The European Parliament SANT Committee Own Initiative Report on EU Nursing Workforce Shortages

Introduction

The global nursing shortage has consistently been a significant political focus before, during, and after the COVID-19 pandemic. The 2020 report, State of the World’s Nursing [1], highlighted a global nursing workforce of 27.9 million, with an estimated shortfall of 5.9 million nurses. The European Commission Joint Research Center report [2] on Healthcare Workforce Demand and Supply in the EU 27, with projections for the period 2021-2071, projects a 28% increase in the number of nurses. It is clear that the pandemic’s aftermath has worsened staff shortages across many regions. Some studies indicate that as many as 30% of nurses are contemplating retirement or leaving the profession [3]. Factors such as rising workloads, burnout, exhaustion, and inadequate recognition and compensation drive these troubling trends. While these challenges are not new, the pandemic has intensified awareness and underscored the urgent need to confront this impending crisis.

Addressing the issues leading to the nursing shortage is critically important, and looking for evidence-based recommendations for supporting the workforce is essential. The OECD report Health at a Glance [2] concluded that urgent action is needed to address health workforce shortages in Europe, stating that in the shortterm, improving working conditions and remuneration are critical to increasing the attractiveness of the profession and retaining current nurses. A focus on improving recruitment and retention is urgently needed at the EU level to address the healthcare workforce crisis.

In this paper, we will 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. Throughout, we will draw attention to the pivotal policy window on the horizon: The SANT Committee has the ambition writing an Own Initiative Report on the EU Health Workforce. This offers an opportune moment for proactive and focused EU measures on three pivotal areas that require decisive action: recruitment and retention within the nursing profession, establishing safe staffing levels for nursing care, and targeted investment in domestically educated and trained general care nurses.

Cuts affecting the EU Nursing Workforce since 2009

The nursing profession in the EU continues to face severe challenges stemming from budget cuts and cost-saving measures initiated during the 2009 financial crisis. Staffing levels have diminished, with some nurses experiencing wage cuts of up to 25%. Despite a growing need for healthcare, exacerbated by the COVID-19 pandemic, dangerously low nurse staffing levels have persisted. This situation has been further worsened by the mass resignation of frontline nurses who cite exhaustion, unsafe working conditions, and unsatisfactory salaries as reasons for their departure [4]. Consequently, there has been a notable increase in the outflow of nurses across EU Member States, with an estimated 30% of nurses leaving the profession, prompting calls for urgent legislative responses from the European Commission.

In response to the ongoing crisis, the EU has introduced new legislation aimed at enhancing health system readiness and coordination among Member States. These efforts, outlined in the COM Decision C (2021) 6712, 2021, seek to strengthen the EU Health Union and improve the capacity to manage future health threats. However, to effectively address the nursing shortage and ensure a coordinated approach, a legislative focus is necessary both at the EU level and within individual countries. This strategy should prioritize the adequate development of the health workforce and other related fields in order to establish a more cohesive and robust 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 Commission. Unfortunately, the health workforce has not been mentioned in the Commissioner’s Mission Letters and, as such, is not part of any Commissioner agenda. This makes the Own Initiative Report even more timely and important. Addressing the health workforce in the Own Initiative Report is a political imperative, considering that the scarcity of nurses is a prevailing reality across EU Member States, posing a significant risk of collapse for the European healthcare systems.

The EU’s Inaction on the Nursing Workforce Shortages

As the nursing workforce in many EU countries is in crisis, the SANT Own Initiative Report is vital in better preparing European healthcare systems for future health emergencies and safeguarding the accessibility, quality, and safety of direct patient care. This is particularly crucial in light of the missed opportunities that have occurred in the past.

The European Commission Green Paper on the EU Workforce for Health [5] led to the European Parliament’s written declaration on the EU Workforce for Health [6]. However, bold actions have not been taken and are now urgently needed to address the dire situation of the EU nursing workforce. Although the Council conclusions in December 2010 re-launched the EU Health Workforce file, they need urgent updating and re-orientation if we want impact and change. Let us critically analyse the 2010 Council Conclusions:

• Strengthening collaboration and exchanging good practices are no longer enough.

