Professionalization of nursing in Slovenia: challenges and responsibilities for nurses with a higher education degree Profesionalizacija zdravstvene nege v Sloveniji: izzivi in odgovornosti za visokošolsko izobražene medicinske sestre in zdravstvenike

Introduction: An occupation becomes a profession once it uses a systematic approach to generate new knowledge and transfer it directly into professional work. The aim of this paper is to show the attitudes of nursing care professionals towards the professionalization of nursing care and make a contribution by means of identifying the factors that are important for the development of the professionalization of nursing in

Fast-paced development of society and increasing needs for healthcare services call for a discussion on knowledge in nursing which could help meet these new demands.This leading article further develops some topics previously touched on in the leading article Professionalism in nursing: what is its current level in Slovenia (Skela-Savič, 2016a), adding new evidence from the project Nursing as a scientific discipline in Slovenia (Skela-Savič, et al., 2017a).
Based on my previous research work, I would describe the process of nursing professionalization as an organized system of formal higher education for an occupation with a strongly defined work ethic, responsibilities and code of conduct where its practitioners are members of a professional association.The work in performed on the basis of clearly defined guidelines and standards for monitoring work quality, self-monitoring, and evidence-based practice.The latter calls for a system of scientific research which provides new knowledge, assesses the appropriateness of existing practices, successfully addresses professional issues and needs of the society, and poses challenges for a new paradigm-in our case, the paradigm of nursing as a socially responsible scientific discipline and profession.

Who is responsible for professionalization of nursing in Slovenia?
A profession develops as the end result of the process of professionalization which is not a one-time event, but rather a series of development activities dependent primarily on the competencies of the highest-level decision makers, on their ability to strategically plan the implementation of changes and to clearly articulate the need for improvements in clinical practice to meet the needs of the healthy and ill populations.So-who is responsible for that?The answer lies in representative studies conducted in Slovenia (Skela-Savič, 2017;Skela-Savič, et al., 2016a, 2017a, 2017b).Nursing managers in healthcare institutions and longterm care facilities, managers in higher education institutions offering nursing programs, and managers of the national nursing association are the ones who should assume responsibility for the development of nursing at present and in the future.
The conditions for making the shift from an occupation to a profession include formally acquired knowledge, competencies, abilities, and values for development work in nursing as these can generate the understanding of development competencies and the implementation of evidence-based practice (Skela-Savič, et al., 2017b).In their employees, nursing managers must encourage the development of knowledge in research and evidence-based nursing care (Skela-Savič, et al., 2016a).By doing so, they will overcome the mentality identified in qualitative group interviews of experts in nursing which included, for example, understanding research and development as nurses' leisure activities, low self-awareness, a lack of interest for obtaining knowledge needed to establish research and development, and a lack of respect for research knowledge (Skela-Savič, 2017).
Current healthcare managers (including nurse leaders) must have obtained postgraduate-level managing and leadership skills as well as knowledge and competencies in the following areas: communication and relationship building, knowledge of the healthcare environment, modern approaches to leadership, establishment of
professionalism at all levels, efficient system management, development of employees' knowledge and abilities needed to appropriately meet the needs in their environment, demographic trends, public health issues, establishment of values that support evidence-based practice, responsibility, quality and safety, intersectoral collaboration, implementation of the policy of constant quality monitoring and improvement, implementation of quality principles, and introduction of information technology solutions in healthcare, also in terms of improving work processes and ensuring active involvement of service users (American College of Healthcare Executives, 2014;Skela-Savič, 2016b).According to the American College of Healthcare Executives (2014), a specialization in nursing management is required for top nursing positions, yet no such requirement exists in Slovenia.With this in mind, it is easier to understand research findings that reveal successful professionalization of nursing in Slovenia.Skela-Savič and colleagues (2016a) have found that managers need a clear vision of development in research and evidence-based practice which is an integral part of the hospital's operations.To achieve that, they must develop nurse leaders whose job is to foster a culture of research and evidence-based practice in the clinical settings.
Also, we must reconsider the currently established practice in Slovenia that, when nurses with a higher education get promoted to head nurses, they stop being involved in direct patient care.Does that truly benefit the development of the profession?A comparison with physicians reveals that, when they get promoted to directors, medical directors or heads of major departments, they always retain some of their work in the clinical setting.Therefore, they do not face difficulties when it comes to understanding the clinical setting, being a part of it and returning to the clinical setting after the leadership position term ends.The practice common among nursing managers-that after assuming a leadership position they cut their ties with the clinical setting-is actually debilitating for the profession, possibly deterring the formation of a competitive arena for leadership and development positions, discouraging education at the second and third cycles, and neglecting those with a postgraduate degree who are not given an opportunity to transfer their knowledge into practice.This policy can be destructive and is detrimental for nursing as a profession.Actually, nursing managers should stay involved in clinical work, applying the tools of matrix organizational structure and transformational leadership in nursing and increasing the competencies of lower-level managers.

