8.1.1. The Netherlands and its health system

The Netherlands is a Western European country with a population of 17.08 million (Eurostat, 2017). The Dutch political system is a parliamentary democracy. The health care system in the Netherlands is rooted in the ‘Bismarckian’ social insurance tradition, in which there exists a mandatory social insurance for all citizens. In 1967 a social insurance scheme replaced subsidies to inpatient long-term care, mental health and disability services. This system remained unchanged until the health care reform of 2006, which can be seen as a further refinement of the old Bismarckian system. The reform introduced a single compulsory insurance scheme for essential curative care, in which multiple private health insurers compete for insured persons. This reform has radically changed the roles of actors in the health care sector, in particular the roles of health insurers and patients. Supervision and management of the system have been largely delegated from the government to independent bodies. The organization of social support has become a municipal responsibility (Schäffer et al., 2010). The role of the government changed from direct control of volumes, prices and productive capacity to setting the ‘rules of the game’ and overseeing whether markets are working. The government controls the quality, accessibility and affordability of health care. This leaves health care insurers and health care providers as the market players. In the health care purchasing market health insurers can negotiate with providers on price, volume and quality of care. In the health care provision market, providers offer care to patients. In principle, patients are free to choose their provider. However, health insurers may impose restrictions upon freedom of choice (Schäffer et al., 2010). Between 1998 and 2007 health expenditure increased in real terms by 38%. Health care spending nowadays totals 10.5% of gross domestic product, or US$5 385 per capita (OECD, 2017).

8.1.2. Regulation and legislation of the nursing profession

The 1993 Individual Health Care Professions Act (BIG) regulated the registration and licensing of health professionals in the Netherlands. According to the Act, anyone holding a licence (from the respective professional association) and BIG registration, whether or not they are a Dutch national, was allowed to practise in the field of health care, taking into account 1) stipulated restrictions and 2) protected professional or academic titles. Stipulated restrictions are reserved acts that may only be performed by physicians or other groups of designated professionals. This list describes potentially high-risk actions, which require a high level of competence. Protected professional or academic titles as in Articles 3–33 of the Act specify the professions to which a system of registration and professional title protection applies. These professions are required to comply with legal educational standards and are included in the so-called BIG register (discussed below), which is an instrument of the Act. A sanction specified in the Act is disqualification from practising (Schäffer et al., 2010).

The BIG register contains well over 350 000 health care providers (November 2015). Any citizen can access this register by telephone or via the Internet to check the competence of a care provider. In addition to proof of registration, the register provides information, for example on whether physicians or nurses are specialized in certain areas, or whether a health care provider is suspended under a disciplinary law. In January 2009 five-yearly re-registration was introduced. The register includes physicians, dentists, nurses, physiotherapists, midwives, psychotherapists, health care psychologists and pharmacists (Schäffer et al., 2010). Enrolled nurses are not included in this register. To remain on the register, health care professionals are required to have worked at least 2 080 hours or have undertaken the equivalent in educational and professional development.

Traditionally, quality improvement among Dutch health care providers has been largely self-regulated. This began to change with the Care Institutions Quality Act of 1995, which offered a simple framework for quality assurance and improvement. The Act mandated that every profession or organization in health care set its own standards for optimal care; develop strategies for monitoring and improving care; and create systems to enable public reporting to the health care inspectorate. The first major movement to improve quality in the Netherlands focused on the development of national clinical guidelines. This initiative was spearheaded by the Dutch Institute for Health Care Improvement, which stimulated the development of multidisciplinary guidelines in 1983, and the Dutch College of Family Physicians (Nederlands Huisartsen Genootschap), which supported the development of primary care guidelines in 1987. Organizations of medical specialists, nurses, allied health workers and mental health professionals began to develop their own guidelines in the mid-1990s. A large body of guidelines has since been developed and is regularly updated, mainly through systematic and rigorous evidence-based procedures (Grol, 2001). Educational materials and tools have been developed to supplement these guidelines. Furthermore, specific indicators to monitor adherence to the primary care guideline recommendations have been developed and rigorously tested (Grol, 2006).

