Lessons learned from Ebola & COVID19 - June 2020

EUROPEAN FEDERATION OF NURSES ASSOCIATIONS




EFN Report on

LESSONS LEARNED FROM

EBOLA & COVID-19





June 2020

TABLE OF CONTENTS


Table of Contents .............................................................................................................................. 2
1. Introduction .................................................................................................................................. 3

2. EU legislative Frameworks ............................................................................................................ 4
i. Health and safety of healthcare professionals EU tools........................................................ 5
ii. Digitalisation & Electronic Health Records ........................................................................... 6

iii. European Pillar of Social Rights ............................................................................................ 8
iv. Professional Qualifications Directive .................................................................................... 8

v. Proportionality Directive ...................................................................................................... 9
vi. Continuous Professional Development (CPD)/Lifelong Learning .......................................... 9

3. Challenges ................................................................................................................................... 10
4. Recommendations & Lessons Learned ........................................................................................ 13

5. Conclusion .................................................................................................................................. 22

















































EFN - Lessons Learned from Ebola & COVID-19 Page | 2

1. INTRODUCTION



The significant toll COVID-19 has taken on the 2015, the EFN was already stressing the need to get
citizens of Europe, in terms of lives lost, human prepared in case of a new pandemic. This COVID-19
suffering as well as the impact this has had on crisis demonstrates once again the reality of the
people's daily lives is unprecedented. All over concerns EFN raised from experience of the Ebola
Europe, nurses, as frontline, are working pandemic: “WE ARE NOT PREPARED, UNLESS WE
exceptionally hard to contain the pandemic and ARE ALL PREPARED”. Only 5 years after Ebola, we
protect people, doing their job in challenging work have learned from the challenging and tragic
environments, lacking enough and/or proper
outcome of COVID-19 that, again, WE WERE NOT
protective equipment, putting themselves at risk to
protect the communities and often getting infected PREPARED!
by the virus themselves, with deadly consequences
in some cases. In response to a question about the extent to which
the European Union was prepared to respond to
Stella Kyriakides, European Commissioner for Ebola, the special advisor to the United Nations on
Health and Food Safety, expressed “In the last few Ebola, Dr Paul Farmer, noted that ‘we cannot be
months, we saw how prepared anywhere if
COVID-19 has really we are not prepared
impacted and changed “WE ARE NOT PREPARED, UNLESS WE ARE everywhere, such is the
2
our lives and how ALL PREPARED” nature of pandemics’ .
much suffering it has This is still valid today.
caused throughout the
world. Our health systems and our health Unfortunately, not many efforts have been made to
professionals, social services and social services co-design with the healthcare professionals, in
providers had been stretched beyond their limits. As particular nurses, the Infection Diseases of High
the society is starting to emerge from the shadows Consequence (IDHC) preparedness protocols, the
of COVID-19, and after weeks of lockdown, we start needed protection materials until COVID-19
acquainted with a new normal in our future. This happened to all of us. The EFN therefore urges the
pandemic has reshaped the way we will leave our European Commission to, out of this experience,
lives and interact with each other, and how we GET PREPARED!
work. For the most vulnerable groups, this
experience will be difficult to overcome.” In this special year for the nurses and the nursing
profession, named by the World Health
3
As this was the case in 2015, with Ebola, COVID-19 Organization the “Year of the Nurse and Midwife ”,
has revealed many weaknesses but also strengths. in honour of the bicentenary of Florence
It has showed that solidarity is a core value in our Nightingale’s birth. In the context of the ongoing
society. Healthcare professionals have shown not COVID-19 outbreak, nurses as always are at the
only their capability but also their dedication frontline with patients who need them, doing their
towards society and EU citizens. We have seen utmost to provide high quality and safe care. In
nurses supporting their colleagues from abroad, recognition of the invaluable contribution and
and patients being helped across borders. expertise of the nursing profession the EFN calls all
Healthcare professionals, especially nurses, have the EU Institutions and health stakeholders for
been putting themselves at an enormous personal greater involvement of nurses in the co-design of
risk, working long and difficult hours, and risking healthcare policies to ensure policies respond to
their own lives. the individuals and societies health needs and
1
In the EFN Ebola Recommendations Report , “We support nurses in further supporting and
are not prepared, unless we are all prepared!”, from empowering patients.

1 http://www.efnweb.be/wp-content/uploads/EFN-Report-MS- http://kapuscinskilectures.eu/lectures/failure-to-collide-ebola-
Preparedness-Ebola-Final-Sept.2015.pdf and-modern-medicine/
2 Farmer P (2015) Failure to collide: Ebola and Modern 3 https://www.who.int/news-room/campaigns/year-of-the-
Medicine. Kapuscinski Development Lectures. nurse-and-the-midwife-2020


EFN - Lessons Learned from Ebola & COVID-19 Page | 3

2. EU LEGISLATIVE FRAMEWORKS













































4
Infectious diseases of high consequences (IDHC) can pose a real threat to the life of healthcare professionals,
especially nurses, if they are not adequately equipped with education, training, appropriate resources within
working environments and protective equipment. The result of this has been seen in the case of Ebola and now
again with COVID-19. The Ebola outbreak in West Africa, led to thousands of deaths, being a challenge not only
for Africa but also a great concern of the European Union. Although the outbreak was eventually under control
due to well-coordinated efforts with a highly trained frontline, especially nurses, the EFN Report recommended
at that time (2015) that it was crucial to continue to learn from our mistakes as complacency is dangerous and
can lead to more unnecessary deaths.

Overall, the EU and its Member States have contributed with billions of Euros to fight against both pandemics,
but equipment and training for the frontline health professionals involved in managing people with Ebola and
COVID-19 was and has not been consistent, and in some cases totally lacking, despite the fact that according
5
to the EU policy strategies , healthcare professionals are required to be equipped with the right material and
st
to have received adequate and appropriate training, confirmed by the Health Council on the 1 December
6
2014 .

IDHC, such as Ebola and COVID-19, have a huge impact on frontline, especially nurses, especially women. Every
day, nurses provide the best possible health care for patients infected with the virus, and provide high quality


4 https://www.ecdc.europa.eu/en/publications-data/health-emergency-preparedness-imported-cases-high-consequence-infectious-
diseases
5 Council of the EU (2014) Council Conclusion on the Ebola Crisis in West Africa.
https://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/EN/foraff/145195.pdf
6 http://register.consilium.europa.eu/doc/srv?l=EN&f=ST%2015979%202014%20INIT


EFN - Lessons Learned from Ebola & COVID-19 Page | 4

and safe nursing care with the stark knowledge that they and their families are at risk of infection which could
be life threatening or fatal, especially if denied access to proper equipment and training. Therefore, it is of
greatest importance that the politicians, virologists, policymakers and coordinators of any pandemic we are
currently dealing with, take the working conditions and appropriate resources to support nurses very serious
when their facility accepts a potential or confirmed patients with IDHC.

