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EFN Report on Covid-19 crisis management at national level - November 2020

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Published by EFN, 2020-11-20 04:18:43

EFN Report on Covid-19 crisis management at national level - November 2020

EFN Report on Covid-19 crisis management at national level - November 2020

EFN – European Federation of Nurses Associations

Table of Contents

EXECUTIVE SUMMARY.................................................................................................................. 3
SUMMARY REPORT ...................................................................................................................... 5

1. BACKGROUND ................................................................................................................................. 5
2. THE KEY RESULTS............................................................................................................................. 6

2.1 What is the State of Art on the impact of COVID-19 on nursing?............................................. 6
2.2 What can the European Institutions learn from these data?.................................................... 7
3. DETAILED RESULTS & POLICY RECOMMENDATIONS ............................................................................... 8

Q 1.a COVID-19 Infection rates / hospital admissions / deaths .................................................. 9
Q 1.b Infection and mortality among nurses ............................................................................ 10
Q 2.a Protective measures ........................................................................................................ 11
Q 2.b Testing for nurses ............................................................................................................ 12
Q 2.c Resources for COVID-19................................................................................................... 13
Q 2.d Resources for usual care.................................................................................................. 14
Q 2.e Critical care capacity ........................................................................................................ 14
Q 3.a Most serious challenge .................................................................................................... 16
Q 3.b Stigmatisation .................................................................................................................. 17
Q 3.c Psychological support ...................................................................................................... 18
Q 3.d Preparedness ................................................................................................................... 19
Q 3.e Stakeholder involvement................................................................................................. 20
Q 3.f Budgets ............................................................................................................................. 20
Q 4.a Risk of infection................................................................................................................ 21
Q 4.b Burnout ............................................................................................................................ 22
Q 4.c Shortage ........................................................................................................................... 22
Q 4.d Long-COVID...................................................................................................................... 23
4. WHAT CAN THE EUROPEAN INSTITUTIONS DO? ................................................................................... 23
5. WHAT CAN WE DO LOCALLY TO SUPPORT PROTECTION OF NURSES?........................................................ 24
6. CONCLUSION................................................................................................................................. 25
EFN MEMBERS INPUT COUNTRY PER COUNTRY........................................................................... 26
EFN MEMBERS ..........................................................................................................................110

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EFN – European Federation of Nurses Associations

Executive Summary

In the current COVID-19 pandemic climate, ensuring the uninterrupted provision of safe and quality
healthcare in Europe hinges on those healthcare professionals on the frontline working safely to their
full scope of practice. Nurses are the single largest, and most trusted, professional group in healthcare
across Europe, delivering the majority of healthcare 24 hours a day, seven days a week and 365 days
a year. They are the linchpin around which healthcare is organised and delivered; the current pandemic
has left little room for doubt on the irreplaceable contribution of nurses in health service delivery.

The European Federation of Nurses’ Association (EFN), as the representative body for nurses in Europe,
has long used its ‘Tour de Table’ as a key policy support mechanism to gather intelligence and enable
the exchange of best practices among its membership. The policy reports developed from this
intelligence gathering are a vital source of factual, comparative data and insights into health and social
care in the European Union and Europe.

The current report examines input from 29 National Nurses Associations across Europe, representing
77% of the EFN membership. Through identifying shared concerns across different countries, the EFN
presents this document as a resource for healthcare stakeholders, policy makers, clinicians, patients
and the public to invite discussion, policy response and exchange of practice to strengthen ongoing
resilience in health systems across Europe during and after the COVID-19 pandemic.

Analysis of the data submitted by the EFN Members presents a distressing picture with regard nurses
and nursing in Europe. The impact of the pandemic on health service delivery has been significant, with
hospitalisations relating to COVID-19 remaining high across countries with negative consequences for
the work and workload of frontline nurses. Alarmingly, EFN Members report inconsistency and
uncertainty with regard to steady provision of personal protective equipment (PPE) as well as COVID-
19 testing for nurses, irrespective of setting; nurses employed in care homes are especially concerned.
Current capacity of healthcare systems to respond to the pandemic appears to hinge on nurses’
flexibility to go above and beyond; to work in excess of their normal working hours and in settings
outside their areas of expertise.

Not surprisingly, the impact the COVID-19 pandemic has had on nurses is substantial, with many EFN
Members already concerned about increasing levels of burnout among nurses. In addition to the
physical and psychological impact, nurses in some countries have also experienced negative social
consequences including violence and stigmatisation. Disappointingly, nurses report that psychological

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EFN – European Federation of Nurses Associations

and social support for those affected by the pandemic is not readily available on a national level in all
countries; rather, in most countries, it appears to depend on voluntary or private initiatives, and to
vary depending on health setting and employer. Given this bleak picture, European initiatives are
urgently needed to protect, support and encourage nurses to continue their vital work safely; and
these initiatives require development through a co-design approach involving nurses and their
representatives at the highest levels of decision making.
The COVID-19 pandemic has highlighted the importance of consistent support to frontline healthcare
workers when such health emergencies arise. It is imperative that the European Commission, the EU
Member States and other European Stakeholders increase their efforts to ensure healthcare
professionals, and nurses in particular, are adequately protected. This includes protection from
physical, psychological as well as social risks. The EFN Members urge the European Institutions to
invest in:

• increasing nurse staffing numbers through recruitment, retention and training initiatives
following the provisions of Directive 55;

• allocate dedicated funding for the provision of essential protective and care equipment to frontline
workers, irrespective of health setting;

• provide psychological, physical, financial and social support to nurses adversely affected by the
pandemic; and,

• ensure a safe workplace through following available legislation for appropriate health and safety
measures and positive work environments.

The EFN Members acknowledge that the best time to have started preparing for the current COVID-19
pandemic was back in 2015, after the Ebola crisis; the second-best time is now. Preparing now can only
benefit any future response, as well as restore confidence in Europe’s health systems more widely. It
is vital for the European Institutions and stakeholders to invest in the nursing profession now, to
safeguard Europe from further devastating effects of the current and future pandemics.

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EFN – European Federation of Nurses Associations

Summary Report

1. Background

In the current pandemic climate, ensuring the uninterrupted provision of safe and quality healthcare
in Europe hinges on those healthcare professionals on the frontline working safely to their full scope
of practice. Nurses are the single largest, and most trusted, professional group in healthcare across
Europe and worldwide, delivering the majority of healthcare 24 hours a day, seven days a week and
365 days a year. They are the linchpin around which healthcare is organised and delivered; the current
pandemic has left little room for doubt regarding the irreplaceable contribution of nurses in health
service delivery.

The COVID-19 pandemic has affected all layers of society, reshaping political priorities, strategies and
budgets all over Europe, and the world. Supporting healthcare professionals is a common priority
across European countries but actions have so far been local, ad hoc and disjointed. As Europe braces
for the winter months ahead, it is imperative that concrete and immediate actions are taken to support
and protect frontline healthcare professionals, and nurses in particular.

Nurses across Europe, as the frontline of health and social care, are uniquely positioned to feel the
pulse of present developments and challenges. The European Federation of Nurses’ Association (EFN),
Members have long appreciated that nurses’ real-world experiences from the frontline are a vital
resource to inform and support healthcare planning, system design and evidence-informed policy
making. During these rapidly changing times, nurses’ real-world experience is essential to ensuring
safe, effective, accessible and resilient healthcare.

The EFN National Nurses Associations (NNA), representing 3 million EU nurses, met online for the EFN
General Assembly (GA), taking this opportunity to share key information on the COVID-19 crisis
management at national level. Facilitating the exchange of knowledge, experiences and developments
among the EFN membership is a very much valued function of the EFN bi-annual GA meetings. The
EFN has long used its ‘Tour de Table’ during its GAs as a key policy support mechanism to gather
intelligence and enable the exchange of best practices among its membership. The policy reports
developed from this intelligence gathering are a vital source of factual, comparative data and insights
into health and social care in the European Union and Europe.

Data for the current report originate from all the EFN Members participating in the GA and were
collected both through an online survey and during online discussions. The EFN Members have been

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EFN – European Federation of Nurses Associations

asked to feedback on key question concerning the national response to COVID-19 and impact on
nurses, by completing a semi-structured, standardised data collection form. EFN Members were also
given the opportunity to present verbally and discuss their concerns with other EFN Members present
at the General Assembly.
Following this data gathering exercise, key messages and national developments have been
summarised, analysed thematically and are presented below. The findings presented here are shared
with key stakeholders and among the EFN Members not to compare or rank national responses to the
pandemic, but rather to inform the work of the European Commission and of the EFN Members in
different countries; and, to foster development of connections to support each other in this joint effort
to combat the COVID-19 pandemic.

