Is there an EU framework for nurse education?

Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.22 | No.1 | 2016 14 IS THERE AN EU FRAMEWORK FOR NURSE EDUCATION? By: Tom Keighley Summary: This article explores the unplanned way in which a framework for nurse education has emerged within the European Union. Using the reform of Directive 2005/36/EU and its subsequent amendment (2013/55/EU) as the lens for this exercise, certain issues worthy of further examination emerge. Among them are the likely impact of the Professional Card, a competency-based EU-wide nurse education programme, and what the mechanisms will be for exercising the delegated acts. The article concludes with observations about current policy making and its implications both for Member States and accession countries. Keywords: Nurse Education, Nurse Qualifications, Mutual Recognition, Free Movement, EU Policy Tom Keighley is an independent health care consultant. Email: nurprc@nursing.u-net.com Introduction The immediate answer to the question in the title is no, as there is no European Union (EU) competency to create such a framework for nurse education; but this is an oversimplification. The nursing profession, the single largest workforce in the EU, is subject to numerous EU policy structures and processes, not least those designed to ensure workforce free- movement, harmonisation of training, and mutual recognition of education and training standards. Other policy developments, especially in public health, education and consumerism, also influence nurse education, with the current initiative on Active and Healthy Ageing being an example. This requires nurses to participate more actively in patient adherence to medical prescriptions, initiating falls prevention programmes, improving assessment skills in levels of frailty and functional decline, and developing more integrated health care delivery. The picture, therefore, is of a complex matrix of influences all impacting on nurse education and practice while focusing on other EU policy concerns. Inverting the image, and seeing nurse education as a major component of policy delivery within the EU opens a different perspective on the relationship between the ways that the workings of the EU both impacts on nurse education and is dependent on it for the successful delivery of many of the health and consumer related initiatives. This article will briefly describe developments in nursing education and mutual recognition of professional qualifications, as well as identify the key legislative and non-mandatory influences, determined both within the EU and external to it, but applied within its policy framework. Finally, the adoption of a competency-based approach to nurse education within the EU context will be addressed. Acknowledgement: This article is based on a chapter in the forthcoming study: Rafferty AM, Busse R, Zander B, Bruyneel L, Sermeus W. The contribution of nursing to heath system performance: A European perspective. Copenhagen: European Observatory on Health Systems and Policies. Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.22 | No.1 | 2016 15 A legal-base for nurse education The enactment of the sectoral directives in 1977 brought closure to a nursing initiative pursued for over twenty years. 1 2 It instituted a mechanism for both mutual recognition of qualifications in general nurse training and the regulation of nursing practice. Over the next twenty years, there were several amendments, especially the agreement on the balance between theory and practice in the training programmes. Further, there were advisory documents on cancer, palliative care, public health and care of older people to act as a backdrop to the development of training programmes, leading to a separate form of recognition which permitted the free-movement of specialist nurses. 3 An attempt in the late 1990s to move over to a competence-based approach to training failed but further revisions of the directives resulting in Directive 2013/55 finally achieved that goal. 4 ‘‘ moving to competency-based educationNon-mandatory, and not specific to nurse education, but deeply influential on how nurse education has developed across the EU, are the European Qualification Framework (EQF) and the European Credit Transfer and Accumulation System (ECTS). These have determined the academic level of nurse training that is professionally desirable (EQF level 6) and the duration of training (180 credits). This structuring has enabled a shift of nurse education from mono-technical schools and colleges into higher education university settings. The move has been contended by numerous governments and remains a controversial development, especially in German speaking countries and some of the EU accession and recently acceded countries in Central Europe. In these countries, the combination of state- level decisions about the status of different occupations and the appropriate level of associated education has previously precluded nursing from integration into higher education. EU policy making can move in step with non-EU bodies, and so influence the framework for nurse education as well. The Bologna Process to increase compatibility between European higher education systems is one example, while the World Health Organization (Europe), 5 the International Labour Organisation on health and safety at work, 6 and the International Council of Nurses 7 have all issued reports and advisories which have influenced the content and shape of nurse education in recent years. The current situation The revision timetable for Directive 2005/36/EU slipped considerably and in doing so illuminated the tensions between first order intentions (improving the flexibility of the workforce and associated free-movement at a time of financial crisis) and the wish of the nursing profession to see major improvements in the nature of nurse training. Some decisions have been pushed through despite great concerns about their deliverability. These include the Professional Card, the development of competency-based education, and the creation of delegated acts. The Professional Card, issued to all nurses in the EU since 18th January 2016, contains details of their education and registration. While a worthy idea, it does not address the complexity of the mutual recognition process, with several hundred regulatory organisations in which recognition can be checked and the lack of resources (both human and IT) in many countries to ensure such a card is kept up-to-date. Article 31 of Directive 2013/55/EU lays out in broad detail the nature of the competencies to be adopted in nurse education. These competencies have been developed in great haste to meet the deadlines for the issuing of the Directive and have not been tested. Further, they have not been examined to determine how a person emerging from a programme designed around such competencies will integrate into the multi-disciplinary arena that constitutes modern health care delivery. More importantly, the competencies have been developed in the knowledge that many countries do not have the faculty to teach such competency- based programmes or the clinical arenas to provide the associated training and permit subsequent practice. Of greatest concern must be questions about quality of care and patient safety, issues not of concern in a directive focusing on free-movement of the workforce but which could be affected by the over-rapid development of the competencies. Delegated acts are a new phenomenon. They are a mechanism to enable the revision of course content and approval of education developments without requiring a revision of a complete directive. This is a mechanism that will apply primarily to the Annexes