• Collecting high-quality, reliable, and comparable data remains challenging. Despite investments from the OECD, WHO, EUROSTAT, and ILO to gather quantitative data, incompatible methodologies hinder nursing workforce policy design and evidence-based workforce science [7]. The nursing profession categories in the OECD-WHO-Eurostat Joint Questionnaire, based on the ISCO-08 code, mismatch occupations and qualifications, creating confusion and unreliable data for EU health workforce planning. Unfortunately, the ILO will not make changes before 2028.

• Policies contributing to equal access to care for all are wishful thinking as we move toward an EU with two speeds: those who can pay their workforce and those who cannot.

• Forecasting future health workforce requirements to develop effective health workforce plans across the EU is akin to predicting the weather: inaccurate and unreliable.

• Raising awareness of the importance of attractive working environments and working conditions is no longer sufficient since 30% of nurses have already left the profession.

• Professional development opportunities: It is impossible to follow CPD courses as there is nobody in the nursing team to replace you, so CPD is not a priority when health systems are in survival mode.

• Stimulate training and education of the health workforce to promote the quality and safety of care: The workforce, puzzlingly, is not part of the Recovery and Resilience Facility.

• Considering how to best use EU financing tools without prejudice to the future Financial framework has been intractable with no EU Health Workforce funding mechanism existing While the EU has held multiple consultations and launched several Joint Actions with Member States and 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 Facility was put in place during the COVID-19 pandemic.

• The WHO Global Code of Practice on international recruitment has not been adhered to, with Member States signing bilateral agreements with Bangladesh, India and other non-EU countries on the Health Workforce Support and Safeguards List to bring nurses to the EU.

Regrettably, the Council Conclusions of 2010 did not result in any meaningful improvements in the healthcare sector over the past 14 years. Despite the Commission’s response to the Action Plan on the EU Workforce for Health in 2012 and the Joint Action Health Workforce Planning and Forecasting (EUHWF) in mid-2013, which was extended in 2022 (Heroes), the situation worsened due to the COVID-19 pandemic. The pandemic highlighted the absence of policy coordination and funding to address the nurse shortage. It is disheartening to identify that the EU and its Member States missed the opportunity to implement the policies that would have ensured workforce resilience.

Therefore, the European Parliament SANT committee Own Initiative Report needs to convince the Commission to legally address multiple critical facets of the EU health workforce:

• Ensure that the EUROSTAT, OECD and WHO data collection is not using biased data. In 2024, the European Semester started to use the Directive 2005/36/EC definition for the nursing category, resulting in different data plots and interpretations.

• Develop domestically educated and trained nurses. It is key to ensure the development of a sufficient, high quality and motivated nursing workforce through education and training as outlined in Directive 2013/55/EU.

• Diminish dropouts during the 4-year EU education cycle for nursing students by advocating and investing in high-quality mentorship programs.

• Transform the WHO Global Code of Practice on the International Recruitment of Health Personnel [8] into a legal framework. With a global health crisis, every country needs nurses, including the Philippines, Pakistan, India, Bangladesh and Africa. On the one hand, Member States commit on paper to implement ethical recruitment policies, but on the other hand, EU national governments and individual employers sign bilateral agreements and keep “robbing Peter to pay Paul”.

• Define and enforce safe staffing levels to sustain high-quality patient care standards across the EU.

• 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.

Being Prepared for the Next Health Crisis

Nurses in the EU are still suffering the repercussions of the COVID-19 pandemic, including in many EU Member States, where there are huge workforce shortages, low pay, and unfavorable working conditions. During the disruptive pandemic, three broad types of workforce strategies were implemented to scale up the health workforce’s capacity to manage the crisis:

• Working harder: the first strategy was to increase the working time of existing nursing staff by asking frontline nurses to work overtime, asking part-time workers to work full time, cancelling or postponing leave, and even not going home from work, with sleeping facilities in the hospital. This strategy had a huge negative impact on the wellbeing of frontline nurses.