2. The Key Results

2.1 What is the State of Art on the impact of COVID-19 on nursing?
Data from EFN Members, representing NNAs across Europe, present a distressing picture with regard
to nurses and nursing. COVID-19 has clearly affected some countries more than others, but on average
the scale and impact of the pandemic on healthcare is significant. As the results in the following section
of this report show, hospitalisations relating to COVID-19 have been high across countries which have
had a negative impact on the work and workload of frontline nurses.
Concerningly, there remain concerns regarding availability of personal protective equipment (PPE) as
well as COVID-19 testing for nurses. This is especially a concern in non-acute healthcare settings, such
as care homes. Moreover, while in the main EFN Members report that currently there appear to be
sufficient resources to provide care to both COVID-19 and non-COVID-19 related care, this is only
possible because of nurses’ flexibility to work above their normal working hours and in settings outside
their areas of expertise.
Critical care capacity, in terms of both equipment and nurses, has been a concern at the early stages
of the pandemic though currently most respondents did not identify major concerns. However, there
are concerns around critical care nurses feeling overworked and lacking the resilience to continue with
the same intense rhythms. To increase surge capacity some countries experimented with setting up
field hospitals, however these have not been used to their potential mainly because of a shortage of
nurses.

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EFN – European Federation of Nurses Associations

The impact of the pandemic on nurses has been significant, with EFN Members already noting signs of
burnout among their nurses. In addition to the physical and psychological impact, nurses in some
countries have also experienced a level of stigmatisation. Unfortunately, psychological support for
nurses is not available on a national level in all countries; rather, it appears to largely depend on
voluntary or private initiatives.
Preparation for subsequent waves of COVID-19 is high on the agenda of many countries, but
disappointingly, EFN Members report limited attempt by national governments to engage with nurses
and their representative organisations at national level. This is concerning since the nursing workforce
is unlikely to be able to sustain their superhuman efforts in the long term. Initiatives are needed to
protect, support and encourage nurses across Europe; and these initiatives require development
following a co-design approach involving nurses and their representatives as the end users.

2.2 What can the European Institutions learn from these data?
The EFN Members’ data from the COVID-19 frontline have significant lessons for the European
Institutions based on real-world experiences, rather than detached statistics. Evidence submitted by
EFN Members reveal that the resilience seen in health systems Europe-wide derived firmly from the
willingness and flexibility of the nursing workforce to provide care to those in need, irrespective of the
negative impact it could have on nurses themselves. However, this flexibility appears to be time-
limited with early signs suggesting nurses may not be able to sustain their superhuman performance
for much longer.
The COVID-19 pandemic has taken its toll on nurses, leaving many with physical and mental health
difficulties arising from their exposure to the virus itself, as well as to the care needs of critically ill
patients, devastated family members and high rates of mortality. It is clear that across Europe nurses
have been expected to bear the brunt of the pandemic response, but have been offered little in terms
of protection either physical or psychological. Concerns about lack of protective equipment,
psychological support and even safe working conditions abound in the dataset analysed for this report.
While nurses are no strangers to adversity, the data suggest the situation is reaching a crisis point. If
action is not taken soon, the nursing workforce may suffer irreplicable damage, recovery from which
will be difficult. Given the fundamental and indispensable role that nurses play in health service
delivery, such outcome would damage healthcare across Europe and compromise health system
resilience; the ultimate losses will be faced by the patients and citizens of Europe.

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EFN – European Federation of Nurses Associations

A powerful message arising from the available data is that of a serious lack of parity and consistency
in preparedness and response to the pandemic, both across and within countries in Europe. The
COVID-19 outbreak and the Ebola crisis have shown significant similarities and challenges, to which
frontline nurses have had to respond to with little preparation; but as the EFN warned in 2015: “we
cannot be prepared anywhere, unless we are all prepared everywhere” (EFN, 2015 , 2020). We have a
precious and small window of opportunity to prepare ourselves and get our health workforce and
health systems ready to respond to upcoming waves of the COVID-19 pandemic. In times of pandemics,
ad hoc, fragmented responses cannot be effective or sustainable in the long run. We urge European
stakeholders at all levels to listen to and work with each other; and, importantly, to involve in future
pandemic response and planning those on the frontlines.

3. Detailed Results & Policy Recommendations

This survey represents input from 27 NNAs across Europe, representing a response rate of 77% of EFN
Members. The EFN Members’ inputs are presented below, synthesised and grouped under each survey
question.

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EFN – European Federation of Nurses Associations

Participating Countries

n=27, 77% response

Switzerland Croatia
Sweden UK FYR MHaucnegdaornyia
Spain
Luxembourg
Malta

Slovenia Netherlands

Romania Serbia

Portugal Slovakia

Poland Albania

Norway Austria

Montenegro Belgium

Lithuania Bulgaria

Latvia Cyprus

Italy Czech Republic
Ireland Denmark
Estonia
Iceland FrancFeinland
GreGeecremany

Question 1 - Country Profile:

a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?
b. Number of nurses infected with COVID-19?
c. Number of nurses who died from COVID-19?

Q 1.a COVID-19 Infection rates / hospital admissions / deaths
The picture concerning the impact of COVID-19 across the EFN Members remains alarming, though
accuracy is challenged by the rapidly evolving situation and limitations of available data on infection
and mortality rates, which are reported differently across countries. A snapshot of key variables is
discussed next, not as a representation of current data but rather to contextualise the survey results.

Table 1: Aggregate data on key variables across countries

Cases +ve Deaths Hospitalisations Nurse infections Nurse deaths

Average across 132,292 7,654 38,764 2,623 12
countries (n)

Min – Max 1,559 – 888,968 29 – 42,350 210 – 231,217 49 – 16,000 0 – 101
range (n)

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EFN – European Federation of Nurses Associations

Due to the significant geographical and contextual differences among EFN Members direct
comparisons are not helpful. However, on average, EFN Members noted 132,292 positive cases of
COVID-19; 7,654 COVID-19-related deaths; and, 38,764 hospitalisations due to COVID-19. The smallest
numbers were noted in those countries with lower population density such as Cyprus, Latvia and
Norway; while the highest numbers were reported from countries such as Italy, Spain and the UK. The
most significant number to consider here is the number of hospitalisations due to COVID-19 (range
from 210 to 231,217), since these give a clearer indication of nurses’ working conditions, increase in
workload and risk of infection during this pandemic period.
Q 1.b Infection and mortality among nurses
Further to the increase in hospitalisations, which directly and negatively impact on nurses’ work,
nurses themselves have been victims of the pandemic. While rates per country vary, on average, at
least 2,623 nurses have been infected with COVID-19; and, in total, at least 101 nurses have died so
far. These numbers, however, can only be taken as conservative estimates since in many countries
official records of nurse infections and deaths are not publicly available. It is notable that only 12
countries reported to have some data on nurses who either got infected or died as a result of COVID-
19.

Policy Recommendations:
• Ensure accurate and continuous recording of cases of nurses infected with and died
from COVID-19
• Make data on the impact of COVID-19 on nurses and nursing available to help plan
accurate response to the pandemic
• Acknowledge the significant negative impact and risk of COVID-19 to nurses and nursing;
and offer support to manage the damage and contain the risk

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EFN – European Federation of Nurses Associations

Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were nurses
prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO, has your
national government taken any action to address this? What has been/will be put in place
to avoid this in the future (second wave)?
b. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?
c. Were there enough resources/nurses to handle the COVID-19 patients?
d. Were there enough resources/nurses to handle all other (NON-COVID) patients?
e. Some European countries experienced lack of ICU beds, equipment, and trained nurses; how
is your national government planning to tackle this?

Q 2.a Protective measures
At the beginning of the pandemic, all EFN Members who responded in this survey noted a serious lack
of PPE and protocols to ensure nurses caring for patients with COVID-19 were sufficiently protected.
The general picture across EFN Members was one of lack of preparedness, since resource expectations
were based on modelling for influenza, which proved insufficient. After the initial shock, respondents
indicated improvements in governments procuring adequate supplies of PPE, at least for those working
in the acute sector. New protocols and guidelines were also developed across countries to raise
awareness and education of nurses on the correct use of PPE.
However, the experience in care homes appears to have been different and more challenging
compared with the acute care sector since PPE and protocols were introduced much later. This left
those nurses working in care homes with limited education and protection during the initial surge.
Currently, respondents report different initiatives being in place to ensure adequate supply of PPE such
as significant orders of PPE directly from China (e.g. Cyprus, Italy and Norway) and moving production
of PPE at national level by repurposing some existing factories (e.g. Italy and Portugal). As the
responses to the following questions illustrate with greater detail, some countries remain concerned
about having enough supply of PPE to manage future surges.

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EFN – European Federation of Nurses Associations

Q 2.b Testing for nurses

Was testing offered regardless of
symptoms or exposure?

Portugal Austria Estonia
Norway France

Czech Republic Latvia

Cyprus Lithuania

Bulgaria Montenegro

UK Romania

Switzerland Slovenia

Sweden Albania

Poland Belgium

Italy Denmark

Ireland Germany Finland

With regard to testing, the majority of respondents indicated that currently some form of testing is
made available to nurses, though only a few categorically declared testing was offered without
conditions; these included Austria, Estonia, France, Latvia, Lithuania, Montenegro, Romania and
Slovenia. In many countries, availability of testing was limited in the early phases of the pandemic but
currently it appears that testing is more widely accessible. However, there also seems to be a level of
inconsistency within countries concerning access to testing being influenced by the healthcare setting
(i.e. acute or residential care) and kind of hospital employer (i.e. large/ small, public/ private) nurses
find themselves in.