The Ebola evidence showed that EU facilities inadequately developed protocols and risk techniques to protect
those on the frontline; and as such health professionals were not educated on the correct handling of
equipment. Of particular concern was, and still is 6 years later, that the nurses were neither consulted on the
policies to respond, choice of personal protective equipment (PPE), nor the practicalities and suitability of the
care environment to be used. Again, it is crucial to remember that policies cannot be fit for practice without
engaging frontline nurses. The COVID-19 has demonstrated how easily the virus can be contracted among nurses
or other healthcare professionals if they are not equipped appropriately with adequate measures. This includes
education, PPE and safe working conditions.

Overall, and with the learning that is developing within Europe on COVID-19, it is clear that sufficient and
appropriate resources were not made available and that the capacity to have an appropriate number of
professionals available, as well as the needed protection measures, are important factors that contributes to
7
the safety of healthcare professionals and patients . Many countries recognise the particular vulnerability of the
elderly in our societies and experience devastating loss of life in long term residential care facilities across Europe
and the necessity to redouble our efforts across Europe to protect them in the context of this pandemic. This is
especially important for the nurses and the nursing profession knowing that most of the caring activities for a
patient with an IDHC are carried out by nurses. Therefore, action at EU level is key.

i. Health and safety of healthcare professionals EU tools

Broader EU legislative frameworks are already in place, which protect the health and safety of healthcare
professionals such as from risks related to exposure of biological agents at work and from sharp injuries
10
9
8
(2000/54/EC , 2010/32/EU ). Also, in its Strategic Framework on Health and Safety at Work 2014-2020 ,
identifying many important challenges facing European employers and employees in the area of occupational
health and safety, the Council confirms the need to improve the implementation of occupational safety and
health legislation; to prevent risks to health and safety at work; and to address the challenges posed by an ageing
11
workforce and longer working careers . And some positive results have been achieved, if we consider that many
EU Member States have adopted national action plans based on this framework. However, as COVID-19
experience demonstrates a lot is still to be done. Therefore, it is key for the European Commission, the EU
Member States and the EU Stakeholders increase their efforts to ensure healthcare professionals, and in
particular nurses, are protected when there is a pandemic, including psychological risks, work-related accidents
and diseases and the inclusion of disabled and older professionals.

With the new upcoming EU Strategic Framework on Health and Safety at Work (2021-2027), enhancing the
implementation of Occupational Safety and Health (OSH) in the EU is crucial, knowing that professionals’
wellbeing is the cornerstone for economic growth and competitiveness in the EU. The October 2019 Council
12
13
Conclusions raise that with the proclamation of the European Pillar of Social Rights , the European Parliament,

7 Boozary AS, Farmer PE, Jha AK. (2014) The Ebola Outbreak, Fragile Health Systems, and Quality as a Cure. JAMA 312(18):1859-1860.
doi:10.1001/jama.2014.14387
8 Directive 2000/54/EC on the protection of professionals from risks related to exposure to biological agents at work. https://eur-
lex.europa.eu/legal-content/EN/ALL/?uri=CELEX%3A32000L0054
9 Directive 2010/32/EC on implementing the Framework Agreement on prevention from sharp injuries in the hospital and healthcare
sector concluded by HOSPEEM and EPSU. https://osha.europa.eu/en/legislation/directives/council-directive-2010-32-eu-prevention-from-
sharp-injuries-in-the-hospital-and-healthcare-sector
10 https://www.europarl.europa.eu/doceo/document/A-8-2015-0312_EN.html
11 Council of the European Union (2015) EU Strategic Framework on Health and Safety at Work 2014-2020: Adapting to new challenges.
Retrieves from: http://register.consilium.europa.eu/doc/srv?l=EN&f=ST%206535%202015%20INIT
12 https://data.consilium.europa.eu/doc/document/ST-13321-2019-INIT/en/pdf
13 https://ec.europa.eu/commission/priorities/deeper-and-fairer-economic-and-monetary-union/european-pillar-social-rights_en


EFN - Lessons Learned from Ebola & COVID-19 Page | 5

the Council and the European Commission affirmed their strong commitment to fundamental rights of
professionals and improved living and working conditions. Principle 10 of the pillar, for example, stresses the
“right of professionals’ right to a high level of protection of their health and safety at work and to a working
environment adapted to their professional needs and which enables them to prolong their participation in the
labour market”. It is therefore key that in order to address the challenge of a changing world, the EU continuously
improve the national OSH strategies and policies, as well as the protection of the self-employed through
legislative or other measures, to make sure that we are prepared for any other upcoming crisis as we had with
Ebola and COVID-19. Furthermore, it is important that the existing EU legislation is being implemented correctly
and that action is being taken by the European Commission to ensure that the EU Member States comply with
the EU legislation that protects the frontline workforce.

14
In line with the European Centre for Disease Prevention and Control (ECDC) , data is crucial to better understand
and address the needs of the frontline staff possibly dealing with an IDHC. Hence, the data collected from the
15
EFN questionnaire on Ebola (2015) , mapping the level of preparedness in the European countries for a possible
outbreak of IDHC, was aiming at raising awareness on the importance of the correct implementation of existing
EU legislation and further EU action supporting capacity building and appropriate training and equipment.
Nurses need to be supported and empowered, since they are the backbone of frontline care in every healthcare
setting. They need to be included in the decision-making processes to address the existing gaps in preparedness
for a future possible outbreak of such diseases. The EU institutions & policy makers need to understand the
requirements of the frontline workforce to provide practical support where it is required. Academic insights are
crucial, but not at the expense of those caring daily for IDHC patients. The European Commission, especially DG
Sante, should recognise this and factor it into future work.

We recognise that the European Institutions have been taking this health crisis very seriously, with a common
European response to the outbreak, taking actions to reinforce the public health sectors and mitigate the socio-
economic impact in the European Union, and to help the EU Member States coordinate their national responses,
with a Coronavirus response team established at political level to coordinate the European Commission
16
response to the pandemic; the first ever strategic rescEU stockpile of medical equipment such as ventilators,
protective masks, vaccines and therapeutics, laboratory supplies, to help the EU countries; a €3 billion from the
EU budget to support the EU healthcare systems; two legislative acts adopted to quickly release funding from
the EU budget for tackling the COVID-19 crisis: One amending the rules of the structural and investment funds,
17
18
and the other extending the scope of the EU Solidarity Fund; the activation of the EU's crisis response
mechanism – the Integrated Political Crisis Response (IPCR), which allows an increased focus on identifying major
gaps across sectors and elaborating concrete EU response measures at presidency-led roundtables, and an EU
civil protection mechanism bringing together the national civil protection authorities with the European
Commission, DG ECHO, putting a solidarity pool of nurses together to help other EU countries in need of support
in times of crisis and for which the EFN provided its expert input to.

ii. Digitalisation & Electronic Health Records
Digitalisation is a crucial aspect of modern societies and health and social care ecosystems, with technology
having an important role to contribute to enhancing patient safety and patient empowerment as well as
facilitating frontline healthcare professionals’ work, with electronic tools supporting them in their daily work
and allowing an easy and fast collection of relevant data, to hopefully free up time for direct patient care.
Digitalisation and the EU Electronic Health Record is essential for preparedness.

