International studies support the fact that the higher rate of Bachelor nurses and lower nurse/patient rate significantly reduces the hospital mortality rate of patients. Every 10% increase in bachelor’s degree nurses was associated with a 4-7% decreasing of the patient mortality risks. Patients in hospitals in which 60% of nurses had bachelor’s degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an average of eight patients.
In other literature resources, in hospitals, where 60% of nurses had Bachelor degree have 19% lower mortality rate, than in hospitals where only 20% of nurses have Bachelor degree, and the 10% increase of Bachelor nurses have decreased the mortality rates by 9/1000 patients. In the surgical department, in case of a rate of 6 patient/nurse for 1000 patient admissions and a Bachelor nurse rate of 30%, the 30-day mortality rate following admission was 19.5 individuals, while mortality due to complications was 84,4 individuals. With a 4 patient/nurse rate and a 60% Bachelor nurse rate, the 30-day mortality rate following admission was 15,6 individuals, while mortality due to complications was 68,2 individuals. With a rate of 8 patient/nurse and a 20% Bachelor nurse rate, the 30-day mortality rate following admission was 25, 1 individuals, while mortality due to complications was 105,9 individuals. A suitable number of nurses with suitable qualifications can decrease the occurrence of health care- associated infections – e.g. a decrease of bloodstream infections by 70%, urinary tract infections by 29%, pneumonia by 4,2%, surgical site infections by 74%. (Regarding the significance of the subject, we will be discussing the connection of the nurse staff and the infections resulting from health care services separately in point II.6.).2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15
Increasing the proportion of RN nurses and BSc nurses in many countries is an important issue for nursing management, such as the need for a more efficient and effective care. Thus in Israel, published in 2007, they want to increase their number from 73% to 80%.16 According to the recommendation of the Institute of Medicine the ratio of Bachelor nurses should be increased by 2020 up to 80% in the USA.17
Accordingly if we are to realistically reach those standards archieved in other countries we need to be open to the integration of successful international developments into our health care system. Given the current health status of the Hungarian population, the demographic trends and the health care indicators, it can be assessed that for one, the responsible Government of Hungary needs to take further steps to increase the number of physicians, and aside from our visible results and the efforts made vocational nurse education and the nurses’ wage settlement, we need to make deliberate steps for the case of the degree nurses taking working in Hungary. The improvement of the primary care and the reaching of the primary care goals cannot be realized without the improvement of nurse staff’s roles and the establishment of the Bachelor and Master’ roles either internationally or nationally. In Hungary, since the 1989 initiation of the college/Bachelor education, 9273 individuals were registered as degree nurses (college/Bachelor), and following the 2000 university/Master level education, 674 individuals acquired a professional degree nurse qualification. In 2000, during the first Orbán-government, the introduction of the Hungarian university-level nurse-education could be realized, followed by the 2017 third Orbán-government, which enabled the Hungarian advanced practice Master nurse education as well. At the same time, it is an unfortunate fact that only 5415 individuals among the degree nurses (58,3%), and 446 individuals out of the university/Master’s (66,1%) are recorded in the national operational registry, i.e. currently working in Hungarian health care. A further problem that the number of individuals participating in Bachelor-Master nurse education is continuously decreasing, while the number of individuals acquiring degree nurse qualification was 823 in 2001, this number barely reached 334 in the recent academic years, i.e. the annual number of qualified degree nurses decreased by almost 60%. The decrease of the number of degree nurses was also facilitated by the fact that the number of health care related educational programs multiplied in the past decades, which – aside from the underdeveloped practice-expansion of college/Bachelor nurses – had a negative impact in the number of qualified workers within the college/Bachelor education in a way that qualified unemployment occurred in other degree programs in the health sciences field. This process was strengthened by the fact that while in the area of nursing, no substantive professional competence-expansion was provided for the qualified nurses, in contrast to other higher education qualifications in health sciences, they had substantial competencies supported by an appropriate legal framework that goes far beyond the remit of vocational professionals before the appearance of the new educational and outcome requirements in 2017, (e.g. paramedics, midwives, health visitors) thus, they became more attractive as career choices for those interested in higher education in health sciences. A further problem is that in the past 30 years, no specialized nursing programs on Bachelor/Master level were established established except for a few specialized continuous development courses of unsurtain legal status, which is an issue in dire need of clarification. Consequently the nurses with Bachelor or Master level education until the introduction of theadvanced practice master degree nursing education only had the opportunity to complete specialized nursing programs on a vocational level.