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EFN – European Federation of Nurses Associations

Q 2.c Resources for COVID-19

Were there enough resources to care for
COVID-19 cases?

Portugal Austria Belgium
Italy Czech Republic

Estonia Latvia

Bulgaria Lithuania

UK Montenegro

Switzerland Romania

Sweden Slovenia

Poland Albania

Norway France Cyprus

Ireland Denmark
Germany Finland

A mixed picture is also seen with regard to availability of resources, although the majority of
respondents did indicate having sufficient resources at present. At the beginning of the pandemic
many countries noted challenges with regard to availability of PPE, ventilators and nurses. Across
countries, a key factor that enabled system resilience to the increasing pressure appeared to be the
flexibility of nurses to be redeployed where they were needed, often asked to provide care beyond
their areas of expertise or specialisation. There are concerns, however, that this flexibility of nurses
came at a cost with many now suffering from exhaustion and likely burnout. In some countries, there
are still significant concerns regarding lacking enough PPE and nursing personnel to adequately
respond to subsequent waves of COVID-19.

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EFN – European Federation of Nurses Associations

Q 2.d Resources for usual care

Were there enough resources for non-
COVID-19 cases?

Slovenia Albania Austria
Portugal Belgium –…

Norway Bulgaria

UK Cyprus

Switzerland Latvia

Sweden Montenegro

Poland Romania

Lithuania Czech Republic

Italy France Denmark

Ireland Estonia
Germany Finland

In terms of non-COVID-19 cases, in the main, respondents noted sufficient resources and capacity to
provide usual care. However, this was only possible because routine care, such as cancer screening,
chemotherapy treatments, non-urgent surgery, etc. were cancelled or rescheduled. This led to
increased capacity within hospitals to manage the pandemic surge in the short term, but a significant
number of routine or long-term cases remained untreated. Many countries reported facing a
significant backlog of appointments and concerns over displaced care. For example, in the UK, it was
estimated that there are two million people who have been waiting for treatment for more than 18
weeks; and around three million people waiting for cancer screening. A shortage of nurses appears to
lie at the heart of this growing concern across most countries.

Q 2.e Critical care capacity
Finally, critical care equipment and nurses have been in short supply across many countries, though
almost half of respondents to this question (n=9) indicated having sufficient critical care resources;
such countries included Belgium, Estonia, Germany, Latvia, Lithuania, Montenegro, Poland, Romania

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EFN – European Federation of Nurses Associations

and Sweden. The remaining respondents indicated concern to varying extent, mainly related to lack of
nurses at national level, such as in the UK, Switzerland, Slovenia, Norway and Bulgaria. Concerns
related both to current as well as expected staff shortages as nurses start to experience the negative
effects of going over and above their normal work during the pandemic conditions. In some countries,
to increase surge capacity, field hospitals were built to care for COVID-19 patients needing critical care
support, such as in Italy, the UK, Cyprus, Finland and Portugal. However, these hospitals have not been
utilised to the extent anticipated because countries lacked the nurses to staff them properly;
consequently, these field hospitals have since been shut down and are essentially warehouses of beds
and ventilators.

Policy Recommendations:
• Ensure adequate supply of protective and care equipment for healthcare workers and
nurses in particular irrespective of their work setting (public or private, in community
or acute care settings)
• Provide freely and easily accessible testing for nurses, regardless of symptoms or
exposure to the COVID-19 virus
• Increase capacity in the health system to respond to and address care needs that have
been displaced due to the pandemic, such as cancer screening and treatments

Question 3 – Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?
b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes, how
was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?
c. Did your national government/health setting put in place appropriate mechanisms for
psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?
d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?
e. And how is your national government planning to engage with EU/national nurse
representatives to better engage the nursing profession in a future health crisis?

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EFN – European Federation of Nurses Associations

f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?

Q 3.a Most serious challenge
A third of respondents (28%) indicated that the biggest challenge they face in combating COVID-19 is
lack of public adherence with restrictions pertaining to social distancing and use of face coverings;
these included Estonia, Germany, Switzerland, Denmark, Spain, Finland, Austria and the Czech
Republic. The EFN Members noted that the public is becoming weary of the ongoing restrictions and
consequently instances of non-compliance are increasing. Furthermore, for a quarter of respondents
(24%), their main challenge related to nurse shortage (e.g. France, Ireland, Bulgaria, Norway, Poland,
Czech, Portugal); while a further fifth of respondents (21%) noted concerns with nurse burnout.
While the challenge of nurse shortage has been around since the beginning of the pandemic, EFN
Members (e.g. Denmark, Spain, Belgium, Sweden, Finland, Portugal) are expecting this to worsen as
more and more nurses begin to experience burnout as a result of being overworked over the past few
months. In addition, some EFN Members are expecting a rise in intentions to quit nursing due to a
general feeling among nurses that their contribution is not valued, which will make managing future
surges highly problematic. For example, in Finland, nurses feel that they are appreciated with ‘words’,
but economic compensation does not follow. Given the difficulties of providing nursing care during the
pandemic, with limited access to PPE, increased workload, and rising uncertainty there is a real risk of
further nurses leaving the profession at a time when they are needed most.

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EFN – European Federation of Nurses Associations

What is your most serious challenge?

(% of respondents mentioning each theme)

30

25

20

15

10

5

0

Public Nurse Burnout Nurse Shortage National Availability of Accessibility of

Adherence Economy PPE Testing

Q 3.b Stigmatisation
When asked about stigmatisation, over half of respondents noted that nurses in their country
experienced some form of stigmatisation, to a greater or lesser extent. Examples included nurses
facing issues with their accommodation as other tenants became concerned nurses might be carriers
of the virus (e.g. France, UK). This concern among the public also led to other forms of stigmatisation
and victimisation including incidents of bullying and harassment (e.g. UK), difficulty in securing
childcare (e.g. Ireland), and even physical violence (e.g. Portugal). Respondents did not report any
significant national initiatives to combat stigmatisation of nurses, though some countries stopped
reporting publicly incidents of COVID-19 infections among nurses in an effort to restore public
confidence (e.g. in Lithuania).

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EFN – European Federation of Nurses Associations

Were nurses confronted with
stigmatisation?

Switzerland Austria Belgium
Sweden Denmark

Slovenia France

Norway YES Germany
Montenegro Ireland

Latvia NO Lithuania
Italy
Poland
Finland
Portugal
Estonia Romania
Cyprus Spain
Bulgaria UK

Q 3.c Psychological support
Despite the significant, negative psychological impact of delivering care during a pandemic has had on
nurses, few respondents indicated the availability of national government psychological support
services. In the majority of countries, some form of psychological support is indeed available, but this
is largely supported through volunteering and individual employers. Examples of psychological support
services offered include telephone hotlines, online support platforms, consultations, wellbeing mobile
applications, and online education programmes.

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EFN – European Federation of Nurses Associations

Did your national government set up
psychological support services for
nurses?

Switzerland Albania Belgium

Sweden Czech Republic

Poland Denmark

Norway YES France
Latvia Lithuania

Italy NO Montenegro
Ireland Portugal

Germany Romania

Finland Slovenia
Estonia Spain
CyprBusulgaria AustriaUK

Q 3.d Preparedness
In terms of measures taken by national governments to increase preparedness for future waves of
COVID-19 or other pandemics, respondents indicated these largely centred around having adequate
supplies of PPE, mainly through an increase in purchasing and availability of stock; e.g. in Austria,
Finland, Romania, Denmark, Estonia, Lithuania, Portugal and Norway. Moreover, increasing the
volume and reach of nurse training, alongside an increase in the availability of evidence-based
guidelines, were additional areas of priority in terms of preparedness. Of note, two respondents
(Portugal and Poland) made explicit reference to the availability of vaccination for nurses against
seasonal influenza; as well as for COVID-19 when a vaccine becomes available.

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EFN – European Federation of Nurses Associations

Measures for preparedness

(% of respondents mentioning each theme)

40

35

30

25

20

15

10

5

0 Nurse Vaccination Nurse Training Evidence-based
PPE Supplies Guidelines

Q 3.e Stakeholder involvement
In response to the question on how national governments plan to engage with nurse representatives
in preparation for future crises, the majority of respondents (70%, n=14) indicated that there were not
aware of any initiatives underway or planned; which is a grave concern among these EFN Members.
Only four respondents noted clear nurse representation in national level committees (e.g. Cyprus,
Denmark, Ireland and Portugal) though others did also mention some involvement in government
meetings and discussion events (e.g. Bulgaria, Switzerland).

