Healthcare faces European countries and our country, Hungary as well, with increasingly serious and complex problems. Over the past decades, many people have worked hard to find the most favorable and sustainable solution for disease prevention, health restoration, prevention and reduction of harmful health effects, using the available resources and capabilities of the system.
A forward-looking, inspirational discussion paper entitled “Az Ápolásfejlesztés koncepcionális elemei” was published in the Nővér journal, in 1994, its’ author was Ferencné Sövényi, who was the government chief nursing officer those days. Since then, there was no comprehensive proposal for the development of nursing, however, I am convinced for a long time now that in view of the situation of nursing care in Hungary, it is indispensable to create a complex development proposal based on an objective assessment of the situation with the widest possible cooperation by the nursing professionals. We cannot expect others to recognize and solve the problems we face in our area, and it is very important that professional development suggestions can be presented from time to time, which can be discussed afterwards, so that a broad consensus can be developed on each other's views and arguments. This can not only help to initiate developments in the field of nursing care, but can also provide an appropriate background to prepare professional resolutions with short deadlines, to formulate well-founded, consistent opinions with adequate quality.
Constructive professional discussions and arrangements based on open positions are essential to achieve the above mentioned (I think it is a great achievement that it could finally be realized in the case of this discussion paper and that it can take place after the written text will be published), in contrast with lobbying activities that sometimes ignore the facts and the interests of our profession.
As a result, in May 2018, I initiated the development of a strategy based on the common consensus of professionals and other relevant organizations to serve and represent the development of nursing and patient care. I also proposed to publish the finished document as a discussion paper in Nővér or other professional journal in 2019. This not only promotes a broad debate on the concept, but also pays tribute to the 25 years anniversary of the nursing development concept and its’ author, which was a discussion paper in 1994, and also to promote the wide-ranging debate of the concept. I am honored that Ferencné Sövényi, Klári, former government chief nursing officer is also a member of the community of values creating this discussion paper, and undertook a summary of her thoughts in the foreword.
In the recent period, we reviewed the situation of Hungarian nursing in comparison with international trends. During the process, we tried to identify the main problems affecting the area and in a gap filler way taking into account the relevant international responses, to formulate concrete solutions for success in Hungary. It is a joyful fact that as a result of this development work, a comprehensive professional study entitled “National strategy for the development of nursing care professionals in Hungary” was made, written by 65 authors and 27 nursing and medical professional organizations/university faculties/departments/specialists/heads of healthcare institutions. It can be said that in our country there was no professional proposal made so far in the field of nursing care, as the complexity of the proposal, its’ approach to present good international practices can be considered as a niche. In our opinion, the process of creating the discussion paper is an important value, as the logistic of the development of the study, the cooperation of the organizations and the common thinking is a great achievement.
However, not in contrast with all these joyful results, but it is worth mentioning the fact that the period from May 2018 to March 2019 was not enough to reach a consensus with a few organizations invited to participate. The authors and support organizations of the study showed full openness to consultation along with the pros, to define a common minimum professional compromise, and, indeed, to present the different positions and the justification behind them as an alternative in the discussion paper. I am convinced that the completed study will serve the interests of vocational, Bachelor/Master nurses and society and employers alike. As a result, I consider it an important result that in many cases of these organizations, their committees, subordinate organizational units supported the strategic proposal, and many of their leaders, members of management, and their members also undertaken to participate as private individuals, professionals in writing and representing this study despite their organization’s viewpoint. I would like to thank them for their responsibility for nursing care and assuming their professional position!
We have also conducted numerous consultations with the Hungarian Health Care Professional Chamber – the study has been developed taking into account the Hungarian Health Care Professional Presidency’s suggestions – in which the National Educaional, Postgraduate Educational, Committee of Chamber supported two times, then the Chamber’s National presidency unanimously supported the current version of the study. Later, during the long development and conciliation period of the discussion paper, the Chamber’s Presidency referred to some of the elements and asked that instead of dividing short-term, medium-term and long-term objectives, only short-term objectives and to invest in acute measures to mitigate the human resource crisis. The developers of the study expressed a view that the solution to the human resources crisis can only be successful if we set short-term goals - all levels of education -in a well-founded way and to fit them into a medium- and also to a long-term development concept. At the end the Chamber’s Presidency suggested that only a brief summary of the development proposal should be sent to the High Authority what we did not consider professionally reasonable (we also consider the explanatory and literature part as important supporters for our proposals) because of the nearly one-year consultation process with authors of the study and support organizations we were unable to support it.