The situation is further aggravated by the fact that early in the decade an approx. 500 nurses requested statutory certificates for employment abroad and the ratio of freshly degree nurses being significant, as their foreign language knowledge is of a higher level and they are looking for professional challenges and recognition matching their higher level qualification. Fortunately, this number seems to have decreased since 2013. The expansion of the nurses’ practice, however, is not a new effort in our country, as the expansion of the nurses’ scope of practice by a physician’s written order has been possible for many years (notwithstanding vocational - and degree qualifications), in practice might result in the fact that certain nurses can perform some actions in one institution today, while in other institutions, they are not allowed, and it is also a possibility today that certain nurses need to carry out tasks which they have not been prepared for during their theoretical- and practical education, without the recognition by a suitable legal background or with a suitable financial recognition. Aside from the career-leave, the migration and the drastic decrease in the choosing of the degree nurse career, a further problem is the scarce number of degree nurses working in health care working directly next to patientbeds, the majority of their tasks are management of nature; they carry out administrative or management tasks.
As a result of the decrease in the number of nurses, there is also a growing problem of nurses working as a sole trader in hospital wards, even away from their permanent residence. This phenomenon raises concerns from a number of points of view, on one hand, it is unmanageable for workers to have a rest period, so they may not take enough rest time between two shifts at workplaces, and thereby they seriously endanger patient care and his/her own health. A further problem is that in many cases these “hired” nurses do not have local knowledge and professional practice related to the given speciality area, which again threatens the safety of patients. All these can result in the case of nurses very difficult situations (E.g. when 15 out of 20 nurses worked as “hired” nurses, or every nurse is “hired” nurse beside the head of the department). Working as sole traders and this way not having rest period is a livid problem at surgical nurses and anesthetic assistants.
Nowadays, it can happen as a serious problem that in some cases there are no nurses at all in the given shift, only lower educated health care professionals, like practical nurse, nursing assistant etc. At the same time in generally, the Royal College of Nursing recommends in the acute care wards the ratio of the registered nurses should be 65% and this of the nursing assistants 35%.18
Recommendations for a Solution
The expansion of the practice of Bachelor/ Master level qualified nurses may have a positive effect on the national prestige of the internationally-cherished degree nurses. This will not only increase the interest toward the Bachelor nursing education, it will also increase the number of individuals transferring to the vocational level nursing-education as well; it will also motivate qualified vocational nurses as well to complete Bachelor-Master level nursing educational programs. The Hungarian Government guaranteed to increase the rate of qualified workers by 30.3% (within the 30-34 age bracket) by the year 2020. To achieve this, we need to find areas, where, firstly, there is no current over-education, secondly, qualified workers are able to start their careers in their profession, and the social usefulness of the education financed from the money of the Hungarian taxpayers will be unquestionable. The expansion of the scope of practice and the wage settlement of Bachelor and Master level qualified nurses and the new scope of activities for the Master’s (eg. on the field of the primary care) are eligible to ensure that level of salary and scope of practice for nurses working abroad or other sectors (eg. Pharmacy), which can be enough for them to consider returning back in health care.
Re-establishment of practice financing in health sciences higher education by a manner equivalent to the 2018 solution of the same problem within medical education. Unfortunately, in 2004, the normative practice related to the health sciences education programs was deleted, resulting in a 500 million HUF decrease in financing at certain higher education institutions, worsening the quality of education.