The Commission’s plan is to promote health, prevent and fight diseases, contributes to responding to unmet
patient needs and make it easier for citizens to have equal access to high-quality care through appropriate use


14 https://www.ecdc.europa.eu/en
15 http://www.efnweb.be/?page_id=766
16 https://ec.europa.eu/commission/presscorner/detail/en/ip_20_476
17 https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:52020PC0113
18 https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:52020PC0114


EFN - Lessons Learned from Ebola & COVID-19 Page | 6

of digital innovations and social economy, (namely through European Electronic Health Records – being a
growing priority for the EU Institutions, as pointed out in the Council Conclusions on Health in the Digital Society
19
- making progress in data-driven innovation in the field of health (2017/C440/05) and the European
20
Commission Recommendation on a European Electronic Health Record exchange format (C(2019)800) ).
Advanced application of health data and artificial intelligence in nursing care can support clinical decision-
making by improving clinical pathways interpretation and enabling more effective care processes and outcomes.
21
A recent Communication from the European Commission on ‘enabling the digital transformation of health and
care in the Digital Single Market - empowering citizens and building a healthier society’ is a key starting point for
change.

For digital health to deliver its full potential, co-designed tools and programmes, co-created with nurses, is a
facilitator for successful deployment and as such, an investment for being prepared. Among all the new digital
health tools, Electronic Health Records have the most significant potential for change when it comes to
improving the quality of cross-border care and interoperability. The importance of electronic health records and
end-user involvement in co-creation is being positively demonstrated in two EU-funded projects working on
23
22
Electronic Health Records, InteropEHRate and Smart4Health , with the determine ambition to digitalise
healthcare to support health for all across Europe. Positioning nurses and nursing central to digital health policy
design and ensuring that they can use and develop their eSkills, to their full capacity, can lead to improved
24
citizens and patients’ health and well-being, enabling the achievement of Universal Health Coverage .

Therefore, within the context of the digitalisation of the EU health systems, it is key to:
✓ Have fast and full access to Electronic Health Records (EHR) in order to be able to diagnosis, plan and
care for patient in an effective and efficient way;
✓ Boost continuity of care throughout the patient’s journey by using fit-for-purpose digital tools;
✓ Deploy digital tools and systems that reduce the workload of nurses and safeguard the quality of care.

In 2015, the 5 guidelines published by the EFN at the end of a 2-year European Commission funded project on
25
eHealth (ENS4Care) showed the importance of having the health and social ecosystem, or its redesign, with
frontline, strengthening nurses capacity, and of bringing knowledge together, to be ready to address frontline
concerns and offering immediate solutions for preparedness. The developed evidence based ICT guidelines for
eHealth services in nursing and social care are essential for preparedness at local level and are based on 175
existing good practices in the EU, in five core areas: prevention, clinical practice, advanced roles, integrated care
and nurse ePrescribing. Moving towards preventive care will make digital health deliver at its fullest potential,
with nurses co-designing tools and programmes, facilitate access and successful deployment in the many
environments in which nurses are located, including home care and nursing homes, hospitals and primary care
settings. We are only prepared if we are all prepared, including community care.














19 https://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:C:2017:440:0003:0009:EN:PDF
20 https://ec.europa.eu/digital-single-market/en/news/recommendation-european-electronic-health-record-exchange-format
21 https://ec.europa.eu/digital-single-market/en/news/communication-enabling-digital-transformation-health-and-care-digital-single-
market-empowering
22 http://www.InteropEHRate.eu - EU project funded from the European Union’s Horizon 2020 research and innovation programme under
the grant agreement: No. 826106.
23 http://www.smart4health.eu - EU project funded from the European Union’s Horizon 2020 research and innovation programme under
the grant agreement: No. 826117.
24 https://www.who.int/health-topics/universal-health-coverage
25 http://www.efnweb.be/?page_id=7060


EFN - Lessons Learned from Ebola & COVID-19 Page | 7

iii. European Pillar of Social Rights

The European Commission developed the European Pillar of The European Pillar of Social Rights in 20 principles
26
Social Rights , designed to act as a policy tool for EU policy
makers to foster the involvement and rights of the civil society Chapter I: Equal opportunities and access to the labour
market
on the EU’s policy development and outcomes. Including 20
1. Education, training and life-long learning
principles aiming to address crucial topics such as equal 2. Gender equality
opportunities and access to the labour market; fair working 3. Equal opportunities
conditions; and social protection and inclusion. 4. Active support to employment


Chapter II: Fair working conditions
When the Pillar was launched in 2017, EFN members fully
5. Secure and adaptable employment
supported the intent of the policy and selected 4 Pillar 6. Wages
priorities, Education, Wages, Access Health care, Long-term 7. Information about employment conditions and protection
care, which are for preparedness essential. Lessons leaned in case of dismissals
8. Social dialogue and involvement of professionals
from COVID-19 shows the importance of CPD, the importance 9. Work-life balance
of elderly care, the importance of keeping the nurses in the 10. Healthy, safe and well-adapted work environment and
profession, and having access to healthcare facilities. The EFN data protection
has stated that designing the key milestones for a Triple ‘A’
Chapter III: Social protection and inclusion
Europe, implies supporting and engaging frontline in policy-
11. Childcare and support to children
design, and putting in place concrete actions that facilitate the good quality
daily work of the EU nurses. 12. Social protection
13. Unemployment benefits
14. Minimum income
Therefore, addressing the unmet needs of nurses throughout
15. Old age income and pensions
the EU is a priority, with the situation for nurses working 16. Health care
environment deteriorating impacting on their ability to deliver 17. Inclusion of people with disabilities
appropriate safe and quality care (demonstrated during the 18. Long-term care
19. Housing and assistance for the homeless
COVID-19 pandemic) many nurses only choice is to leave the 20. Access to essential services.
profession. Without appropriate and timely policy measures
from within the European Pillar of Social Rights, nurses will become difficult to be recruited to and retained in
already challenged healthcare delivery services. Anyone who has ever experienced, either as patient or relative,
the need of receiving healthcare recognises that without the nurses these essential life changing and saving
services could be no longer provided. Again, this has been demonstrated during this current COVID-19 pandemic
crisis.


iv. Professional Qualifications Directive
27
The key EU legislation for the nurses, is the Directive 2013/55/EU and it is vital that it is adequately transposed
into national education programmes to further develop nursing education curricula and ensuring nurses have
the right competencies to shape and deliver effective nursing and health care.
One of the important competencies the European Commission should be cognisant of in the Directive refers to:
“To independently initiative life-preserving in crises and disaster situations”. This shows that in their education,
nurses learn how to be prepared for a crisis such the COVID-19 one. All our nurses in the EU are prepared for
crisis management. Therefore, it is vital that the EU Institutions recognises nurses’ expertise and best practices
in the field of health delivery and health promotion. Engaging with EU nurses and empowering them to do so.
The EU Member States need to take this into account when developing any new policies. Nurses are essential
to contribution to the solution of any problem and ensuring it is fit-for-purpose and can be implement with
efficiency and effectiveness



26 https://ec.europa.eu/commission/priorities/deeper-and-fairer-economic-and-monetary-union/european-pillar-social-rights/european-
pillar-social-rights-20-principles_en
27 Recognition of professional qualifications Directive. https://ec.europa.eu/growth/single-market/services/free-movement-
professionals/policy/legislation_en


