I. AN EXECUTIVE SUMMARY OF DEVELOPMENTAL SUGGESTIONS

I.1. SUGGESTIONS FOR THE EDUCATION SYSTEM

Currently 5000 individuals are finishing health care vocational training on a basic level (not including the vocational high school students) additionally there are approximate of 1900 individuals, who qualify annually as a practicing nurse and 1300 individuals as nurse, 250 individuals as Bachelor nurse. In keeping with the current health care strategy, a minimum numbers will be required:

1. 7000 individuals (counting with only 5000 individuals studying on vocational level and 2000 full-time Bachelor first-year students in health sciences, with integrating the nursing assistats’ education hours to their curriculum and counting without other potential target groups with short-term training programs) are educated as nurse assistant (450-hour education without graduation from age 16 based on the international model, with the scope of practice of the earlier 4-year nursing and health care assistant education of 1912 hours, subject to 18 years of age and post-vocational education),
• including 4000 individuals as general nursing and health care assistants (18 years of age, graduation, with the scope of practice of a further 1-year nurse practice following graduation),
• including 3000 individuals as vocational nurses (2 years of associate degree education following graduation, fulfilling the EU directive in place of the present situation),
2. 1000-1500 individuals as Bachelor nurses (in a two-year education programme for colleagues with other Bachelor health care degree, supportive scholarship programme, with appropriate competences and starting salary)
3. and 250 individuals as Masters can be educated in Hungary.

These new objectives can be accomplished by the implementing the solution of the nursing human resources crisis (for more information on nursing deficiency, see Part II.1), creating health care in lagging regions, the gradual improvement of individuals enrolled in lower educational levels, and the significant improvement of patient care quality.

Short term objectives (2019–2022)

I.1.1. Development of vocational nursing education:

• Reforming the vocational nursing education, according to the EU directive which is currently not followed.
• Number of hours, educational hours and curriculum adjusted on the various levels of vocational nursing education to the actual scope of practice and curriculum reduction: more competitive, in a much shorter time, professional education for professionals – goal: qualified assistant nurses can take over the role of general nursing and health care assistants (they can apply for the 3,5-year-long education without a high school degree, after the age of 16), general nursing and health care assistants take over the role of nurse practitioners (via a 1-year shorter training, with a high school degree).
• Raising the hours of public knowledge lectures in vocational high schools, transformation of general nursing and health care assistant education, with the competence of a practical nurse, 1 year after the graduation.
• Introduction of qualified assistant nurse education (from the age of 16, 450 educational hours, without a high school diploma, with the current competence of 4 year and 1912 hour long general nursing and health care assistant education, for which a high school diploma is required, after the age of 18 – based on international example). The education should be conducted aside from the faculties of health sciences and public educational institutions, by health institutions and national institutions involved with skill development.
• Impleenting of the coordination of the higher education institutions by means of changing the nursing education to a 2-year-long associate degree education. The practical nurse- and nursing education programs need to be taken out of the National Education Registry and by incorporating them into higher education – in an utilizable manner –, organized as e.g. associate degree education or dual education. Establishment of nursing educational system suitable for mass education with the coordination of universities which results it being attributable to higher education by means of correction of legal errors - stemming from not following the EU directive – and professional errors – due to the poor structure of the vocational high school system – within the national vocational nursing education. Aside from the Health Sciences Faculties, education needs to take place within the vocational health care educational institutions to be established and the vocational educational institutions operated per county in sufficient numbers, maintained by higher educational institutions.
• Attributing prior knowledge, qualification and work experience from the associate degree education, with the substantive shortening of the education period (Bachelor nursing degree during 2,5 years) in case the determined subjects of the associate degree nursing education was completed by the student with at least average results.
• Introducting of a professional competence system. No health care worker unsuitable – either mentally or physically – for carrying out the given tasks should enter the sector.