• Reallocate and reskill nurses to meet critical needs in intensive care units (ICUs) in hospitals overburdened by COVID-19 patients. The shortage of ICU nurses was solved by upskilling general care nurses from general care units to achieve ICU capacity at the expense of all other general care nursing units, such as cardiology, internal medicine, cancer care units, and even mental health units. DG Sante even funded this strategy through the public health program.

• Mobilizing additional staff: The third strategy was to mobilize additional professionals and workers, notably to support testing, tracing, isolating activities, vaccination campaigns, and information and advice to the general public. Moreover, nurses’ scope of practice was expanded to respond to the huge demand for nursing care. Most countries also mobilized nursing students nearing the end of their studies. This strategy had a profoundly detrimental impact on future nursing students who left the profession before completing their studies.

The pandemic left frontline nurses overstretched and exhausted. Consequently, in 2023, we saw that nurses who moved to the ICUs (ESICM, 2022; Arabi, 2021) left the hospital and even resigned from the nursing profession, leading to more scarcity of nurses in general hospital units, leading to the closure in 2023 of general care hospital beds, emergency units and ICU units, in almost all EU Member States (Sen-Crowe, 2021; De Standaard, 2021; Harvard Kennedy School, 2022) [9]. Furthermore, the number of students in nursing education programmes declined by 40% in 2023 (compared to 2019). It is clear that the interest of young people in pursuing a career as a nurse has appeared to have lessened since the pandemic (Azzi‐Huck & Shmis, 2020).

Therefore, it will be crucial for the Own Initiative Report to concentrate on enhancing the preparedness of healthcare systems’ workforce capacity in the EU to withstand unpredictable future shocks. Since frontline doctors and nurses, who constitute the largest proportion of healthcare professionals, are the ones who can effectively and swiftly respond to emergencies and possess the most comprehensive knowledge of their population and the environment in which citizens reside and operate, it is imperative to focus specifically on these two healthcare professionals.

A crucial part of such preparedness is providing sufficient education and training for the nursing workforce to enable safe patient care and meaningful patient engagement without lowering standards of education/training (Directive 2013/55/EU and the Updated Annex V). This will contribute to highly qualified and motivated domestic nurses in the EU. Furthermore, preventing dropouts during the 4-year EU education circle can be achieved by promoting and investing in mentorship for nursing students. Let us strive to retain more nursing students and ensure they complete their education and commence their careers as registered nurses.

EFN Workforce Matrix 3+1

The Sant Committee has a window of opportunity that could lead to concrete policy initiatives at the EU level. Any initiative should build on the developed EFN Workforce Matrix 3+1, which clarifies the three categories of nursing care: General Care Nurse (Directive 2013/55/EU), Specialist Nurse, and Advanced Practice Nurse (APN). It should also include critical principles for the development of Healthcare Assistants (HCAs) [10].

Recognised as the lead in this crucial topic for the nursing profession, and acknowledging that the EFN brought this debate to the European Parliament in 2010 through the launch of a written declaration on the EU Workforce for Health (n°40/2010), the EFN and its members have been lobbying intensively to get researchers and policy-makers to collaborate in this crucial topic for nurses and the nursing profession. However, European, and international institutions have made minimal progress on the EU Workforce for Health. The data collected at national, EU, and international levels tend to be fragmented, incomplete, and incomparable nationally and internationally. As such, they cannot be used confidently in EU policymaking.

Therefore, the EFN members decided to develop an “EU Nursing Workforce Matrix 3+1” with the three categories of nursing care, general care nurse, specialist nurse and advanced nurse practitioner, and recognize the important role of Healthcare Assistants (HCAs) and the leading role of nurses in their supervision in the development of HCAs. The Matrix, which includes information on education, qualifications, and competencies for each category, must be part of the Own Initiative Report. All developments to strengthen healthcare systems depend on clarity on “who is who” and “who does what.” It is the only way to ensure safe and highquality care.