EFN - Lessons Learned from Ebola & COVID-19 Page | 8

DIRECTIVE 2013/55/EU - COMPETENCIES (Art 31) for Nurses

✓ To independently diagnose the nursing care - plan, organise and implement nursing care
✓ To work together effectively with other actors in the health sector
✓ To empower individuals, families and groups towards healthy lifestyles and self-care
✓ To independently initiative life-preserving in crises and disaster situations
✓ To independently give advice to, instruct and support persons needing care and their attachment figures
✓ To independently assure quality of and to evaluate nursing care
✓ To comprehensively communicate professionally and to cooperate with members of the other professions in the health sector
✓ To analyse the care quality to improve the own professional practice as a general care nurse


v. Proportionality Directive

28
The Directive 2005/36/EC (modernised by Directive 2013/55/EU) strengthens nursing as a profession, and the
proportionality Directive goes even beyond that strengthening as national governments need to co-design
preparedness policies, with the profession. The delivery of hands-on care for patients, and coordination of the
care process to achieve better health outcomes requires a highly qualified nursing and health workforce. The
29
European Commission Directive on a proportionality test used before adopting new or modified regulations
impacting on nurse education, service delivery and health outcomes, is key for preparedness, even in crisis, even
more in times of crisis as Ebola and COVID-19. Ministers of Health need to decide based on the dialogue they
had with the representatives of the profession, and any legislative outcome, need to be in line with the existing
European Directives. It is key to ensure the adoption of legislative measures able to preserve the safety and
quality of patient care, as well as the national specificities in their demographical, geographical and cultural
realities and make sure that regulation is based on proper justifications by the EU Member States. It is also
crucial to ensure that the level of protection of public health will not be undermined by the new provisions and
that EU citizens continue to enjoy access to appropriately trained and regulated professionals. The
proportionality test can play an important part in achieving this across the EU.

vi. Continuous Professional Development (CPD)/Lifelong Learning

Finally, investment in the education of the nursing workforce, enhancing the role of Continuous Professional
Development (CPD)/Lifelong Learning is an equal important step forward, to ensure the nursing workforce is
properly skilled and prepared to provide high quality care and patient safety, next to contributing to improving
patient outcomes and increasing the public confidence in the nursing profession. However, in reality, it is evident
that nurses lack working time to attend face-to-face courses and other educational opportunities. In COVID-19
times, there is little time to become a “link COVID nurse”, which is not a specialist nurse, but a general care nurse
with a specific COVID-19 responsibility on each unit. In addition to specific requirements in the current COVID-
19 crisis other essential policies such as the elimination of unsafe procedures as well as the transition to safe
sharps protection mechanism and devices is key for frontline nurses.


















28 EFN Competency Framework. http://www.efnweb.be/?page_id=6897
29 http://eur-lex.europa.eu/legal-content/EN/ALL/?uri=COM:2016:0822:FIN


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3. CHALLENGES





























































Infographic 1: Practising nurses, 2017 1

There are 21 million professionals active in the hospital and healthcare sector in Europe, being one of the largest
sectors in Europe, employing around 10% of professionals in the EU, with women accounting for 77% of the
30
workforce. 6 million health professionals are nurses , in Europe, of which 92% are women. A significant
proportion of healthcare professionals are employed in hospitals; however, we cannot ignore the importance of
other sectors within the healthcare sector, namely nursing and care homes, and community care in which
primary care plays a crucial role. The nurses working in all facilities are all potentially at risk and need adequate
preparation and protection!






30 http://www.euro.who.int/en/health-topics/Health-systems/nursing-and-midwifery/data-and-statistics


EFN - Lessons Learned from Ebola & COVID-19 Page | 10

31
In the survey conducted by the EFN in 2015 , 1.800 health professionals from across 23 countries shared their
insight about the state of preparedness for Ebola in Europe from the perspective of frontline staff. This report
provided an analysis of this rich and unique dataset, which led to important lessons for policy makers and health
professionals, showing that the level of preparedness for IDHC, and in this case Ebola, was different from country
to country Europe, with some countries appearing to be ahead of others.

As recommended in the EFN report at that time, and still accurate today, it is important that EU citizens, including
patients and health professionals, have equitable access to safe and quality healthcare regardless of the country
in which they may live. The ECDC and the EU institutions need to support those countries that find certain areas
of preparedness challenging in order for the EU to reach a common and safe level of preparedness. Adequate
EU legislation is in place, however, it needs to be correctly transposed by the EU Member States into health
policies and implemented in daily practice to AVOID to be in the same situation of NON-PREPAREDNESS as was
the case for Ebola in 2014 and again in 2020 with COVID-19.

While further resources were welcomed by many of the respondents of the Ebola survey, it was capacity building
that appeared to be mainly lacking for healthcare professions. And unfortunately, this is still evident in 2020.
Education and training on how to manage cases of IDHCs need further support through life-long learning for
nurses. In order to reverse this lack of specific training, the EU Member States should make more use of the
32
European Social Funds , that each year helps millions of Europeans to improve their lives by learning new skills
and finding better jobs, with the objective of strengthening the capacity of the health and nursing workforce.

Areas for this specific training must cover are:
a) use and disposal of PPE;
b) risk assessment;
c) infection prevention and control procedures;
d) protocols for managing patients with the virus;
e) drills on donning and doffing;
f) staffing level and skill-mix policies.

33
Being a compulsory requirement of Directive 2010/32/EU , more actions are needed to engage nurses, the
health workforce, to appropriately manage IDHC. Engagement goes far beyond employers and managers
consulting professionals’ representatives on the choice and use of safety devices; it must extent to identifying
‘fit for practice’ training and tools, next to information on what is needed to create safe working environments
and using awareness-raising campaigns to make change possible. Involvement of nurses in the decision-making
in terms of the necessary equipment, development of protocols and sharing of risk assessment outcomes, needs
to be improved. Professionals working in the field, at the bedside, must be engaged in better preparedness for
IDHC.

As articulated in the 2015 EFN Preparedness Report, a first step to improve this situation could be the
development of a reference colleague, a “link nurse”, being located within the team of nurses, health
professionals and other professionals, who can be consulted flexibly and take up a more prominent role in policy
design and implementation. Nurses need to have a say on the equipment and technologies deployed
(procurement nurse), the organisation of their daily work, their working conditions, the composition of the levels
of qualifications, the importance of work related psycho-social factors (stigmatisation) and the influence of
factors related to the difficult working environment in which ‘opt out’ must be an option.





31 http://www.efnweb.be/wp-content/uploads/EFN-Report-MS-Preparedness-Ebola-Final-Sept.2015.pdf
32 https://ec.europa.eu/esf/home.jsp
33 https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A32010L0032


EFN - Lessons Learned from Ebola & COVID-19 Page | 11

The EU Institutions should encourage transparency of learning following incidents leading to health
professionals’ exposure to any IDHC in Europe (e.g. affected countries). The need for timely and transparent
information following analysis of incidents is crucial (e.g. breach of PPE and/or needle-stick injuries) in allowing
any learning to be identified and transferred to nurses working clinically within the EU Member States in order
to help reduce risks of transmission in these settings whether hospital or community based.