Knowledge and competencies in nursing
Extant research (Skela-Savič, et al., 2016b;2016c;2017a) clearly shows that nursing professionals in Slovenia have difficulties when it comes to the basic understanding and implementation of the first phase of professionalization, namely ''the formation of profession'', as termed by Watkins (2011), because they do not understand nursing competencies according to educational levels.Although competencies from secondary school nursing programs are not repeated in higher education nursing programs, the reality of clinical practice reveals a different picture.In fact, competencies for specialist work and for advanced practice in clinical settings, as outlined by the European Federation of Nurses Associations (EFN Workforce Committee, 2014), do not yet exist in Slovenia.Moreover, research (Skela-Savič, et al., 2016b;2016c;2017a) conducted as part of a two-year project has indicated a host of issues, such as education-related differences and mistrust among secondary schools and higher education institutions, or the still prevalent belief that a secondary school degree in health care is required for enrollment into higher education nursing programs, despite the fact that a European Directive (Directive 2013/55/EU of the European Parliament and of the Council, 2013) unambiguously defines the requirement for enrollment as having completed 12 years of general education.Such attitudes are hindering the development of university programs which earn graduates the professional title registered nurse (RN).After all, all European Union (EU) member countries and most former Yugoslavian countries committed to developing these programs.A four-year education at the university level would better equip graduates with the knowledge necessary for understanding and implementing nursing professionalization.
Finally, the system of continuous professional education-a condition for obtaining a nursing license-is in need of reform.It has been shown that Slovenian nurses holding a higher education degree receive very little education in applied research, development work and evidence-based practice (Skela-Savič, et al., 2016a).The obligatory programs for a nursing license have to be expanded to include the understanding of ethics not only in terms of responsibility towards the patients and long-term care residents, but also in terms of responsibility for the development of the profession-that is what nursing care should be like, but it is sadly not.Obligatory educational programs should also include evidencebased practice.