The first category, “General Care Nurse or Registered Nurse” (EQF 6), is legally set by EU law, Directive 2005/36/EC, chapter 3 of the Acquis Communautaire, modernized by Directive 2013/55/ EU and the recently updated Annexe V. In the second category, “Specialist Nurse” (EQF 7), we find different specialties and lengths of education across the EU Member States. However, specialist education starts after achieving the qualifications of a General Care Nurse through postgraduate studies. The third category, “Advanced Nurse Practitioner” (EQF 7 – EQF 8), is a registered nurse who has acquired further knowledge and expertise, clinical judgment, skilled and self-initiated care, and research inquiry.

Importantly, there are common principles for defining and differentiating specialist and advanced practice as nurses take on important roles in enhancing service delivery and improving health outcomes of diverse client groups:

• Advanced practice describes a level of practice rather than a specific role.

• Advanced practice encompasses direct clinical practice, research, education, management, and leadership.

• Advanced practice builds on and adds to the competencies that all nurses attain after completing their initial education and recognizes nursing expertise as a continuum.

• Specialist practice describes a depth of competence in a particular clinical domain. The two are not mutually exclusive, and some specialists may practice at an advanced level in their field.

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 organisation, 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.

Finally, the education and development of healthcare assistants (HCAs) is an increasingly important issue for patient care across Europe. Healthcare systems increasingly rely on HCAs to perform an ever-increasing number of duties due to increased pressure on health budgets and task shifting.

An HCA is an auxiliary who assists the nurse directly in providing nursing care in institutional or community settings under the general care nurse’s standards and direct or indirect supervision.

Nurses play a crucial role in supervising HCAs and ensuring an effective line of accountability between the registered nurse and the HCA. HCAs are not nurses and cannot replace the care that nurses provide. The division between the role of nurses and the role of HCAs must be clearly defined, mainly knowing that across the EU, there are very different approaches to the role, regulation, and employment of HCAs. To enable the effective development of HCAs in the future, the EFN calls on the SANT committee to support the following principles:

• A clear articulation of the line of accountability between a registered nurse and a health care assistant.

• A commitment to comprehensive and consistent frameworks ensures that HCAs can deliver safe, effective care and public protection in each Member State.

• A robust quality assurance system for all HCA programs carried out in individual Member States.

Within a context of growing and changing healthcare needs, health system reform, and new and more exigent requirements of care, a broader understanding of the different roles and professional categories in nursing care is needed, next to having a clear picture of the exact and comparable numbers of the entire nursing workforce.

EU-WHO Nursing Action

The European Commission has signed a contribution agreement with WHO Europe to support Member States in retaining nurses in their health systems and making the profession more attractive to young people. Particular focus will be given to countries with significant shortages of healthcare professionals, specifically nurses.

The scope of this Nursing Action is to work on solutions to increase the supply of nurses in all the Member States and reach the policy level to ensure a quicker take up of necessary measures to alleviate the nurse workforce crisis. This action will pursue two objectives:

• Building up the pool of European nurses to counteract structural shortages of nurses in the Union and their negative impact on other regions of the world.

• Drive more policy focus and mobilize efforts to address nurses’ critical situation. This will improve the resilience of health systems and the safety of care, which are the European Health Union’s central objectives.

The action will focus on measures to attract more students and mid-career people to nursing and on measures to retain nurses. Therefore, it can serve as a useful reference point for the SANT Own-Initiative Report on Health Workforce Shortages, and the EFN, as a key partner in the EU Nursing Action, can act as a natural bridge between the two initiatives.

Nursing Students

Get more Nursing Students with more supportive Clinical Placements

To address the nursing shortage in the EU, substantial investment in domestic nursing education and training is essential. Governments should prioritize cultivating domestic nursing talent to replace retirees and those exiting the profession. Developing a sustainable workforce through robust educational programs is critical for the healthcare system’s longevity and efficiency. Attracting more individuals to nursing education requires channeling resources into nursing schools and identifying barriers that deter young people from the profession.

A significant challenge is the declining interest in nursing, evidenced by a nearly 20% reduction in applicants to nursing programs in the UK, with over 33,500 applications in Autumn 2023—an 18.5% drop from the previous year. This trend is mirrored across EU Member States, where the number of nursing education students decreased by 40% in 2023 compared to 2019. Additionally, a concerning number of students leave nursing programs prematurely, particularly in Belgium, where 41% of nursing students do not complete their studies, highlighting a critical issue within nursing education.