In Hungary, the number of health care professionals with a recognized nurse qualification – along with the nurse assistants – is 39572, and 12,28% possesses Bachelor nurse, while 0,71% possesses Master level nurse qualification. In case we examine regarding the 29899 individuals with nurse qualification (Nurse/Infant- and pediatric nurse [vocational], Nurse [Bachelor], Degree nurse [Master]), it can be assessed that 16,25% possess Bachelor nurse- and 0,94% Master’s qualification. Unfortunately, a minority of these individuals work directly next to a patientbed, while there are also currently thousands of Bachelor nurses are not working neither in health care nor in social care. The aim must be to have them return to their profession of choice by providing the suitable scope of practice and salary. For the sake of health care services, we wish to set the goal to double the number and proportion of graduate nurses in the medium term in the national health care service system, by the determined undertaking of the requirements stated in our nation’s “Európa 2020” program. The scholarship support of the Bachelor nurse education as a shortage-profession, the suitable scope of practice and salaries are all necessary for making the education more desirable, in order to maintain qualified workers within the career and to make the activities bedside activities more attractive instead of an administrative manager position. On the long term, the needs of our society dictates that the lowest level of the nurse education should be the Bachelor education, as in the majority of the European Union member states; this is realized in 19 member states out of 28 as of today, while in a further 2 member states, the de-recognition date of the vocational level nurse education is already statutory.
In case the number of Nurses with Bachelor’s qualification would be doubled compared to their current number, besides, the total number of Nurses would not be increased, so the rise is the result of the continued education of the Nurses trained on vocational level, then the real weight of wages would be the sum of the difference between the payments of nurses with vocational certificate and with Bachelor’s certificate. It is hard to estimate the wage situation of 4859 Nurses with Bachelor’s degree educated form vocational level because the number of the working years is not available. That is why we apply an estimated average of difference which equals gross 88875 HUF (106205 HUF with fringe benefits). Thus, 4859 Nurses with Bachelor’s degree means an increase in the wages „only” by 6.2 billion HUF compared to the current situation. Besides, the ratio of Nurses with Bachelor’s certificate would be raised to 32,5% within the group of employees with completed nursing qualification.
Admission requirements can possibly hamper the increased number of bachelor nurses. From 2013, there was a significant change in the tightening of the requirements for the higher education admission process (Government decree 423/2012 (XII. 29.) on the admission to higher education institutions), which included the scheduled increase of the minimum entry points (with the change of the system of extra points) as follows: 2013: 240 points, 2014: 260 points, 2015: 280 points, 2016: 300 points. According to the Decree of Admission, the minimum entry point limit for 2016 should have reached 300 points, but this measure has not been taken so far and the regulation does not currently include the 300-point minimum limit.
It is also worth considering that the Admission Decree has been changed 23 times in the recent period – for example, the 300-point minimum point limit that previously should have been applied since 2016 is still not introduced – and items that are relevant to the admission process, such as a pre-scheduled continuous raise of the minimum admission points, and the system of additional points that can be taken into account at the minimum entry point has been modified 5 times.
It is also important to note that Article 23 para. (3) of the Government Decree effective from 1 January 2020, includes an amendment to allow applicants to obtain admission for higher education with intermediate language exam ,and secondary school degree, or candidates with a degree of higher education. Of course, this modification can fundamentally change the number of students that can be enrolled and thus the number of students, but we do not currently have an analysis of the expected impact of this modification and should therefore be prepared. In addition, it is advisable to develop a national strategy on the matter, because this change can have unpredictable consequences for the human resources of health care. Examining data from the 2018 admission process, the proportion of students with both entry criteria is generally below 40% for health education institutions (within this, the situation is even worse in the case of part-time education, where in some institutions the proportion of students fulfilling the admission criteria does not even reach 21%). The situation is even more serious if we look at the areas of shortages, which have paramount importance for the functioning of health sector (eg. nurses, paramedics, midwives, health visitors) because the proportion of applicants who meet with both intake conditions is below the average of health science faculties in almost all cases, for example in the case of full-time programme the amount of students meeting the admission conditions is under 30%, while only 11.11% of part-time nursing students meet the stricter admission requirements. It can be stated, if no substantial move is expected in the rules of the admission procedure which is effective from 2020, then in most universities nursing, paramedics, midwife and health visitor education could be ceased, because supportive, scholarship programmes by the government will not be enough to offset the tightening admission requirements.
