II.11.3.3. General nursing and healthcare assistant education 1911 hours (theory: 1324 hours; practice: 587 hours)

The number of hours to be included in qualified assistant nursing education (450 hours), and the hours of the 11th and 12th year of education (604 hours of practice, 587 hours of practice) are counted into number of hours of Nursing education, while Bachelor nursing students receive a general nursing and healthcare assistant degree by completing 4th semester.

II.11.3.4. Transformation of nurse and infant- paediatric- nursing education for 2 years (theory: 1070 hours; practice 1170 hours) for associate degree education

First year of education: The foundation year of nurse and infant-, paediatric nurse education is common, after which the student can decide whether the specialisation nurse or infant and paediatric nurse will be chosen in the second, final year. Due to the large overlap between the two educations, this solution would be practical, could increase the number of nurses, and shorten the time for the second qualification.

Conditions of admission: high school degree, general nursing and health care assistant education (in case of high school degree, the general nursing and health care assistant education in vocational school can be completed in one year [1191 hours - theory: 604 hours; practice: 587 hours]). In order to preserve nursing education as a public education, nurse and infant - and paediatric nurse education can only be successfully converted to associate degree education, if in the section (1) of par. 40. of the 2011 CLXXXVII. Act and in par. 14. of 423/2012 (XII. 29.) on the higher education admission procedure the conditions of the higher education degree results and calculation of points of admission to associate degree education are changed. Currently, the condition for admission is a successful completion of high school degree, health, professional or career aptitude test, or a secondary school study and / or high school degree results (taking into account the two best graduation results) if the calculated score reaches a minimum of 240 points or more than the cut-off point of admission established by the institution. Under these conditions of admission, it is not possible to provide the education of the appropriate number of nurses with regard to the shortage of nurse professionals. Therefore, it is necessary that as applied by practicing Nurse vocational education, only a successful high school degree is defined as an input condition. At the same time, following the vocational education, it is possible to determine the appropriate additional conditions (E.g. basic and professional courses of nursing education on vocational level to be determined later, certification of at least medium level completion per subjects) that only those in Bachelor nursing can continue their studies with the appropriate skills and learning outcomes. The latter students can obtain a Bachelor nursing qualification with 2.5 years of education instead of 4 years, with 90 credits included.

Comment: We also investigated that if the first year of nurse and infant - and paediatric nurse education is not organized as one education, but as two separate education section. Then the first year of the education, the 13th year would be consisted of theoretical lessons (1010 hours of theory and 110 hours of practice) and a practicing nurse (or practicing infant - and paediatric nurse) qualification could be given (and, with this qualification, could have a job covering most of the nurses' competence under the supervision of a trained nurse after one year of high school degree). While the second year of education could be a full-time practice (1120 hours of practice) that the student could already spend at the hospital / workplace, and after a successful completion of a practical final exam, he / she would have a nursing degree (or practicing infant and paediatric nurse) qualification. In this case, the training cannot be organized because the Associate degree education consists of 2 years according to the law, and there is no exit after the first year. As well as the first year of the education, in which the total theoretical content of the two years has to be taught, cannot be jointly organized in nursing and infant and paediatric education, due to the tearing of different theoretical content of the curriculum for the first year. Since in this case of associate degree education is not feasible, it could only be implemented as vocational education.

Figure 9: Transformation of the Hungarian nursing education on vocational level to associate degree corresponding to the 2005/36 EU Directive, with the possibility of joining higher education.

II.11.3.5. The currently not fulfilled EU Directive 2005/36 will meet further barriers if the Hungarian nursing education is held within the frameworks of vocational education

We have examined whether secondary education can be converted into nursing education on vocational level (and not as associate degree) to meet the requirements of EU Directive 2005/36. To sum up, it can be said that there is no legally, pedagogically and professionally acceptable solution to this: The requirements of the EU Directive 2005/36 could be provided by nursing education on vocational level only in the case of seemingly impossible changes as a higher level nursing education. Solving the situation would require significant changes in many laws, significantly increasing the hours spent by students, because in contrast to associate degree education in primary and secondary school education, there is no possibility of counting the individual preparation, neither pedagogically and professionally, nor can we provide support for professionals of in primary and secondary school education. In primary and secondary school education – as opposed to the associate degree education / higher education – there is no possibility of counting individual preparation hours, so the 4600 hours of EU directive starting from the 11th year is very difficult to implement, only by amending the legislation. This means 1191 hours of 11th and 12th years of the General Nursing and Healthcare Assistant education and after the high school degree ,and over the 2240 lessons of the 2 years long nursing education on vocational level, or the 1 year long practicing nurse education on vocational level or the 1 year long general nursing education on vocational level , in the absence of individual practicing accountability, 1169 hours are still missing for the 4600 hours required by the EU directive, to be distributed in the year of 11th and 12th (since under the EU Directive only the 10th year completed can be counted in the training), which not only makes it difficult / impossible to carry out general nursing and health care assistant education, but the possible solutions are currently unlawful.

