Paul De Raeve, Secretary General and Elisabeth Adams, President of the European Federation of Nurses Associations (EFN) tell us why the European Pillar of Social Rights should help nurses to remain in the nursing profession

During the last World Economic Forum in Davos, the United Kingdom (UK) shadow chancellor, John McDonnell, states that: “Ten years after the financial crash, with ten years of austerity and ten years of paying their taxes and seeing public services cut, people have had enough”. He strongly calls to: “Pay your workers a living wage”. This statement captures what European Federation of Nurses Associations (EFN) has been advocating for years: “Keep the nurses in the profession by providing reasonable working conditions and decent pay”. (1)

EFN has monitored the impact of the economic crisis on nurses and the nursing profession since 2008 across Europe. In the analysis, it is evident that the negative impact on nurses and the nursing profession has demonstrated serious consequences for health systems outcomes, not only with regards to the safety and quality of care but the attrition in significant numbers of nurses leaving the profession. Ten years later, doing more with less, has created increased unsustainable workloads with a high price being paid for employees and employers.

Furthermore, financial cuts and regressive spending review policies have shaped a new austerity environment within the European Union (EU), that focused and was over-dependent on meeting financial and economic targets, rather than defending the values that constitute the fundamental principles of the European project: prosperity for all.

The number of nurses leaving the profession has become an alarming indicator for the negative consequences and the deteriorating health outcomes that are evident in the EU health system: for instance, the Belfast Telegraph reported (2) that just under 600 nurses left the Northern Ireland NMC register in 2013/14. The figures increased to 928 in 2016/17, while a further 506 left the register in the first two- quarters of 2017/18. In parallel, the number of nursing vacancies increased by over 8% in 2017, from 31,634 to 34,260. But the Northern Ireland case is only one example; for Belgium, the nursing profession is the first listed profession in 2018 with the highest vacancies. In Belgium, over the past four years, significant numbers of nurses have left the profession while ironically this country is leading an EU Project on workforce planning and forecasting. Demonstrating a serious dichotomy between theory and practice that is replicated across the EU and its Member States.

“We are losing our frontline nurses while civil servants are planning and forecasting! We need to act now to limit the damage”

Therefore, the answer to the question: “Why do we keep failing to have ‘enough nurses’?” is simple: “Because we keep undervaluing the importance of nurses’ contribution.”

EFN nursing leaders warned that the situation will deteriorate in 2018-2019 as nurses’ face some of the most difficult working conditions in living memory. With the current pressure on the workforce, the shortages and the substandard workplace environments, which includes physical and verbal violence and abusive behaviour while nurses deliver essential and lifesaving care, the relentless negative pressures have become unbearable for nurses and therefore, they are forced to walk away from the profession to protect their own health and family. Consequently, nurses’ trust in Europe’s ability to shape their future and to deliver both fair and prosperous societies has been eroded since 2008.

It is, therefore, imperative that the European Pillar of Social Rights provides effective hard and soft law initiatives and frontline incentives to retain the nurses in the profession.

EU efforts to achieve social convergence

In the attempt to respond to the well-known social challenges, the Juncker Commission presented some initiatives aiming to boost the social dimension of Europe. In this context, the reflection paper on the social dimension of Europe (3) developed by the European Commission in April 2017 examines how to sustain our standards of living, create more and better jobs, equip people with the right skills and create more unity within our society, as well as adapting our social models to current and future challenges and to galvanise Europe’s social spirit. The document acknowledges that much still needs to be done to achieve a social convergence between European countries in Europe.

The reflection paper sets a timeline for Social Europe, that includes the design of the European Social Rights Pillar, the main goal of which is to act as a driver for social change in Europe and serve as a guide towards efficient employment and social outcomes. The 20 principles enshrined in the Social Pillar aim to address crucial topics, such as equal opportunities and access to the labour market; fair working conditions and; social protection and inclusion (4).

But how do we ensure that such ambitious the European Pillar of Social Rights principles turn into concrete support for three million frontline nurses in the EU? Or is this not what the EU is about?

To deliver on these initial objectives, the Social Pillar must be developed for people and with people. Therefore, it is crucial to ensure that its implementation, as a primary objective with the drive to improve the life and well-being of EU citizens, including the valuable and essential human resource of the three million nurses, by concretely engaging in its co-design and implementation. Council recommendations are not enough in isolation, indeed frontline action implementing political agreements and commitments are an absolute requirement. Therefore, to achieve real frontline change, under the Pillar principles of “access to health care” and “work-life balance and wages”, clear proactive priorities and actions with the support of the nursing profession have the potential to make a significant difference for all the citizens of Europe. Investing in nursing is a positive investment in the quality of life and the well-being of all.

