13.1.1. Sweden and its health system

Sweden is a Northern European country with a consti-tutional monarchy and a parliamentary government (Anell, Glenngård & Merkur, 2012) and a total population of 10 million (Eurostat, 2017). Cornerstones of the Swedish health care system are the principles of human dignity, need and solidarity, and cost-effectiveness, with an emphasis on equal access to care regardless of socioeconomic status or geographic location. This principle is mirrored in the organization of health care in Sweden at three independent governmental levels: national government, county councils/health care regions and municipalities. Overall goals and policies are set at the national level by the Ministry of Health and Social Affairs, while county councils are responsible for the development, organization and provision of health care for residents in their respective regions. The county councils’ responsibility for planning also includes health services provided by other actors, such as private practitioners and physicians in occupational medicine (Anell, Glenngård & Merkur, 2012). In addition to Sweden’s seventeen county councils, there are also four health care regions with the same functions and responsibilities as the county councils (Anell, Glenngård & Merkur, 2012). National health care spending totals 11.0% of gross domestic product, or US$5 488 per capita (OECD, 2017).

The Health and Medical Services Act (Hälso- och Sjukvårdslag (SFS 2017:30)) forms the basis for the organization of responsibilities between county councils/health care regions and municipalities. The county councils mainly provide hospital/inpatient care and primary/ambulatory care, while 290 municipalities are responsible for nursing-home care, social services and the housing needs of the elderly, as well as care for the physically and intellectually disabled. The responsibility for home medical services in regular housing, i.e. home nursing, has been changing from being mainly the domain of the county councils to becoming a responsibility for municipalities instead (Szebehely & Trydegård, 2011) – this is now the case in 90% of the 290 municipalities (Socialstyrelsen, 2017). In 1992 a major reform took place, known as the ÄDEL-reform, which changed responsibility for long-term inpatient health care and care for the elderly from county councils to municipalities (Anell, Glenngård & Merkur, 2012). As a result of this shift in responsibility, a new Registered Nurse function (Medicinskt ansvarig sjuksköterska) was instated in the municipalities with responsibility for maintaining patient safety and quality of care in all the municipal health care services (Hälso- och Sjukvårdslag (SFS 2017:30)). The county councils and municipalities enjoy a high degree of self-governance; this results in different practices depending on the political composition of the representatives on each county council board, on the specific health care needs of the residents, and on the health care infrastructure in the area (Palier, 2006).

13.1.2. Regulation and legislation of the nursing profession

The National Board of Health and Welfare (NBHW) is responsible for the registration and licensing of registered nurses and other licensed professions in health care. The licence does not have a time limit, meaning that health care personnel do not have to reapply to maintain their licence (Anell, Glenngård & Merkur, 2012). The NBHW can revoke a licence to practise and/or other authorization or invoke a trial period of three years in the case of malpractice. In nursing, licensure is granted for registered nurses, midwives and radiology nurses. Licensure is applied for by the individual nurse, after successfully completing education, and granted without further requirements. Nurse specialists, for example in surgery, anaesthesia and intensive care, do not have specific licensure. However, the registered nurse title is a ‘protected professional title’ in Sweden, and can only be used by those with particular qualifications. Eleven different nurse specialties also are considered to have ‘protected professional titles’ (see below). The right to use the title of registered nurse or specialized nurse is also applied for by the individual nurse and granted by the NBHW when applicants demonstrate appropriate qualifications.

Under Swedish law, all health care staff must work in accordance with scientific knowledge and proven experience of practice (Patientsäkerhetslag (SFS 2010:659)). This means that research results and extensive clinical experience should guide the delivery of health care in Sweden. The NBHW publishes evidence-based guidelines and recommendations for practice for health care professions, including registered nurses and midwives, to make delivery of health care as equal and safe as possible throughout the country. These guidelines and recommendations are produced in collaboration with, among others, the Swedish Council on Technology Assessment in Health Care. The Swedish Higher Education Authority reviews the quality of higher education, including nursing education, and ensures that higher education institutions comply with relevant legislation, based on the Higher Education Act (Högskolelag (SFS 1992:1434)) and the Higher Education Ordinance (Högskoleförordning (SFS 1993:100)). The Authority reviews the quality of higher education in four-year cycles and can revoke the accreditation of a particular educational programme which does not meet the quality standards at a university or university college (Swedish Higher Education Authority, 2018b).

13.1.3. Nurse education

13.2.1. Composition and configuration

According to OECD (2017), in 2015 the number of practising nurses per 1 000 population was 11.1, and the ratio of nurses to physicians was 2.7, which is just below the OECD average. Among the Nordic countries, Sweden has the lowest number of registered nurses per 1 000 population and the increase of registered nurses per 1 000 population was only 12% between the years 2000 and 2015, compared to both Finland and Denmark where the number of registered nurses increased by 35% and 37% respectively (OECD, 2017).