To mitigate student attrition, enhancing mentorship and providing necessary practical guidance throughout their education is crucial. Nursing students often face excessive practice hours, insufficient mentorship, and tasks beyond their educational scope, leading to dissatisfaction and a disconnect between their expectations and real-world demands. Policies promoting mentorship and clear career pathways in healthcare are vital to not only retain nursing students but also support their professional development after graduation, ensuring a stable and skilled nursing workforce for the future.

Tutorship & Mentorship

All undergraduate nursing study programmes in the nursing field must be developed according to the EU directive (2005/36/ EC amended by Directive 2013/55/EU), which demands that half of all contact hours of each study programme are done in the clinical environments as clinical practice and mentored by the clinical mentors. However, clinical mentor education is greatly lacking in nursing education (Westphal et al., 2016). Quality mentoring significantly affects student learning outcomes and greatly influences novice professionals’ intention to stay in the profession after graduation. It also increases satisfaction with professional growth and identification with the nursing role (Hale & Philips, 2019).

The SANT Committee Own Initiative Report must distinguish between tutors, nurse teachers, clinical mentors, and experienced frontline nurses who guide students. All play a key role in the early professional development of nursing students, and their roles and responsibilities are closely interlinked (Macintosh, 2015; McSharry et al., 2010).

The term tutor refers to the range of education and clinical instruction roles undertaken by nurses with primarily an education rather than a clinical focus in association with an institution of higher education (WHO, 2016). However, the ways in which nurse teachers support student nurses in the clinical environment can vary from institution to institution and from hospital to hospital. Generally, they are a key resource to clinical staff and provide opportunities for assessing students in practice. Nurse teachers are also regarded as having a key position to contribute to in-service and practice development (Lovrić et al., 2014).

A clinical mentor is a “registered nurse who supports undergraduate students in their learning and is responsible for teaching and assessing students in clinical practice” (Tuomikoski et al., 2018, p. 79). Saarikoski and Leino-Kilpi (2002) affirmed that one of the main elements of an excellent clinical learning environment is: “Supervisory relationship: the one-to-one relationship is the most important element in clinical instruction and mentoring/ supervision”.

The quality of the clinical learning process depends mostly on the quality of mentoring. Mentoring, also called supervision, of nursing students during clinical practice should serve as the professional development vehicle for nurses and be crucial for students’ professional modelling. Mentoring is essential for future nursing professionals’ socialization and cultural competencies, with the mentor as a key factor in this process (Gurková et al., 2016; Flott & Linden, 2016). Positive characteristics in mentorship include the elements of flexibility, negotiation, confidence, and positive reinforcement of the student. Negative characteristics in mentorship include being insensitive, not tactful, not showing compassion towards the student, and having excessive expectations of perfection (Hale & Phillips, 2019; Dobrowolska et al., 2016). Furthermore, mentors of culturally and linguistically diverse students must have good theoretical and clinical judgment skills, good interpersonal skills, mentoring and assessment skills, and the ability to understand the impact of cultural diversity and defend this.

As healthcare environments are complex and demanding, mentorship must provide a supportive framework for student nurses to navigate everyday challenges. This framework should foster growth, confidence, and competencies in accordance with Directive 2013/55/EU. Considering these aspects, it becomes clear that mentorship is a crucial aspect of nurse recruitment and retention and should, therefore, become a central component of this Own Initiative Report.

Recruitment of General Care Nurses

An EU standardised approach to the recognition of qualifications and competencies of third-country nationals in line with the Directive 2013/55/EU

The EU faces significant nursing shortages and must attract qualified nurses from non-EU countries without compromising the competencies outlined in Directive 2013/55/EU. However, the ethical standards set by the WHO’s Global Code of Practice on the International Recruitment of Health Personnel are at risk, particularly evident in cases like Ukrainian nurse refugees. These nurses, unable to meet the Directive’s compliance due to their diplomas, are relegated to assistant nursing positions instead of utilising their full qualifications. The EU’s failure to implement bridging courses to help elevate their qualifications represents a lost opportunity to enhance the nursing workforce.