Q 3.f Budgets
Finally, current data do not provide sufficient clarity on national budget reconfigurations as a response
to the COVID-19 pandemic, to support the nursing workforce in the event of future pandemics. Most
respondents noted some financial support would or is expected to be redirected to healthcare, and
nurses, though this appears variable and inconsistent among countries. For example, some countries
noted extra payments or bonuses to health professionals, either as a one-off payment or a salary
increase (e.g. Germany, Bulgaria, Montenegro, Latvia, Portugal and Lithuania). Other countries noted
an increase in health spending towards ensuring adequate supply of equipment and PPE, and hiring
new staff including nurses (e.g. Denmark, UK, Italy, Albania, Slovenia, Ireland and Sweden). For
example, in Sweden, the government will allocate SEK10 Billion in general government grants to
municipalities and regions in 2021, with municipalities receiving an additional SEK4 Billion/ year (2021-

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2023) to strengthen care for older adults. In most countries it is not clear how much will be allocated
specifically to support the workforce, though in the UK and Slovenia there is additional £546 Million
and €30 Million respectively for health professionals.

Policy Recommendations:
• Engage with nurses and their representatives at national and European level to plan the
provision of adequate support for nurses, especially those whose health has been
negatively affected by COVID-19
• Plan and initiate measures to protect health systems across Europe from the imminent
worsening of the nurse shortage, by focussing nurse staffing and wellbeing
• Overcome the variability and inconsistency nurses across Europe experience with
regard to pandemic planning and response; work towards a coordinated approach
across health settings and countries

Question 4 - Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.

The EFN Members remain increasingly concerned over the duration and scale of the COVID-19
pandemic, and national capacity to respond effectively to future waves. Free-text comments provided
in the survey point to six key areas of concern, examined next: risk of nurse infection, nurses being
overworked and experiencing burnout, nurse turnover and long-term health consequences of COVID-
19.
Q 4.a Risk of infection
The rates of nurses getting infected with COVID-19 is alarmingly high across many countries, and a
major area of concern and focus for the EFN Members; e.g. in the Czech Republic, Denmark, Iceland,
Ireland, Montenegro and Portugal. For example, in the Czech Republic and Portugal about 2,000 and
1,500 nurses have been infected respectively, while Denmark and Ireland also note nurses being the
most infected professional group in the health sector. This has grave consequences for the capacity of
the workforce to respond to the pandemic demands, as well as for the health of nurses themselves
and of their family members. With the majority of nurses being women with caring responsibilities, an
infection with COVID-19 and subsequent isolation has significant, negative ripple effects for family
units. The EFN Members are concerned with ensuring nurses receive adequate support, including

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financial support, and protection to avoid high levels of burnout and minimise the risk of massive
exodus from the profession.

Other comments

(% of respondents mentioning each theme)

35%

30%

25%

20%

15%

10%

5%

0% Turnover Infections
Burnout Long-COVID Overworked Shortage

Q 4.b Burnout
Another significant worry reflects the very real risk of nurse burnout due to increased working hours
and workloads. A concern over nurses’ rising workloads has been expressed by EFN Members across
Europe including Belgium, Cyprus, Finland and Sweden. Nurses’ weekly working hours have increased
while their time off work (and holiday time) has been decreasing as a result of the increased demand.
Inevitably, nurses being overworked leads to high incidents of exhaustion, fatigue and stress which are
key symptoms of burnout; as reported by EFN Members in Finland, Montenegro and Romania. Surveys
conducted among nurses at national level, e.g. in Finland, found high levels of uncertainty and feeling
lack of control; making caring during the COVID-19 pandemic a highly traumatic experience for many
nurses.

Q 4.c Shortage
The aforementioned issues regarding the negative impact of the pandemic on nurses’ physical and
mental health, lead to concerns over increased nurse turnover and worsening of the nursing shortage;
concerns collectively reported by EFN Members including from France, Norway, Ireland, Italy and
Sweden. In Norway, for example, critical care nurses have reported uncertainty with regard to how

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much longer they could manage to work under these conditions. Similarly, in France, nurses have
started to resign or are intending to resign; this is an issue compounded by the fact that many nurses
are older and nearing retirement.
Q 4.d Long-COVID
Additional concerns shared by EFN Members relate to the long-term physical and mental health
consequences for those infected, including nurses, and the capacity and preparedness of national
health systems to respond and support long-COVID. Related to this is the issue of resuming and
catching up with non-COVID care needs, which have been postponed since the pandemic but now
reaching a crisis point. The EFN Members warn that shifting the majority of resources to COVID-19 and
suspending routine care cannot be sustainable in the long run and is an inadequate response to future
waves of the virus.

Policy Recommendations:
• Provide adequate support for nurses and their families who have been significantly and
adversely affected by the pandemic on a physical, mental and social level
• Encourage measures that do not rely on nurses doing more and with less resources;
contain nurses’ workloads to protect both the workforce and their capacity for safe care
• Invest in managing and preventing nurse burnout, both through addressing the
contributing factors and through offering material and financial support

4. What can the European Institutions do?

In the current context of COVID-19, and in preparation for future pandemics, it is crucial that the
European Commission, the EU Member States and other European Stakeholders increase their efforts
to ensure healthcare professionals, and nurses in particular, are adequately protected. This includes
protection from psychological risks, work-related accidents and diseases, and the inclusion of disabled
and older professionals.
A key challenge for the European Institutions in the months and potentially years to come is to
incorporate in the design of pandemic responsiveness planning the experience and expertise of those
at the coalface, frontline nurses. It is vital to continue to explore how different healthcare systems
within and across European countries are responding to the current pandemic; and, to monitor and

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measure the impact of such pandemics on nurses and nursing. It is clear from the real-world evidence
amassed and shared by the EFN Members that the nursing workforce needs to be better equipped,
prepared and protected if it is to continue to enable and drive health system resilience and an effective
response to the real risk of ongoing pandemics. The EFN Members acknowledge that the best time to
have started planning for a future pandemic was back in 2015, after the Ebola crisis; the second best
time is now. Preparing now can only benefit any future response, as well as restore confidence in
Europe’s health systems more widely. It is vital for the European Institutions and stakeholders to invest
in the nursing profession now to safeguard Europe from further devastating effects of future
pandemics.

The EFN Members urge the European Institutions to invest in increasing nurse staffing numbers
through recruitment, retention training of new nurses following Directive 55; allocate dedicated
funding for the provision of PPE to frontline workers; offer psychological, physical, financial and social
support to nurses adversely affected by the pandemic; ensure a safe workplace through legislation for
appropriate health and safety measures and positive work environments.

5. What can we do locally to support protection of nurses?

When a health crisis occurs, the nursing profession is always at its frontline serving in very difficult
conditions the citizens and patients of Europe. This has been part of European history since the times
of Florence Nightingale. In times of war and pandemics, when the population of Europe needs healing
and support, the nurses are always at the frontline, day and night. The COVID-19 pandemic has shown
that more EU support to frontline healthcare workers is needed when such health emergencies arise.
EU citizens need EU policies that protect frontline staff from working overtime and of services being
continuously understaffed.

The updated Directive 2000/54/EC of the European Parliament and of the Council as regard to the
inclusion of SARS-CoV-2 in the list of biological agents known to infect humans will provide a solid
protection to healthcare workers, including nurses, implementing strict obligations for the employers.
The EFN encourages its members and European partners to question employers about how the new
legislation on Biological Agents concerning SARS-CoV-2 as a group 3 biological agent will be
implemented in their workplace; seek confirmation that aerosol transmission will be taken into
account in the workplace risk assessment; ask how scheduling practices, ventilation, use of PPE and
medical devices such as smoke/aerosol evacuators are being employed to keep non-urgent but

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important surgery going; advocate for and raise awareness of improved ventilation (doors, windows,
air conditioning) and/or aerosol evacuation across different health settings, and look out for new
scientific evidence on safe workplace practice as and when it becomes available; and, finally, continue
to lobby for and raise the issue with national policy makers and regulators.

6. Conclusion

Nurses play a fundamental and indispensable role in the provision of safe and quality healthcare; this
is accentuated in times of pandemics. The current COVID-19 pandemic poses a threat both to those
who receive and those who deliver healthcare. To ensure the safety of all stakeholders, measures to
ensure adequate protection against the transmission of COVID-19 must be consistently applied across
Europe. The devastation seen during the current pandemic is a stark reminder of the importance of
having strong healthcare systems in Europe, which relies on supporting and protecting frontline nurses
while doing their job and putting their own lives at risk.
An initial, important and concrete step forward would be for the EU Member States to strengthen
capacity of their health workforce by implementing Directive 2000/54/EC at the earliest. In addition,
at local level, employers need to establish policies and procedures to apply Directive 2010/32/EU
correctly. The success of all these will hinge on genuine collaborative working between policy makers,
employers and frontline nurses to ensure any initiatives are fit for purpose. Engaging frontline staff,
and nurses in particular, has never been more important.
The EFN will continue to work with the European institutions to ensure nurses are better prepared,
protected and supported for future disease outbreaks or health crises in the EU. The COVID-19
outbreak has had an enormous impact across all layers of EU society. During such times of health crisis,
it is vitally important to support healthcare professionals, nurses in particular, to respond to the
challenge of the COVID-19 pandemic without compromising their safety and wellbeing; and, to
continue to encourage investment in preparedness, learning from the lessons and knowledge gained
so far. The EFN reminds that during this era of pandemics: we cannot be prepared anywhere, unless
we all prepared everywhere.