During the past two decades the composition of the nursing workforce under the control of Swedish county councils has changed. In 1993 registered nurses made up 57% of the total nursing workforce, while nurse aides and assistant/practical nurses made up the rest. In 2007 the proportion of registered nurses had increased to 71%, due to a decrease predominantly in nurse aides (Sveriges Kommuner och Landsting, 2011). The proportion of assistant nurses has remained fairly stable during this period. In the municipalities the composition patterns are similar, except for a slight decrease in the total workforce, which might be due to privatization of the health care provided by municipalities. Palier (2006) argues that the increased proportion of registered nurses may in part be a means of better meeting challenges related to demographic changes with an increasing ageing population and technological developments in the health care sector.

In the period 2000–2015 there has been little change in the distribution of registered nurses among geographic regions, with all regions increasing the number of registered nurses per 100 000 inhabitants (Socialstyrelsen, 2018a). The overall number of registered nurses per 100 000 inhabitants working in health care increased by 12% during this period. The range of registered nurses per 100 000 inhabitants across the country in 2017 ranged from 965 in Södermanland county in the population-dense southeast of the country to 1 392 in the relatively rural Västerbotten county in northern Sweden. The nurse-to-physician ratio in Sweden is 2.7 (OECD, 2017) while the nurse-to-patient ratio was just over 7 patients per registered nurse involved in direct patient care according to the RN4CAST Swedish data (Sermeus et al., 2011).

The total number of employed licensed registered nurses in Sweden has increased by 13%, from just over 110 000 in 2005 to approximately 123 000 in 2015 (Socialstyrelsen, 2018c). Male registered nurses have increased from 10% in 2005 to 12% in 2015, from approximately 11 100 to 14 600 (Socialstyrelsen, 2018c). The median age range of registered nurses in both public and private health care is 45–49 years old for women, with male registered nurses slightly younger, 40–44 (Statistiska Centralbyrån, 2018). In 2015, 4 754 licences were granted by the NBHW. Of these, 85% received their nursing education in Sweden, and 13% had an education from within the EU/EEA area (Socialstyrelsen, 2018b).

Registered nurse employment in Sweden in 2015 was approximately 64% (of the total population of licensed registered nurses, including those unemployed, retired, etc.) and of those, most registered nurses work in health care (69%) or in care and social services (14%), and approximately 5% work within education or administration (Socialstyrelsen, 2018c). The proportion of male and female registered nurses is equal between the public and private sectors, with 12–13% men in both sectors (Socialstyrelsen, 2018c). From 2004 to 2015 the largest increase in employment was for male registered nurses, with a 40% increase in the nine years, compared to female registered nurses (12% in the same period) (Socialstyrelsen, 2018c). The International Council of Nurses reports an unemployment rate of less than 1% among registered nurses in 2015 (International Council of Nurses, 2015). For women in general, national unemployment in 2015 was 7.2% compared to 7.5% for men (Statistiska Centralbyrån, 2016). According to the report from the International Council of Nurses, 86% of the members of the nurses union, the Swedish Association of Health Professionals, were employed full-time (35 hours or more per week) in 2015, while 16% were employed part-time (International Council of Nurses, 2015). National statistics from 2017 show that among all professions employed in the health care sector (both public and private, both men and women), 65% work full-time and 35% part-time (Statistiska Centralbyrån, 2018).

13.2.2. Deployment and skill-mix models

The Swedish labour market is regulated both through law and through collective bargaining between employers and unions. The collective agreement for registered nurses employed by county councils and municipalities states that full-time employment, in which the ordinary work week extends over the weekend, consists of 38.25 hours per week compared to the legally stated full-time work week of 40 hours/week in the labour market as a whole (Sveriges Kommuner och Landsting, 2017). For registered nurses working night shifts as well as day or evening shifts, i.e. three-shift employment, full-time working time is 34.33 hours per week (Sveriges Kommuner och Landsting, 2017). Staffing levels are the responsibility of the regional authorities, and are often delegated to hospital or departmental level.

13.2.3. Career structures

Apart from career paths offered through further specialization in nursing, there are no national regulations, guidelines or plans for structuring registered nurses’ careers. Each county council and municipality has its own staffing policies and it is up to each specific health care institution to decide upon career structures in different professions.

In many county councils and municipalities there is a trend towards having positions for registered nurses which require some continuing education, such as registered nurse-led ‘clinics’ for patients with diabetes, chronic obstructive pulmonary disease or congestive heart failure (Nolte & McKee, 2008). In other cases, continued education as a registered nurse does not guarantee either a new set of responsibilities or an automatic increase in salary. In the Swedish RN4CAST data just over 60% of the approximately 11 000 registered nurses participating in the study reported having a bachelor of science in nursing. The proportion of registered nurses with a PhD was approximately 1% in 2010 (Hermansson, 2010). There is currently no common infrastructure in place within the health care system as a whole to systematize benefits from the higher level of education in the registered nurse workforce; instead, how registered nurses with advanced degrees are used in health care is ad hoc, differing on county council, hospital and even departmental levels.