Patient needs and human resource requirements
It has to be carefully considered which knowledge and skills nurses need to meet current patient needs and how human resource requirements should be set to ensure enough patient time and an acceptable quality and safety of patient work.For the past decade, higher education system has produced masters in nursing, but advanced practice positions in healthcare institutions have yet to be systematized although the needs for these positions already exist.Good examples are family medicine reference clinics (FMRCs).Nurses with a higher education degree employed at these clinics are included in postgraduate education modules planned by family physicians.However, these modules are not accredited and therefore do not earn them a higher level of education.According to the ICN guidelines, nurses working in advanced practice should have a master's degree.When we come across the fruits of labor by RNs employed at FMRCs published by family physicians in international and Slovenian journals, these nurses are rarely credited as co-authors and their position is stated as advance nurse practitioner.That is the case in articles, but a master's degree is not a requirement for their position in practice.What is more, few community health centers support RNs working in FMRCs in their efforts to obtain a master's degree in nursing of health promotion.
Evidence-based results must be presented to underline the need for more nursing professionals with a higher education degree.As part of nursing development nursing, nurses should go on strike as a unified occupational group and demand that human resource requirements be increased, that European directives be followed in practice, and that the level of education in nursing be raised, as these measures would lead to a decrease in complications which come with a price.There is more than enough evidence to support these demands.The most recent study by Aiken and colleagues (2017) revealed that, if a nursing team consists of four nurses with a higher education degree and two nurses with a lower education and cares for 25 surgical patients, substituting one nurse with a higher education for a nurse with a lower education increased the patients' odds of dying by 21 %.The study was conducted in Belgium, England, Spain, Switzerland and Finland.And how many nurses with a higher education degree care for 25 surgical patients in Slovenia?After considering this question, we can no longer claim that Slovenian nurses will never go on strike, but we should rather say that they must strike-by doing so, we take the right ethical stance for the provision of high-quality, safe nursing care.A strike would let patients know that they could receive better care if our conditions were similar to those in other countries and if work standards for nurses were comparable to those of physicians.
Slovenia is at the bottom of EU member countries in the percentage of nurses with a higher education degree (OECD, 2013).It is not enough that only a few members of the higher education arena are drawing attention to the fact that although Slovenia's educational system is in line with the European directive for regulated professions, this is not reflected in human resource requirements only in the field of nursing, unlike in medicine, dentistry, midwifery, pharmacy, veterinary medicine, and architecture.After 90 years of existence, RNs are still not the predominant nursing care providers in Slovenian clinical settings.Most nursing care is still conducted by assistant nurses who lack the necessary level of education and professional competencies for the scope and level of difficulty of the work they conduct.In reality, nursing managers drive assistant nurses into exceeding their professional competencies on a daily basis (Skela-Savič, et al., 2016c) by failing to employ enough RNs.Who is responsible for this situation?The answer is provided in a research report by Skela-Savič and colleagues (2017a)-the fact that assistant nurses are exceeding their competencies due to a lack of nurses with a higher education degree was created within the nursing profession itself.An interesting research question therefore emerges: what would the study by Aiken and colleagues (2017) reveal if it was conducted in Slovenia?
The study conducted by Albreht (2005) projects the need for more higher education nursing programs by taking into account only the demographic data for nurses with a higher education degree without considering patient needs.When Slovenia acceded to the EU and the Directive for regulated professions was implemented, nursing managers, higher education managers and the Nurses and Midwives Association of Slovenia (NMAS) failed to explain, based on international research evidence, that the number of higher education nursing programs must be increased and the number of secondary school nursing programs decreased as even then many assistant nurses faced unemployment.Moreover, a divergence began to be seen between nurses with a secondary school degree and a higher education degree when Slovenia entered the EU, and that divergence continues to be felt and is hindering the development of nursing as a profession.We continue to focus on the fifth and seventh levels according to the Slovenian Qualifications Framework, while patient needs call for specialist nurses, masters in nursing, and doctors of nursing practice.Today, Slovenia no longer faces a lack of nurses with a higher education degree; the issue today is that there are not enough systematized positions for these nurses.Systematization of four categories of practitioners (EFN Workforce Committee, 2014) with clearly defined competencies is sorely needed.

Professional title after completed formal education
Another issue related to professionalization of nursing in Slovenia concerns the professional title of this occupational group.The project Nursing as a scientific discipline (Skela-Savič, et al., 2016c) revealed that the term caregiver has low social status, being perceived as less worthy and as such being inappropriate for a nursing care practitioner.In addition, the representatives of secondary healthcare schools did not embrace some new areas of nursing work, such as long-term care.Since 2007, there has been an ongoing debate about the professional title for nurses with a higher education degree which would clearly illustrate the nature of work they conduct.In the last decade, the Slovenian Board for Nursing (SBN) has adopted a different title for this occupational group twice, most recently in 2014 when the adopted title was 'health care practitioner'.This represents only a minor change since this title ('zdravstvenik') has been in use for male nurses since 2004.The Ministry of Health has not yet implemented this proposal by placing it on the list of healthcare professions.
Discussions on the need to rename the professional title have sparked and continue to spark objections.A frequently heard reasoning is that the existing title, 'medical nurse' ('medicinska sestra'), is accepted in Slovenia and there is no need to change it.These arguments show a lack of understanding for the concept of professionalization.After all, even Angela Boškinthe first Slovenian nurse with a higher education degree-had the title 'care nurse' and not 'medical nurse'.As the occupation of nursing undergoes the process of professionalization, we should think about whether the professional title of Slovenian nurses is appropriate for usage of today and tomorrow.Decades ago, medical schools in Slovenia were renamed into healthcare schools, while the professional title of female nurses still holds the word 'medical'.No matter how we try to find evidence in an effort to understand why the professional title cannot be changed, one conclusion can be drawn: caring as the essence of the nursing profession has not been researched enough to withstand expert judgment, in nursing and outside of it, that it is also science.And that is the key problem with nursing as a scientific discipline, if compared to medicine.Both nursing theory and practice have to be developed and compared.We have to stop with the division of theoretical discourse in schools and practical knowledge in the clinical setting.
According to Carvalho (2014), healthcare professions differ from each other primarily in knowledge obtained through research work.Some nurses perceive this new knowledge as a deviation from nursing care and rather opt to support the local context of knowledge in practice.Horton and colleagues (2007) claim that, from a historical perspective, nursing entails the basic tasks of caring for and helping the ill and their families.At the moment, the profession is caught between the provision of care which was historically practiced by less educated 'caregivers' or those who acquired the knowledge, and nursing as a science which is-or should be-practiced by nurses with a higher education degree.Why is the proposed professional title 'graduated nursing practitioner' unacceptable if the occupation is termed nursing care?