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EFN Members input country per country

ALBANIA

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?
14,410 cases 8,825 recovered 400 deaths (Date 05/10/2020)
b. Number of nurses infected with COVID-19?
516 Nurses
c. Number of nurses who died from COVID-19?
2 Nurses

2. Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,
has your national government taken any action to address this? What has been/will be put
in place to avoid this in the future (second wave)?
Since the beginning of the pandemic in Albania, the Ministry of Health has imposed all
protective measures for nurses and health personnel. implementing the protocols approved
by the WHO. The situation appears more positive in hospitals COVID-19 (QSUT and “Shefqet
Ndroqi”), however less than half of the staff claims adequacy and abundance of MMPs, while
the primary system (without beds) has suffered the most too lack of proper MMPs and in
necessary quantities. Although the situation has come to be improved from March to May
2020, again staff in the hospital system (with beds), including COVID-19 hospitals, shows a
higher degree of improvement of the situation.
b. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?
According to the protocols approved by the ministry of health as for health services.
c. Were there enough resources/nurses to handle the COVID-19 patients?
2 hospitals anticovid-19 were established, the Infectious Diseases Hospital and the
Sanatorium Hospital, where current staff was trained to proceed on how to protect and care
for patients. The ministry of health called for volunteers who were trained.
d. Were there enough resources/nurses to handle all other (NON-COVID) patients?
Yes, there are.

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e. Some European countries experienced lack of ICU beds, equipment, and trained nurses;
how is your national government planning to tackle this?
With all the difficulties that Albania had, as it came from a natural disaster such as the
earthquake of November 27, 2019. The lack of beds and the fulfilment of needs came with
the replacement and filling of the number of beds. During all this time a lot of training has
been done for health personnel.

3. Question 3 - Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?
The Ministry of Health from the beginning has been in coherence to fulfill all measures and
strategies set by the WHO.
b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes,
how was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?
No answer.
c. Did your national government/health setting put in place appropriate mechanisms for
psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?
In the hospital there are psychological.
d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?
In coherence with the World Health Organization
e. And how is your national government planning to engage with EU/national nurse
representatives to better engage the nursing profession in a future health crisis?
Albania Order of Nurses will seek government cooperation to increase the figure of the nurse
in Europe. Many nurses are being employed in many European Union countries such as
Germany
f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?
By decision of The Council of Ministers, the Albanian government decides to use the Ministry
of Health and Defense Social a fund of 400 million ALL for taking measures to meet the
preliminary needs for infection caused by COVID-19.

4. Question 4 - Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.
Salary increase

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AUSTRIA

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?
48969 tested positive since March 2020/today (5.10.2020) 8984 are registered as tested
positive/(5.10.2020)488 hospitalized/(5.10.2020) 795 deaths since March 2020
b. Number of nurses infected with COVID-19?
No numbers available
c. Number of nurses who died from COVID-19?
No numbers available

2. Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,
has your national government taken any action to address this? What has been/will be put
in place to avoid this in the future (second wave)?
At first there was a shortage, but now there is enough protection equipment on stock.
b. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?
Yes, but only at local level
c. Were there enough resources/nurses to handle the COVID-19 patients?
Yes, there are
d. Were there enough resources/nurses to handle all other (NON-COVID) patients?
Yes, there are
e. Some European countries experienced lack of ICU beds, equipment, and trained nurses;
how is your national government planning to tackle this?
Several precautions have been taken such as social distancing, regulations concerning
assemblies, the requirement of wearing masks for example in public transportations, etc.
Surveillance of daily infection rates, strict contact tracing.

3. Question 3 - Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?
The duration of the pandemic causes people to show a lack of discipline. This effects the rates
of infections.

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b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes,
how was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?
Yes, nurses were and are confronted with stigmatisation mainly in private settings. There are
no specific actions so far.

c. Did your national government/health setting put in place appropriate mechanisms for
psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?
No, they did not.

d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?
Arrangements to stock protection gear to prevent a shortage.

e. And how is your national government planning to engage with EU/national nurse
representatives to better engage the nursing profession in a future health crisis?
The Austrian government started a process to evaluate the standing and working
circumstances of nurses on all levels integrating nurse representatives.

f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?
There is some re-arrangement going on, but in general and not only because of the
healthcare crisis we are facing at the moment.

g. Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.
No information provided.

BELGIUM

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?
See: https://covid-19.sciensano.be/fr/covid-19-situation-epidemiologique &
https://epistat.wiv-isp.be/covid/covid-19.html
b. Number of nurses infected with COVID-19?
No numbers
c. Number of nurses who died from COVID-19?
No numbers

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2. Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,
has your national government taken any action to address this? What has been/will be put
in place to avoid this in the future (second wave)?
At the beginning and at the height of the crisis there was a (significant) lack of equipment.
The government ordered equipment and after receipt distributed it according to a priority
category to health professionals. The government set up the Sciansano user's councils
addressed to both the population and the health professionals on the recommendations for
the use of the equipment. The government has set up working groups to determine the needs
and how best to meet them. The government has questioned the institutions about their
need for equipment and has started a stockage of equipment for the 2nd wave.

b. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?
Not at the beginning because there wasn't enough testing. The nurses even with some
symptoms (unless fever) had to continue working. Once there was enough testing, they could
be tested.

c. Were there enough resources/nurses to handle the COVID-19 patients?
Yes (because the elective activities of the hospitals have been stopped and non-essential
services have been closed) there has been a transfer of staff from these services to the (newly
created) Covid-19 services and/or to the emergency and intensive care units.

d. Were there enough resources/nurses to handle all other (NON-COVID) patients?
Yes

e. Some European countries experienced lack of ICU beds, equipment, and trained nurses;
how is your national government planning to tackle this?
We have not experienced this situation. A number of beds have been specifically reserved
for Covid patients. Each hospital was allocated the number of beds (intensive care and Covid)
that it had to reserve by the government.

3. Question 3 - Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?
Breathlessness of the nursing staff.
Not really

b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes,
how was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?
Some nurses have indeed experienced this kind of situation. But their number has been very
limited. The government did not take any specific measures for this kind of very isolated

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situation. Conversely, the population has been generous towards the caretakers who have
found themselves in difficulty because they would rather not live in their own homes in order
not to contaminate their families.
c. Did your national government/health setting put in place appropriate mechanisms for
psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?
Yes, free psychological support is provided by the government.
d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?
Better communication and more involvement of nurses in discussions and decisions.
e. And how is your national government planning to engage with EU/national nurse
representatives to better engage the nursing profession in a future health crisis?
No plan.
f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?
The government has adjusted the budget as it went along to ensure that it supports the front
line. Depending on the needs, the government provides the necessary aid and financial
support for front-line staff.

4. Question 4 - Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.
Work overload, overtime, leave postponed and/or not taken. Ensuring an adequate workforce.

BULGARIA

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?
21518 people infected, 5693 active, 14984 already cured, 912 hospitalized, 54 in critical care
wards, 841 dead. The information comes from the special register from the Ministry of
health. The data is from 13.03.2020 up to 04.10.2020.
b. Number of nurses infected with COVID-19?
396
c. Number of nurses who died from COVID-19?
2

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2. Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,
has your national government taken any action to address this? What has been/will be put
in place to avoid this in the future (second wave)?
There were not enough PPE for the nurses in the first wave (in March and April).Nurses were
not prepared to handle COVID-19 patients. After that, in May the National government took
actions and sufficient PPE were provided to all healthcare professionals. National operational
headquartes was situated and it gave information about COVID-19 situation to the public
every day. The leading medical specialists in infection deceases prepared protocols for
professional conduct and medical treatment for the infected patients. Nurses, working at
“the first line” In the COVID wards were trained how to use in correct manner the PPE, how
to keep themselves from the infection and how to fulfil their professional duties in safety for
themselves and for the patients. All doctors, nurses and the allied health professionals,
working at “first line” receive additional 500 Euro to their monthly salary. In order to manage
properly the second wave, the National government assured allocation for the whole
healthcare system, and the employers are obliged to prepare plans for reorganizations in
their hospitals, i.e.to open additional COVID wards, to hire additional personnel, etc.

b. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?
Only nurses, reporting symptoms were tested.

c. Were there enough resources/nurses to handle the COVID-19 patients?
No, there were not enough resources in the first months of the pandemic. Later there were
allocations.

d. Were there enough resources/nurses to handle all other (NON-COVID) patients?
Yes, there were enough resources to handle the other patients, the money came from the
National health insurance fund.

e. Some European countries experienced lack of ICU beds, equipment, and trained nurses;
how is your national government planning to tackle this?
With the allocation in May and August, ICU beds and equipment were assured. There were
allocations from different donors, too. The lack of nurses is critical and it is extremely difficult
to tackle this problem. The employers are obliged to manage the personnel in their hospitals
in a way to meet the challenges.

