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New challenges for nurse specialists in the EU

Nursing specialisation standards are needed in free border European Union

Antonio Ranchal PhD
Senior Lecturer
Faculty of Medicine & Nursing 
Nursing Department, Córdoba University
Nurses in this century are facing new challenges such as nurse prescription, the need to take care of an increasingly ageing European population, the emergence of new diseases such as infection like the Ebola virus, or coping with health needs derived from the population that are migrating to Europe searching for a better life. Apart from the challenges outlined above, we face the standardisation of nursing specialties among European Union countries.
In an article recently published in the journal International Nursing Review1 I present, along with other colleagues from different European faculties and the United States, how challenging it would be to standardise nursing specialties in Europe.
The issue of specialisation in nursing is still a matter of debate. Terms such as clinical nurse specialist, clinical nurse consultant, advanced practice nurse and post-basic education coexist at the European level. Dury et al. mention this existing confusion in their articles.2 Duffield et al. had already mentioned this confusion in 20093 showing professional boundaries involved in an international context. Also Antoinette Cotton cited that with historical variable periods, contexts, individuals, groups and institutions are factors that influence the characterisation of the term of expertise and that it can be seen as a discourse.4
This issue is not trivial, in as much that the recognition of specialisation will depend on whether the mobility of registered nurses (RNs) between the different countries of the European Community is fostered or not. Taking this into account and relating it to another challenge, the ageing population and an increasing demand for more professionals, that is, nurses specialising in geriatrics. Another issue is if governments are really willing to recognise specialisation in nursing. Continuing the debate of the generalist nurse versus the specialist nurse,5 is whether it improves the quality of patient care.6
I will take as an example the nursing specialisation system at the place where I work in Spain, in order to raise the need for establishing an appropriate standardisation since a significant percentage are considering migrating to another European country to find work as specialists.
Conceptually, in Spain we can understand the definition of specialist as “a nurse with formal training that focuses on a clinical area or specific population, which is formally recognised by certification, authorising them to work in a field of practical nursing”.1
The official specialties recognised currently in Spain are (RD):7
a) Obstetric-gynaecologic (midwife)
b) Mental health nursing
c) Geriatric nursing
d) Occupational health nursing
e) Medical-surgical nursing care
f) Family and community nursing
g) Paediatric nursing
Some areas are similar to the ones that Peplau et al. mention in their article on the expertise in professional nursing.8
To access to these areas, being a nursing graduate was required (a four-year university degree) and to pass a selective national exam that is held once a year, with a limited number of positions. The test is classically called Specialist Nursing Resident (SNR). This test is a multiple-choice type. The difficulty lies in the limited number of positions. Table 1 shows the distribution of vacancies for nursing specialties in Spain over the last few years.
As can be seen in Table 1, specialisation in medical-surgical nursing care is still not being offered, despite it already having an academic training programme.9
For 2016, out of the 7501 vacancies offered, 6098 are for doctors and 968 for nurses; the rest are for pharmacists, psychologists, biologists, radiation physicists and chemists.10 That is almost 13% of the positions offered for nursing: a curious fact when nurses quantitatively exceed medical personnel in any health centre. Any registered nurse in the European Union can be entered into this examination, as long as they demonstrate a sufficient level of Spanish (diploma in Spanish as a foreign language) and have the title of graduate in nursing with standardisation (non-European countries as well). The percentage for non-EU nurses is 2% for 2016.
This postgraduate training is a real challenge for the nursing graduate. To illustrate this point, Figure 1 shows the ratio of nursing graduates presented with the exam to be an SNR compared with the proportion of medical graduates who showed up to be a resident medical intern over the last three years.
Fig. 1: Ratio of nursing graduates presented to the exam to be an SNR compared with the proportion of medical graduates who showed up to be a resident medical intern over the last three years (SMR; Specialist Medicine Resident).
For instance, this means that in 2015 SNRs have been presented for each of the 959 positions available, an average of almost 17 graduates for a position in nursing, while in medicine the ratio is almost two candidates for a position. This finding is remarkable, considering that in any health centre in Spain there are more nurses than medical staff. For example, at the Reina Sofia Hospital in Córdoba 52.3% of the staff belongs to the direction of nursing, whereas 20.3% are doctors.
Also, an upward trend in the evolution of the ratio in the SNR candidates can be observed. This makes it more difficult each year to succeed in the exam and start a specialisation. Why? Because a greater number of nurses are graduating every year without the national labour market to absorb them. As it is well known, Europe has been suffering an economic crisis for the last five years. In this situation, the newly graduated nurses see specialisation (SNR exam) more as a job prospect. 