Access to health care

Related to Chapter III of the European Social Pillar, social protection and inclusion, the principle 16 “access to health care” is the core business of all EU nurses. The right of everyone to timely access, affordable, preventive and curative healthcare of good quality, emphasising the importance of long-term care, becomes a key societal challenge in the EU. This needs to be addressed, with an urgent re-focus on ‘moving care back to the community (5), by designing in partnership with the nurses, a more holistic approach to value-based healthcare. Due to the close relationship nurses nurture naturally with citizens and patients that considerably contributes to the implementation of a people-centred approach, co-designing is the only way forward. However, barely 3% of the health budget goes to prevention, a sector that heavily suffered during the 2008 economic crisis, leading to worsening statistics on all key indicators across every public health topic. (6)

Within this context, it is important to recognise the contribution of nurses’ in combatting the main challenges that European health systems are facing, for example, the increase of people living with multi-morbidity and chronic diseases, antibiotic resistance (AMR) and a lack of trust in vaccinations, all conditions that not only have negative health outcomes for the whole community across Europe, but increase the workload of the frontline nurses, which in turn risks nurses leaving the profession which has serious implications in a people-centred approach model. It is, therefore, central to invest in and develop an efficient primary and community care system, which is considered to have crucial added-value in terms of moving care back to the community, boosting the social economy and becoming a driver of well-being, productivity and growth.

However, this model of care delivery requires a deep change of mindset and the paradigm shift of those writing and signing off public health and workforce policies. However, co-design is one solution to reduce the policy and reality divide to make a real difference on the frontline. There are many successful examples of nurses’ co-design in delivering primary care through e-health services: nurses’ close relationship with citizens/patient place them in an ideal position to consider all the physical and social factors that influence an individual’s health. These are the essential preconditions that make prevention work, with nurses becoming the natural leaders in reforming health systems, moving from cure to care, from therapy to prevention. In this sense, nurses working in primary care centres, schools, in the community and, not least as informal carers in their own families, are in a unique position to perform advanced roles to increase the accessibility to prevention and care (7).

Improving timely access to affordable health and social care is also ensured by the support that nurses provide in bringing the population closer to digital innovations that are reshaping our healthcare systems. It is within this context that nurses act as coaches, introducing and guiding many European citizens/patients to e-health services that are fit for purpose. It is within this context that nurses’ advanced roles in blockchain technology will smooth access to the personalised electronic health records and as such, ensure it all works more effectively and efficiently. The ENS4care prevention guideline, developed with industry and civil society, is a good example of upscaling innovation to combat ongoing austerity in the health sector.

To guarantee the delivery of safe healthcare of good quality, the EU and national policies should improve their focus on the features that make healthcare systems communicate more efficiently. With the endless EU efforts on interoperability and semantics, still, today discharged patients struggle with the ‘integrated model of care’ and ‘continuity of care’. Therefore, the Social Pillar should support nurses in leading the transition towards an integrated care model through measures that acknowledge and emphasise the frontline responsibility in ensuring continuity of care. To make this vision a reality, a new mentality concerning the health and specifically, the nursing workforce must be embraced. National governments should immediately reverse the focus from only planning and forecasting and collecting mainframes full of data, towards supporting frontline nurses to prevent them leaving the nursing profession due to unsustainable workloads and poor working environments. The European Social Pillar should focus on the harmonised development of the advanced nurse practitioner (ANP), to better address the unmet health needs of the European population. (8) This means boosting the first principle of the Pillar: education, training and life-long learning.

Education – Advanced Nurse Practitioner (ANP)

The Social Pillar Chapter I – equal opportunities and access to the labour market, education, training and life-long learning – has been key for EFN since 1971, when the discussion on the nursing education and free movement started to take place. (9) The contribution of the nurses to the EU policy process, especially related to the free movement of nurses within the EU, resulted in the Directive 2005/36/EC, modernised by the Directive 2013/55/EU and importantly, in the co-design of the Proportionality Directive, that concerns strengthening nursing as an independent profession in the EU. That independence in coordinating and delivering care is a significant contributing factor to nurses staying committed to their profession.  

Therefore, the Social Pillar should build its developments on these EU legislative successes of 50 years in European Commission DG Internal Market, Industry, Entrepreneurship and SMEs (DG GROW). It is only by ensuring through education and training – the right skill-mix and a sustainably designed workforce composition (10) that nurses can qualitatively contribute to increasing the access to health and social services for EU citizens. To this purpose, the bachelor programme as harmonised by the European Directive 2013/55/EU and specifically article 31, needs to create a complementary and harmonised EU education programme for ANP, building on and going beyond the eight competencies as set out in Directive 55. To make integrated care and continuity of care a reality throughout the EU, it is particularly important that advanced nurse competencies highlight the importance of managing care throughout the system. With progressive developments, such as e-skills making the digitalisation of health and care a fact, supporting people and healthcare professionals communicate flexible and optimal in the people-centred system is the future reality of effective and efficient healthcare. As such, blockchain technology (11) can become a support for nurses when technology starts collecting the data needed to move towards a value-based health system, where outcomes define the financing methodology. The Social Pillar should, therefore, provide not only the basic ingredients to start implementing continuity and people-centred care, but it needs to provide the supporting framework and the concrete tools for the nursing workforce to close the existing EU implementation gap.

