HealthManagement, Volume 23 - Issue 5, 2023


Frontline nurses in the EU have been profoundly affected by the repercussions of the COVID-19 pandemic. Consequently, there has been a massive exodus of frontline nurses, which has far-reaching implications for the healthcare system. This shortage of nurses has resulted in compromised patient safety and quality of care. It is essential to keep experienced nurses in the nursing profession. Failing to retain frontline nurses in the nursing workforce will render the EU and Europe ill-prepared for the years ahead.


Key points

  • The COVID-19 pandemic has highlighted the need for adequate preparedness in the face of health crises.
  • From 2020 to 2022, the pandemic caused significant disruption, leading to various challenges in the nursing workforce.
  • Nurses were required to work overtime, part-time workers were asked to work full-time, and leaves were cancelled or postponed. Nursing students were assigned tasks beyond their training.
  • The shortage of general care nurses in general wards resulted from the reallocation and reskilling of nurses to meet the critical needs in intensive care units that were overwhelmed by COVID-19 patients. To bridge these gaps, non-qualified workers and nursing students were mobilised.


Safe Staffing Levels as Basis for a Resilient Healthcare System

To ensure timely and accessible healthcare for European citizens, efforts must be made to increase the availability of qualified professional nurses. (De Raeve 2021) The European Pillar of Social Rights and Directive 2013/55/EU promotes this goal. The EU Institutions, including the European Commission, the European Parliament, and the Council of Ministers, should mandate Member States to invest in building a resilient nursing workforce. This can be achieved by implementing safe staffing levels and educating and training enough domestic nurses in line with Directive 2013/55/EU.


Maintaining optimal staffing levels is crucial for public health and patient safety. (De Raeve 2023). More needs to be done at the EU level to protect frontline nurses, ensure quality and safety, and secure access to healthcare services. (De Raeve et al. 2023) Efforts should be made to improve data collection on the nursing workforce through enhanced collaboration between the OECD, the European Commission, and WHO-Europe. (De Raeve et al. 2021a) Waiting until 2028 for improved data definitions is not a viable option for better pandemic preparedness. (De Raeve et al. 2021b)


Strategies for Ensuring Safe Staffing Levels in Nursing

It is crucial to invest in retention programmes from the early stages to address the exodus of highly skilled nurses and retain these professionals. Education plays a significant role in strengthening the nursing profession, encompassing both basic education and continuous professional development (CPD) through lifelong learning (LLL).


While ethical recruitment of nurses from abroad is often seen as a solution to domestic nurse shortages, it should not be relied upon as the sole approach. All countries, including the Philippines, Pakistan, India, and Africa, require their nurses during global health crises. Member States should implement ethical recruitment policies aligned with the WHO Global Code of Practice on the International Recruitment of Health Personnel, as endorsed by WHO Europe’s Tallinn Charter in 2008. Therefore, prioritising effective nurse retention should be a key focus in nursing workforce strategies. Retaining scarce and highly skilled staff is more efficient and cost-effective than continually replacing them. Post-pandemic policies aimed at improving nurse retention should emphasise professional autonomy, participation in decision-making, effective supervision and mentorship, reduced workloads, safe staffing levels, support for nurses’ health and well-being, and better compensation for their efforts. Additionally, expanding the capacity of domestic nurse education systems and implementing advanced practice roles are important steps forward.


Investing in mentorship programmes for nursing students is crucial to prevent high dropout rates. Despite a decline in the number of students in EU nursing education programmes in 2023 compared to 2019, there remains significant interest among young individuals in pursuing a nursing career. Policy initiatives should prioritise support for nursing students to successfully complete their education.


LLL and CPD are pivotal in shaping a sustainable future for the healthcare sector. Insufficient investment in these areas deprives the healthcare workforce of essential skills necessary to meet the increasing demands and complexities of patient care. To address workforce shortages, the retention crisis of frontline nurses, and the challenges posed by rising workloads, inadequate remuneration, and unattractive working conditions, it is imperative to prioritise opportunities for nurses to engage in digital and green upskilling and reskilling. By placing a strong emphasis on the physical and mental well-being of the workforce, upskilling and reskilling initiatives can cultivate a future-ready healthcare workforce, contributing to the modernisation, upgrade, and greening of the healthcare sector.


Digital and green upskilling and reskilling initiatives are indispensable in empowering nurses to actively participate in the digital and green transition within the health and care ecosystem. Through initiatives like the Pact for Skills and the BeWell EU Project, the nursing workforce can gain a comprehensive understanding of digital and green solutions, thereby enhancing their digital literacy. This, in turn, enables nurses to optimise their time and daily work organisation, reduce administrative burdens, improve record-keeping, make evidence-based decisions, increase patient engagement, address health inequalities, and enhance cost efficiency in healthcare systems. As resilient and sustainable healthcare systems continue to evolve, digital and green skills will play an increasingly critical role in improving people’s healthcare experience, driving technological and sustainable innovation, and creating better working conditions for the healthcare workforce.


Stop Violence Against Nurses

Violence against nurses has grown into epidemic proportions during the COVID-19 pandemic. Therefore, EFN members believe that national and EU initiatives to support women should consider severe prison sentences and legal sanctions against perpetrators of violence. (De Raeve et al., 2023) Although the EU Victims’ Rights Directive (EC 2012/29/EU) and strategy (EC COM/2020/258) offer better protection from violence and harassment, the European and international institutions should look at the achievements to date alongside current risks and discuss the next steps forwards in strategic cooperation between EU institutions and member states, international organisations, NGOs, and researchers in combatting gender-based violence. Nurses must be protected and supported through the development of policies, initiatives, and legislation at the national and European levels. Given the severity of the situation, inaction could lead to irreplicable damage to the nursing workforce, with more frontline nurses leaving the nursing profession.



Increased workloads during and after the COVID-19 pandemic, disproportionate and unattractive remuneration, difficult working conditions, and impact on the mental and physical health and well-being of the nursing workforce led to an exodus of frontline nurses. Therefore, the EU institutions should immediately focus on developing EU legislation to improve the recruitment and retention of domestically educated nurses. Improving retention of nurses and the attractiveness of nursing as a career by providing fair pay and better conditions of employment. It is essential to keep experienced nurses in the nursing profession. Failing to retain frontline nurses in the nursing workforce will render the EU and Europe ill-prepared for the years ahead.


Conflict of Interest



De Raeve P (2021) Building & Sustaining a Resilient EU Nursing Workforce & Healthcare. LAP LAMBERT Academic Publishing.

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De Raeve P, Xyrichis A & Adams E (2021b) The impact of the COVID-19 pandemic on nurses in Europe: a critical discussion of policy failures and opportunities for future preparedness. International Journal of Nursing Studies Advances. 3:100032.

De Raeve P (2023) Nurses Silent Resignation – Stop the ‘Ticking Bomb’. Health Europa Quarterly. Issue 24. Available at

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Directive 2013/55/EU of the European Parliament and of the Council of 20 November 2013 amending Directive 2005/36/EC on the recognition of professional qualifications and Regulation (EU) No 1024/2012 on administrative cooperation through the Internal Market Information System (‘the IMI Regulation’) (2013). Available at EUR-Lex - 32013L0055 - EN - EUR-Lex (

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