The 720 professional hours of 10th and 9th year should be transferred to 11th and 12th year, and instead general classes should be transferred from 11th and 12th years to 9th and 10th year. However, this is currently facing a vocational education framework plan, which requires that all 4 school years (9-12 years) should receive 60% of the time frame for general education, as well as pedagogically worrying, because the general subjects are thus professionally unjustifiably far from the high school degree. In the case of a possible implementation of a change that is likely to be difficult in the primary and secondary school education r, there is still a 449-hour gap that needs to be integrated into education. A further disadvantage is that credits of vocational education cannot be counted into the higher education, and to a considerable extent, in a shortened manner.so in this case the nursing education on vocational level would not be able to provide the possibility to complete the 4 year Bachelor nursing education in 2,5 years.

According to our information, the transformation of vocational education is on the agenda, even the sectoral advisory boards are already working on it. We find it regrettable that the professional advisory board has not started to operate in the health sector, so it cannot participate in the preparation of the vocational education’s amendment. We can only hope that the interests of health care and health care professionals can be properly represented in the transformation of vocational education. The lack of information on the ongoing transformation of vocational education may lead to the situation that the legal background changes (e.g. health care professionals cannot start working after graduation, only after a one-year-long technician training), in such a way, when a review is needed for the concept of the transformation of vocational education developed in this study. In this case, authors and supporting organizations of the present study in addition to maintaining the goals set (e.g. providing appropriate, large number of nurses for the current secondary education; compliance with the 2005/36 EU Directive; counted 1.5 years/90 credits in the Bachelor nursing education; etc.), will later update their proposal for the transformation of vocational education. Competitiveness and qualitative, professionally and legally appropriate education, which provides career and development opportunities remain important, it needs to be clarified whether the transformation of vocational education is in proportion to the benefits pursued in health education as well; or health care requires special solutions for its special aspects. In our view, the sector should not accept an education system that allows nurses work at different levels on the labour market after a longer education period, still does not ensure compliance with the EU directive, an unreasonably large number of hours / too long education time, or allows significantly less time for counting in credits than 1,5 years/90 credits stated in this study. Obviously, until the introduction of the associate degree education as a transitional measure (for a period of about 2 years), it is appropriate to maintain the current or similar vocational education in a way, when the Ministry of Human Capacities and higher education institutions declare the date for the development and implementation of frameworks (e.g. changing admission requirements to ensure a large number of participants in the education programme) of nursing associate degree education.

II.11.4. The opportunity to complete a four-year nursing bachelor education in 1,5-2 years for professionals from other health science education or within 2,5 years for those coming from associate degree education

As mentioned above in the study, we recommend the duplication of the number and ratio of nurses, who completed higher educational programmes, in the Hungarian health care system to 2030. It can be ensured by making the educational programme attractive with the following methods: it is offered as a 2-year-long programme for Bachelor graduates from different health care related fields, and after converting the vocational nursing training to a 2-year-long associate’s programme it is possible to complete the Bachelor of Nursing degree within 2,5 years. In order to make the education attractive, to keep the graduates on the career path, and to make the bedside activities more appealing than the administrative leader position, the support of the Bachelor of Nursing education – which faces with shortages – with scholarships, suitable competencies and wages are needed.

As introduced above, the conversion of the vocational nursing training to associate’s degree programme ensures the establishment of the nursing education that meets the requirements of the 2005/36 EU Directive with the acceptance of contact hours and credits with individual preparation. Furthermore, after the transformation of the vocational nursing training to associate’s programme (FOKSz), the Act CCIV of 2011 On National Higher Education facilitates the accpetance of max. 90 credits to the Bachelor education on a given field (in this situation, to the Bachelor of Nursing programme) so the 8 semesters long study programme can be completed within 2,5 years.

