidence-based decisions; increase quality of care; contribute to the reduction of health inequalities; and ultimately, support the enhancement of cost efficiency in health systems through increased use of interoperable tools and data platforms. However, the urgent need to upskill and reskill the nursing workforce with digital skills to tackle these challenges is impeded by several severe constraints: the nurses are under pressure due to the large-scale resignation of frontline nurses, adding to already known workforce shortages. Increased workloads, disproportionate and unattractive remuneration, difficult working conditions and their taxing consequences on the mental and physical health and well-being of the nurses not only demotivate nurses to retain their jobs but also significantly reduce their availability for training opportunities, such as Life-long learning (LLL) and Continuous Professional Development (CPD).

Insufficient investment in LLL and CPD deprives the healthcare workforce of skills that are key to shaping a sustainable future for the healthcare sector. Healthcare systems need highly qualified and motivated nurses at the bedside to cope with the significant volume of healthcare needs and to better manage rising, more complex workloads amidst increasingly difficult working conditions. Hence, several pressing issues must be addressed to allow nurses the necessary time and opportunity for further development, enabling them to capitalize on digital and green upskilling and reskilling opportunities. Paramount among these are workforce shortages, the crisis of retaining frontline nurses, escalating workloads, remuneration misaligned with working hours, and unappealing working conditions. Prioritizing solutions for these challenges is essential to create an environment that supports the growth and development of nurses while simultaneously addressing critical gaps within the healthcare workforce. With the workforce’s physical and mental health and well-being in mind, upskilling and reskilling have the potential to train a future-ready healthcare workforce and, as a result, contribute to the upgrade, modernization and greening of the healthcare sector [27].

This paper advocated for decisive and targeted Council conclusions to facilitate an ethical and sustainable resolution to the persistent healthcare workforce crisis affecting the EU and Europe. Examining evidence preceding and exacerbated by the COVID-19 pandemic illuminated the adverse consequences of inadequate workforce planning, excessive workloads, inadequate staffing, and insufficient educational support, all of which contribute to nurse burnout, impact mental health, and degrade the overall quality of care. We have argued that the consequential shortage of nurses significantly imperils patient safety, demanding immediate action from EU institutions to formulate legislation that bolsters the recruitment and retention of domestically educated nurses.

We caution that the quick fixes of international recruitment have deleterious impacts on the health and well-being of other nations, increasing our vulnerability to future health crises. The emphasis on safe staffing frameworks, regulations, and professional judgment in addressing recruitment and retention challenges is therefore vital as an alternative. This necessitates a delicate equilibrium between policy initiatives and workforce strategies to establish a conducive work-life balance for frontline nurses, ultimately enhancing their well-being and the quality of care they deliver. Interventions at the level of the individual nurse, health care organization and funding/ policy levels are urgently needed.

The authors report no known financial conflicts of interest related to this manuscript.

The work leading to this manuscript received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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