I.1.2. Providing a nurse assistant health sciences qualification for health sciences Bachelor students in the first academic year, as well as providing a general nursing and health care assistant qualification for Bachelor nursing students, following the 4th semester. By this change, as much as 2000 professionals competent to complete basic care and certain professional care tasks may begin part-time work annually during their higher education within the health care system. Aside from the crisis due to the lack of nurses, this may significantly support the professional development, career guidance and financial situation of the students concerned.

I.1.3. Providing the acquirement of other health sciences Bachelor professionals’ Bachelor nurse graduation in 1,5-2 years.

I.1.4. Scholarship support for the Bachelor nurse profession as well as other shortages in the vocational/degree nursing sector according to the needs of the labour market.

I.1.5. In the case of social care carers and nurses the word „nurse” should be removed from the title of qualification, which is not included in the health care sector’s nursing education in this level of education and scope of practices. Instead we should use the word „assistant”.

I.1.6. 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.

I.2. RECOMMENDATIONS REGARDING THE HEALTH CARE SYSTEM

Short term objectives (2019–2022)

I.2.1. Introducting of a nurse’s legal scope of practice, determined by qualification levels, also recognizing the expanded role of higher level Bachelor/Master level qualified nurses, utilized for the benefit of the clients.

I.2.2. Developing nursing protocols and health care directives based on evidences from practice based international results.

I.2.3. Renewal of the further educational system, with a review of the feasibility of an free certification system:

• It is important to establish the scope of mandatory further educational programs by qualification levels and specializations in a manner, which enables the professionals to complete practice-expanding certification educational programs as well.
• It is important to modify the educational programs, in order to eliminate mandatory continuing education courses or certification education programs on unjustified fields, instead to have the students receive the practice-expanding knowledge integrated within the relevant vocational and higher educational programs (on Bachelor and Master levels).
• Scope and subject of licenses to be completed with vocational or exclusively higher education qualification needs to be determined.
• Vocational nursing licenses are intended for the elimination of deficiencies resulting from the natural forgetting and development of professional experiences, as well as the legitimization of activities conducted in a wide scope (e.g. performing intravenous injection, administration of IV fluids, stoma treatment, wound treatment, male patient bladder catheterization), yet not aptly established from an educational- and regulation perspective (or conducted based on a “mandate system”, which from a quality system and professional standpoint cannot be maintained for a long term).
• Activities transferred from the medical scope of practice (not including the invasive procedures already conducted by nurses, e.g. bladder catheterization, short cannula puncture, intravenous injection, artery cannulation) should be exclusively granted to graduates of Bachelor and/or Master nursing programs.

I.2.4. Modification and regular review of the 60/2003. (X.20) ESzCsM regulation, regarding the problems related to the professional minimum conditions necessary for providing health care services. It is a basic principle to define the required number of profesionals in a long term (by 2030) according to the minimum requirements, to develop an appropriate education and motivation system to achieve it. At the same time, it is not a realistic expectation in short and medium term to perform the parameters of the long term goals in order to improve the quality of patient care, thus, they must not cause difficulties in the operation of the institutions. In this context it is justified:

• Based on the minimum requirements such as the number of nurses and the required qualifications we need to transform the staff needs, which are needed to be developed in short, medium and long term proposals, based on methodology and international best practice.
• Identification of the missing specialized worker qualifications (e.g.: Master level specialized nurses, subject teachers, educational officers, nurses with specialization in epidemiology, primary care- and epidemiological inspector, health care professional manager, quality- and patient safety manager), revision of the number of workers and expected tasks of other professions (physiotherapist, dietitian, etc.).
• The reporting system of the number of total nurses designated per bed number needs to be changed to the nurse/bed number (patient number) ratio, because the total number of nurses given per bed number does not reflect the number of patients per one nurse working in one shift, while several international studies suggest that it is a very important indicator: 1 nurse can only safely care for a limited number of patients, e.g. he/she can take responsibility for 5 patients on surgical fields, above that, every patient increases the mortality risk by 7%. With the decrease of patient numbers to one nurse, the occurrence of patient mortality or complication can significantly decrease, as well as the cost of care. The designation of employee numbers needs to be conducted regarding productive treatment time.