II.11.4.1. Nursing and patient care, nurse major 4 semesters long programme

The Bachelor of Nursing education has been regulated by the 18/2016. (VIII. 5.) decree of Ministry of Human Capacities. However, the autonomy of the university may result in minor or major differencies in the implementation of the Bachelor of Nursing study programme regarding its curriculum in compliance with the mentioned regulation. Completing the Bachelor of Nursing programme within 2 years can be ensured with an appropriate curriculum, and the education with standard contents and examination system in the different courses (basic natural sciences, social sciences, etc. – see later) of the different health science related study programmes, besides, with the acceptance of these courses and a special curriculum for the shortened educational programme. On this way the educational content of the whole Nursing study programme (e.g. clinical theory, pharmacology, nursing skills, clinical practice) will be instructed without any reduction of the contact hours/credits (in part-time study programmes it can take 4 or 5 weeks in different semesters / in case of 5 weeks, the 0. week of instruction would take place in August/January). The 2-year-long programme can be organized among all the listed educational programmes (e.g. from Nurse to Dietitian within 2 years, from Physiotheapist to Paramedic Officer within 2 years), the only barrier can be the fact if the part-time study programmes will not be started.

The 10th figure shows an example of the 2-year-long curriculum of Bachelor of Nursing programme organized for the different health science related Bachelor degree owners (universities can apply different solutions for their own study programmes, according to the above mentioned autonomy of the universities). As the graphic shows, 110 credits can be accepted in the case of Dietitian, Physiotherapist, Paramedic Officer, Midwife, Health Visitor, Ergotherapist professionals (full-time programme: 1088 hours [theory: 562, practice: 386, clinical practice: 140], part-time programme: 505 hours [theory: 284, practice: 171, clinical practice: 50]) from the 240 credits of the 8 semesters long Nursing programme, accordingly the following courses/fields of knowledge: first aid, medical latin, cell biology, biochemistry, biophysics and health technological studies, nursing skills, microbiology, communication in health care, public health, ethics, law in health care, health pedagogy, it in health care, dietetics, health sociology, health psychology, health education-health promotion, public hygiene-epidemiology, anatomy, physiology, pathophysiology, research methodology and biostatistics, thesis, optional courses. Therefore, after the acceptance, 130 credits need to be completed in the 4 semesters long Bachelor of Nursing programme, divided into semesters based on the 10th graphic (full-time programme: 2188 hours [theory: 864, practice: 314, clinical practice: 1010], part-time programme: 1121 hours [theory: 465, practice: 176, clinical practice: 480]). 32-33 credits need to be completed in the different semesters in compliance with the 54. § 1. section of the 87/2015. (IV. 9.) governmental decree. In case it is possible to organize the standard education and examination system of further courses between the given specialities, the length of completion the new degree can be reduced to 1,5 years (e.g. joint education for Nurses, Midwifes and Health Visitors in some clinical courses and their practices [internal medicine, surgery], pharmacology).

This educational programme has been launched on an experimental basis at the University of Pécs, Faculty of Health Sciences since September 2018. Its experiences may ensure to develop a student-friendly, executable, attractive and professionally authentic programme.

II.11.4.2. Nursing and patient care, nurse major 5 semesters long programme

After transforming the vocational Nursing training to the 2-year-long associate’s degree, the Act CCIV of 2011 on National Higher Education facilitates the acceptance of maximum 90 credits into the Bachelor’s degree on the same field (in this situation, into the Bachelor of Nursing degree), so the 8 semesters long educational programme can be finished within 2,5 years, instead of the 4 years.