Moreover, nurses representation at strategic European, national and local level decision making committees is
essential to ensure that decisions made can be implemented safely and effectively and avoiding potential risks
to health professionals as well as to the delivery of health services and patient safety. It is important to
encourage consistency on the selection and use of PPE. In addition, timely planning of reactive strategies to
recognise and manage potential cases of IDHC, as COVID-19, is crucial. Reactive practices require considerable
planning to be implemented in a safe and effective manner. Whilst individual Member States will make individual
decisions on what reactive needs are required, the European Commission should provide coordination on the
impact on capacity of areas where staff are drawn from, payment and hours worked in excess of contracts, as
well as training and selection of staff to ensure suitability for the task required. This coordination needs to be
linked to the European Pillar of Social Rights, which needs to be reviewed based on the COVID-19 experience, to
make policies and laws fit-for-purpose!

It is important to acknowledge that IDHCs have no borders, boundaries, or healthcare settings. It is therefore
important to provide support to nurses working across settings, not just in the reference hospitals, or the COVID
units. While different healthcare settings appear to face similar challenges, the elderly and community care
sectors are often the ones overlooked and which suffer from substantial disinvestment in nursing. If we are to
be adequately prepared for any pandemic, we must all be prepared - across sectors, all nurses working in
different sectors, in all EU countries, and secure the safety and quality of healthcare service provision in the EU
and Europe.

The main takeaway of the COVID-19 outbreak shows that the EU Institutions, and the European Commission in
particular, need to look for formulas to advance the healthcare emergency coordination, at least in the context
of the health crisis, and ensure that the EU can act in a co-ordinated and even manner across all EU countries. If
the European Commission and the EU Member States fail in this, there is a risk that the EU Institutions might be
perceived as a bureaucratic, complex, and potentially unreliable in the context of health emergencies. The
COVID-19 crisis is proving that keeping healthcare governance at the national level is creating more problems
than solutions, as different approaches to tackle the emerging health crisis confuse and even upset EU citizens,
34
putting their trust in the EU at risk . The European Commission should not only facilitate collaboration among
Member States but increase its set of competences in the health area.

The public has shown endless support to their frontline work. Now it is time to translate this citizens’ support
into political support. In doing so, the EU countries would be much better prepared for frontline action, now and
for any next health emergency. This can be done by focusing on the collection of robust data at EU level from
the professions concerned - in our case, 3 million nurses - to assess the impact of the lack of preparedness, draw
lessons and anticipate the next crisis. As nothing or very little was done with Ebola crisis, all the EU stakeholders
need now to turn this COVID-19 crisis into more EU action - not just another awareness campaign, lifelong
learning course, National congresses or webinars discussing the challenges, rather than solving them. A frontline
approach, supported by the EU Institutions, the European Parliament, the European Commission, and the
Council, is urgently needed to protect EU citizens and its nursing workforce in times of emergency and crisis.










34 OECD's analysis on the State of Health in the EU. https://www.oecd-ilibrary.org/social-issues-migration-health/state-of-health-in-the-
eu_25227041


EFN - Lessons Learned from Ebola & COVID-19 Page | 12

4. RECOMMENDATIONS & LESSONS LEARNED




























































th
Throughout the European history, since the time of Florence Nightingale – with a global celebration of her 200
anniversary in parallel with a devastating health crises causing the most serious and complex social and
economic challenges in living memory, the nursing profession on the frontline always serve citizens and patients
without hesitation. In times of war and pandemics, when populations at their most vulnerable, needing expert
health care including physical and psychological support, nurses regardless of the personal threats, selflessly
deliver for the greater good of humanity. Therefore, it is not unreasonable to expect the EU, national leaders
and health stakeholders to appreciate the value and contribution of nurses and take immediate actions to
resource and support nurses to protect the lives of EU citizens. In the current context, it is key to reflect on the
existing EU legislation to strengthen healthcare systems in the EU and - importantly - support and protect
frontline nurses as they put their own lives at risk.

The COVID-19 pandemic is currently taking a devastating toll on the EU citizens and the healthcare systems of
the European Union, in addition to having a significant negative impact on the health and wellbeing of frontline
nurses. Nurses are delivering expert health care in poor and dangerous working conditions, with not enough



EFN - Lessons Learned from Ebola & COVID-19 Page | 13

human resources and appropriate and safe protective equipment. Similar to the EFN call during the Ebola crisis,
again with this life threatening pandemic, it is crucial that the EU institutions, EU national governments, health
industry and other health stakeholders, develop health and workforce policies based on the lessons learned
from Ebola and COVID-19:





1. PROVIDE NURSES THE MATERIALS THEY NEED TO DO THEIR FRONTLINE NURSING CARE!



 IMMEDIATE ACTION:
✓ The European Commission secure and maintain an EU repository with appropriate
protection equipment and resources for the entire European Union.
✓ Eliminate the bureaucracy of the public procurements procedures while ensuring that the
right equipment (e.g., FFP2 masks, mechanical respirators) is accessible to the frontline
nurses. To ensure confidence it is important that the distribution remains transparent and
proportioned for all EU Member States.

Europe has experience being the global centre of the
COVID-19 pandemic, with all EU Member States
impacted, healthcare professionals are working
relentlessly to contain the spread of the virus, placing
themselves at risk to protect the EU citizens. It is
important to note it is predominantly nurses who remain
24h on 24h at the bedside of the COVID-19 patient.
Nurses have been at the frontline without adequate
35
Personal Protective Equipment (PPE) , leading to
unnecessary number of infections and deaths within the
nursing community. Therefore, all frontline nurses must
be provided with PPE and be regularly tested,
regardless of reported symptoms or exposure. It is
crucial to keep our nursing workforce safe, in all sectors,
not only in hospitals, but also in residential care homes
for older people and community care settings.
The EU Institutions and national governments need to recognise that most nurses’ daily reality is a
struggle to source the appropriate equipment to protect themselves, their colleagues, and patients in
delivering appropriate COVID-19 care. The lack of PPE, as seen with COVID-19, has created an enormous
anxiety for nurses and their patients, in addition to the worry of contributing to the spread and
transmission of the pandemic.

36
In Europe, we have a legislative framework since 2010 (Directive 2010/32/EU ) to provide clear,
professional and legislative answers. Yet, governments have delayed in transposing the legislative
compliance into daily operational reality. It is vital that the EU Institutions and the national governments
support and protect healthcare professionals fighting COVID-19, (or any other future IDHC) by ensuring
the legislation and the operational tools are in place in preparation for any future pandemic.
A similar action was raised in relation to protect nurses and doctors, the key frontline professionals
dealing with life and death decisions and providing often lifesaving care to patients at a personal risk to

35 https://ec.europa.eu/growth/sectors/mechanical-engineering/personal-protective-equipment_en
36 http://www.efnweb.be/eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32010L0032&from=EN


EFN - Lessons Learned from Ebola & COVID-19 Page | 14

their own health. Throughout Europe, during this pandemic, the lack of PPE has been consistently
reported. For the greater good of all European citizens we have an opportunity to learn from mistakes
and ensure that we are prepared for the next potential wave!





2. INVEST IN NURSING CARE!



 IMMEDIATE ACTION:

✓ Allocate the necessary funds to support frontline nurses. The EU population health is
dependent on highly qualified and motivated nurses in compliance with Directive
2013/55/EU.
✓ The EU Institutions should re-arrange already agreed budgets to inject funds into frontline
nursing workforce, in the hospital sector, residential care and older person care sector and
the community care.