3. Question 3 - Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?
The main challenge is the lack of nurses and the government confessed that. There will be
negotiations between the trade unions and the ministry of health to increase the nurses’
salaries.

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b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes,
how was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?
There is not stigmatisation or violence against nurses during the ongoing COVID-19
pandemic.

c. Did your national government/health setting put in place appropriate mechanisms for
psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?
No, there is not assured psychological support.

d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?
The hospital managers are obliged to assure specific training for all personnel, concerning all
COVID-19 matters – protocols, PPE, etc.

e. And how is your national government planning to engage with EU/national nurse
representatives to better engage the nursing profession in a future health crisis?
The minister of health invited our organization to speak about the future plans to engage us
to tackle the health crisis. In Bulgaria, it is mainly the lack of nurses. We expect better salaries,
more student places in the universities and better working conditions.

f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?
The national government allocated finances, so that every nurse, working at frontline
receives additional 500 EURO per month.

4. Question 4 - Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.
No information provided.

CROATIA

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?

b. Number of nurses infected with COVID-19?


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c. Number of nurses who died from COVID-19?


2. Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,
has your national government taken any action to address this? What has been/will be put
in place to avoid this in the future (second wave)?

b. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?

c. Were there enough resources/nurses to handle the COVID-19 patients?

d. Were there enough resources/nurses to handle all other (NON-COVID) patients?

e. Some European countries experienced lack of ICU beds, equipment, and trained nurses;
how is your national government planning to tackle this?


3. Question 3 - Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?

b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes,
how was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?

c. Did your national government/health setting put in place appropriate mechanisms for
psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?

d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?


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e. And how is your national government planning to engage with EU/national nurse
representatives to better engage the nursing profession in a future health crisis?


f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?


4. Question 4 - Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.


CYPRUS

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?
1559 confirmed case, / hospital admissions 210 /deaths 29
b. Number of nurses infected with COVID-19?
102 nurses infected with COVID-19
c. Number of nurses who died from COVID-19?
0 (No nurses died from COVID-19)

2. Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,
has your national government taken any action to address this? What has been/will be put
in place to avoid this in the future (second wave)?
No at the beginning there were not sufficient supplies. The government chartered flights and
brought personal protective equipment from China. Moreover nursing organizations in
Cyprus bought supplies for nurses in hospitals. Citizens also voluntarily prepared and donated
face shields to the hospitals. Gradually sufficient personal protective equipment for the
nurses was achieved (masks, gloves, etc.). Nurses were prepared to treat patients with
COVID-19 (protocols, awareness, facilities, education, etc.)
b. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?
Nurses at national level were examined for Covid-19 when they came in contact with a
confirmed case or if they had any symptoms for COVID-19 or if when they worked in

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departments that treated patients with Covid-19 (periodically)/ tested positive for COVID-19
after admission.
c. Were there enough resources/nurses to handle the COVID-19 patients?
As said above gradually there were enough resources to treat patients with COVID-19
patients. At this stage there are again some shortages in protective gowns and FFP3 masks
as Cyprus depends on other countries for supplies. Regarding nursing personnel, nurses were
urgently moved from different units at all hospitals to work in units specially prepared to
treat COVID-19 patients. Nurses worked overtime to manage the shortages that existed and
became worse during the first wave of the pandemic due to nurses getting sick or were out
of work due to vulnerability by illnesses.
d. Were there enough resources/nurses to handle all other (NON-COVID) patients?
Yes, there were enough resources for non -COVID patients.
e. Some European countries experienced lack of ICU beds, equipment, and trained nurses;
how is your national government planning to tackle this?
During the pandemic, two intensive care units were set up at the capital's hospital with all
necessary equipment. Nursing staff has been trained and re-training is planned for intensive
care unit nurses in the following period. No lack of equipment has been experienced.

3. Question 3 - Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?
The most serious challenge that our country is facing at this point is the economic crisis and
certainly measures have been taken to tackle this.
b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes,
how was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?
Stigmatization of Nurses (due to their job) was not experienced by the public in general but
some stigmatization was faced at their working environment mainly if tested positive. At
national level during the pandemic, nurses were applauded by citizens, the public and the
politicians.
c. Did your national government/health setting put in place appropriate mechanisms for
psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?
The government / health framework did not establish appropriate psychological support
mechanisms for nurses who experienced severe anxiety and stress during the pandemic.
d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?

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The measures taken by our national government for health professionals, especially nurses,
for preparation for a possible next COVID-19 wave consist of: training, proper design of
clinical guidelines and establishment of protocols.
e. And how is your national government planning to engage with EU/national nurse
representatives to better engage the nursing profession in a future health crisis?
Cyprus Government includes in the decision making process Nursing personnel who are at
managerial positions or in the infection control committees either at ministerial level or
hospital level.
f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?
Unaware of the matter.

4. Question 4 - Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.
Nurses due to COVID-19 pandemic had to face: at times issues related to shortages mainly of
protective equipment/ movement to other units/hospitals, working long hours without an Off duty
day. Moreover during the periods of increased cases of COVID-19 the main issue was the
separation from their families in order to protect them (nurses working in wards with Covid-19 or
that tested positive or became ill with COVID-19 or had the possibility to come in contact due to
work with possible cases of patients testing positive).

CZECH REPUBLIC

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?

b. Number of nurses infected with COVID-19?

c. Number of nurses who died from COVID-19?


2. Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,
has your national government taken any action to address this? What has been/will be put
in place to avoid this in the future (second wave)?


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b. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?


c. Were there enough resources/nurses to handle the COVID-19 patients?


d. Were there enough resources/nurses to handle all other (NON-COVID) patients?


e. Some European countries experienced lack of ICU beds, equipment, and trained nurses;
how is your national government planning to tackle this?


3. Question 3 - Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?

b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes,
how was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?

c. Did your national government/health setting put in place appropriate mechanisms for
psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?

d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?

e. And how is your national government planning to engage with EU/national nurse
representatives to better engage the nursing profession in a future health crisis?

f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?


4. Question 4 - Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.


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DENMARK

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?
Date: 23. September 2020 - Population in Denmark: 5.8 mio.
Total infections: 23.799
Total Hospital admissions due to covid: 3.072
Hospitalized today: 79
Deaths: 641 (2,7% of total of infected)
b. Number of nurses infected with COVID-19?
1.536 – d. 22. September. We receive new data once a week. Within the social- and
healthcare sector infection among workers are highest in the hospitals (also higher than
nursing homes). The nurses are overrepresented among the infected – due to the close
contact with the patients.
c. Number of nurses who died from COVID-19?
0 according to our knowledge. In Denmark, we have no official systematic data regarding
death and occupation.

2. Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,
has your national government taken any action to address this? What has been/will be put
in place to avoid this in the future (second wave)?
PPE, measures and preparedness of nurses:
The Danish Health Authority prepared many guidelines in order to help the frontline nurses
how to deal with COVID-19 patients - however, in the beginning the guidelines were
frequently revised and it seemed like a potential lack of personal protective equipment was
a higher priority than the safety for the nurses.
The hospitals were prioritized over nursing homes etc when it came to stocks of PPE. Nurses
were reporting about re-use of PPE due to lack. According to the guidelines nurses should
not use PPE if the patient wasn’t suspected with covid-19 – even if she was not able to keep
distance.
Fortunately, the guidelines have been revised and are now taking the safety of the nurses
into consideration as well – but still room for improvement and currently a new revision is
underway with further intensified measures for the benefit of the nurses´ security. We don’t
experience lack of PPE any longer. However, we have a problem with the fitting of PPE – it
doesn’t work with the “one size fits all” approach.

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The employer and the management level also established different measures to prepare the
nurses. One example was a hospital department (ICU) establishing “The school of uniform”
for all HCW – it was a big success also when it came to reducing infection among workers.
Some nurses were temporarily moved to work in the covid-departments – the training was
an employer responsibility. It was not without problems! End of April DNO conducted a
survey among our members showing:
- More than every 5th nurse has felt stressed 'all the time' in the last two weeks
- 16% have felt pressured to accept a new workplace
- 33% have felt pressured to accept new work assignments
- 20% have felt pressured to accept new working hours
- 57% are very worried about passing on the infection

Action by government:
• The government has ensured that there is enough personal protective equipment,
which has been a big problem in the beginning of the pandemic.
• The guidelines for using personal protective equipment has also become clearer and
more streamlined.
• The government has established a national coordinating body “The Danish Agency for
Security of Supply” that is going to focus on future security of supply to prepare for the
next wave of COVID-19 or future pandemics.
• Establishment of a national logistics center to redistribute personal protective
equipment between municipalities and regions (hospitals) - so the municipalities wont
experience another acute shortage.

b. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?
In the beginning, nurses could only be tested if they showed minor or severe symptoms. Now
everyone can be tested - and guidelines have also been drawn up for when regular testing is
recommended, for example by increased infection in a geographical area weekly testing is
recommended.

c. Were there enough resources/nurses to handle the COVID-19 patients?
There is a general shortage of nurses in Denmark - before the corona and during the corona.
However, the number of hospitalized due to covid-19 in Denmark has not exceeded the
capacity (ICU beds and staff). Most of the non-emergency treatment were put on stand-by
during the spring and nurses were transferred to ICU and covid-departments. Otherwise lack
of staff would have been the reality. The country specific recommendations for Denmark
under the European Semester pointed out the issue:
“The ongoing COVID-19 crisis underlines the need for Denmark to continuously work to
strengthen the resilience of its health system. One issue of particular concern is the shortage
of health workers, and the lack of specialised doctors and nurses in e.g. intensive care (in
particular nurse anaesthetists). Continuous efforts to address these labour shortages is key”.

