P OLICY RESPONSES TO THE SHORTAGE

Policy measures for addressing nursing shortages can be developed in order to increase the number of worked hours per active nurse; to delay the exit from the profession; to call back early exits; to increase the number of young people applying for nursing education; and to limit abandonment during the bachelor programmes. Moreover, when considering the international labour market, shortages can be reduced by recruiting nurses abroad or by retaining national ones from leaving the country. Further measures include the efforts to use nurses on an effective way, focusing their jobs on the core tasks of the profession and allocating administrative, support or maintenance activities to other professional groups (McKee et al., 2006).

This section will present some policy measures influencing the Italian labour market or the professional system, while the next section will deal with managerial measures adopted by healthcare organisations. In particular in this section we will consider:

- the national process for defining the numerus clausus for bachelor in nursing;

- the current efforts to change the division of work among the health professions;

- the changes in work conditions set by the national collective agreements valid for the NHS salaried staff;

18 For example, the reform of 1999 introduced the three-year bachelor, with an increase of one year compared with the previous two-year university degree. Consequently, a one-year cohort inflow was delayed by one year.

19 The analysis of monopsonistic labour markets was initiated by Archibald in 1954 and nursing soon became a classical example for it (Yett, 1970; Hurd, 1973; Link and Landon, 1975). Recent contribution, however, sow mixed results and suggest that «nursing should not be held up as a prototypical example of monopsony» (Hirsch and Schumacher, 2004).

- the attempts of – and the constraints to – foreign recruitment.

1. Table 3.2 shows the progression of registered nurses in Italy since the establishment of the colleges in the mid fifties. Numbering 23,720 in 1956, registered nurses overcame 50,000 in 1974, 100,000 in 1982, and 200,000 in 1992, reaching 361,000 in 2007 (IPASVI 2008a)²⁰. Those data confirm a major long-term increase that accompanied the development of the Italian healthcare system.

Table 3.2. Registered nurses, 1960-2005.

Year Registered nurses

1960 25,408 1965 29,487 1970 37,259 1975 67,973 1980 83,277 1985 137,449 1990 183,734 1995 286,386 2000 319,123 2005 342,273 Source: IPASVI (2008).

In recent years this effort has been sustained by the increase in the numerus clausus for entering bachelor programmes, from 10,135 for the academic year 2000-2001, to 13,445 for 2005-'06.

Moreover, the ratio of students who, once passed the exam, confirmed their enrolment with the bachelors, increased from 82.3% to 85.5% in the same years, also supported by grants and other financial aid offered by some Regions in order to increase the appeal of nursing education.

2. A second policy for coping with the nursing shortage refers to the improvement of the competences of the support staff. This has made possible a gradual shift of many tasks from nurses to support staff.

The main action was the definition of a new figure, the OSS (Operatore Socio-Sanitario, or socio-health worker). So far, this attempt to devote nursing competences to the core activities of

54 the profession, did produce limited effects, while perspectives are good. A first problem is that support staff already employed was offered the possibility to attend special courses in order to become OSS, but the quality of those courses, as well the quality of the students' selection, were often questioned. A second problem is the organisational and the individual resistance to implement such a task shift, also because of the mixed trust that nurses devote to OSS. Another problem, maybe more important for the future, is that many activities run by nurses cannot be easily split in simpler activities and then distributed to different professional groups. In surgical wards, for example, short stays and intensive technology make difficult to physically and temporally separate the tasks that can be given to OSS.

Another possible measure for reducing the nursing shortages is to increase the substitutability among health professions with similar education or activities. Unfortunately, the Italian healthcare system looks increasingly crowded of separate professions, claiming for their legal monopolies and hindering inter-professional substitutability (De Pietro, 2005a).

3. A third policy sphere is about work and pay conditions. Also in this case, several responses were implemented, along with the professionalisation process.

A first major attempt was in 2000, when a general increase in pay levels for the salaried nurses of the NHS was decided. This decision, based on the perceived shortage of nurses, led to claims by the other health professions that traditionally had enjoyed the same work status of nurses (laboratory technicians, radiology technicians, midwives, physiotherapists, etc.). Unfortunately those claims proved successful: the pay increase was recognised to all professions "similar" to nurses, so the premium for nurses was cancelled.

A second measure gave to nurses and other similar health professions the possibility to enter the management of the NHS organisation.

Furthermore, since 2002 NHS organisations can buy extra-time activities provided by their employed nurses. The law n. 1/2002 recognises to nurses employed by the NHS the possibility to carry out private practice within the premises of the organisations they already belong to, in order to guarantee through «additional services […] the healthcare standards in wards and in the operating theatres»²¹. This law includes also the possibility to re-employ nurses who had retired and sign contracts for a limited period of time.

21 NHS nurses also asked to run private independent activities inside the NHS facilities (as already permitted to doctors; see De Pietro, 2006a), but did not obtain it.

4. The last policy action worth to remember refers to recruitment from abroad. In this sense, Italy is much less attractive than other countries with stronger immigration tradition, such as the United Kingdom, France, or the United States (see for instance Pittman et al., 2007 and the following articles). Major obstacles for international recruitment by the Italian healthcare systems are: the language difficulties (Italian is almost not spoken outside the country); the difficulties in the immigration bureaucratic procedure; the need of recognition of education and degrees by the Italian ministry of health; and, for NHS organisations, the law requiring the citizenship of the European Union in order to become life-long salaried staff.

However, the number of foreigner nurses registered with the colleges has increased during the last years, from 2,612 in 2002 (37% from Rumania; 16% from Poland; 13% from Tunisia; 8%

from Peru) to 6,739 in 2005 (30% coming from EU-15 countries)²², often supported by the agencies for temporary work (De Pietro, 2005b). Despite the low absolute number, the incidence is higher in young cohorts.

Finally, if the number of foreign nurses will continue to increase in the future, then the Italian nursing profession, the NHS, as well as the healthcare organisations, will be asked to develop measures to compensate for the «brain drain», i.e. the reduction in human resources for health available in the origin countries (Nullis-Kapp, 2005)²³. Until now, those issues have raised very little debate in Italy.