The COVID-19 outbreak has impacted on all EU countries
affecting all elements of society. It is reshaping EU
political priorities, strategies, and budgets to ensure the
EU takes cohesive and co-ordinated action. The European
Commission in collaboration with the nursing profession
have delivered on many important policy initiatives,
however a new area of co-operation has emerged: the
co-ordination of actions to tackle the health crisis with
EU Member States.

Over the last 12 years, since the beginning of the global
financial crisis in 2008, the EFN and its 36 EU Member
National Nurses’ Associations have raised concerns in
relation to the negative effects on nurses and nursing, as
reduction in nurses’ posts, nurses’ pay cuts, salary
freezes, diminished recruitment and retention rates, and compromises in quality of care and patient
safety.
Regrettably, the repeated cuts in the health care systems, and especially in nursing, are now very evident
during this pandemic. The lack of appropriate resources and investments, and without a sufficient
number of highly qualified and competent nursing workforce, vulnerable populations such as our older
citizens or those with underlying health conditions have tragically suffered the worst burden and effect
of this virus. Safeguarding quality and safety requires appropriate consideration and investment.
Therefore, it is crucial that the EU Institutions and the national governments take adequate actions to
protect the most vulnerable: to support the frontline health professional that provide direct patient
care, including recognising the added value of the nursing profession to the healthcare sector, to improve
nurses’ salaries, working conditions, and ensure safe levels of staffing delivering good quality care and
patient safety.
The EU Institutions and the national governments should ensure that the health facilities have the
necessary qualified nursing workforce to provide safe and quality healthcare services; in addition to
support the role and working conditions of nurses in the healthcare system by deploying the European
funds to strengthen the human capacity of the European healthcare Ecosystems; to ensure that the EU
Member States comply with the European Directives (qualifications and employment), even in times of




EFN - Lessons Learned from Ebola & COVID-19 Page | 15

crisis; to value nurses’ salaries taking into account the extra hours worked; and to design career
pathways for nurses, with the promotion of advanced roles and more opportunities in community care.
Policymakers and politicians often say “nurses are very important!” but there is an urgent need to put
this sentiment into tangible EU policies and laws, so that the European Social Pillar supports nurses.
Nurses are the largest occupational group in the health sector, providing frontline care, 24 hours/7 days
in a roll, 365 days a year. Therefore, when redesigning healthcare ecosystems in the EU and their
financial mechanisms to guarantee quality and safety, it is critical to foster nurses’ solutions to
strengthen integrated care and workforce development.






3. COMBAT FRONTLINE STIGMATISATION



 IMMEDIATE ACTION:

✓ Protect frontline nurses against violence and stigmatisation during the pandemic.
✓ Positively and proactively engage media and social media against the stigmatisation of
nurses caring for COVID-19 patients.
✓ Ensure appropriate mechanisms for psychological care of nurses who are experiencing
extreme anxiety and stress during the crisis in addition to protecting against potential post-
traumatic stress disorder.

Stigmatisation is a concern for the nurses and the
nursing profession when caring for patients with IDHC.
The daily lives of nurses, and other healthcare
professionals, has been impacted on by discriminatory
attitudes and harassment. The COVID-19 outbreak has
shown positive support from society. However, it has
been demonstrated that IDHC diseases attitudes can
change overtime and social stigmatisation and
discriminatory behaviours, including physical
37
violence , becomes a reality. Predominantly frontline
hospital and community care nurses, report as a result
of their role, rejection by individuals in society including
38
family and friends who fear of contamination , leading
to isolation impacting on their mental health and
39
quality of life .
Stigmatisation was also a challenge during the Ebola crisis. For example, in Spain, parents and grand-
parents encouraged their son(s)/daughter(s)/grand-son(s)/grand-daughter(s), who were nurses, to
resign from their job, so they would not contract or risk bringing “Ebola” home. A similar pattern has
been reported with COVID-19, where nurses are delivering homecare patients were denied access due
to the concerns that their nurse could transmit COVID-19 to them, neighbours of those patients in
community were also challenging nurses delivering care and denying access to their building or
neighbourhood.

37 Lancet-ICN Article on “Attacks against health-care personnel must stop, especially as the world fights COVID-19”.
https://www.icn.ch/system/files/documents/2020-05/Lancet%20nurses%20attack%20article%2021May2020.pdf
38 EFN (2014) Nursing and Ebola Virus - Fieldworkers safety at high risk due to cuts in health sector. http://www.efnweb.be/?p=6241
39 Kinsman (2012) A time of fear


EFN - Lessons Learned from Ebola & COVID-19 Page | 16

EFN Report on Member States Preparedness – Ebola, 2015


In 2020, stigmatisation of nurses, and patients, is unacceptable. It is essential to stop stigmatisation and
express solidarity with those who need care. There are many ways to address this, including through
40
adequate education and prevention for example, which is crucial to combating stigmatisation. People
need to be educated and reassured that health professionals such a nurse ensures that the risk of
infection from dealing with a patient with IDHC is limited. It is the role of the healthcare facilities,
financially supported by their government, to ensure that education and prevention is in place. The more
is done to ensure the safety and health of the professionals, the less likely is that stigma will occur.
It is also important to provide biological, psychological, and social support to nursing staff involved in
such cases.
Stigmatisation needs to be addressed in a systematic way, its causes and consequences need to be
researched thoroughly. Designing a proposal for effective crisis management and investing in capacity
building by drawing conclusions from past experiences will inform policy makers and politicians to
appropriately strengthen healthcare systems.

A key recommendation is to: Explore the causes, mechanisms and consequences of stigmatisation
related to the care and treatment of IDHC within Horizon Europe and based on outcomes, take
appropriate actions to address appropriately.
The wellbeing and mental health of frontline nurses has been severely impacted by the COVID-19 crisis.
41
As highlighted by the United Nations “although the COVID-19 crisis is, in the first instance, a physical
health crisis, it has the seeds of a major mental health crisis as well, if action is not taken” (2019). More
than ever, it is crucial to keep the nurses protected from chronic stress and poor mental health, so they
have a better capacity to fulfil their vital roles in fighting the outbreak and saving lives during this crisis,
knowing that this situation will stay with us still for long, and to put in place all the needed psychological
support for the frontline. Heavy workloads, life-or-death decisions, and risk of infection are sources of
42
stress for all of them. Support for mental health must be integrated into every component of national
responses to COVID-19.
Working in such challenging conditions as currently being experienced with COVID-19, it has been
recognised that in some EU Member States there has been a significant psychological health toll on nurses
who have been continuing to deliver health services in crisis while an entire society was in lockdown,
putting their own lives at risk, and being often the only professional with the patient dying. Therefore,
appropriate support services must be put in place for nurses to address the impact of the numerous
stressors. It is now important that healthcare professionals are all prepared for a next wave, ensuring

40 Global Life (2014) Addressing Ebola-related Stigma: Lessons Learned from HIV/AIDS
41 UN Policy Brief on COVID-19 (May 2020). https://www.un.org/sites/un2.un.org/files/un_policy_brief-covid_and_mental_health_final.pdf
42 WHO Mental health and psychosocial considerations during the COVID-19 outbreak. https://www.who.int/docs/default-
source/coronaviruse/mental-health-considerations.pdf



EFN - Lessons Learned from Ebola & COVID-19 Page | 17

their well-being and mental health is key to sustain COVID-19 preparedness, response and recovery.
Action is required to be prepared for the next wave. The EU Institutions need to support nurses and
work closely with the nursing profession to develop policies that project nursing staff from
unnecessarily difficult or unsafe working conditions, particularly when caring with COVID-19 patients.