Aging of the society, health status of the population, and the increasing cost-demands of the health care service system, the waiting lists as well as the lack of physicians are serious challenges our country has to face as well. In the majority of the OECD countries, the advanced practice nurse (Advanced Practice Nurse APN Master level nurse) education and position was introduced to solve these problems.
According to the definition of the International Council of Nurses (ICN), APN is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice. The advanced practice Master’s, with physician’s supervision and in a manner which is regulated by protocol can provide service even on a level which is equivalent to a physician’s, some literary data on the subject:
Regarding emergency treatment, 70% more patients left abortively without being seen if no advanced practice Master’s was on duty, while during their work, the lengh of stay decreased by 48,8% and mortality decreased by 5%.19, 20
Utilizing them, the costs of health care treatments can be decreased (e.g. lab utilization rate is 24% below 22% in the case of tumor patients, 83% in the case of combined treatment of chronic illnesses, and health care costs by 23% below the average cost in primary care setting).21, 22, 23, 24, 25
Utilization of advanced practice Master’s decreased length of hospital stay by 56%, decreased the occurrence of complications – e.g. pressure ulcer by 83% –, rehospitalization by 48%, improved the quality of hospital care, patient satisfaction, and decreased the number of malpractice claims suits.5, 12, 26, 27, 28, 29, 30, 31
Their presence can strengthen the primary care setting: NPs safely and effectively managed 67% of their patient visits without physician consultation, increasing availability; they increase the annual rate of women screened for cervical cancer by a NP at the intervention location, they are able to (e.g. cervical cancer by 40% and mammography screening participation by 20%); their work resulted in longer, patient-specific consultations, increasing the trust of patients and patient satisfaction; the patients treated by them are more likely to cooperate as well as their preventive health behavior, thus the occurrence of illnesses are of a smaller rate; their patients participate in screening tests more frequently. Within the primary care settings and the follow-up of chronic patients, the advanced practice Master’s provides a comparable but lower cost service under identical health care conditions regarding patient satisfaction and treatment results, their application resulted in a significant improvement and development in the control of patients suffering from hypertonia and diabetes.23, 29, 32, 33, 34, 35, 36, 37
The employment of Master nurses in the case of professional home care services as an independent unit of primary care would make it possible to shorten and to take up new tasks that can replace hospital care (e.g. compilation of a treatment plan, independent prescription of certain medications; prescribing medical aid; performing certain special invasive procedures).
Within the framework of geriatric care, their application resulted a significantly improved urinary incontence, pressure ulcers and aggression, they are able to validly recommend order changes by 50% among elder patients because of changes in patients’ plans of care, ineffectiveness, change in diagnosis, unable to manage the medication, inappropriate active ingrediants, dosage/duration, utilization time possibly due to medication form).38, 39
The presence of degree nurses, and within those, advanced practice Master level nurses as first assistant of the surgeon or as a health care professional responsible for post-operative care and discharge, decreased the surgical wait time by 93% by providing the surgery team, and minimizing surgical cancellations by 64% and increased the patient access to surgery by 79% by doubling the surgeons’ capacity for surgery. Accordingly, the authors suggested the desire to explore different RNFA models including an Advance Practice Nurse mode, particularly in large teaching hospitals.40
No evidence that opting out of the oversight requirement resulted in increased inpatient deaths or complications can be detected between cases when an advanced practice Master level nurse (CRNA) or a Nurse Anesthetist specialist performed anesthesia, the patient’s safety is guaranteed on a high level, at the same time, in the case of anesthesia performed independently by an advanced practice degree nurse (CRNA), Nurse Anesthesia is significant more cost effective than the next least costly anesthesia delivery model.41, 42, 43, 44, 45
The advanced practice Master’s like their profession: 92% of them would encourage other nurses to become NP. The developmentof APN roles may also serve to attract and retain more nurses in the profession by enhancing careerprospects.The role increases the number of individuals choosing the nursing career, the development of APN roles is also seen as a possible means to reduce the emigration of nurses to other European countries to seize better job opportunities. By increasing the education level of the nurses, less nurses left their career.46, 47, 48, 49