As a principle, it can not be required for the associate’s degree owners to have the same knowledge regarding the determinant basic courses on the field of natural sciences as the health science related Bachelor’s degree owners because the graduates have not been educated on the same level. The mentioned courses can not be accepted in case of associate’s degree graduates (e.g. anatomy, physiology, pathophysiology). Some courses are not part of the training on vocational level which is below the Bachelor’s level (in this situation, vocational Nursing training) so these courses need to be instructed (e.g. research methodology and biostatistics, management skills that meet the competencies of a position which requires at least Bachelor’s level, examination of patients on the field of internal medicine, thesis). From a Nursing education below the Bachelor’s level, courses/fields of knowledge also can not be accepted which are built on a deeper basic knowledge of natural sciences and which need a deeper acquisition (e.g. clinical theory, diagnostics, pharmacology, professional nursing skills and the related practices, etc.). Therefore, associate’s degree graduates need one more semester to complete the Bachelor of Nursing programme with proper academic performance and to acquire the correspondent knowledge and skills. The 11th figure shows the special curriculum sample of a 5 semester-long enshortened study programme for the 2-year-long vocational training graduates. In practice this means, these students are able to acquire the proper level of knowledge in the fields of anatomy, physiology, pathophisiology and diagnostics, and the missing research methodology and biostatistics and management skills in one semester.

Figure 10: 4 semester long modelcurriculum Nursing and Patient Care major, Nursing speciality,(for professionals graduated in the dietetian, physiotherapy, midwifery,paramedic officer, health visitor Bachelor education ) (Full/Part time education)

Figure 11: 5 semester long modelcurriculum Nursing and Patient Care major, Nursing speciality, (for professionals graduated in the Associate degree education) (Full/Part time education)

As the 11th figure shows, 75 credits of the associate’s degree can be accepted (full-time programme: 643 hours /theory: 301, practice: 192, clinical practice: 150/, part-time programme: 273 hours /theory: 141, practice: 72, clinical practice: 60/) from the 240 credits of the 8 semesters long Nursing programme, accordingly the following courses/fields of knowledge: first aid, medical latin, cell biology, biochemistry, biophysics and health technological studies, nursing skills, microbiology, communication in health care, public health, ethics, law in health care, health pedagogy, it in health care, dietetics, health sociology, health psychology, health education-health promotion, public hygiene-epidemiology, optional courses.

Therefore, after the acceptance, 165 credits need to be completed in the 5 semesters long Bachelor of Nursing programme, divided into semesters based on the 11th graphic (full-time programme: 2493 hours /theory: 1055, practice: 438, clinical practice: 1000/, part-time programme: 1283 hours /theory: 573, practice: 240, clinical practice: 470/). 33 credits need to be completed in the different semesters in compliance with the 54. § 1. section of the 87/2015. (IV. 9.) governmental decree.

II.11.5. Launching a list of competencies in line with the level of education which focuses on the advanced Nursing competencies on Bachelor’s/Master’s level and utilizes their knowledge in favour of the patients

In the followings, we propose a modification of nursing education on vocational level as described above according to the list of competencies recommended to each educational programme.

II.11.5.1. Qualified Assistant Nurse

The main elments of the planned scope of practice: he/she is able to supply by ordering pre-packaged enteral medicines, immediately intervening in case of emergency; recognising direct life threatening situations; supplying first aid, recognizing status and processes differing the physiological function of the human body; documenting, carries out basic care tasks (hygiene, nutrition, emptying, nursing, patient movement); performing primary care (hygienic, nutrition, performs assistant tasks (measuring cardinal symptoms in non-invasive manner, blood glucose measurement; urine test with quick test; recognising decubitus, preparation for certain examinations/interventions and assisting in performing; assist the patients before and after the examinations, accompany the client if necessary; apply the supporting systems of patient transport properly; support in administrating medicines; administering IC, SC, IM (predosiged) injection to delta muscle and recognising possible complications, performing ECG, blood and other specimens sampling.

II.11.5.2. General Nursing and Health Care Assistant

The main elements of the planned scope of practice: he/she is able to insert, remove, care short peripheral cannula, performing enemas, changing and empting stoma bag; performing dermatology testing; feeding through gastric tube; irrigation of bladder; blood sampling from CVC; administering i.m. injections; preparing for administrating medications, fluid therapy; assisting providing medication, assisting in the performance of intravenous infusion, she/he able to change the infusion bottle, (not allowed to start new therapy) is able to change the drip rate, is able to change dressings around the intravenous catheter; (not allowed to do it at CVC); is able to remove the midline catheter and the IV cannula. Prepare the patient: to some diagnostic and therapeutic procedures and assist in some interventions and; able to care some acute wounds, use of oxygen therapy with low flow systems. He/she is able to recognize the signs and grades of decubitus. It is capable of directly administering the prescribed analgesic, anti-emetic, anticoagulant, diuretic, corticosteroid, physiological solution, heparin physiological solution and glucose over 14 years.