8.1.3. Nurse education

8.2.1. Composition and configuration

According to OECD (2017), in 2015 the number of practising nurses per 1 000 population was 10.5, and the ratio of nurses to physicians was 3.0. General hospitals and university medical centres have 1.22 and 1.50 full-time equivalent (FTE) nurses per hospital bed respectively (Vandermeulen, 2010).

In 2010 almost 258 000 nurses were BIG registered, but by 2015 this number had decreased to 188 163 BIG-registered nurses. The decrease can be explained by the first re-registration round after more than five years of being registered in 2014, whereas previously registration was ‘for life’. Intermediate-educated nurses are on average slightly older compared to nurses educated to a higher level; their mean age is 43 years compared to 38 years. Intermediate-educated nurses have been working for the same employer on average for 13.2 years and higher-educated nurses for almost nine years, possibly reflecting average age differences. An estimated two thirds of registered nurses work in a care or welfare setting (Smeets, Albers-Haye & Van der Windt, 2010).

The precise number of enrolled nurses working is not known. Based on estimates, there were about 150 000 enrolled nurses working in 2009. This estimate does not include temporary and independent workers. Approximately 27 900 enrolled nurses were working in home care, 97 100 in nursing homes, 5 100 in hospitals, 1 900 in mental health care, 13 200 in care for the disabled and 5 000 in other care and welfare organizations (Van der Windt, Smeets & Arnold, 2009; www.nu91-leden.nl). The number of enrolled nurses in the job, however, is decreasing and was estimated at about 110 000 by Van der Velden et al. (2013). The mean age of enrolled nurses is 42 years and they work on average almost 11 years for the same employer. Enrolled nurses form the largest group of nurses.

The turnover of nurses leaving their employment (all fields) has decreased significantly. For example, in 2004, 10.1% of nurses left their hospital employment, while in 2010 this was only 4.0%. Almost 90% of the hospital nurses and mental health nurses who left their employer in 2010 continued to work in their own field. Almost 5% of the nurses employed in home care left their job in 2011, and in the nursing homes this figure was almost 4% (AZWinfo, 2014).

The percentage of part-time workers in hospitals increased between 2005 and 2009, from 40% to 42% (Vandermeulen, 2010). The average working hours of part-time workers in general hospitals have been rather stable, with a mean of working hours of 74% of a full-time job in 2012. In the academic medical centres and in nursing homes this was respectively 82% and 63% (AZWinfo, 2014). Nurses working part-time are far more satisfied with the opportunities they have to combine work and their personal lives than nurses working full‑time.

At first sight, geographical inequalities in health care labour supply appear to be of minor importance in a small country such as the Netherlands. However, regional differences in demographic development have an increasing impact on the demand for health services. Some regions are ageing rapidly and face a relatively rapid decline in the population. The composition of the largest Dutch cities has also been changing in recent years and is expected to continue to change, most notably in terms of rising shares of foreign-born citizens and single households. These developments have led to a growing geographical variation in the demand for health services (Schäffer et al., 2010).

It is expected that shortages will develop, particularly in the most densely populated parts of the country, particularly the western part of the country, with larger cities such as Amsterdam, Rotterdam, The Hague and Utrecht (Van der Windt, Smeets & Arnold, 2009).

8.2.2. Deployment and skill-mix models

Labour market issues are complicated by an increasing demand for nurses to take on medical tasks. A major issue which has been discussed for many years is the lack of clarity over which training level is required for which level of intensity or complexity of nursing care. This issue has remained largely unresolved within the Netherlands, thus complicating the calculation of workforce planning needs. There are clear profiles and levels of practice available for nurses and enrolled nurses, but these are not really implemented in practice.