In 2012, the Hungarian Health Care Professional Chamber – within the framework of the TÁMOP project supported by the European Union and the Hungarian State – have issued a publication entitled „Hatásköri Listák egészségügyi szakdolgozói területen (Scope of practice regarding health care professional areas)”50, in which we have summarized the international practice of the advanced practice Master’s education and its possible introduction in Hungary. The MESZK consulted several professional organizations and medical boards for the preparation of the book, and have sent the completed publication to them. Aside from that, the Nursing Council and Chapter of the Healthcare Professional College conducted detailed work on the introduction of the education, and submitted it to the state secretariat as a development to be carried out in 2015. The submission justified the advantages of the nationalization of the advanced practice degree nurse care- and educational program in detail. Due to the reasons stated earlier, the Hungarian health sciences faculties – with the control of the Medical- and Health Sciences Committee of the Hungarian Rector Conference – have established the education- and qualifying conditions of the advanced practice nurse masters' studies. The Ministry of Healthcare made a fully consistent decision regarding the professional submissions on the support of the new educational program, thus the 18/2016. (VIII.5.) EMMI regulation enabling the practice-expansion could be issued. The education is currently conducted on four universities, and the list of competencies of Bachelor and Master nurses are included in the EMMI regulation but it is highly important to develop a legislative framework for expanding the scope and competence of Master nurses with extended competence, because the first Master grade graduates in the spring of 2019 and no Master nursing roles and pracices are available, thus, Master nurses are unable to fulfill their contractual obligations at work and also their competences are not legally regulated.
Recommendations for a solution
Regarding the advanced practice Master’s education, practically an immediate legislative change is necessary, as the first Advanced Practice Nurses on Master level will commence work in 2019.
Regarding the above statements, our emphasized aim with the introduction of the advanced practice nursing Master’s degree program and the modernizing of the nursing competencies according to the international trends is to make bedside work activities more appealing for a significant proportion of near 5000 degree nurses, who came to realize following their graduation that their high-level professional qualification is not coupled with a scope of practice according to international trends, professional or financial recognition, resulting in them not looking for employment within the health care sector. Furthermore, we wish to provide an alternative for a portion of degree nurses, who could only find suitable challenges to their higher-level qualification in the administrative sectors within healthcare so far. International results show that the currently introduced advanced practice Master’s education and its related positions provide professional and financial recognition for degree nurses, which may not only decrease the rate of career-leave and employment abroad, we believe it can invite a portion of nurses currently working abroad home as a competitive alternative.
The main competencies of the advanced practice Master’s introduced in Hungary, according to the educational- and executive conditions (the further legal framework system for these competencies is needed to be established as well) are the following: He/she may conduct patient treatment with a physician’s supervision, in cases and by means determined in policies/protocols, according to Master’s nurse specializations. His/her scope of practice e.g.: performing a complex physical examination in determined cases; ordering diagnostic tests/analysis of results; establishing diagnosis; compilation of treatment plan; independent prescription of certain medications; prescribing certain medical aid; performing certain special invasive procedures, Performing treatment of acute patients with a basic care-competent physician’s supervision, performing on duty tasks, treatment of chronic patients, performing independent anesthesia within the anesthesiology sector in cases determined by a specialist, with low-risk patients, during planned surgeries with physician’s supervision (there are examples today for the performance of this task with a vocational qualification) etc.51, 52
In primary care, the average age of general practitioners and the number of permanently unfilled practices are increasing, the latter results in caring inequalities (see daily 20 vs. daily 100 patient turnover) drastically increase (for example in some municipality if there is a general practitioner once a week, no preventive work can be carried out and in acut cases the issue of patient safety is also comes up).Establishing the positions of Nurses with Bachelors and Masters degree as additional service supplier professionals in currently launched practice community teams, and consolidating the professional position by determination of the competencies, shaping the additional competencies and local procedures, protocols is needed to efficient functioning of the practice communities. Furthermore, it is needed to assure the opportunity to Nurses with Bachelor’s and Master’s qualification to be able to take coordinative roles (practice/public health/care coordinator), with correspondent certificates to organize patient path, management in practice communities and participate in attendance. Last but not least, General Practitioners need the motivation to employ high qualified Community Nurses with Bachelor’s and Master’s degree who are able to offer high quality care, on the fields of individual health management, prevention, lifestile coaching, testing and care, chronic care, and professional care, with special knowledge and certificates, similar to models of Skandinavian and developed European communities so they will improve the bad health state of Hungarian population. In order to improve the quality of district nursing, it is important that no one could fill a nursing practice without nursing qualification, since a significant part of professionals do not finish within the 2-year legal deadline for obtaining a qualification and most of them have no mursing vocational education. In terms of primary care, there is no significant difference between the content of regional community nurse education and nursing education on vocational level, so there is no need for the latter education in this form. At the same time it would be important to introduce the appropriate hours and contents of primary- regional nurse modul to vocational education and developing the competence of vocational / district community nurses currently working in primary care in line with public health priorities.