Some local initiatives have been made to introduce the role of advanced practice nurse (APN) in Sweden. There was, for example, an educational programme at master’s level at the University College of Skövde, in which five registered nurses specialized in advanced nursing practice (Hallman & Gillsjö, 2005). These advanced practice nurses graduated in 2005 and took up qualified positions in primary care, taking care of children and adult patients with chronic infections, skin problems and chronic conditions leading to impairment (Fagerström, 2011; Lindblad et al., 2010). After the Skövde-programme ended, the University of Linköping introduced an educational programme in advanced nursing practice for surgical care (Linköpings Universitet, 2018).

13.2.4. Planning mechanisms

There are a number of agencies involved in producing data and information on health care workforce planning and forecasting. Sweden uses both integrated workforce planning and separate planning by professional group. At one level, projections are made by Statistics Sweden, encompassing the whole of the labour market. At another level, projections are made by the NBHW after analysing the supply of and demand for physicians, registered nurses, midwives, dentists and dental hygienists in the health care sector (Socialstyrelsen, 2018a). While gender equality is prioritized in many areas of national and regional policy-making, it is not specifically addressed in national health care workforce planning. The Swedish Higher Education Authority is responsible for analysing supply from education and the balance between the number of graduated registered nurses and the corresponding demand.

An annual report from Statistics Sweden shows that in 2017 the shortage of newly educated as well as experienced registered nurses with basic nursing education has increased, with around 80% of employers reporting difficulties in recruitment (Statistiska Centralbyrån, 2017). The shortage of specialist registered nurses is also increasing rapidly (Statistiska Centralbyrån, 2017) despite efforts to increase educational seats and facilitating ways for registered nurses to further educate themselves (Socialdepartementet, 2017). Most county councils currently offer, to some extent, paid specialist education depending on regional shortages of certain specialist registered nurse groups (Socialstyrelsen, 2018a).

13.2.5. Mobility

During the past decade the mobility of health care professionals to and from Sweden has increased, primarily among newly licensed physicians where 59% in 2015 had been educated in another country. The comparable figure for registered nurses is 15% (Socialstyrelsen, 2018b).

13.3.1. Working conditions

The Swedish labour market builds upon principles of collective agreement between representatives of employers and employees in a centralized bargaining process. The main components of wages and working conditions in Swedish health care are partly regulated by law and partly determined in central negotiations between the employer associations and the different health care professional unions. Working conditions regulated by law are, for example, employment security (Lag om anställningsskydd (SFS 1982:80)), rules for annual leave (Semesterlag (SFS 1977:480)), working hours (Arbetstidslag (SFS 1982:673)), parental leave (Föräldraledighetslag (SFS 1995:584)), work environment (Arbetsmiljölag (SFS 1977:1160)), right to staff participation (Lag om medbestämmande i arbetslivet (SFS 1976:580)), and rules for the protection of unions and their elected representatives in the workplace (Lag om facklig förtroendemans ställning på arbetsplatsen (SFS 1974:358)). Conditions regulated by central bargaining agreements include, for example, salary increases, compensation for working ‘unsocial hours’ (Gustafsson, 2017), complementary rules for employment, increased staff participation and influence, and collective insurance policies. The different laws form the basis for negotiation in the collective agreements.

The county councils and municipalities are represented by the Swedish Association of Local Authorities and Regions (SALAR) at the national level. SALAR functions as the employers’ central association for negotiating wages and terms of employment for personnel employed by the county councils and municipalities. SALAR represents the largest employers in Sweden, with more than 1 million employees in 2015, and about one third of these are employed in the health care sector (Sveriges Kommuner och Landsting, 2016).

The majority of Swedish health care personnel are members of labour unions. The Swedish Association of Health Professionals represents registered nurses, midwives, radiology nurses and biomedical scientists in the central bargaining process.

In Sweden the average gross salary for a registered nurse with basic education in 2016, excluding managers and leaders, was approximately SEK 31 850 (about €3 100) within the county councils and approximately SEK 32 575 (about €3 300) in the municipalities (Statistiska Centralbyrån, 2017). Sweden employs a wage negotiation system where the norms for employees in the public sector, including registered nurses, are based on wage norms for Swedish-based industries which compete in the international market (Konjunkturinstitutet, 2017).

In the Swedish RN4CAST data, it was found that approximately 61% of the surveyed registered nurses reported almost never (a few times a year or less) feeling burned-out from their work. In a survey undertaken in 2011 by the NBHW, registered nurses working full-time or more reported being satisfied with the number of hours they worked rather than wanting to work less (Socialstyrelsen, 2011). According to the Swedish RN4CAST data, the majority of registered nurses surveyed (57%) reported being moderately satisfied with their current job. Most registered nurses (66%) who participated in the Swedish RN4CAST survey reported having no intention of leaving their current job within the next year due to dissatisfaction.

13.3.2. Governance and leadership

Due to the high degree of local governance within the county councils and municipalities, the organizational structure of nurses in leadership positions varies across the country. Until the late 1990s only physicians were allowed to have positions as head of a health care unit or facility. In 1997 this regulation changed, making it possible for health care professionals other than physicians to become the head of a health care unit or facility (Hälso- och Sjukvårdslag (SFS 2017:30)). In 2005 approximately one third of all clinical directors in Swedish public hospitals were non-physicians, and 40% of primary care health centres were run by registered nurses (Granestrand, 2005).