Challenges for the future
Several years of research work went into defining, at the strategic level, the national responsibility for the development of nursing as a scientific discipline and the indicators of whether national responsibility is being fulfilled (Skela-Savič, 2017), and the results are published in this issue of the Slovenian Nursing Review.Fulfilling the national responsibility for achieving progress in professionalization of nursing is of utmost importance and must become the priority in the national strategy of nursing development in Slovenia.The defined national responsibility can be fulfilled by responsible managers who possess the knowledge and skills needed to recognize resources and opportunities for meeting the indicators for fulfilling the national responsibility.The goal is professionalization of nursing for high-quality, safe and efficient health care provision.The tools for reaching this goal include systematic research, expert judgment, development of critical thinking, and evidence-based decision making.
The efforts to make research work in nursing established can only be realized through a national institute for research work in nursing which must be founded by the NMAS.It is not reasonable to wait that nursing receives support from other institutions on this issue, especially regarding the current state of healthcare policy in Slovenia.The institute should be funded from membership fees of NMAS members and from calls for application.Such a national research institute will have an 'evidence-based' influence on politics; once it becomes scientifically established, it can obtain public funding for its operations.The institute should follow the maxim expressed in the previously mentioned study: ''The center of development and research work must be the patient'' (Skela-Savič, 2017).
Our professional association is celebrating 90 years of its existence.The national professional association (NMAS) is facing a special challenge: it has to formulate an ambitious and modern vision of development and set down its goals and the strategy for achieving them.A clear vision of development which supports social responsibility and responds to the needs of society calls for a systematic division of funding, a reflection on the current structure, and allocation of funding for research and development.It is crucial to demand a transparency of operations both at the level of the Association and at the level of regional societies.Professional associations must become the engine of professionalization, advocating evidence-based practice and research work.At the level of the national association, a clear distinction between the profession and politics must exist because only nonpartisanism will enable it to function in an evidence-based manner regardless of the political party in power.This is not to say that political activation of nursing professionals is undesired-on the contrary-, but it should take the form of candidacy in national and regional elections.

Final thoughts
As an expert and researcher in nursing and health care, I wish to convey the following message: the development of nursing as a profession and a scientific discipline is becoming increasingly dependent on how it is perceived within the occupational group.There are two distinct dimensions of perceiving nursing which have to coincide-the scientific dimension of nursing care provision and the dimension of reflection on nursing practice.The first provides nurses with a higher education degree with new knowledge to be tested in practice, while the second must serve as an imperative to researchers for scientific investigation and be categorized either in the field of nursing knowledge or, conversely, in the field of non-evidence-based practice.To achieve the latter, every RN must possess the necessary knowledge to understand the importance of research resulting in scientific findings.RNs should support development work in nursing and contribute to the exchange of evidence and findings from practice.That is how nursing will be able to retain the values which have historically shaped its relation to the healthy and the ill, and add the values of scientific knowledge on nursing care, professional development and evidence-based practice.Such a compromise is beneficial, enabling theory and practice to merge into one.A combination of these two dimensions will solidify the position of nursing as a profession and a scientific discipline providing care based on scientific evidence.If nurses with a higher education degree will fail to undertake this task, nursing will become a peripheral supporting service of the healthcare system and get lost in a myriad of those who, in the increasing needs for health and health care provision, will seize the opportunity and become advocates for the needs of the healthy and ill populations.Therefore, we cannot afford to waste time on unproductive squabbles and reproaches on excessive ambitiousness of individuals proposing changes.Instead, we should come together and scientifically substantiate our work-nursing care provision-as was done previously by our forerunners, Florence Nightingale and Angela Boškin, according to the level and understanding of the occupation at the time.