Israeli doctors and nurses claim they are overworked and underpaid, a cry which only intensified during the height of the pandemic. However, this is also a global trend.
“Healthcare workers have been worn down to the limit of their abilities,” Mervi Jokinen, chair of the European Forum of the National Nursing and Midwifery Associations, and former chair of the International Midwifery Association, told Davar in a recent interview. “Maybe the difference is where the labor unions have power. When they don’t have power, the workers don't have many options except to leave the job. In countries where the labor unions have a place around the decision-making tables, they feel that even if the conditions are difficult, they have the ability to influence working conditions and create solutions.”
As part of her position, Jokinen maintains a dialogue with the healthcare workers' unions in European Union countries and with the European Union governments. In a joint interview together with Razvan Gae, Vice President of the Federation of Health Workers Unions in Romania and a member of the European Public Service Employees Union, the two described the burden and difficulties that healthcare workers face in the post-pandemic world. They emphasized the importance of strong labor unions in the healthcare workforce, not only as a tool for protecting workers’ rights, but also as a factor that improves healthcare systems overall and can benefit all citizens.
“Healthcare worker burnout is happening across roles and across countries,” said Jokinen. "The work is more stressful, there’s more to do, you have to keep adjusting to new situations. In surgery, gynecology, gastroenterology, you need separate beds for people with COVID-19 and this creates a burden on the teams. In winter, this is a real problem. Another difficulty is that they do not recognize long COVID-19, and the stress it creates on the system. In Romania, Poland, Bulgaria and the countries of the Balkan region, there is not enough staffing because the wages are too low. There is no work-life balance. The pay does not match the workload."
Jokinen emphasized that the current crisis was found in countries with strong healthcare systems as well as those that were already struggling before the pandemic.
“We are used to thinking that northern Europe has developed rules of health and safety at work. But nurses are now striking there as well, not only for wages, but also for better working conditions.
“In Finland, the government does not allow nurses to strike, which is very unusual and worrying. This shows how unstable the labor market is at the moment. The problem is also related to the economic crisis. All of Europe is in an economic recession right now, and healthcare workers are a large part of the economy. In France, nurses took to the streets, and in Holland and England, nurses are also considering going on strike.”
Do you see healthcare workers from countries with weaker healthcare systems leaving to go to countries with stronger healthcare systems?
Gae: “Definitely. In Romania, we are facing a shortage of doctors, nurses and midwives. In 2009, the state decided to lower the salaries of public employees by 25%. More than 35 thousand nurses emigrated from Romania to England, Ireland, Germany, Austria, Spain and Italy. In 2018, the salary of doctors increased, but not that of nurses. The salary of doctors, who earned 1,500 euros monthly [$1482] in 2017, was doubled, and meanwhile the salaries of nurses rose from 600 to 800 euros [$593 to $791]. Assistants received no wage increase.
“The government promised that they would raise our wages in four stages, but then the government itself was replaced in 2021, and the new government canceled the wage increase. Only after we exerted pressure, did we receive the full wage increase. There are not enough personnel in the entire healthcare system, but the government pays attention only to the doctors. Especially during a pandemic, the nurses and assistants are the ones who see the patients and are with them.”
Jokinen: “There is a lot of economically motivated immigration, but that is not the only reason health workers leave. I think it’s important for nurses to be educated. There are countries where nurses are directly under the control of doctors and cannot provide care without a doctor’s supervision. Midwives have a little more autonomy. Many times nurses have to move to another country to get a master’s degree or to receive advanced training, and even if we hope that most of them will return to their countries of origin, this doesn’t always happen, and if they do return, their higher education isn’t always recognized and they aren’t allowed to teach at a university.”
What are the differences between countries with strong professional unions of healthcare workers, and countries where they are weaker?
Jokinen: “In England and Ireland, our unions have a place around the table. In Israel, the Nurses’ Association really leads the healthcare system. They also participate in international forums. But in Romania and Bulgaria, it is very difficult for unions to get the attention of politicians. In Georgia, Pakistan, and Uzbekistan, the head nurse has a role, but it is not certain that the unions have a role, and this is important to me — not only the position of the head nurse, but also that the union represents the majority of workers.”
Gae: “In Romania, they say that any proposal by the union to improve work or the system isn’t a high priority and isn’t required by law. Even when there are things that are required by law, such as a rule designed to protect workers from needlestick injuries, they only translate the law from English to Romanian and don’t take responsibility for it. According to the law, there’s supposed to be a team that meets and examines why these needlestick accidents have occured.