During this long creating process of the discussion paper, only a few managers representing nursing directors have expressed concerns, which we would like to clarify later in the future in the sake of the consensus – we believe due to a misunderstanding – about some aspects of this paper, however, we did not have the opportunity to learn about their alternative solutions and their justification. At the same time, one of the main strengths of the study is the diversity of the authors, since domestic and international experts, including nursing researchers, professionals in secondary and tertiary nursing education, nurses, health finance professionals, physicians leaders of professional organizations, and of course many nursing supervisors were involved in the preparation of the discussion paper.
In the case of two of these organizations, there was no possibility of an oral consultation on the study. The head of one organization reported that the organization wants to represent its own strategy – which is not presented to us –, a leader of another organization said that he considered the cooperation for nursing care to be very important and indispensable, however, only supports a common consensus-based development concept in which a particular nursing organization is not involved. Of course we distanced ourselves from this exclusionary behavior towards a professional organization and its membership. A question of these organizations was also raised if the making of our study was right in the absence of request, so he freedom of authors' scientific work and universities’/professional organizations’ independent professional and cooperation initiatives was questioned.
At the same time, in recent years, we were not able to understand the position and grounded development suggestions of these two organizations that do not wish to participate in the development of this nursing development strategy proposal, for example: following the establishment of a vocational nursing education that does not comply with the relevant EU directive or after we raise the issue; when setting excessive requirements for competitiveness in primary health care (in 1912 hours of education, after 4 years, at the age of 18 and with high school diploma the certificate could be achieved in Hungary, which is internationally achieved by nursing assistants after 150-200 hours of education, after 1-2 months, at the age of 16); despite a long-term model focusing on the development of vocational education, the drop in student numbers in both vocational and Bachelor nursing education; and on the impediments of counting vocational education in the higher education. It can also be stated that these organizations are also challenging a development, that is already supported by the Government and has no legally feasible alternative (eg. within public education frameworks without individual preparation lessons and the amount of adequate credits compliance with the EU Directive cannot be ensured without a significant increase in training time. As in this case, leaders of these nursing organizations are not in dispute with the authors of this study and with the organizations that support the study when – differing the position of nursing organizations operating internationally in the same field – for example the benefits and importance of increasing the Bachelor nurse ratio, but with the scientific evidence available in the field internationally.
It is an unfortunate fact that in recent decades changes in education – inadequate, not comprehensive and not taking into account all levels of education - did not delivered the expected results. The current system of Hungarian vocational education does not fulfill the conditions set out in the relevant EU Directive 2005/36, which is binding conditions for our country as well. In addition, in past years, the number of students in school system education in the health care profession group fell from 8,000 under 4,000 and, unfortunately, some of the health care qualifications came to the fore, which do not relieve shortages – especially the lack of nurses. In 2016, in Hungary, the number of nurses newly enrolled in the register compared to 2015 fell by 45% and the situation is exacerbated by the fact that only 50% of graduates had been registered in the operational register (namely in patient care). Higher-level nursing education is also in a crisis, as in recent years more than 800 people have graduated in nursing education each year, by now, this number hardly exceeds 300 people a year, this means the number of graduated nurses dropped by nearly 60%. The latter is also very unfortunate because the importance of employing Bachelor nurses as much as possible is supported by a series of scientific research results, including the announcement in Lancet that a 10% increase in the number of Bachelor nurses can reduce mortality by 7%.
Here it is also important to emphasize that in recent years, a number of useful programs to support healthcare professionals have been launched and implemented. These include the introduction of dual vocational education; the development of universities’ and hospitals’ skill laboratories; upgrading training for workers with the old type qualification of general nursing and health care assistant; development of accomodation for health care providers; development of nursing equipment park; reduce the number of vacancies; as well as improvement measures of working conditions; providing career support scholarships for students attending full-time education in health-related qualifications – including nursing students –; scholarship support for students participating in the Nursing Master education within the Michalicza Scholarship Program; creation and regulation of the Professional Textbook Commission; placing vocational education under sectoral management; multi-step wage development.
The work paper of this Nursing Development Strategy proposal has been sent to the Ministry of Human Capacities on several occasions since May 2018, we had the opportunity to conduct a personal, forward-looking consultation at ministerial and state secretary level. We were pleased to note that in the meantime, we had seen significant progress in several of our proposals, eg. in the case of certain Bachelor programmes the introduction of a scholarship grant with a high ranking of nursing education; a supportive decision of the transfer of state-run secondary health care institutions to healthcare higher education institutions; the beginning of the development of health care career pathway concept.