Potential solutions for shortages assume greater importance with shortages looming. Investing in the attractiveness of the profession and the quality of the practice environment, clearly defining training levels matched with staff profiles, investing in technology, increasing patient self-management and the retention of older nurses are all promoted as relevant options (Prismant, 2011).

One trend that affects health care professions is commonly called ‘substitution’. This can be defined as (partial) ‘vertical’ transfer of tasks from doctors to nurses, and ‘horizontal’ task reallocation between groups of health care workers. Substitution is mainly driven by efficiency, but can also be seen as inevitable in order to cope with the increasing physician workload. New occupations such as practice nurses, nurse practitioners, nurse specialists and physician assistants have been trained to fill the gap between physicians (specialists and GPs) and nurses (Schäffer et al., 2010).

8.2.3. Career structures

There are several opportunities for continuing education following general nurse education. Some choose to specialize, for example, in intensive care nursing, paediatric nursing or geriatric nursing.

All registered nurses can apply for specialist training courses (post-basic nurse training). These are designed to develop their competences and skills through a mix of theoretical and clinical training.

Nurses from the higher levels with relevant experience can become nurse specialists. This is a newly recognized segment of the profession laid down in the Individual Health Care Professions Act. Nurse specialists are qualified to treat specific groups of patients independently, such as those individuals who are chronically ill. Nurse specialists play an important role in carrying out tasks that have historically been performed by physicians. The most important requirement for becoming a nurse specialist is a diploma from a recognized master’s level course (Schäffer et al., 2010).

More than half of nurses and enrolled nurses (57%) have followed additional training (mostly including a final test) in the past. Normally this has been voluntary, and overall 79% of enrolled nurses undertook work-based training. Short vocational training courses are more common: 84% of nurses and enrolled nurses (carers) followed some form of short training. Two thirds of nurses and enrolled nurses are satisfied with the training provided by their employer. Almost 40% are (very) satisfied with their career prospects, but 16% report dissatisfaction (De Veer, Spreeuwenberg & Francke, 2009).

For management roles, there are two possibilities. A slow route can be followed by part-time training and several short courses. A faster route involves following a university master’s degree that specializes in areas such as policy, management, and health or health sciences. These degree programmes help to prepare students for senior positions in health care, as well as other positions in health policy, education or the human resources departments in health care institutions.

8.2.4. Planning mechanisms

According to Dutch Hospital Data (the official data management of self-registration by Dutch hospitals), the number of nurses per bed is an important indicator of acuity and care intensity. Other indicators need to be developed and explored because of changing productivity structures in hospitals. New indicators, such as the number of care personnel per bed, should be reproducible to monitor the intensity of care required (Vandermeulen, 2010).

Shortages in the Dutch health care workforce alarm policy-makers, the media and patients organizations alike. Suggestions regarding possible initiatives to avert staff shortages are provided through the Care Innovation Platform. This platform describes three important trends and the search for solutions resulting from:

• the increasing demand for care (for an ageing population);
• the decrease of the labour force (through ageing); and
• an increasingly diverse labour supply (because of demographic and social-cultural change.

For the Nursing and Welfare sector there exists a research programme called ‘Labour-market Care and Welfare’ (Van der Windt & Bloemendaal, 2015), through which national, regional and local organizations can monitor relevant labour market developments and in which forecasts are made on the balance between supply and demand for several types of nursing care professional. This system is an initiative utilized by different organizations in the sector.

The ‘Labour-market Care and Welfare’ research programme has undertaken a supply and demand analysis, based on some assumptions which include: current workforce, employment trends, available resources and expected growth, turn-over of employees, the part-time factor, sick leave, education, and opportunities in other branches of the sector.

Two scenarios for the period 2005–2019 have been highlighted. Both scenarios show that there will be sufficient enrolled nurses and carers to meet the current demands, but that a shortage of higher-educated nurses is to be expected. This concerns nurses educated at both bachelor and master’s levels. One of the main causes of this expected shortage is the tendency for patients to be treated on an ambulatory basis as much as possible, while length of stay in hospital (or other institutions) is reduced. The remaining patients in the institutions demand more complex care from all health professionals. At the same time extramural patients are often in a more complex situation compared to the past, and are therefore also demanding more complex care, and higher-educated professionals (Van der Windt & Bloemendaal, 2015).