of the directive and circumvent the delays that reforms have experienced in the past. While this is a positive development, it is still unclear quite how they will operate. The policy debate on nurse education has been invigorated by the discussions about the revision of the directive. In many countries in Western Europe, this is the first time in over a decade that governments have had to address the framework of nurse education actively and to encounter how this is seen both by the professions in their own countries as well as the responses of other countries. The challenge, however, remains the same, and that is how to have a policy debate about nurse education in the EU when the decisions about it are made secondary and some cases tertiary to higher-level policy decisions. There is increased awareness in the Commission and amongst MEPs about issues like gender challenges implicit in decisions about nurse education and concerns about patient safety and quality of care. However, the focus now needs to turn to whatever mechanisms can be agreed to draft and implement specific competencies in line with the Directive, as well agreeing the revision mechanisms to keep the Directive up-to-date while being applied in a harmonised fashion across the EU. Challenges for accession countries The stream of countries still preparing to accede to the EU presents particular challenges for nurse education. Turkey, Montenegro, the Former Yugoslav Republic of Macedonia, and Albania Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.22 | No.1 | 2016 16 are all working to achieve conformity with the EU directives. In nursing, this requires not only the reform of nurse education, but also fundamental changes to education at high school level and the re-classification of professions with all that that entails in terms of remuneration and social recognition. It is the area of reform that has caused a focus to develop on opportunities for women and their right to education. In particular, adopting the EU directives that apply to nursing has shone a lens on the historic communist types of education which even now have not been fully reformed. The major policy challenge for much of the EU and the accession countries when developing nurse education is how to generate the professional space to permit comprehensive and autonomous nurse practice to be delivered. The lack of integrated policy for nurse education highlights the problem. The lack of negotiation with key stakeholders, like doctors and national law makers, jeopardises the development of a competence-based education system. The resistance to such developments limits the opportunities for women accessing higher education when it was not open to them in their nation’s previous educational systems. In positive terms, the development of the EU directives on professional qualifications has resulted in the creation of regulatory structures which, as a by-product, have not only improved patient safety and quality of care, but also enabled nurses to engage more fully with the decision-making concerning their career paths. In so doing, this process has assisted in addressing the internal democratic deficits in countries. Conclusions No single policy or strategy has been determined and pursued within the EU on nurse education and training. Indeed, given the diversity of decisions and influences it may come as a surprise to some that such a framework has emerged. The consequences of this are multiple. It means that there is no particular focus within the European Commission structures whereby nurse education matters can be discussed or facilitated. Moreover, no mechanism exists for the Commission to work with Member States on matters concerning the training of nurses, unless this relates to free movement of nurses. It has been a source of great frustration to the nurse associations and their representatives at a European level that this cannot happen, even when consensus exists that such discussion would aid all concerned. Despite creating a common platform mechanism in Directive 2005/36/EC, which could have been used for the reform of nurse education, no attempt was made between 2007 (when the Directive became active) to 2012 to use it. Therefore, from the perspective of nurse associations, it seems fair to conclude that seeking specific policy direction for nurse education within European Commission procedures is currently not a fruitful exercise. However, decisions both within the EU and in organisations that relate to it have created a de facto policy framework which has demonstrated an evolutionary capacity over time. What has emerged is a process of validation, some of which is embedded in law and some within voluntary ‘good practice’ frameworks which have reformed the nature of nurse education and training in the last two decades and looks set to continue to do so. While the stimuli for this have emerged from a concern about creating a skilled and sophisticated workforce equipped for the coming decades, and to ensure ease of movement between national borders, nurse educationalists in particular have reshaped delivery mechanisms and course structures to a profound degree. So effective has it been that accession countries aspire to imitate this in their reform proposals to the European Commission, even when the requirements exceed the legal requirements for accession to the EU. Further, because nursing is considered to be one of the liberal professions, nurses have rights of individual establishment meaning that irrespective of what national governments, trade unions or nurse associations may wish in attempting to ensure conformity amongst practitioners, individual nurses have the right to practice based on their training and the recognition of their qualifications. Thus, it would be fair to state that examination of this implicit policy framework is rich territory for those who wish to look in detail at the stimuli for change in nurse education and training and the drivers behind the aspirations and outcomes expressed in nursing forums and publications cross the EU. References 1 European Economic Community. Council Directive 77/452/EEC of 27 June 1977 concerning the mutual recognition of diplomas, certificates and other evidence of the formal qualifications of nurses responsible for general care, including measures to facilitate the effective exercise of this right of establishment and freedom to provide services. Luxembourg. 2 European Economic Community. Council Directive 77/453/EEC of 27 June 1977 concerning the coordination of provisions laid down by Law, Regulation or Administrative Action in respect of the activities of nurses responsible for general care. Luxembourg. 3 European Economic Community. Council Directive 89/48/EEC of 21 December 1989 on a general system for the recognition of higher-education diplomas awarded on completion of professional education and training of at least three years’ duration. Luxembourg. 4 European Parliament and Council. Amending Directive 2005/36/EC on the recognition of professional qualifications and Regulation (EU) No 1024/2012 on administrative cooperation through the Internal Market Information System (‘the IMI Regulation’) (Text with EEA relevance). Official Journal of the European Communities, L354, 132 – 170. 5 World Health Organization Regional Office for Europe. European strategic directions for strengthening nursing and midwifery towards Health 2020 goals. Copenhagen, WHO Regional Office for Europe, 2015. 6 International Labour Organisation. Occupational Safety and Health, 2016. Available at: http://www.ilo. org/safework/lang-en/index.htm 7 International Council of Nurses. The Code of Ethics for Nurses – Revised. Geneva, ICN, 2012.