In addition to the above mentioned positive measures, there are a number of problems to be solved in the field of nursing, which are systematically presented in the completed strategic material. The strength of this development concept is that it proposes solutions to strenghten vocational nursing education and for the acute lack of nurses (the proposal’s alternative is not known yet), by thinking in a career model it also helps the development and advancement of vocational professionals (they will be able to complete the Bachelor nursing education in 2.5 years), and increasing the number and expanding the professional opportunities of Bachelor, Master graduates.
As we discussed in this paper based on international good practices and scientific result, we could set ourselves more ambitious targets, as in 19 out of the 28 Member States of the European Union there is no longer any vocational nursing education and two other Member States also decided to end it. At the same time, in Hungary, there had been no comprehensive strategy for stabilizing and raising the number of nurses in the last decades, supported by the most important professional partners, this way it is not a realistic goal to end vocational education. As a result we propose until 2030 (immediate, short, medium, and long term goals, aligned with government cycles) a stable program for a strenghtened, reinforced, multi-level, with a training time (reduced) adapted to the actual competences, marketable, and a vocational mass education that can be counted in higher education, and to create a responsible programme for the continuously increasing number of Bachelos and Master nurses.
Statements in the development proposal can help to solve the nursing human resource crisis, create workplaces in lagging regions, upgrade enrolled students from lower educational levels, to significantly improve the quality of patient care and to increase patient safety and satisfaction.
In order to facilitate these, we ask the Ministry of Human Capacities to set up a working committee and as a result prepare a proposal for government decision in the matter of “National Strategy for the Development of Nursing Care Professionals in Hungary” concept.
In the interest of a consensual development, we would like to present a discussion paper entitled “National Strategy for the Development of Nursing Care Professionals in Hungary” to provide and to promote a consultation process (eg. consensus conference, facilitating the accession of other organizations) on the subject, among a wider community of society, as well as representatives of the medical and nursing areas and patient organisations. Our discussion paper is also published in English language and we are confident that we can promote discussion, joint thinking on development proposals with relevant international nursing organizations and nursing institutions, in order to adapt internationally good practices to the Hungarian system.
We hope that as a result of our work professional and other relevant organizations can accept a common consensus on nursing development and we can jointly serve the development of nursing and patient care.
Dr. habil. András OLÁH RN, MNS, PhD
Hungarian Society of Nursing Sciences
president, initiator and coordinator of the strategy development
University of Pécs Faculty of Health Sciences
dean, head of institute
I was honestly glad to read the discussion paper “National Strategy for the Development of Nursing Care Professionals in Hungary”. This document can also be considered as a supplement to the shortage, because recently the question of “what’s next nursing” has not come to wide professional publicity in such complexity. The special value to be highlighted of the document is its commitment of the “publicity”.
The “discussion paper” summarizes the values, mistakes and the current situation of our wide-ranging nursing matter, and according to these it builds recommendations on “how to go ahead”.
The working paper is thinks in a long term perspective and motivates to cooperation. It “forces” the reader to criticize, answer, and make further recommendations.
It gathers the most important issues among the reasons of recommendations for improvement. The discussion paper, after describing the situation, consolidates the “development proposals” in four points. These are also called the pillars of the “internal life of nursing”. The disquisition comprehensively discusses the most important elements of nursing development and provides an international outlook where necessary. I collected it in a few lines:
In this state of discussion, there is no “consignee yet”, but knowing its internal content suggests that almost all of the recommendations for developing areas require a “high level” political decision. Based on my experience from the past, we can only make those entitled for making decisions to make a decision if there has been made a previous consensus between the different areas and levels of nursing.
For the consensus of the “nursing elite” this National nursing strategy discussion paper is a good example, as it assumes publicity and substantive criticism, expects proposals for improvement from representatives of different fields of the profession. I wish to have a “final product” and later a “consensus document” for a longer term. (For example, this way the accepted model of nursing training cannot be changed every year!)
The responsibilities of those in charge of certain areas of care today are much more enormous than decades ago, as all nurses, who graduated from college or university are present in all areas of caring, who need to recognize the changes of the world around them and accept the challenges.
Recognizing or not, the biggest challenge in the field of medicine and nursing today is the “paradigm shift”, i.e. the loss of the old, security-conscious habit. In the process of paradigm shift in practical medicine and nursing, the professional arrangement of competencies can create order. Today’s current issue is the integration of Nurses with Master’s degree into the system or the issue of “triage”.
It has to be accepted that medicine and nursing are complementary, both have specific characteristics, so there is a difference between them. However, there are similarities, overlap, same knowledge and same activity between them. Those who do not accept this, deny the reality and its consequence is meaningless debate and conflict. Regulating the frames is a basic tool for consensus building.
This document should be followed by a consensus conference where the afore-mentioned consensus document could be adopted.
Former government chief nursing officer (CNO)