Observation (CEACR) - adopted 2020, published 109th ILC session (2021)

Nursing Personnel Convention, 1977 (No. 149) - Greece (Ratification: 1987)

The Committee takes note of the supplementary information provided by the Government in light of the decision adopted by the Governing Body at its 338th Session (June 2020). The Committee proceeded with the examination of the application of the Convention on the basis of the supplementary information received from the Government this year, as well as on the basis of the information at its disposal in 2019.

The Committee takes note of the observations of the Greek General Confederation of Labour (GSEE) received on 3 September 2019. The Committee requests the Government to provide its comments in this respect.

Article 2 of the Convention. Formulation and implementation of a nursing services and personnel policy. Nursing education and training. The Committee recalls that, in its previous report, the Government had indicated that a national health strategy was being developed and that a bill concerning reform to primary health care had been submitted to the Parliament. The Government reports on a series of labour law provisions adopted since 2013, indicating that they apply to workers in dependent employment relationships in the private sector, including to nursing personnel. The Committee notes that amendments were introduced to Law No. 1579/1985 that define nursing specialties in Pathology, Surgery, Paediatrics and Mental Health. In addition, Ministerial Decision No. A4/203/1988 established the requirements for obtaining a special nursing certificate. The Committee further notes that, pursuant to Law No. 2519/1997, graduates of the Technological Educational Institutes (TEI) Departments of Health Visitors can obtain a nursing specialty in mental health. The National Council for the Professional Development of Nursing defined other nursing specialities through the promulgation of section 45 of Law No. 4486/2017. The Government reports that, according to data compiled by the Nursing Directorate, as of November 2018, 1,550 nurses had acquired a specialty in pathology, 1,953 nurses in surgery, 920 nurses in paediatrics and 945 nurses and health visitors in mental health. In respect of the education and training policy for nursing personnel, the Government indicates that substitute teachers in the relevant specialties are recruited through a call for candidates issued by Ministerial Decision, whereas school nurses are recruited by the Regional Directorates of Education. The Committee notes that, in the field of higher education, during the reference period, two Higher Educational Institutes (AEI) and seven TEI provided first cycle programmes of studies in nursing. In its supplementary information, the Government indicates that, in the context of addressing the COVID-19 pandemic, enhancing nursing personnel and upgrading their skills are among the key actions taken by the Ministry of Health to strengthen the health care system. In this respect, the Committee notes with interest the adoption of Law 4690/2020 ratifying: (a) the Emergency Law of 13 April 2020 on “Measures to address the continuing impact of the Coronavirus COVID-19 pandemic and other urgent provisions” and (b) the Emergency Law dated 1 May 2020 on “Additional measures to address the continuing impact of the Coronavirus COVID-19 pandemic and return to normal, social and economic life and other provisions”. According to Law 4690/2020, all nursing specialties are established in line with European standards. It also provides for the creation and filling of 2,250 posts for trainee specialist nurses. In order to meet the needs created by the pandemic, the Government introduced training programs in the specialties of Critical Care and ER Nursing and Public Health/Community Health Nursing, which will be offered for the period 2020–2021, targeted mainly at unemployed male and female nurses. Under the same law, the Programme “Be a Volunteer to tackle address Covid-19” was established and implemented in public health facilities until June 2020. The Committee notes that more than 10,000 participants providing voluntary services in specialties relevant to healthcare account for 38.9 per cent of the total participants. Of this 38.9 per cent, 6.4 per cent were nurses and 11.9 per cent were assistant nurses. The Committee requests the Government to provide information on developments in relation to the adoption of a national health strategy as well as reforms to primary healthcare. It further requests the Government to provide information on any legislative amendments introduced relating to the operation of public and private health services and, if applicable, to supply copies of any relevant legislative texts. It also requests the Government to provide information concerning measures taken in order to prevent or address the shortage of qualified nurses, indicating the measures taken in relation to education and training as well as in relation to employment and working conditions, including career prospects and remuneration, with the aim of attracting men and women to the profession and retaining them in it. In the context of the global COVID-19 pandemic, the Committee invites the Government to provide updated information on the implementation of the measures taken to strengthen the health system and to address the increasing demand for qualified nurses.