However, it is a short-term solution because the duration of the specialisation in nursing is just two years (unlike 4–5 years in medical specialties). Besides, once the training is done it is difficult to find a specific position as a specialist nurse in the same professional area. This is because, unlike medicine where each specialty has an associated position, the reality of nursing specialties is quite different. 
Mental health, paediatrics, geriatrics, family and community nursing or medical-surgical care do not require specialisation to work in this field. It is just in the case of obstetric-gynaecologic (midwives) and occupational health nursing that you need to have certification in a specialisation. Can you imagine a psychiatrist doctor working in paediatrics, or vice versa?
Hence, midwifery is the most demanded specialty by applicants, since working as midwife the nurse should be a specialist in gynaecological nursing.
Therefore, it is reasonable that many Spanish nurses decide to think of emigration as a job opportunity for their future careers. The unemployment rate in the Spanish active population was 23.7% in 2014 (22.8% in men and 24.7% women), with 51.8% of unemployed people under 25 years old compared to 21.6% over 25.11 With reference to nursing, the unemployment rate reached 8.3% in 2013 (compared to 1.31% in medicine). 
Countries like Britain and Germany are among the main countries that receive the most Spanish nurses, both generalists and specialists. And although the degree of nursing is usually standardised in these countries, that does not happen with the specialists. A former student of the Faculty of Medicine-Nursing at Córdoba, which I lectured to become a paediatric specialist, has taken more than 12 months to validate her specialty in the UK. While a colleague who is a specialist in traumatology, did the same in just two months. In other countries, standardisation is virtually impossible, simply because there are no nursing specialties.
Spain has recently commemorated the 30th anniversary of its accession to the European Union. Far from becoming a ‘free market’ where RNs can work in any country, the complexity of regulatory procedures is excessive. This makes free movement of professionals through a borderless healthcare in Europe almost non-existent. This is a challenge to be overcome by European health systems.
Another crucial point is which official specialties should be common in the EU. In this regard, there are other fields that require specialised knowledge. For example, oncology, nuclear nursing, intensive care, accident and emergency care. How can you tell if they have specialised in other European countries and are not official specialties in their original country? To that end, I would propose a recognition of the expertise gained through experience as a continuum7 under the auspices of international professional associations (for example, the International Nursing Council) in coordination with professional associations, requiring a minimum level of training certification; a level that in my opinion should be equivalent to a master’s degree. 
This experience in advanced practice requires a period of at least two years, as specialties training in Spain.
So Europe faces the challenge of establishing an official recognition of the specialties in nursing, or at least a minimum of them, as well as establishing a system for the standardisation of nursing specialties. Even considering the progressive increase in the mobility of migrant populations and professionals in a Europe without borders.
  1. Ranchal A et al. The challenge of the standardization of nursing specializations in Europe. Int Nursing Rev 2015;62(4):445–52.
  2. Dury C et al. Specialist nurse in Europe: education, regulation and role. Int Nursing Rev 2015;61:454–62.
  3. Duffield C et al. Advanced nursing practice: a global perspective. Collegian 2009;16(2):55–62.
  4. Cotton A. Power, knowledge, and the Discourse of Specialization in Nursing. Clin Nurse Spec 1997;11(1):25–9.
  5. Footner A. Nursing specialism or nursing specialization? J Orthop Nurs 1998;2(4):219–23.
  6. Chuk K-C P. Clinical nurse specialist and quality patient care. J Adv Nurs 1997;26:501–6.
  7. Spanish Government. Royal Decree 639/2014. August 6. Procedure to access for nursing specialities.
  8. Peplau H. Specialization in Professional Nursing. Clin Nurse Spec 2003;17(1):3–9.
  9. Padilla C et al. Reflections on the draft of the Nursing in Medical-Surgical Care speciality training program. Enferm Clin 2013;23(1):1–3.
  10. Spanish Government. Decree SSI/1892/2015. September 10. A test in 2015 to access in 2016, positions for specialized training for doctors, pharmacists, nurses and other graduates/university graduates in the field of psychology, chemistry, Biology and Physics.
  11. La crisis del empleo en los jóvenes: ¡Actuemos ya! OIT 101 reunión, Informe V.
  12. Scott C. Specialist practice: advancing the profession? J Adv Nurs 1998;28(3):554–62.