I.2.5. Improvement of primary care and the improvement of Bachelor and Master’ roles in primary care (e.g. ordering diagnostic and screening tests, wide scope-care of patients with chronic illnesses) in order to meet the primary care needs whereas fulfilling such needs has not been possible internationally and likewise cannot be realized in our country without expanding the current roles and better appreciation of Bachelor and Master level nurses. The Swiss-Hungarian co-financed practice community modelprogram did not place sufficient emphasis on the role of nurses, thus, a significant number of abnormal cases (eg hypertension, prediabetes, diabetes) have been detected in the focus of the care system (around 10% on average). The reason for this was that the screenings were implemented of the daily work of the practice in space and time. Enhanced filtering capability was not associated with GP practices, and missed out qualified nurses from the filtered cases who can manage and initiate critical steps of care independently. Beside developing the competence of existing vocational nurses, establishing the positions of Nurses with Bachelors and Masters degree as providers of expanded professionals are required for the successful operation of the practice communities in currently launched primary care teams in various communities. Under their control, caring for small and medium risk patients (under the supervision of a physician) can be made smooth, thus, complications associated with inadequate care can be prevented, and indicators of health care quality (Core Health Indicators) in Hungary could be significantly improved. To ensure this, it is necessary to strengthen the professional position by defining the competences, developing the additional competences for the primary care services by developing sample procedures and protocols. In addition, it is necessary to provide a coordinating role (practice/public health/care coordinator) for Bachelor and Master nurses in organizing patient’s navigation, practice community management and on-call duties with the adequate license. 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, lifestyle coaching, diagnostic and screening 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. There is also a need to employ more Bachelor and Master nurses and the competence development of the existing nursing staff in the case of professional home care services as an independent unit of primary care. This way, the scope of activities could be safely maintained, and it will also be possible to shorten and to take up new tasks that can replace hospital care. Financial motivation is required for the employment of highly qualified nurses in the field of professional home care services.

I.2.6. The question of transferring chronic beds to the social sector. We suggest keeping of chronic beds, because we see the following main risks: the difference between the prescribed qualifications; the difference in content regarding care and attendance; the different professional content of service; the increase of the active waiting periods for beds.

Medium term objectives (2022–2026)

I.2.7. Providing suitable working conditions (e.g.: modern care equipment, environment, personal protective) (aptly involving the nursing profession in the planning process), for the safety of the patients and for the physical, chemical, biological safety of the workers.

Long term objectives (2026–2030)

I.2.8. Based on the minimum requirements such as the number of nurses and the required qualifications we need to ensure the staff needs, based on methodology and international best practice.

I.3. HEALTH POLICY AND FINANCING QUESTIONS

Immediate action

I.3.1. Improvement and development of the advanced practice Master level nursing education, the establishment of the legal framework related to the practice expansion. There is an urgent need for immediate intervention, because in the spring of 2019 the first Masters will graduate and no workplace duties are available for Master nurses, which was a condition to get the Michalicza scholarship – so Master nurses are not able to fulfill their working obligation according to their contract –, neither the scope of practices according to the workplace duties and the Regulation are legally regulated. Although it must be stated that the education makes the nursing career more desirable, reduces migration and career-leave. By evaluating patient safety, the results and patient satisfaction, according to the indicators a Master level nurse provides a service equivalent to a physician while more cost-effective in determined areas, under equivalent health care circumstances. The Master’should be able to conduct high-level patient-care with physician’s supervision in cases and methods determined in principles/protocols.

Short term objectives (2019–2022)

I.3.2. According to the facts stated in point. I.2.1., aside from introducing a nurses’ scope of practice, determined by qualification levels, also recognizing the additional knowledge of higher level Bachelor/Master level qualified nurses utilizing such knowledge for the benefit of the clients, the introduction of a fitting compensation system and career model is also necessary.