There is an urgent need to recognize and validate the skills of migrant health professionals, even when formal documentation is inadequate. Evaluating and acknowledging their competencies is essential to leverage their potential contributions to the healthcare sector. Establishing effective communication and understanding between EU and non-EU authorities, particularly through systems like the IMI of Directive 2005/36, is vital for improving the recognition of qualifications. This approach would enhance trust and expedite the integration of skilled health professionals into the EU workforce.

To foster a standardised recognition process for nursing qualifications obtained outside the EU, Member States should prioritize aligning training assessments with Directive 2013/55/ EU’s minimum training requirements. This standardisation will help ensure patient safety and care quality while creating a fair evaluation system for all nurses. Additionally, establishing clear language requirements for health professionals is crucial to guarantee effective communication with patients, reinforcing the importance of language proficiency within the recognition process.

Retention of General Care Nurses

Salary - European Pillar of Social Rights (EPSR)

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 EPSR Principle 6 ‘wages’ is an important political priority to tackle the shortage of nurses. The 2008 Financial and Economic Crisis cuts in the financing of the healthcare systems in the EU had a negative impact on health outcomes, with nurses expected to provide the same level of care, the same quality, if not higher, with fewer resources, leading to burn-out and consequently nurses leaving the profession since 2009.

While practically every Member State faces a shortage of nurses to meet the unmet needs of its population, little or nothing is done to strategically and politically address these shortages. It is well established that the remuneration of nurses is one of the key factors influencing their job satisfaction and the appeal of the profession.

Governments, even post-pandemic, are hesitant to increase nurses’ salaries or provide COVID-19 bonuses as a token of appreciation for their unwavering dedication on the frontlines.

EFN collected data [12] reveal great disparities among European countries and are, as such, not straightforward to compare or explain. The data confirm that despite the harmonized educational framework of Directive 2013/55/EU, nurses’ salaries vary significantly and randomly across the EU.

The European Pillar of Social Rights and the European Semester should address these wage disparities, leading to an enormous “brain drain” within the EU. The EFN data analysis clearly shows that the EPSR still has a long way to go, as great disparities between countries in the EU and Europe are obvious. It is clear, especially post-COVID-19 that more EU policy and political efforts need to focus on increasing the net salary of frontline nurses in the EU through strengthening collective bargaining and Social Dialogue.

Working Conditions

Workforce working conditions are more talked about than changed for the better. Decent and healthy working conditions are essential as frontline nurses frequently operate in hazardous environments that jeopardize their health and safety. The lack of work-life balance is one of the main reasons for nurses leaving the profession; therefore, this should be a clear focus within the Own Initiative Report.

No longer mandating overtime, short notice calling in, or even cancelling vacation time can achieve a better balance. 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.

Nurses’ hard physical work and demanding operational environments lead to physical impairment, with nurses being confronted with violence and harassment, which is unacceptable. As violence against nurses has grown into epidemic proportions [13], the SANT Own-Initiative report 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.

EU Safe Staffing Levels

The current body of research highlights the significant impact of increased nurse staffing with an appropriate skill mix on patient outcomes, mortality rates, job satisfaction, and nurse retention [14-18]. Studies indicate that proper nurse staffing is essential for ensuring quality patient care. When nurses are allocated too many patients, the risk of errors and negative outcomes increases, leading to heightened stress and potential burnout among nurses, especially amidst ongoing nursing shortages.

Globally, there is a growing trend toward legislating nurse staffing ratios. Several states in the USA and Australia have started implementing minimum nurse-to-patient ratios, reporting positive effects on patient care. As of 2019, 14 states in the US have established laws regarding nurse staffing, either through mandated ratios or by forming staffing committees to ensure patient safety. California led the way by mandating minimum staffing in 2004, and more recent legislation in Oregon emphasizes the importance of safe staffing requirements in hospitals.