“Exclusive” nurses. In its previous comments, the Committee noted that the shortage in qualified nursing personnel led to specific practices, including recourse to so called “exclusive” nurses, namely female migrant workers employed in a quasi-nursing capacity and even informal hospital services provided by patients’ families, which are increasingly tolerated by public establishments. In response to the Committee’s previous request for information on “exclusive” nurses, the Government provides data from the different regions in the country regarding the employment of this category of nurses. In its observations, the GSEE expresses its concern with respect to this form of atypical work. The Committee requests the Government to supply detailed information in its next report on the conditions of recruitment and work of foreign nurses and “exclusive” nurse, as well as measures taken to regulate their activities. The Committee requests the Government to provide its comments in respect of the observation of the GSEE.

Article 5(2) and (3). Determination of conditions of employment and work. The Government indicates that there is no collective agreement in force covering the country’s nursing personnel. It nevertheless refers to the 19 September 2014 Collective Labour Agreement “on the regulation of the conditions of remuneration and employment of workers, members of primary associations of the Federation of Greek Healthcare Institution Unions (OSNIE) employed at private clinics that are members of the Association of Greek Clinics (SEK) across the country”. The Government adds that legal disputes arising between nursing employees and their employers can be submitted to conciliation, mediation or arbitration procedures. The Committee notes that, each year, the competent department of the Ministry of Labour registers a relatively small number of cases of dispute resolution involving parties from trade union organizations of workers covering hospital staff and employer-operators of health service providers. In particular, the Government indicates that, from 1 June 2019 until 15 July 2020, the Ministry’s relevant Department has not handled any cases involving resolution of disputes between nursing employees and their employers through conciliation. The Committee takes note of a series of arbitration awards referred to by the Government. On the other hand, the GSEE observes that there are important difficulties concerning the procedure for collective bargaining and the conclusion of new sectoral collective agreements, which were aggravated by the expiry of former collective agreements enabling employers to pay nursing personnel in private hospitals on the basis of the minimum wage. The Committee requests the Government to provide information on the progress and results of collective negotiations to determine employment and working conditions of nursing personnel.

Article 6. Employment conditions of nursing personnel. Social security. Hours of work. The Government indicates that nursing personnel in the public and private sectors enjoy insurance coverage against risks of old age, disability, death, illness, maternity and unemployment. In its supplementary information, the Government indicates that the relevant Department of the Ministry of Labour and Social Affairs is considering including nurses who fall under the pension protection of the former Public Sector Fund, in the pension scheme for Heavy and Arduous Occupations. In response to the Committee’s previous request regarding the List of Arduous and Unhealthy Occupations set out in Law No. 3863/2010, the Government reports that a new List was finalized after consultation with the social partners through the Social Security Council. In this regard, the conclusions of the Standing Committee on Arduous and Unhealthy Occupations, in which representatives of the social partners, experts from the Ministry of Labour and Social Security (formerly IKA ETAM, now known as EFKA) and representatives of scientific institutions participated. The Government indicates that the new List attempted to rationalize and modernize the old one, taking into account the technological developments and their consequences in current labour data. It also indicates that, under Law No. 3863/2010, employees excluded from the prior List continued to be covered under the pension scheme until the end of 2015, with a view to ensuring their protection. In particular, the Committee notes that the new List stipulates, inter alia, that, male and female nurses working under fixed-term or indefinite contracts in nursing institutions, clinics, microbiological and biochemical laboratories and health insurance institutions are covered under the Regulation on Arduous and Unhealthy Occupations, with the exception of those employed in health centres within the framework of rationalization and modernization of the Regulation on Arduous and Unhealthy Occupations. In its observations, the GSEE expresses concern with regard to the difficult working conditions of nursing personnel, which are aggravated by the understaffing of hospitals and the imposed working hours schedule. The GSEE maintains that, under the current legislation nursing staff in hospitals works in three consecutive 8-hour shifts. The Committee requests the Government to supply a copy of the Regulation on Arduous and Unhealthy Occupations. In addition, it reiterates its request that the Government provide information on whether and to what extent this exclusion impacts on social security protection for nursing personnel. Recalling that this Article of the Convention aims to ensure that nursing personnel – as any other worker – are entitled to sufficient rest and leisure in order to avoid fatigue, the Committee requests the Government to address GSEE’s observations regarding the legal provisions allowing for 3 consecutive 8-hour shifts and to provide information on the provisions or other measures taken guaranteeing that nursing personnel enjoy conditions of employment and work at least equivalent to those of other workers in relation to hours of work, including regulation and compensation of overtime, inconvenient hours and shift work.