Work-life balance and wages

Related to Chapter II – fair working conditions, work-life balance is a key principle for nurses to stay in their profession. Nurses with caring responsibilities have the right to suitable leave, flexible working arrangements and most importantly, safe environments with specific attention paid to the increasing violence against nurses in different working settings, in both the hospital unit and the community. Nurses have the right to a high-level protection of their health and safety at work, to allow them to remain in the nursing profession for as long as possible. Ensuring that these conditions are met should be a key incentive in the Social Pillar.

The Pillar should include measures to respond to nurses needs as professionals, recognising that 92% of the workforce is female, performing a high-risk, high-skilled job with inappropriate recognition and reward. Good examples of national legislation exist, for instance in Belgium, where since 1993, the country introduced a financial system incentive for frontline nurses: at 45 years, one extra compensation day/month, at 50 years, two and at 55 three extra days off per month, with the option to choose between an increase in the salary or extra days off. This system has proven to be a measure keeping nurses in the profession and valuing their tuff frontline work.

As more good practices exist in the EU, the Social Pillar should scale them up and allocate EU funds to the Pillar and as such, recognise the high-risk job of nurses. The nursing profession needs and expects from the European Social Pillar, a coherent implementation of what already exists and has proven to be successful, aiming to bring an overall EU improvement to several aspects related both to professional and personal features of the profession. Only by incorporating nurses’ needs, utilising and maximising the use of their skills and engaging them in the co-design and implementation of social and healthcare policies, the Pillar will enable nurses to carry out their mission to prevent diseases, deliver high-quality and safe care and enhance health and social care throughout the EU.

Fair working conditions also include the right to fair wages that provide for a decent standard of living, but this is not always the case for nurses, for whom meagre salaries and demanding hours are making the profession too hard to stay in. Although, since 2004, the 15 countries who joined the EU – complying with the Acquis related to the education of nurses (Directive 55) – have registered an improvement with salaries of nurses going up from €250 to €780 net a month (Poland), nurses wages in all EU Member States are way too low compared to other professions, taking into account the huge risks nurses take when delivering care and the enormous positive difference they make to health and social care delivery.

In addition, a significant wage disparity within Europe leads many nurses to leave their own country in search of better conditions abroad, but this causing serious shortages in several countries. The expression, “Peter robbing Paul” is not new and the European Social Pillar should examine the wage issue urgently, to both attract and retain nurses into the nursing profession.

Reflecting again to the words of John McDonnell: “Pay your workers a living wage”, the European Commission needs to investigate what decent pay means for nurses, compared to other professions, like teachers, firemen/women, policemen/women for example – this is an exercise that does not require nurses’ wages to be compared with doctors’, as the differences are already well known. However, when reforming health systems, by introducing advanced nursing practitioners and nurse-prescribing, it could be interesting to know how to increase accessibility and at the same time, making EU health systems resilient.

Conclusion: Make the European Social Pillar work for 3 million nurses!

Considering the increasing pressure faced by European healthcare and social systems today, it is central to invest in a motivated and skilled nursing workforce who are delivering frontline care. Addressing the unmet needs of nurses throughout the EU cannot be further postponed, with the situation for nurses deteriorating beyond terrible levels, impacting on their ability to deliver appropriate safe and quality care, and as such, many nurses have no choice but to leave the profession. Without the appropriate and timely policy measures from within the EU Social Pillar, nurses will become difficult to recruit and to retain in their job. Anyone who has ever experienced, either as patient or relative, the need for receiving healthcare, know that without nurses, such highly qualified services could no longer be provided.

However, to enable nurses to deliver on a key priority such as access to health and social care, it is fundamental to substantially improve nurses’ wages and working conditions, both of which are already over-stretched, leading to burnout and increase of sickness days in each Member States. For EU citizens, including three million nurses, ‘enough is enough’! There is a real tangible opportunity with the Social Pillar to make a significant difference, but there needs to focus on nursing workforce policies that promote an integrated level of and a continuity of care, with advanced nurse practitioners and nurse prescribing deployed throughout the EU, engaging local frontline nurses, co-designing ‘fit for purpose’ health and social care systems.


Paul De Raeve

Secretary General






Elisabeth Adams


European Federation of Nurses Associations (EFN)

Tel: +32 2 512 74 19


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