The American Nurses Association has recommended specific nurse-to-patient ratios for various healthcare settings in the US, such as 1:2 in intensive care units and larger ratios in intermediary and medical-surgical units. As of 2023, more states are pursuing similar laws to enhance patient outcomes and nurse job satisfaction. In Australia, legislative measures for nurse-patient ratios have been in place since 2001 in public hospitals, showing a commitment to maintaining high standards in patient care.

In contrast, Europe is still lagging behind in establishing comprehensive legislation related to nurse staffing ratios. The landscape across the 35 countries monitored by the European Federation of Nurses (EFN) shows limited progress, with only 11 countries indicating some relevant legislation. Even those with existing frameworks face challenges, such as ineffectiveness or lack of enforceability, showcasing a need for more significant policy changes and the establishment of standardized staffing methods across the continent.

Barriers to implementing robust nurse staffing legislation in Europe include political hesitance, decentralized healthcare systems, existing nursing shortages, and financial concerns. A thorough examination reveals that many countries do not have approved or recognized methodologies for determining sufficient nurse staffing levels. This situation highlights an urgent need for better frameworks that ensure safe staffing ratios necessary for protecting patient care and supporting nursing professionals. Despite persisting national differences, it is clear that striking the right balance in nurse-patient ratios, which must be accompanied by meaningful action to address both recruitment and retention issues across the nursing profession and ensure sensitivity and adaptability to local demands, is therefore essential to ensure optimal patient care, enhance job satisfaction, and mitigate the risk of adverse events [19]. Safe nurse staffing is an incentive to attract nurses, aiding recruitment and retention, and reducing the reliance on unethical recruitment practices, such as the inappropriate recruitment of overseas nurses, contrary to the principles outlined in the WHO Code on Ethical Recruitment of Health Personnel. As such, Safe Staffing Levels, with a focus on developing EU legislation that builds on the EFN data collection, must therefore be included as a priority in the SANT Own-Initiative Report on the Health Workforce Shortages.

EU to Finance the Health Workforce Recruitment & Retention

EU to look at the US financial mechanism to develop Nursing Workforce

The EU and Europe should align their workforce policies with those of other nations, particularly observing the US’s legislative actions aimed at enhancing nurse education and expanding the nursing workforce. The Health Resources and Services Administration (HRSA), part of the U.S. Department of Health and Human Services, allocated over $100 million, in addition to the annual $300 million, for nursing workforce development initiatives focusing on various elements of workforce demand, including education, practice, recruitment, and retention. These investments aim to meet the rising need for registered nurses, nurse practitioners, nurse midwives, and faculty. Political advocates acknowledge the nursing workforce’s vital role in enhancing health outcomes and healthcare services across different environments, such as hospitals, nursing homes, and community care. Thus, the Biden-Harris Administration has demonstrated a commitment to supporting nurses. We hope the incoming Trump Administration will continue to back the nursing profession education. Given this US context, as a best practice example, the SANT Committee Own Initiative Report should suggest developing an EU financial framework to support Member States or at least amend the Recovery and Resilience Facility to make health workforce recruitment and retention budgets mandatory.

Urgent Review of the Recovery and Resilience Facility

In the framework of the European Semester, all Member States receive country-specific recommendations (CSRs) in the area of health policy. To address these recommendations and their health systems’ weaknesses, all the Member States have envisaged investment and reform measures adapted to their national contexts and included them in their NRRPs. The most recent annual report from the European Commission on the RRF estimated the total healthcare-related expenditure at €43 billion for the 27 NRRPs. However, the key question is: Are these billions used to address the shortage of nurses?

Article 3 of the RRF Regulation defines the instrument’s scope and six pillars, the fifth of which is ‘Health, and economic, social and institutional resilience, with the aim of, inter alia, increasing crisis preparedness and crisis response capacity’. The RRF focuses more on expanding healthcare infrastructure, modernizing primary care, addressing staff shortages, and digitalizing health services. These measures contribute to various health objectives, such as improving primary healthcare, transitioning from hospital to outpatient care, reorganizing hospital networks, stepping up prevention, increasing the quality of diagnosing and treating patients, strengthening the healthcare workforce, and modernizing healthcare facilities.