Article 7. Occupational safety and health. In response to the Committee’s previous comments, the Government indicates that the National Strategy for Health and Safety at Work (2016–20) was adopted following consultations with the social partners in the Health and Safety at Work Council of the Supreme Labour Council. In its observations, the GSEE comments that the poor health and safety conditions under which nursing personnel work expose them to exhaustion and burn out. The GSEE refers to a series of studies, which show that irregular shifts in combination with the very small number of nurses working during each shift place a heavy burden on these workers, making the performance of their duties extremely difficult. In particular, the GSEE indicates that the morning shift is usually served by two to four nurses but the afternoon and night shifts by only one nurse. The Committee notes that, in the context of the COVID-19 pandemic, the need for nursing personnel has increased, which may aggravate these phenomena. The Committee requests the Government to provide a copy of the National Strategy in force and reiterates its request that the Government provide information on progress made and results achieved with respect to occupational safety and health for nursing personnel, including with respect to ensuring adequate staffing on all shifts during the COVID-19 pandemic. The Committee also requests the Government to provide information on the measures implemented to prevent and reduce psychosocial risks, and promote mental health and well-being, in addition to preventing the risk of long-term effects on nurses’ well-being, particularly in the context of the pandemic.

Exposure to special risks. The Committee notes that according to “ILO: Country policy responses, COVID-19 and the world of work”, the Government has allocated €85 million to the Ministry of Health to support the purchase of sanitary equipment and the hiring of 2,000 health professionals. The Committee draws the attention of the Government to Paragraph 49 of Recommendation No. 157, which provides that: “(1) all possible steps should be taken to ensure that nursing personnel are not exposed to special risks. Where exposure to special risks is unavoidable, measures should be taken to minimise it; (2) measures such as the provision and use of protective clothing, immunisation, shorter hours, more frequent rest breaks, temporary removal from the risk or longer annual holidays should be provided for in respect to nursing personnel regularly assigned to duties involving special risks so as to reduce their exposure to these risks; (3) In addition, nursing personnel who are exposed to special risks should receive financial compensation.” The Committee also draws the Government’s attention to the ILO Guidelines on decent work in public emergency services, 2018, which recognize the need to protect public emergency workers, including emergency health workers, from exposure to communicable diseases. In particular, paragraphs 50 and 51 of the Guidelines stress that suitable and sufficient personal protective equipment (PPE) should be provided as protection against exposure to hazardous conditions for public emergency services (PES) workers and that workers and/or their representatives should be consulted and participate in relation to the selection and correct use of PPE. Noting that nursing personnel are at high risk of being infected while treating patients with suspected or confirmed COVID-19, particularly when infection control precautions including use of personal protective equipment (PPE) are not strictly practiced, the Committee requests the Government to provide detailed updated information on the safety measures adopted or envisaged including the provision of PPE and training in its use, as well as provision of adequate rest breaks during workers’ shifts and limitations on excessive hours wherever possible, with a view to protecting the health and wellbeing of nurses and limiting as much as possible their risk of contracting COVID 19.

Part V of the report form. Practical application. The Committee notes the data provided on the number of registered nursing students for the 2017–18 academic year, as well as statistics on the number of nursing students enrolled from for the academic years from 2013 to 2018. The Committee also takes note of the detailed information on persons practising in the nursing profession per level of training and field in the public and private sector based on the estimates, according to which 135,361 doctors and 55,963 nurses and midwives were employed in the beginning of 2020. The Committee notes a pronounced imbalance in the availability of doctors compared to nurses in Greece and observes that, according to the European Commission 2019 Country Health Profile on Greece, the country has the highest number of doctors but the lowest number of nurses per 1,000 population of any country in the European Union. The Committee requests the Government to provide detailed information, disaggregated by age, sex and region, concerning the situation of nursing personnel in the country, including the nurse-population ratio, the number of nursing personnel broken down by public and private healthcare establishments, the number of students who graduate from nursing colleges annually and the number of institutions offering nursing education and training, the number of female and male nurses who enter and leave the profession each year, the organization and the operation of all institutions which provide healthcare services, as well as official studies, surveys and reports addressing health workforce issues in the Greek health sector, including those that might have been developed in the context of the COVID-19 pandemic.