8.2.5. Mobility

The Netherlands has experienced frequent shortages of nurses from the Second World War onwards. One way of compensating for these shortages has been recruitment from abroad. Precise numbers are not known but the inflow of foreign-trained nurses has been quite low and even showed a drop between 1996 and 2000. Despite the shortages, international migration into Dutch health care has never been large. The most important reason is that of language, since nurses are required to speak Dutch. Furthermore, this may also be exacerbated by the fact that most EU countries experience shortages, which creates competition for recruiting nurses from abroad (De Veer, Den Ouden & Francke, 2004). Increased demand for recruitment from abroad is very likely for long-term facilities and home care, since these areas are where the shortages will be most serious.

Several studies show that foreign nurses in the Netherlands are generally treated well by their employer. Unfortunately, it is also true that foreign nurses often work below their skill and qualification levels. Such nurses often work as enrolled nurses. The most important reason for this is that the largest shortages occur in care for the elderly.

8.3.1. Working conditions

By law there are a number of responsibilities that Dutch employers must adhere to. These include the Minimum Wage Act, the Collective Agreement Act and the Minimum Holiday Allowance Act. There are also legal regulations on the timely payment of salaries, disability and holiday entitlement. In addition, working conditions and safety measures are recorded in law. According to the collective agreement for health and welfare personnel, the maximum full-time hours are 36 hours a week. The employer determines working hours, in accordance with the law. According to the collective agreements of general hospitals, academic medical centres, long-term care facilities/nursing homes and home care, health care employees are entitled to an additional bonus because of their irregular working times. For example, if an individual works between 2000 and 0800 hours, the bonus can range from 22% to 60% of their basic salary (www.loonwijzer.nl; SOVVT, 2010).

In recent years health care institutions have increased their focus on working conditions for health care personnel. Unfortunately, a quarter of hospitals and long-term facilities do not protect their employees against physical overload, aggression and violence. Furthermore, a quarter of hospitals are poorly equipped to deal with risks to personnel regarding toxic substances. Working conditions are regarded as fair in more than half of hospitals (De Veer & Francke, 2010; De Veer, Spreeuwenberg & Francke, 2009; De Veer, Verkaik & Francke, 2010; Harrington, 2001; Peters & De Rijk, 2007).

Nursing wages in the Netherlands are comparable to other Western European countries. The salary of Dutch enrolled nurses is between €1 510 and €2 480 gross per calendar month, depending on the institution, work experience and the collective agreement. The salary of Dutch nurses is between €1 900 and €2 900 gross per calendar month, based on a full-time contract.

Recent research has highlighted that career prospects for Dutch nurses are very important. Nurses feel the need to develop their profession. In contrast, results from Prismant (the Dutch expert centre for transparency in health care) show how the lack of career opportunities for enrolled nurses and nursing personnel leads to individuals leaving the profession. One out of three nurses leaving says that a lack of career opportunities was their main reason for leaving (Schalkwijk & Looijenga, 2009). Role and task differentiation, stimulated by the Ministry of Health, Welfare and Sports, could reduce the numbers of nurses leaving the profession. The introduction of nurse specialists through the master’s degree is one such example, as are nurse practitioners and physician assistants.

Role differentiation and task reallocation in nursing both give perspectives on (horizontal) career opportunities. Better career perspectives affect the attractiveness of the nursing profession in a positive way. Otherwise, good career prospects in organizations are of strategic importance for both individual health care workers and institutions.

Research shows that personnel who report higher work demands, lower autonomy and/or less social support on the job are less satisfied with working in day–evening and night shifts (Peters & De Rijk, 2007).