“If this committee had been operating, it would have found that needlestick accidents have increased because there is more pressure to rush procedures because the workload has tripled. There is also a lot of bureaucracy. In Romania, nothing is digital. The doctor fills out a form, and the nurse fills out another form. In the healthcare system there is a position called a medical assistant that is supposed to ease the workload, but the salary of this position is so low that it’s hard to recruit and retain staff.”
"Each country has its own unique conditions and problems. We need to work out what the fundamental problem is"
According to Gae, there are also significant differences in the rates of union formation and the laws related to forming unions. “In Eastern Europe, unionization rates are lower, and this weakens the bargaining power of the workers. In Romania, it’s forbidden to sign sectoral wage agreements. Every small union is left to negotiate on its own, which is impossible. The governments want to continue to weaken the unions as much as possible. In Romania, we are also not allowed as a national union to negotiate wages. Because of the war in Ukraine, refugees are coming to Romania; the government says it would like to help, but they have no money, and this puts even more pressure on us.”
As heads of unions, can your work help countries where the unions are weaker?
Jokinen: “I served for 26 years in the U.K., and after a while, you realize that the problems you hear about are repeating themselves. For example, how do you adjust the standards of care to meet the needs of women? Also home births and birthing centers — I’ve been dealing with these matters for 20 years. Once you have experience and perspective, you realize that the issues you are dealing with are common to many other countries, but the health systems are different, and this is the message you need to get across.
“We visit countries and open doors. I was in Romania and saw that there are no tertiary degrees for nurses at all, and there should be. I spoke with the minister. I also spoke with the ministers regarding the union's instructions. This will not change in a year or two. The World Health Organization initiated talks between us and the ministers on Zoom during the pandemic. We are not the World Health Organization, but we work with them. It is important to us that the ministers understand why there is a personnel problem, because that is the only way that they will bring forward a policy that will improve the situation. We also represent not only the workers' unions but also the professional associations. This is important because some countries do not have functioning unions.”
Gae: “The European Public Service Employees' Union only represents the unions. It is a challenge to find solutions for all countries, even countries that are not part of the EU, and do not commit to its guidelines. Each country has its own unique conditions and problems. We need to work out what the fundamental problem is that all countries have in common, and formulate proposals for solutions that will be relevant to employers.
“For example, we worked with employers on orthopedic problems, which all health workers in all countries suffer from. Back pain and such. From the nursing staff to surgeons, we all stand in challenging positions all day. So we need to study the problem in all countries, locate the main problem, and propose a solution. Then bring it to the EU for approval and act to approve the proposal. This is very important for Eastern European countries. Northern Europe has good work health and safety laws and strong unions.”
The pandemic has also taken a toll on the mental health of medical staff. How do you deal with this as a union?
Jokinen: “In the universities, we hear that both the nursing lecturers and the nursing students are worn out and are considering leaving the profession. This is a big problem. Without education, there is no future for the nursing profession. This is very worrying. We are trying to help the nursing teachers to teach on Zoom, and support the students by establishing a network of nursing students who will share their experiences.
“Before the pandemic, the nursing internship was mainly an educational experience. Today, nursing students are expected to take care of patients on their own, even if they do not yet have enough experience and confidence, because the healthcare system is under so much pressure. We make sure that the regulations protect the students and prevent employers from burdening them with the work responsibilities of a professional nurse.”
"Governments want to strengthen health in the community. We need support for nurses in order to realize this goal"
Jokinen sees nurses as a key factor in the future development of the healthcare system. She calls on governments to commit to empowering their country’s nurses in order to achieve this goal. “Governments have an interest in reducing the workload of hospitals and strengthening health in the community. They must understand that proper support is needed for nurses to realize this goal. With this support, nurses in the community will be able to actually manage the clinics. It’s fine that most nurses will remain in support roles, but there should also be room for nurses to lead.
“In Western countries, there are more nurses in proportion to the number of doctors, and in Eastern Europe, the numbers of doctors are higher in relation to the number of nurses, up to a 1:1 ratio between doctors and nurses. One of the challenges is that doctors will always earn more than nurses. It is difficult to move towards empowering nurses more without the doctors seeing it as a challenge. But that’s the direction medicine should head in: the nurses are in charge of the clinics and the treatment of the patients, and the doctors are there to contribute their professional advice. This is how it operates in Western Europe."
This article was translated from Hebrew by Rose Angela.