4. COLLECT DATA




 IMMEDIATE ACTION
✓ Proactively monitor and transparently report on the number of nurses that are infected with
COVID-19 and register the number of those who died due to the infection.

The importance of valid and reliable statistics in relation
to the prevalence and transmission of COVID-19 among
the European health workforce is essential to inform and
optimise EU policy to protect the public, health workers
and efficiently and effectively allocated valuable and
limited resources to reduce risk and maximise benefit.
National governments recognised the need to be
informed by best available evidence, however, in a
changing and evolving crisis support is needed to collate
and monitor information to inform their decisions
appropriately. Therefore, it is important that the EU
Health Council is cognisant of previous EFN
43
recommendations in relation to the Ebola crisis, that are
applicable to COVID-19 and any future Infection Control
Disease.
Quantitative and qualitative data is crucial to better understand and address the needs of the frontline
staff dealing with an IDHC. Therefore, having the systems in place in advance of any such new crisis for
the central collection and monitoring of data such as exposure of healthcare workers will ensure a more
proactive and timely evidence base to support responsive EU policy.

Currently it is known that worldwide thousands of nurses have been infected with COVID-19 and
hundreds have already died. Some official government figures suggest that 230,000 healthcare
professionals have been infected, and more than 600 nurses have died. But these numbers cannot be
fully confirmed, as the national governments cannot give a precise number, since they are not collecting
these data. This lack of accurate data has led to a serious underestimation of the infection rate among
nurses, and the number of deaths of nurses and other healthcare workers.
This is also a significant risk for the safety of the citizens and of our healthcare professionals. As a
statistician, Florence Nightingale stated: “Collect data to convince politicians!”. The lack of accurate data
is placing nurses, patients and all frontline workers in danger. Therefore, it is crucial to collect qualitative
and quantitative data to analyse and learn from the crisis to inform and build the capacity to protect
and enhance healthcare systems in the EU.
Mechanisms to provide governments the ability to communicate continuously with each other, to
collect information/data in a standardised format to share and translate into best practice to inform


43 http://www.efnweb.be/wp-content/uploads/EFN-Report-MS-Preparedness-Ebola-Final-Sept.2015.pdf


EFN - Lessons Learned from Ebola & COVID-19 Page | 18

policy is essential. It is critical for all European countries to have the best available evidence to combat
the infection control measures and save nurses and patients’ lives. It is crucial that the EU Institutions
and the EU national governments act now to put the systems in place to protect citizens and ensure the
effective utilisation of scarce resources.





5. WORK WITH NURSES! THEY ARE THE FRONTLINE EXPERTS!



 LONG-TERM ACTION
✓ Foster the co-creation and co-design with frontline nurses to enhance the political decision-
making processes concerning IDHC preparedness, protocols, education selection of
appropriate materials and evidence-based practise to support the effective and efficient
implementation of policy.

In the current COVID-19 crisis, and similar to the Ebola
crisis, nurses’ expertise in relation to protocols, selection
of materials and organisational aspects have not been
considered. Decisions are often taken without consulting
those with the most experience on the frontline. Nurses,
as the largest group of the healthcare professionals
providing patient care across many diverse services 24/7
are in pole position to implement policy into practice.
Nurses have the experience, expertise and the knowledge
to ensure that we are appropriately prepared for any
pandemic.

Co-creating and co-designing with frontline nurses
ensures fit-for-purpose political decision-making
processes and policies for IDHC preparedness is
invaluable. The challenge for the European Commission and Member States is that often academics who
provide advice, do not have the experience or expertise of frontline healthcare professionals. Engaging
healthcare professionals and NGOs in the EU Health Policy and decision-making processes can only
enhance and ensure political actions are fit-for-purpose.
EU citizens support EU policies that protect patient safety and limit, for example, the negative impact of
frontline staff working excessive overtime that impairs professional judgment or health services that are
continuously understaffed that overstretch the limits of safety in delivering healthcare for all. It is
important to explore how different healthcare systems are responding to this crisis and to monitor and
measure the impact of any IDHC (e.g.: COVID-19) on the nursing workforce. However, it is already evident
that the nursing workforce will need to be better equipped to be able to enhance the response to the
next pandemic. Preparing now can only benefit any future response. It is vital to invest and take into
account the valuable expertise and experience of the nursing profession on how to plan and implement
for this preparedness.

Action at EU level is essential to led and guide countries to deliver the most appropriate response for all
44
European citizen during times of crisis. Since 2010, an EU legislative framework (2010/32/EU) is in place,
45
which protects workers from risks related to the exposure of biological agents at work (2000/54/EC)
and promotes that employers’ and health professionals’ representatives work together at the

44 https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A32010L0032
45 https://eur-lex.europa.eu/legal-content/EN/ALL/?uri=CELEX%3A32000L0054


EFN - Lessons Learned from Ebola & COVID-19 Page | 19

appropriate level to prevent risks, protect workers’ health and safety, and create a safe working
environment, including consultation on the choice and use of safe equipment, identifying how best to
carry out training, information and awareness campaigns. Staff views are a critical resource in assessing
the preparedness of different countries at the level of everyday practice, where patients are cared for in
risky environments and staff exposure to dangerous IDHC is most significant. It is vital that policymakers
engage the opinions and expertise of frontline staff as they ultimately act as the guardians and protect
against the threat of IDHC in the EU, Europe and worldwide.






6. DEVELOP EU HEALTH POLICIES WITH EFN



✓ Work closely with the nursing profession to develop policies population health and protect
nursing staff from unsafe and challenging working conditions, particularly when caring for
COVID-19 patients.

The EFN represents 3 million nurses in the EU Member
46
States , but across the wider European region with 54
Member States, the EFN represents 6 million nurses.
Globally there are 18 million nurses. There is strength in
numbers, but there are significant challenges to
supporting and protecting such a large cohort of health
professionals. National Nursing Associations are central
to assisting governments to ensure national policies are
translated into healthcare systems with nurses delivering
the majority of safe evidence-based patient care.
Existing EU legislation is vital to strengthen healthcare
systems in the EU and importantly, support and protect
frontline nurses while doing their job. As previously
47
identified, the Directive on Sharp Injuries (2010/32/EU)
is an example of a policy that has engaged nurses to address sharps injuries, and particularly needlestick
injuries with the risk of potentially life-threatening infections into the daily working life of millions of
healthcare providers.
48
The EFN 2013 Report on the implementation of Directive 2010/32/EU in the hospital and healthcare
sector concludes that the transposition and implementation into practice at the workplace shows a
positive impact of the implementation of Directive into the clinical practice, in most EU Member States,
helping some EU Member States to reduce injuries.
The standardisation of registration, reporting and follow-up systems of injuries is important and needs to
be implemented for injuries and COVID-19 infections.
It is time to move from “patchwork” approach to “EU coordination”. It is vital to go beyond “sharing
best practices”, to providing focussed and tangible support to frontline nurses. Transposition to support
the COVID-19 crisis response is key to save lives: citizens and healthcare professionals.

