Parameters with associated values for analysis
Education of nurses
For in-depth comparative assessments of health system performance, the distribution of professional roles and jurisdiction in health service delivery are much more informative than the ratio between professional groups. We consider length and level of educational pathways of different professional groups in the health care workforce an important parameter for comparing interprofessional jurisdiction. While education and training for physicians are largely harmonized within the European Economic Association area (EEA), the educational tracks available to other health professions are organized quite heterogeneously. In our analysis, we focused particularly on the education of nurses, because, more than the ratio of physicians and nurses, we perceive the interprofessional relation between these groups as indicative for the capacity of a given health care system for effective care coordination and integrated service delivery. We scored each country according to the highest achievable educational level within nursing. A value of intermediate was assigned to countries where the highest obtainable degree in nursing ended below a bachelor degree; a value of higher to those obtaining a bachelor (BSc or BA), and of academic to those where it is possible to obtain a Masters and/or PhD-degree in nursing.
Professional autonomy of nurses
The particular tasks specifically assigned to nurses, and the autonomy they have in the execution of their work varies considerably between European health care systems. We scored country reports with a value of low when the professional autonomy of nurses was presented as very limited, and/or their position was described as subordinated and/or dependent on the authority of other professional groups, and/or where nurses were explicitly prevented from working as self-employed. A value of medium was assigned to reports where the autonomy of nurses within healthcare was described in its own right, but where it was not clearly delimited. The same value was also assigned when the work of nurses was described as partly autonomous from the authority of other professions, and/or where nurses mostly were employed by other health professionals. High was assigned when the professional autonomy of nurses was described in unambiguous terms, and when it was described either as autonomous from the authority of other professions or as protected by a specific legal framework for both employed and self-employed nursing professionals.
Professional hierarchy
Physicians represent unequivocally the dominating profession in all European health care systems. As a rule, nurses are the most numerous among the groups of health professions. The professional autonomy of nurses in the performance of their tasks varies as shown. However, the level of professional autonomy is not necessarily indicative for the rigidity of an existing vertical professional hierarchy. We assigned a value of low when a flat hierarchy between occupational groups in the health care sector was indicated or particularly emphasized. Medium was designated to HiT reports when a hierarchical order between occupational groups was indicated and/or the occupational groups were specified, but where it was not indicated who the leading and/or subordinated part in the hierarchy is. High was assigned when a clear hierarchical order between occupational groups was expressed and where the leading profession was mentioned explicitly, and/or where reasons for the hierarchical order were laid out.
Adjustment of professional boundaries (skill mix)
The institutional structure in a welfare state, including its health care system and the regulations governing professional jurisdiction is never static. The causes forcing a redistribution of tasks within the health care work force may vary, not the least changes in the demand for the services needed, the availability of particular professional groups and economic constraints require constant adjustments [
17,
36]. Nevertheless, in most European health care systems an ongoing discussion takes place about the necessity of a new skill mix. The transfer of responsibilities from physicians to nurses dominates the agenda in several European countries, sometimes, for instance in Germany, vehemently opposed by interest groups of the former [
12]. We scored reports with a value of low when the adjustment of professional boundaries was mentioned in passing without specific reasons given for assigning new tasks to another group of health professionals. Also scored as low were reports when a skill mix was described as happening reluctantly, against strong resistance from the profession that performed the task initially, and/or as incomplete in that the originally performing professional group retained a supervising position over the entering professional group. A score of medium was assigned when the reason for the adjustment of professional boundaries was described as a result of an insufficient availability of the necessary work force among the profession that originally performed the task(s), or a financially motivated transfer of tasks to a lower paid professional group. A value of high was assigned when the adjustment of professional boundaries was reasoned for because another profession was more suited for it than the professional group that had performed the task initially.
Interdisciplinary teamwork
The need for delivering health services in a coordinated and integrated manner is hardly controversial. However, our analysis revealed that the practical implementation of care-coordination and -integration in several European countries was described as unsatisfactory. While the concept of interdisciplinary teamwork is rather popular in European health policies, it appears with quite different meanings in a variety of national contexts [
37]. Instead of the generic use of the term interdisciplinary teamwork, we therefore scored the HiT reports for each country according to the emphasis given to specific examples for how health services delivered by different professions were integrated into a holistic parcel of services to the patient.
Low was assigned when interdisciplinary teamwork was mentioned with no specific professional groups addressed and/or without specific reasons given for different professional groups to work together. Medium was assigned where interdisciplinary teamwork specified the professional groups working together, and/or when reasons for why they are working together, and/or when specific tasks for the team and the team members were mentioned. Medium was also assigned when a vertical professional hierarchy within the team or care delivery and coordination was expressed, and/or when interdisciplinary teamwork was described as pilot projects or temporary trials. High was assigned when, in addition to criteria 1–3 for medium, interdisciplinary teamwork was presented with a consolidated status beyond the status of pilot projects.