Medium term objectives (2022–2026)

I.3.3. It is necessarly to strengthen nursing workshops and support efforts to establish a National Center for Nursing Science Methodology, which can uniquely promote patient care, researches, modeling, product development, directive development and education efforts. As a result, it can make a significant contribution to strengthen the research and development capacity of national knowledge bases and to produce internationally high-quality research results. All this can strengthen the appearance and development of new trends and areas represented by the World Health Organization (WHO) and the International Council of Nurses (ICN).

I.3.4. Proper use (consistent and competent) of nursing science. (Promote the development of eHealth services applications, the use of the Electronic Health Services Space and the appropriate quality of electronic documentation, use of smart devices of the modern technology, abolishing nursing plans based on false nursing diagnoses, the occurrence of improperly performed nursing interventions, reduce the lack of knowledge in modern evidence-based guidelines, the use and under-utilization of smart devices and integrated systems.)

I.3.5. From the patient care-perspective, within the framework of the management of problems stemming from the unsuitable healthcare structure, the national introduction of Transitional Care (TC) under the supervision of Masters, to reduce rehospitalization, relief of active care and the overall costs of health care is highly recommended.

I.3.6. Professional home care services as an independent unit of primary care provide services for general practitioner practices from a seperated National Health Insurance Fund of Hungary (Hungarian acronym: NEAK) funding. Although regional service duty is still a contractual requirement within the financial framework of visit, inequality in access to care can be demonstrated, and its’ reason is inadequate funding and lack of professionals. The occupancy rate of home nursing services is 100% country-wide, the aging society, the chronic burden of illness, the waiting time and thus the access will further deteriorate. In order to provide a continuous and safe service and to fulfill the regional service duty it is necessary to professionally and financially strengthen home care services. Increasing the numbers of Nursing Wards and Nursing Institutions.

I.3.7. We highly recommend to develop funding codes, and to carry out code development / code maintenance / review for professionals (especially nursing) – similar to medical practice as in existing areas which could be examples (physiotherapy, dietotherapy).

Long term objectives (2026–2030)

I.3.8. Based on the summary in I.2.4., it is necessary to increase the number of nurses and to increase the proportion of Bachelor nurses. Mortality rate can be decreased by 30% and to mitigate nosocomial infections and complications the nurse/ patient ratio per caring area should be adapted to international recommendations, while the number of Bachelor nurses working directly bedside needs to be doubled to 2030.

I.4. RECOMMENDATIONS REGARDING CHANGE IN THE STATE ADMINISTRATION OF HEALTH CARE

Short term objectives (2019–2022)

I.4.1. We hereby welcome the oversight of professional education under departmental control, this is a vital element our developmental recommendations.

I.4.2. A Nursing Department for the sake of the professional representation of the nursing profession.

I.4.3. Establishment of the Government Chief Nursing Officer (CNO) position on national level with the relevant scope of practice and infrastructure.

I.4.4. Establishment of a ministerial department-level evaluating institution performing coordinative and monitoring tasks (e.g.: professional educational initiation, vocational exam organizing, issuing teacher/exam organizer certificate).

I.4.5. Issues related to the basic- and operational registry database and international data-services. During the query of the basic- and operational registry database and its numbers, the received data unfortunately may differ from the actual professional number by thousands of individuals. Aside from that, regarding both the national (e.g. basic- and operational registry, OSAP), and international (e.g. HFA-DB, OECD) data bases, the definition of the term “nurse” shows significant differences, distorting statistical data to different degrees. In certain data bases, the midwives or even the assistants are listed in the nurses’ group. The lack of consistent terminology makes the validity of the data doubtful and this way, they are only suitable for trend-analysis. Another problem is the fact that profession-oriented professional qualification cannot be recorded in the registry based on section q) of par.3 of the 1997. CLIV Act on health care, regarding the fact that the terminology of profession-oriented professional qualification was and is not included in the list on professional qualifications according to section q) of par. 3 of the A.o.Hc.. Thus the individuals concerned cannot register their newly acquired profession-oriented professional qualification in the operational registry, resulting in them not being able to renew their basic qualification if they are employed in a function according to their new professional qualification (therefore there may be professional qualifications which are hidden or classified as expired).