Suggestions for wages for primary care workers: in case of nurses working in general practitional services, which are maintained by the municipalities, the health care wage table should be applied uniformly instead of the wage table that adversely affects them.
The aims of the European Committee’s 2012–2020 eHealth Action plan: establishing an innovative health care system utilizing 21st century technology, in order to aid the member states to overcome the main challenges of their health care systems by means of eHealth services and the development of applications, for the development of chronic illness management, for establishing more efficient and sustainable health care systems and to develop the legal- and market conditions of the eHealth products and services.
In Hungary, the Electronical Healthcare Interface was established (Elektronikus Egészségügyi Szolgáltatási Tér [EESZT]), which using cloud-based technology connects the health care service providers. Aside from the possibility of a service-oriented and simplified care, there is a possibility for the coherent management and effective analysis of the available data. At the same time, the issue of proper quality electronic documentation of health care has not been solved to this day in Hungary.
The need for smart devices stemming from modern technology is clearly perceivable; the utilization of such devices can support nursing tasks, their quality can be controlled, also the fact that these developments are in the initial phase even internationally provides a significant market-opportunity, only a few original nursing smart device was developed, and a suitable integral system also remains to be developed.
The suitable (consistent and competent) utilization of the nursing science can be a key factor in the transformation of health care as well as the realization of a financeable health care model. The research of the principles and methods of operation of a system regarding and optimizing the direct and indirect costs and profits of reasonable patient care based on the principle of practical applicability, utilizing up-to-date technologies, and the solutions based on such research principles and results can truly result in a product marketable for society as well.
Nevertheless, the realization process of a nursing plan is legally prescribed within the national and international framework, however, it operates with deficiencies and anomalies implying the endangering of patient safety in practice, it is also indicative of significant administrative burden and it increases the costs of care (e.g. missing electronic nursing documentation management, or nursing plans compiled based on groundless- or false nursing diagnoses, the occurrence of not suitably conducted nursing interventions, the abandonment of justified nursing interventions based on patient status). A further significant problem is the fact that patient care is mainly based on the subjective assessment and decisions of the nurse, caused by the difficult verifiability of the professional nursing tasks, the lack of knowledge defined in the modern evidence-based policies, the unsuitable rate of documentability of activities performed during patient care. The fact that there are no evidence-based policies regarding none of the hundreds of nursing activities in Hungary is a delay of several years; the nursing science research workshops necessary for such policies were not established in our country.
Currently no system capable of recording parameters acquired with smart devices within an integrated IT system is available, which is capable of preventing false diagnoses or the abandonment of necessary diagnoses (based on diagnoses, it is capable of determining the performing of necessary professional nursing tasks, according to algorithms (and it can signal the necessary performing of related tasks, e.g. catheter change, flushing of canule, etc.).
The improvement of nursing science workshops is justified as well as the support of the efforts made to establish the National Nursing Science Methodology Center, which is unique in its ability to advance patient care-, research-, modeling-, product development-, policy development- and educational efforts. Therefore, it may significantly contribute to the improvement of national knowledge bases’ R & D capacity and the realization of high-level research results.