The number of extra contractual hours worked and other work circumstances influence the experience of workload. Nurses and enrolled nurses who are more satisfied with their workload consider the quality of care given by their team is better, they feel more appreciated by their managers, and experience a greater sense of authority at work than those who are less satisfied with their workload (De Veer, Spreeuwenberg & Francke, 2009). Reduced job satisfaction, an increased tendency to leave the job and burnout are also associated with increased workload (Harrington, 2001).

One in ten nurses and enrolled nurses report their work is too busy, more than half of them (55%) feel their work is busy, and 32% evaluate their work as neither busy nor quiet. ‘Feeling busy’ is most present in enrolled nurses in nursing homes. Almost 30% work overtime (most of whom indicate because of busyness), and 41% indicated that their work was influenced negatively because of workload. Almost 40% of nurses and enrolled nurses reported that steps had been taken to reduce their workload. When nurses experience a high workload, the risk of burnout, or leaving the setting, is significant. These situations are to be avoided wherever possible, especially as the labour market tightens (De Veer, Spreeuwenberg & Francke, 2009).

Research among more than 4 000 health care workers showed that 15% ran the risk of burnout in the foreseeable future. In addition, 7% were already on sick leave because of symptoms of burnout (Schaufeli & Van Dierendonck, 1995).

A study among European nurses shows that intention to leave (ITL) in the profession is prevalent across Europe, with several countries scoring ITL above 15%. In the Netherlands only 10.4% of the nurses reported an intention to leave the profession (Estryn-Béhar et al., 2007; Heinen et al., 2013).

A Nursing Panel (a group of nurses who have filled out questionnaires) shows that nurses and enrolled nurses in general are very positive about their work. Eight out of ten are proud to work in a health care setting. Extra focus on appreciation by the employer, career perspectives, workload, discussions within the team, and control by management can all impact job satisfaction (De Veer, Verkaik & Francke, 2010).

By the same token, nurses and enrolled nurses are dissatisfied with the lack of appreciation by their employer (Volkskrant, 2010).

8.3.2. Governance and leadership

Nurses’ participation in governance arrangements in the Netherlands is rare. In general, health care facilities have a number of advisory boards to inform the decisions of its chief executives. These boards formulate and implement the general policy of the institution. A works council advises on issues of importance to all employees, such as working conditions and training. In addition, there is often a separate medical committee dedicated to medical staffing issues and general medical policy. It is important that health care professionals have influence on policy at all levels. Therefore, nurses and enrolled nurses are essential to providing advice to determine policy.

In Dutch health care nurses are not part of management in most institutions. A nurse advisory council (VAR) comprising nurses and enrolled nurses can help to contribute to general policy. In practice, such nurse advisory councils act as a permanent committee of the works council.

As the name implies, the VAR is an advisory body to the management or board of directors of the health care institution. VARs can give professional advice from a nursing perspective to the management or board of directors to help improve the quality of care. Given this advisory role, VARs help to provide a voice for nursing staff whilst simultaneously helping to encourage professional development.

VARs can help improve quality of care by promoting policies that better reflect professional practice, a greater commitment of health care professionals within the organization, and broadening the base for new policies. Furthermore, VARs provide the vehicle for quality improvement by optimal utilization of nursing expertise already present in the organization. In practice, 65–70% of VAR advice is accepted by the board of directors.

However, VARs have no legal power or status and employers are not obliged to establish a VAR. In the Netherlands several professional associations for nurses and enrolled nurses exist. The Dutch Association of Nurses and Carers (V&VN) is an important professional association for nurses and enrolled nurses. One of its main goals is to ensure that its members can work effectively in their role. It is important to work in a congenial, supportive environment and to be proud of the profession. V&VN tries to ensure that the numbers of nurses and enrolled nurses is adequate, well prepared and educated. In addition, the voice of the V&VN is an important dimension in major policy decisions. V&VN describes quality of care and offers ways of promoting it. Finally, V&VN aims to help to strengthen the position of the nursing profession (2010a).