Despite the billions of euros available, only Spain, Luxembourg, Bulgaria, Slovenia, Austria, the Czech Republic, Lithuania, and Estonia are implementing measures which target the health workforce and nurses specifically through their Recovery and Resilience Plans. Instead, Member States have been targeting the development of new hospitals and healthcare infrastructure, which is also important. However, at the same time, they do not have the health workforce to service them! Thus, it remains key to demand that Member States invest these funds in the health workforce and demand more information and transparency in the decisionmaking processes surrounding these investments.

Furthermore, the Country Reports indicate that countries scoring the worst on health indicators also have persistent shortages of healthcare professionals. The only way to address this problem is to stimulate the hiring of healthcare professionals. As outlined in the Country Reports, there are many reasons accounting for workforce shortages. These could be due to insufficient wages (making healthcare professions unattractive), poor working conditions, wrong retention measures (as seen by the high number of nurses leaving the profession across many countries), or simply insufficient hiring policies. Moreover, when healthcare workforce shortages occur, these tend to be more acute in the nursing profession.

As such, the SANT Own Initiative Report demands that Member States take concrete actions that impact the nursing profession and not waste the enormous opportunity made available by the EU through the Recovery and Resilience Plan. The Own Initiative Report is crucial for refocusing the RRF funds and directing them more towards the nursing workforce’s capacity to deliver safe and high-quality care.

Conclusion

Job commitment is at stake in healthcare, leading to staff shortages. These shortages further stress the healthcare system, creating a vicious circle of healthcare personnel leaving the job and even more nurse shortages.

Therefore, the Own Initiative Report needs to address the following topics: The 3R² policy actions.

Recovery and Resilience Facility

The Own Initiative Report must highlight the importance of evaluating the RRF in relation to health workforce shortages and propose a renewed focus on building the nursing workforce’s capacity (in quantity and quality). Particular attention should be paid to the possibility of making it mandatory for EU Member States to assign a budget from their RRP dedicated specifically to health workforce capacity building.

Recruitment

The Own Initiative Report must highlight the importance of recruiting more students into the nursing profession and keeping them in the four-year bachelor programme.

• Aligning with the objectives of the WHO EU Nursing Action Project, greater focus should be placed on ensuring the availability of more supportive clinical placements, as well as highly qualified and competent nurse teachers and clinical mentors. As the evidence demonstrates, these key aspects shape nursing students’ final decisions to finish their studies, join the nursing workforce, or abandon their studies altogether.

• Furthermore, in the context of recruiting nurses from non- EU countries, the Own Initiative Report should focus on the possibility of developing an EU-standardised approach to the recognition of competencies and qualifications of third-country nationals in line with Directive 2013/55/EU. At the same time, this would prevent brain drain and unethical recruitment from countries with fragile healthcare ecosystems.

Retention

The Own Initiative Report need to highlight the importance of retaining the nurses we have and getting those nurses who have already left the profession back into nursing. Therefore, particular attention should be paid to:

• Pushing for EU legislation on Safe-Staffing levels that positively impact nurses’ working conditions, as well as the quality and safety of patient care, as demonstrated by extensive global evidence.

• Enhancing working conditions is essential, particularly by promoting work-life balance and actively combating violence against nurses and allied health professionals through a zeroviolence policy. These factors are key contributors to the daily departures of nurses from the profession. Hence, it is crucial to advocate for EU legislation aimed at ensuring a violence-free environment for nurses and allied health professionals.

• Providing adequate salaries that reflect the nurses’ skills, effort, responsibilities, and difficult working conditions in which they have to operate.

• Pushing for the development of EU legislation on Advanced Practice Nursing (APN): in addition to improving the quality and safety of patients’ care, APN development is key to recruitment and retention efforts as it provides a clear career development pathway for registered nurses.

Conflict of Interest Statement

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

Funding Acknowledgements

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

Social media (X/ Twitter) handles

@EFNBrussels.

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