Reports from the EONS Leadership Summit 2017

Better working conditions and patient safety in a challenging workplace

Kristi Rannus, from Estonia, explains that there are a number of aspects to creating a virtuous circle that will bring out the best for nurses and their patients.

Kristi Rannus

Kristi Rannus

The broad picture of a system under strain

A constant challenge for nurses is to work to the high professional standards and regulations which are established, based on the growing health needs of society, and developments in knowledge and technology of health care. On top of this, the big challenge for the whole health care system today is to reorient health sectors toward managing chronic diseases and the special needs of the expanding elderly population. At the same time, a shortage and overloading of the nursing workforce is becoming more and more common in many health care organisations.

Today we have 9149 RN working in the healthcare system in Estonia: that is only seven nurses per 1,000 people. Some 32% of RNs are over 50 years of age, the average age is 45 years, and 98% of RN’s are female. (Sihtasutus Kutsekoda, 2017.) The net monthly salary of nurses is below the average wage in Estonia. (Statistics Estonia, 2017). Due to low income, about 11% nurses have more than one full-time job, and on the average, an estimated 2.5% of working nurses emigrate to another country each year (Sihtasutus Kutsekoda, 2017). This has resulted in 1000 vacant positions in nursing today. Thus, together with the increasing number of new tasks and positions in nursing care there are about 4000 more nurses urgently needed. Then we can talk about optimal ratio of nurses in Estonia, while the average in Europe is 9 nurses per 1,000 people.

The resultant strain on nurses – and possible solutions

These challenges together affect nurses’ motivation as well as their occupational health. Then there is patient safety – you can imagine how many mistakes could be avoided if nurses were well rested and happy within the workplace. Based on my experiences and the literature review, the main solutions for these challenges are workforce planning, training and motivating so that nurses can keep on providing safe, effective and patient-centred care. (Toode, 2015.)

North Estonian Medical Centre

Nursing leaders of the North Estonia Medical Centre Oncology and Haematology Clinic learning how to give positive feedback to each other. It develops communication skills, motivates nurses, and helps to prevent compassion fatigue and burnout syndrome.


Firstly, nurse leaders have to recruit at the right time a sufficient number of appropriate individuals with the right skills (Gopee & Calloway, 2014). In Estonia, this also requires redesign of the workforce. For example, the hospitals need more secretaries and assistants for technical duties, thus saving nurses time (Sihtasutus Kutsekoda, 2017). Also, recruiting social workers, psychologists, dietary nurses and other specialists into the cancer team allows all team members to focus on their own duties and provide together more comprehensive and interdisciplinary cancer cure and care. Sometimes a redesign also means more staff nurses and reorganisation of their tasks. For example, in the North Estonia Medical Centre in chemotherapy and haematology inpatient wards, there are more nurses on day shifts compared with general medical wards because cancer patients need more attention from nurses.

While oncology nursing is not recognised as a specialty in Estonia, nurse leaders have to fight for fair wages for them in order to improve the image and attractiveness of the profession. This can only be achieved by presenting empirical data about nurses’ work (e.g. intensity, emergency rate, bed occupancy, etc.). (That is how we got 10% higher salaries for nurses working in chemotherapy and hematology wards in our hospital in 2017.)


Secondly, nurse leaders need to invest more in the future workforce by developing training programmes and by training more nurses. In Estonia, about 400 nurses graduate each year with the applied higher education in nursing. This is not enough if we are to increase the number to nine nurses per 1,000 people by 2025 (Sihtasutus Kutsekoda, 2017). Therefore, in 2016 five stakeholders signed a joint resolution with a goal to increase the number of study places to 517 by year 2020 in Estonia.

We also need more nurse specialists with a Master’s degree. To achieve this, the nurse specialist masters programme has just been developed and submitted for approval to the Ministry of Education and Research. In addition, it is necessary to distinguish the competences of nurses and specialised nurses (Sihtasutus Kutsekoda, 2017). Currently, the Estonian Nurses Union is working on the establishment of the competencies for nurses and specialised nurses. Alongside professional skills, nurses need better skills and additional knowledge about communication (including standardised nursing language), leadership and technology (Gopee & Calloway, 2014; Sihtasutus Kutsekoda, 2017).


Thirdly, for maintaining and solidifying nurses’ work motivation, nurses need some key things from nurse leaders:

  • support for their self-actualisation and achievements
  • to be valued by the whole organisation
  • more professional training
  • autonomy
  • good teamwork in and across the units
  • a good patient safety culture, and
  • good support structures.

Despite the challenging workplace, Estonian hospital nurses have indicated strong intrinsic work motivation (Fig. 1).

Figure 1. Hospital nurses’ distribution (%) by the responses to items of intrinsic work motivation (Toode, 2015).

Figure 1. Hospital nurses’ distribution (%) by the responses to items of intrinsic work motivation (Toode, 2015).

Therefore, when it comes to motivating nurses, the emphasis should be on their own intrinsic reasons why they are doing this job. It is nurse leaders’ responsibility to provide better working conditions and workplace characteristics in order to sustain and increase such inner motivation. Not only that, the intrinsically motivated nurses are better in helping patients in the most safe and effective manner, and a good patient safety culture in the organisation increases nurses’ intrinsic work motivation in turn. (Toode, 2015). In conclusion, it’s all just a matter of perspective! The way we see things affects our thinking, which affects our decisions and actions.

It’s all just a matter of perspective!

It’s all just a matter of perspective!

Kristi Rannus is Head Nurse of the Oncology and Hematology Clinic in the North Estonia Medical Centre & Docent in the Tallinn Health Care College.