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d. Were there enough resources/nurses to handle all other (NON-COVID) patients?
Most of the non-emergency treatment were put on stand-by during the spring and some
nurses were transferred to ICU and covid-departments.

e. Some European countries experienced lack of ICU beds, equipment, and trained nurses;
how is your national government planning to tackle this?
Right now the solution is the flexibility shown by nurses and other HCW – when temporarily
transferred to ICU (We have a covid-19 preparedness team – a list with nurses volunteering
or appointed to by the manager to transfer to the covid-19 departments like ICU when
needed). Hopefully in the future the solution will be in line with the recommendation by the
Commission to address the shortage of health workers and specialised nurses in ICU.

3. Question 3 - Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?
When the population begins to relax on the recommendations of social distancing and
hygienic precautions. “The one size fits all” approach when it comes to PPE – we must
prioritize the safety of the nurses and other HCW. The nurses and other health care workers
might not be ”ready” to a second wave – It has been physical as well as mentally challenging
working in the frontline.

b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes,
how was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?
To a minimal degree – only few reports about comments when shopping.

c. Did your national government/health setting put in place appropriate mechanisms for
psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?
Psychological support is available in working settings – and a national hotline was
established. Hard to say if the measures were “appropriate” – according to the survey
mentioned above, many nurses still felt stress and high pressure. Some research projects
regarding nurses´ mental health are underway – we expect some results end October.

d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?
• The government has ensured that there is enough personal protective equipment, which
has been a big problem in the beginning of the pandemic.
• The guidelines for using personal protective equipment has also become clearer and
more streamlined.
• The government has established a national coordinating body that is going to focus on
future security of supply to prepare for the next wave of COVID-19 or future pandemics.

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• After political pressure from DNO and others the Danish Health Authority has
established a national coordination group to focus on the long-term effects of people
who has been infected with corona. The aim is to gather knowledge and ensure better
treatment. (see further question 4)

e. And how is your national government planning to engage with EU/national nurse
representatives to better engage the nursing profession in a future health crisis?
• The government are engaged in Nordic (Nordic Council of Ministers decided to
strengthen Nordic cooperation regarding covid-19) as well as European (PPE, Vaccine)
cooperation.
• 2 nurses are members of the national coordination group on long-term effects
• At national level The Ministry of Health has established a sector partnership to ensure
safe reopening of the nursing homes etc. - DNO has been a part of that.
• The DNO is already represented in the pandemic group that is run by the Danish Health
Authority.

f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?
Denmark is in the middle of budget negotiations. The government has suggested to set aside
9,2 billion DKK to handle future costs related to COVID-19 both in relation to healthcare
expenses, but also to support private sector jobs. The government has suggested some of
the money to be used to strengthen the Danish Health Authority and to establish a new
department for pandemics in the Ministry of Health. However, the budget hasn’t been
approved yet.

4. Question 4 - Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.
Long-term effects among nurses is a high priority in Denmark – and DNO has been calling for a
National systematic action plan for patients with long-term effects. In Denmark, we know that
nurses are statistically overrepresented when it comes to COVID-19 infection.
Internationally as well as nationally, we are lacking evidence when it comes to long-term effects –
some international studies expect 10% of all infected will experience long-term effects. However,
we expect the number could be even higher – since data is not systematically collected.
In Denmark, we have around 1400 nurses infected – and the colleagues working with occupational
injuries at DNO have at the moment dialogue with 60 nurses with long-term effects. We expect
more to come. DNO has been calling for a National systematic action plan for patients with long-
term effects. The Danish Health Authority has now established an interdisciplinary working group
– 2 nurses are members of this group. The purpose is:
“The members of the working group must provide input to a set of national recommendations for
how the needs of people with late effects after COVID-19 are best met in the health care system.
Likewise, the recommendations should advise physicians and other healthcare professionals who
see the people with late effects after COVID-19 so that they know how the late effects are to be
investigated and managed”.

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The recommendations are expected to be published at the end of September!
DNO has, together with other unions representing workers in the health care sector, sent a letter
to The Minister of Health as well as The Minister of Employment to ensure the working group will
include the following:
We are calling for the need of data in order to be able to ensure:

• Systematic follow-up and clinical examination
• National offers of treatment and rehabilitation
Furthermore, The Nordic Nurses Federation has high-lighted long-term effects and the need for
Nordic cooperation in a letter to The Nordic Council of Ministers and all the Nordic Ministers of
Health.

ESTONIA

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?
As of 04.10.2020, a total of 3,607 people have given a positive COVID19 test in Estonia, 473
people have been hospitalized and 67 have died. The total number of primary tests is
221,363. More information from the link:
https://www.terviseamet.ee/et/koroonaviirus/koroonakaart
b. Number of nurses infected with COVID-19?
According to the latest data (24.09.2020), 130 health care workers and 48 care workers had
been infected in Estonia since the beginning of the pandemic.
c. Number of nurses who died from COVID-19?
0 nurses, 1 care worker died in April

2. Question 2 - Working environments
f. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,
has your national government taken any action to address this? What has been/will be put
in place to avoid this in the future (second wave)?
Guidelines on how and when to use personal protective equipment were quickly established
in cooperation with the state and health care institutions. There were not enough personal
protective equipment in March and April, but by May there were already enough funds. The
biggest shortage of personal protective equipment was in general care homes, where nurses
have been working in some places since the beginning of this year. At the beginning of the
pandemic, the nurses were not immediately ready and aware of how to deliver in a crisis
situation, but to raise awareness, health authorities and the private sector, together with the
state, began developing various trainings and information days to raise awareness.

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g. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?
Yes, at first rather according to symptoms, but already in March it was regularly tested at
certain intervals to identify infected staff members.

h. Were there enough resources/nurses to handle the COVID-19 patients?
No, the shortage of nurses was felt by all employers, because in a crisis situation, nurses were
not allowed to work for several employers, nurses had to choose, and this further increased
the shortage of nurses.

i. Were there enough resources/nurses to handle all other (NON-COVID) patients?
In Estonia, scheduled work was suspended in March and April, so the workload in this area
rather decreased. At the same time, many healthcare professionals contributed to testing
people, worked in COVID departments or replaced sick or in self- isolations colleagues.

j. Some European countries experienced lack of ICU beds, equipment, and trained nurses;
how is your national government planning to tackle this?
There were enough intensive beds in Estonia in the spring. Today, the situation is also good,
we have enough beds, and the staff is better prepared than in the spring.

3. Question 3 - Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?
Relatives of COVID-infected people often do not adhere to the obligation of self-isolation,
and the first outbreak in the autumn was caused by a person who was infected himself but
did not stay home, but partyed in a nightclub. The state and health care institutions do a lot
of explanatory work and, if necessary, the state is ready to financially punish people who do
not comply with the established requirements. We do not have precise data on who and how
much has been fined.

b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes,
how was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?
No

c. Did your national government/health setting put in place appropriate mechanisms for
psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?
National government- no, however, larger health facilities have provided and continue to
provide psychological assistance to their people.

d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?
Today, the state has a larger stock of personal protective equipment, and the Health Board
provides up-to-date information to all parties and constantly updates instructional materials.

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e. And how is your national government planning to engage with EU/national nurse
representatives to better engage the nursing profession in a future health crisis?
Estonian Nurses Union is working to ensure that the government takes steps to alleviate the
shortage of nurses. Today, government officials also acknowledge the lack of nurses, but no
real steps have been taken by them yet

f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?
The government is only preparing a budget for 2021, so nothing more can be added at the
moment, but the additional costs of 2020 until the end of the emergency situation related to
COVID were covered by all healthcare providers.

4. Question 4 - Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.
In the spring, the work of the COVID departments and ambulance, was remunerated at a higher
rate, but there are no plans to do so now. Negotiations on a collective agreement began in the
autumn and nurses/care workers expect pay rises. Especially in a situation where there is money
to buy oxygen equipment, but there are no nurses put aside.

FINLAND

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?
Finland’s situation 29th September 2020
- The number of verified coronavirus infections have risen in recent weeks. There is
variation between different areas in Finland, the situation is worse in the Uusimaa region
(=capital region + some other parts of Southern Finland) than elsewhere, with fewer than
one in five new coronavirus patients now able to trace the source of their infection.
o Infection rates among young adults aged 20 to 29 have risen sharply during
September. Young people account for almost half of the number of lab-confirmed
coronavirus cases in Finland in recent weeks.
- Reported cases in total: 9,892
- A total of 345 deaths associated with the disease have been reported.
o 48 percent men, 52 percent women, median age 84. The majority had one or more
long-term illnesses. Deaths of working-age people very rare, no deaths of children
and young people have been diagnosed. The coronavirus epidemic has not
increased total mortality in Finland.
- The number of people in hospital care is 22
- The number of people in intensive care is 4

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- In relation to Finland’s total population (5,543,233), the prevalence of cases is 178 cases
per 100,000 people.