He/she is able to participate in the patient's surgical preparation, in the management of patient documentation, in the change of dressings, and in communicating the patient's needs to the nurse with finished education. Performing of laboratory secretion sampling and delivery it to laboratory (stool, urine, sputum, throat-eye-nose ear, wound, vomitus).

II.11.5.3. Nurse with associate degree

The main elements of the planned scope of practice: he/she is able to prepare an individualized nursing plan, as part of it, create a nursing diagnosis, coordinating the nursing care process, and managing the work of health care professionals without finished nursing education. Able to perform patient monitoring, on physicians order administrating medication (intravenous injection infusion therapy, etc.), caring for some additional invasive interventions (inserting/managing of nasogastric tube, invasive patient monitoring, managing central vein/arterial cannula, other cannula), catheterization of men and women and managing the catheter, mobilization/removal of respiratory secretions); use of oxygen therapy (low and high flow systems); carries out the tasks nurses regarding the nutrition therapy, carries out the nursing tasks of the transfusion therapy, is able to perform modern wound care. Performs pain assessment, take part to special pain relief (EDA, PCA); performing the preparatory task at artery cannulation/puncture/other diagnostic and therapeutic interventions; performing paediatric nursing tasks, is able to recognise/prevent/cooperate in preventing unexpected events, to the nursing care of dying patient and dead body.

It is urgent to clarify the list of nurse competencies, I agree with the authors of the study that this should be the basis for any further nursing development strategy. However, competency lists should not only be prepared for nurse/infant and paediatric nurse, Bachelor nurse, Master qualifications, but it must be also described for all health care programs in the current vocational educational system. From these competency lists, we will be able to find out which vocational educational programs provide a minimum amount of new competencies (compared to the 55 nursing vocational education qualifications). These qualifications can be erased from vocational education, the scope of competencies can be given to the employees as a license (e.g. oncological nurse 5572313 – the competence of the nurse other than 55, able to do analgesia by her/himself with or without medication).

One way to change is that the entire health care sector of vocational education should be reconsidered. After the clarification of the scope of competencies, the organization of the remaining basic and top up vocational education system reflecting on real needs of employers, will bring relief to the school system, it is cost-effective and more flexible than the school-based vocational education. However, it is appropriate to consider that under what conditions an educational institution can participate in the education without its own equipment.

II.11.5.4. Bachelor and Master nurse

The 18/2016. (VIII. 5.) Decree of the Hungarian Ministry of Human Capacities on Education and Outcome Requirements of the Associate, Bachelor’s and Master’s education includes the list of the competencies of Nurses with Bachelor’s and Master’s degree. In accordance with this, it is important to form/modify the law which regulates the fulfilment of position and scope of activities. (We not again: the first graduates are finishing their Master’s programme in the Spring of 2019, and neither the scopes of activities of Nurses with Master’s degree are available based on the conditions of Michalicza Scholarship – for this reason the Nurses with Master’s degree can not fulfill the requirements of their contract relating to start a job –, nor the responsibilities related to the job and resulted from the decree are regulated appropriately.)

Details of the further extension of the list of competencies recommended within the frames of the certification education/exam can be found in the II.13. section of the strategy.

II.11.6. Providing professionally- (theory and practice) course instructors who meet standards for teaching selected classes

Regarding certain areas of knowledge, the qualifications expected from teachers are currently unsuitable in certain cases, e.g. regarding nursing education, the education of clinical practice and pharmacology can currently be conducted by e.g. degree nurses or health care vocational teachers.

In order to increase the profession’s prestige, professionally- (theory and practice) and pedagogically educated teachers are needed regarding both the vocational- and higher educational health sciences educational programs. The utilization of the mandatory continuous developmental system in order to reach this goal would facilitate this process. This is probable if a valid operating certification becomes a necessity for the teachers (with the suitable modifications of the requirements). During the compilation of the content of the continuous development courses organized for professionals conducting vocational theoretical- and practical education, several factors are needed to be regarded: the competencies transferred during education; the development of the policies and protocols and technologies related to the professional field; the changes in the legal frameworks, and the age (students/undergraduates/education-participants) of c individuals oncerned with practical education. The possibility for theoretical- and practical knowledge development of the training is important.