Cooperation of health and social services
Health and social services have, in most European countries long co-existed alongside each other with limited coordination across the interface of services. The Chronic Care Model, arguably the most influential among recent models for coordinated service delivery to patients living with chronic conditions, addresses for instance exclusively health services, and not the contribution of the variety of social services to the same service recipients [
38,
39]. However, the argument for integrating service delivery of both sectors is rapidly gaining momentum [
40,
41]. The European Commission has established The European Social Network as a dedicated body for promoting the integration of health and social service delivery.
2 Still, the cooperation and integration of health and social services is a relatively new issue in the skill mix discussion.
We scored as low when the integration of health and social services was discussed similar to the following text sequence: “… the boundaries between the two sectors are quite unclear. Indeed, service categories can overlap and people can be assigned to the wrong setting, such as when long-term social care for the elderly is provided in acute wards due to the shortage of places in residential homes” ([
42]: 155). For this and similar examples, a score of low was assigned when no specific professional groups were addressed, and/or no particular tasks were specified for the services, when the absence of a legal framework enforcing the cooperation between the services was emphasized specifically, and/or the link between health and social services was presented as weak. A value of medium was assigned when specific professional groups working together were pointed out, when reasons were given to why they are working together, when specific tasks that the services had to perform were described, when guidelines (legal or practical) below law status were mentioned or when the link between health and social services was presented as incomplete. A score of high was assigned to reports when, in addition to one of the criteria 1–3 for medium a description of the professional jurisdiction regulating the work of health and social services was mentioned. High was also assigned to cases where the existence of a legal framework specifying conditions for the cooperation between the services was mentioned, and/or when the link between health and social services was presented as strong and consolidated.
Professional jurisdiction in European health care systems
The results of our analysis are summarized in Table
1. Also provided in this table are references to additional sources rectifying obviously incorrect assumptions based on the analysis of the HiT reports.
We ordered the table according to the distribution of values for the parameter of the education of nurses. The number of countries limiting the education of nurses to an intermediate level is the smallest in our distribution. As most of these countries will streamline the education for different occupational groups, nurses included, according to the guidelines of the European Higher Education Area, their number can be expected to decrease further in the near future.
3
In the majority of EEA-countries, nursing education is provided in an academic setting, ending with a BA. A considerable number of countries provide possibilities for further academic education, including a research career within nursing.
With the exception of the parameter “Education of nurses”, some HiT reports did not reveal any information to one or several of the analytical parameters. These gaps limit the methodological possibilities for analyzing the data presented in Table
1. We have no intention to draw statistical inferences from the table, nor will we discuss the idiosyncrasies of interprofessional relations and jurisdictions country by country. Instead, we present our interpretations of tendencies that can be observed in Table
2. These tendencies indicate a horizontal consistency of countries scoring respectively high, medium or low on the parameter of the education of nurses on the score received for the other parameters. Therefore, these tendencies provide empirical support for the three ideal-typical models, which we describe in the
Discussion of our paper.
Table 2
Professional jurisdiction in European health care systems: tendencies
A first tendency regards the position of the nursing profession in the performance of their tasks relative to other professional groups. Marked as tendency 1 in Table
2 it is noticable that academic and higher education for nurses tend to coincide with a reported high and medium degree of professional autonomy for nurses. The opposite can be observed for countries with intermediate and, to a more limited degree, higher educational tracks. Here nursing education tends to coincide with a low degree of professional autonomy. The same is true for the parameter of professional hierarchy. Health systems described with a distinct low and medium level of professional hierarchy are found mainly among those with academic and higher career opportunities for nurses. On the other hand, health care systems with a reported strong professional hierarchy are exclusively among those organizing nursing education in intermediate and higher educational tracks.
Tendency two regards the, in some countries controversial, adjustment of professional boundaries. According to the reviewed HiT reports, this parameter is emphasized most in countries allowing for an academic track in nursing education. On the other hand, a number of eastern European countries, all recently reforming their educational system for nursing, revealed a distinctively low emphasis given to this parameter. No reports with an intermediate nursing education revealed a high emphasis given to the subject, while countries with a higher educational track displayed both high, medium and low emphasis given to an adjustment of professional boundaries.
A third tendency in Table
2 regards the cooperation across professional boundaries, both in the form of interdisciplinary teamwork and across the health and social service interface. The parameter of interdisciplinary teamwork is reported with a strong tendency to high and medium emphasis in countries with academic and higher tracks for nursing education, while it has obviously less relevance in countries with intermediate tracks. Similarly, the relatively new discussion about an integrated approach to care across the interface between health and social services is reported as having a high priority mainly in countries with academic educational tracks for nurses. Low emphasis on the subject on the other hand is spread across countries representing all three educational levels. We must point out that a relatively high number of reports does not discuss the cooperation between health and social services at all. Therefore, the latter tendency should be interpreted with caution.