- During the most recent fourteen-day monitoring period (13–26 September), the incidence
of new cases in relation to the population was 20.1 cases per 100,000 inhabitants.
o To compare: during the previous fourteen-day monitoring period (30 August–12
September), the incidence of new cases was 10.1 cases per 100,000 inhabitants.

- Virus testing capacity is currently about 20,000 tests per day.
- An estimated 7,850 people have recovered, which is over 80% of the reported cases.
b. Number of nurses infected with COVID-19?
Data is not collected.
Based on the report dated on 22nd September 2020: Health care workers accounted for
about 5.3 percent of all coronavirus cases diagnosed among working-age people during the
summer (9.6.–31.8.2020). In the spring, the share of health care workers in all cases of
coronavirus detected among working-age people was about 17 per cent. (For a perspective:
ca 7.4 per cent of all working-age people work in health services).
c. Number of nurses who died from COVID-19?
To that date, no deaths had been reported.

2. Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,
has your national government taken any action to address this? What has been/will be put
in place to avoid this in the future (second wave)?
We were not prepared well enough. There was a severe lack of PPE. All new arrangements
had to be put up in quite a hasty schedule, in the midst of uncertainty. A certain amount of
other than intensive care nurses were getting quick training to be able to work in intensive
care. At the end of the spring we were able to start domestic production of PPEs, but still the
production has not started as was hoped.
b. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?
That varied between the workplaces. There has not been systematic testing of non-
symptomatic nurses. For our knowledge, the testing has been mostly based on exposure or
the symptoms.
c. Were there enough resources/nurses to handle the COVID-19 patients?
That varied, but mostly we have been able to handle our COVID-19 patients well. The
situation in total did not get as bad as we feared. Nevertheless, the situation made visible
the fact that FNA has raised concerns of even before: we have problems in offering
systematically specialist education for nurses, e.g. we don’t have official intensive care

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specialist nurse education in Finland, but the workplaces need to educate their own
specialists. We will continue lobbying around this subject.

d. Were there enough resources/nurses to handle all other (NON-COVID) patients?
For many parts non-acute care was cancelled and some of the patients have not received
care they would have had without this pandemic. That means queues and some unmet needs
for the future.

e. Some European countries experienced lack of ICU beds, equipment, and trained nurses;
how is your national government planning to tackle this?
We built some temporary hospital wards and changed some hospital rooms to be ICU wards.
There was actually extra capacity as the situation didn’t fortunately turned out to be as bad
as were the worst scenarios.

3. Question 3 - Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?
There are many, difficult to mention only one. Of course economic losses are among the most
difficult challenges, but also capacity for testing, people’s fatigue/willingess to follow all the
rules, mental health problems and e.g. domestic violence, inequality of children/adolescents
in copying with the remote school. Nurses tell us that they experience fatigue and the spring
was really demanding as you needed to handle the new and frightening situation and in many
cases without proper PPE, and due to emergency law there was e.g. over time working,
changes of work description, uncertainty of vacations etc. At the same time there was wage
negotiations going on, and for many parts nurses were not happy with the end result. They
feel that they are appreciated with words, but not concretely, e.g. with economic
compensation. We have to follow carefully nurses’ intentions and actual actions to possibly
leave the profession. There is a threat for even greater lack of nurses.
In Finland no “corona bonus”, i.e. economic compensation for more demanding and
hazardous work and times, has taken place. The role of management and nurse/other
leaders’ capacity to handle crisis situation has shown out to be crucial.

b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes,
how was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?
Based on our recent questionnaire (further analysis still in the process):
The majority of respondents (N=2344) did not feel that they, as healthcare professionals,
were treated as a vector for COVID-19 infection, but a negative attitude was also
experienced.
The majority (76%) of respondents did not feel that they were treated or considered to be
carriers of COVID-19 infection and would have been therefore treated differently. However,
more than 15% of respondents felt that they were treated with avoidance and suspicion as a
result. 3% of respondents had been treated unfairly. In addition, seven respondents had been
treated threateningly, five respondents aggressively, and three respondents violently.

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There has not really been any discussion on this matter in Finland.
c. Did your national government/health setting put in place appropriate mechanisms for

psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?
This has varied between the employers, no national programme for this.
d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?
Domestic production of PPEs.
e. And how is your national government planning to engage with EU/national nurse
representatives to better engage the nursing profession in a future health crisis?
We have been lobbying towards the politicians, communicating our members’ experiences,
but there has been hardly any response for that.
f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?
Tehy (the Union of Health and Social Care Professionals in Finland) is lobbying strongly for
this, but so far with no results.

4. Question 4 - Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.
In mid-March FNA launched a qualitative Webropol survey on its website: ‘Being a nurse in the
midst of the corona pandemic’. The survey is still open for respondents and will be kept open until
the epidemic in Finland has subsided. The open-ended responses have been scrutinised by
thematic analysis. The main themes raising from the responses are fear, anxiety, stress, guilt,
anticipation, desire to change field, pulling through together, calm, professional pride. We can also
see three cross-cutting themes: uncertainty, confusion, feeling of lack of control. Messages have
been compiled from the survey for press releases and for various stakeholders, e.g. to members
of parliament on International Nurse's Day.
In September we launched a quantitative questionnaire based on the themes covered. The analysis
of the results is not ready yet.
We can state that even if and when the pandemic subsides, staff recovery may still be in its early
stages. Time and resources must be set aside to unpack the traumatic experience.

FYR MACEDONIA

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?


EFN Report COVID-19 crisis management at national level - October 2020

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EFN – European Federation of Nurses Associations

b. Number of nurses infected with COVID-19?


c. Number of nurses who died from COVID-19?


2. Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,
has your national government taken any action to address this? What has been/will be put
in place to avoid this in the future (second wave)?

b. Were nurses at national/local level tested at their workplace, regardless of reported
symptoms or exposure?

c. Were there enough resources/nurses to handle the COVID-19 patients?

d. Were there enough resources/nurses to handle all other (NON-COVID) patients?

e. Some European countries experienced lack of ICU beds, equipment, and trained nurses;
how is your national government planning to tackle this?


3. Question 3 - Challenges
a. What is the most serious challenge in combating COVID-19 experienced in your country? Is
your national government taking measures to tackle this?

b. Stigmatisation – Were nurses confronted with stigmatisation in your country and if yes,
how was your national government protecting its nurses from stigmatisation and violence
against nurses during the ongoing COVID-19 pandemic? If nothing was done, are they
foreseeing any actions in the future? Which ones?

c. Did your national government/health setting put in place appropriate mechanisms for
psychological support for those nurses who experienced extreme anxiety and stress during
the crisis?

d. What are the measures taken by your national government to make sure the health
professionals, in particular nurses, are prepared for the next COVID-19 wave/a future new
pandemic?

EFN Report COVID-19 crisis management at national level - October 2020

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EFN – European Federation of Nurses Associations


e. And how is your national government planning to engage with EU/national nurse

representatives to better engage the nursing profession in a future health crisis?

f. Is your national government going to re-arrange already existing budget to support the
nursing frontline during future healthcare crisis? If so, which budget areas, how much, and
what for?


4. Question 4 - Please provide any additional information, comments, or challenges nurses are
experiencing in your country due to COVID-19.


FRANCE

1. Question 1 - Country Profile
a. COVID-19 Infection rates / hospital admissions / deaths (for comparison)?
Infection rates varies from week to week but as of October 1st
» Average 105 Covid+ /100 000 varying greatly from region to region rate of positive testing
» Positivity rate on large scale testing 7.6% -in a week(39) 884 990 people tested and the
test was positive for SARS-CoV-2 for 67 385
» 124 377 patients have been hospitalized since March 1st:
» 71 years old in average male for 53%
» 21 201 patients are deceased : 71 were over 75 years old and 59% were male
» 96 327 patients have been discharged home
» September 29th 6500 patients were hospitalised for Covid 19 - 1204 in intensive care
» 10 692 elderly people have died in long term care facilities no official death toll has been
yet communicated for community/home dwelling
» Total death from COVID : 31893 (oct 1st)
b. Number of nurses infected with COVID-19?
No official numbers but 9489 nurses have declared in an official survey having been infected
27% of all HCP ( over 27743 heath care professionals.
c. Number of nurses who died from COVID-19?
No official records but 16 HCP died since March 1st but no nurses.

2. Question 2 - Working environments
a. What was put in place to make sure the nurses were protected in the workplace? Was there
sufficient personal protection equipment for the nurses (masks, gloves etc.), and were
nurses prepared to handle COVID-19 patients (protocols, awareness, facilities, etc.)? If NO,

EFN Report COVID-19 crisis management at national level - October 2020

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