As the European Parliament President, David Sassoli, expressed on 13 May 2020 towards the European
Parliament plenary “Our shared duty is to ensure nurses can carry out their work in security and to do so

46 http://www.efnweb.be/?page_id=802
47 https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=celex%3A32010L0032
48 https://www.europeanbiosafetynetwork.eu/wp-content/uploads/2017/01/Biosafety-Summit-EF-Report-on-Implementation.pdf


EFN - Lessons Learned from Ebola & COVID-19 Page | 20

efficiently. Countries have made hospitals, healthcare material, equipment available to others thanks to
the efforts of civil society. Today we have to strengthen the EU capability in the healthcare field. This is a
duty we owed to our citizens. The Parliament has asked for a European mechanism for a healthcare
response to ensure we can work together to prepare a coordinated response to any type of healthcare
crisis. The COVID-19 pandemic has demonstrated the need for a public health policy. A policy which would
be more proactive, and which involves greater cooperation in order to build healthcare systems that will
be resilient and will ensure a greater solidarity in Europe”.

Let’s work together to make this happen!
Preparedness is essential to prevent any future outbreaks. Planning and having the correct policies and
procedures in place will help to ensure that the EU Member States can respond to any upcoming crisis
and save lives when emergencies occur. This includes coordination with the EU Member States in sharing
information, assessing the needs and ensuring a coherent EU-wide response.
The EFN welcomes the opportunity to work closely with the different European Commission DGs to
ensure that for the next wave Europe is prepared. Nurses are committed and a vital expert resource
supported by the appropriate coordination, procedures infrastructure and resources to positively
deliver in times of crisis including:
- Planning and implementation of acute care for IDHCs (Ebola/COVID-19) patients;
- Essential PPE/infection control procedures to mitigate the risk to the multi-disciplinary care
team;
- Procedures to reduce nosocomial transmission to non-infected patients;
- Contingency plans in the event of a lack of equipment and PPE;
- Human Resource issues, rapid redeployment, return to practice & training of retired/ inactive
nurses, and mental health support for frontline staff.

In addition, it is important to note the ongoing development of Electronic Health Records (EHR) is
essential. Investing in Digitalisation and Electronic Health Records, building on the work done by
Smart4Health & InteropEHRate will be key to be better prepared. Ensuring digitalisation is more practical
oriented will benefit patients, citizens, policy makers and all health professionals.





































EFN - Lessons Learned from Ebola & COVID-19 Page | 21

5. CONCLUSION






























































We can conclude that both the COVID-19 outbreak and the Ebola crisis have shown significant similarities, which
frontline nurses being unprepared but without hesitation rose to the requirements of the challenge within
limited and inadequate resources to protect health and save lives.. It has shown that it is crucial to:
✓ Support the EU health workforce, in particular nurses, to respond to the challenges of Infectious Diseases
of High Consequences (IDHC) without compromising safety and well-being;
✓ Explore the causes, mechanisms and consequences of stigmatisation related to the care and treatment of
IDHC;
✓ Continue to encourage investment in preparedness, learning from the lessons and knowledge gained so
far;
✓ Co-create and co-design with frontline nurses fit-for-purpose political decision-making processes and
policies for IDHC preparedness.




EFN - Lessons Learned from Ebola & COVID-19 Page | 22

The evolving information on the current crisis demonstrates that the appropriate conditions to protect both
patients and nurses from contamination, such as training and equipment were not in place as recommended by
nurses in 2015 Report. Therefore, in order for nurses not to be in a position to put their own life at daily risk, the
following actions are crucial: appropriate application of existing EU legislation; further EU actions and
mechanisms that support capacity building; and the provision of appropriate training and equipment. There is a
requirement to be ensured, that a "safe work environment" is created and that nurses are included in the
decision and organisation process, in order to address the gaps in preparedness for future possible IDHC
outbreak.

Furthermore, the ongoing COVID-19 outbreak has demonstrated to all the citizens of the EU the added value of
the nursing workforce to the European healthcare ecosystems – working at the frontline of care, 24/7, at the
bedside and in communities with the patient, and often being the last human touch for those who pass away.
Both the Ebola and COVID-19 crises have shown us all that nurses’ competencies are needed more than ever
on all fronts; from vaccine production to the epidemiological, economic, social and organisational dimensions
of living with and responding to infectious diseases of high consequences (IDHC).

Therefore, it is crucial to provide politicians and policy makers all the necessary technical and operational
support to respond to this pandemic and future health crisis and build up strategies at EU and national levels to
prevent repeating the same mistakes of the past and limiting the unnecessary suffering of populations
experienced during COVID-19. Citizens trust and confidence in nurses is extremely high, politicians need to give
more structured support to frontline nurses to deliver high quality and safe health care for all A coordinate
approach at EU level is required, so that our frontline care professionals get all support they need. Good
coordination for and between EU Member States is key. In response to crisis there is evidence that a system-
wide change is required, but the nurses will be required more than before on frontline. The evidence of COVID-
19 pandemic is clear.

As John Ryan, Director European Commission DG Sante, explained “It is clear that we did not pick up the lessons
learned from the past! But our strength is working together, with solidarity and cooperation, in these times of
crisis. This is why the European Commission was created, and that is why we need to try to learn the lessons from
this crisis and from the past (Ebola) and improve”.

The EFN recognises and values the efforts and funds invested by the European Commission and the health
industry to research a COVID-19 vaccine and treatment, but it is crucial to recognise the important and essential
role demonstrated during Ebola and the COVID-19 crisis of the frontline professionals.

Therefore, the EFN remains at full disposal to the European Institutions to ensure EU decision reflects frontline
expertise and experience making EU actions and policies fit-for-purpose and designed for successful
implementation. We have now a precious opportunity to prepare our health workforce and health systems to
be future proofed to respond to current and future threats to the health and wellbeing of our citizens and wider
sustainability of our society. .

“Nurses are the real heroes of this outbreak, being at the frontline and taking care of the patients with
COVID-19 24h/day, 7/week!”
















EFN - Lessons Learned from Ebola & COVID-19 Page | 23

The European Federation of Nurses Associations (EFN) was established in 1971.
The EFN represents over 36 National Nurses Associations and its work has an
effect on the daily work of 3 million nurses throughout the European Union and
6 million in Europe. The EFN is the independent voice of the nursing profession

and its mission is to strengthen the status and practice of the profession of
nursing for the benefit of the health of the citizens and the interests of nurses in

the EU and Europe.




Contact Details:
Address: Clos du Parnasse, 11A - 1050 Brussels - Belgium
Tel.: +32 2 512 74 19 - Fax: +32 2 512 35 50

Email: [email protected] - Web: www.efnweb.eu
Contact Person: Mr Paul De Raeve, EFN General Secretary
Registration Number: 476.356.013
Transparency Register: 87872442953-08

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