Swedish assistant nurses want higher status through legal recognition

The Swedish Municipal Workers’ Union – Kommunal – represents assistant nurses, and has been arguing for legitimising the assistant nurse title since 2016. There are several reasons why. Recruitment has become increasingly difficult. Increasing numbers of older and increasingly ill people in care create high expectations for quality and skilled personnel. 

 And the number of older people will increase. Sweden is expected to have 255 000 more octogenarians by 2026. There is a great demand for care and the issue of quality and skills provision is important to both national and municipal politicians.  

“We believe recognising the title assistant nurse will elevate their status and make their profession more attractive. We will also link certain working tasks to the assistant nurse title so that people can see that taking this education means something and that assistant nurses will be performing different tasks compared to what they do in the current system,” says Mari Huupponen from Kommunal.

A profession under pressure

Sick leave is high within the care and health sector, and many are contemplating leaving their profession. In the report “Who will work in elderly care in the future?”, published a few years ago, the authors from the Stockholm University showed that the number of elderly care staff who have seriously considered quitting their jobs is higher in Sweden than anywhere else in the Nordic region. 

49% had considered leaving, while the number in other Nordic countries was 10% lower. More considered leaving than ten years ago, both in Sweden and in the rest of the Nordic region. The reasons given were conditions of employment, the number of dependants, physical and psychological strains at work, support and development opportunities, relations to the elderly and reactions to working conditions.        

Since the report’s publication, municipalities’ economy has deteriorated, and according to the newspaper ”Kommunalarbetaren” (the municipal worker) six in ten municipalities will make cuts to elderly care in 2020. There will be fewer staff, no more temporary workers or further training, more shared rotas and more weekend work. Old people’s housing is also being cut, which means more pressure on home care services.

“Many municipalities struggle to find trained assistant nurses, and this will become even harder when assistant nurses are not offered good conditions and salaries,” says Mari Huupponen. 

Protected title

There has been focus for some time on the importance of securing skills provision and guaranteeing safe nursing and care. A range of proposals have focused on this issue, most recently “Strengthened competencies in nursing and care” which the government presented in 2019. The proposal aimed to identify ways to regulate the assistant nurse profession in order to improve quality and safety within the care and health sector.    

Lead author Harriet Wallberg wrote that there were “widespread gaps in competencies” among people in the profession, which had “direct consequences for the execution of the work tasks”. She concluded that this might be a result of the fact that the job as assistant nurse has not been regulated, meaning anyone could be employed as an assistant nurse and carry out jobs on a ward with no relevant education.

Different paths to the profession

Training to be an assistant nurse takes many forms. It is unclear what tasks assistant nurses actually should perform, and employers do not know exactly what an assistant nurse applying for a job can do either. 

Most assistant nurses train in municipal adult education programmes, but it is also possible to study nursing and care topics as part of the upper secondary education. There are also nursing and care colleges, a platform for cooperation between employers, trade unions and education officials from the nursing and care sector. This training is also a mark of quality which shows that those who have attended a nursing and care college has taken an education in close cooperation with the labour market, which should increase their chances to get a job. A school can be part of a nursing and care college, but not be such a college on its own.

The main result from the government proposal was two ideas which will be implemented by in January 2025. One is to give assistant nurses a protected job title, but not to formally legitimise them. A protected job title means you need certain qualifications in order to take up the title or execute the work. 

It means that an assistant nurse who has finished his or her training can apply for a certificate which would allow them to use the job title assistant nurse. Without this certificate, no-one can call themselves an assistant nurse, and such misuse should be punishable with fines, according to the proposal. 

In order to secure and maintain a long-term competencies level, it is also suggested that the Swedish National Agency for Education and the National Board of Health and Welfare together identify what the assistant nurse training should contain. This would allow for the creation of a national assistant nurse training programme. The government has already presented a new vocational programme for upper secondary education.

Consultation threw up different views

Last autumn the proposal was out for consultation among Swedish municipalities and regions, the Swedish Association of Local Authorities and Regions SKR – the main employer of assistant nurses – and to the Kommunal trade union.

Mari Huupponen from Kommunal is quite happy with the proposal. Kommunal had wanted the profession to be legitimised, but thinks a protected title is better than what came before.

“Legitimation would have been the more attractive option since people understand this better, and it exists for other nursing and care professions. But a protected title together with regulated working tasks still amounts to approximately the same thing. We are also positive to the proposed nationally regulated assistant nurse training,” she says.

In later years, Kommunal has notes that municipalities are hiring more unskilled people for work in the care sector. This is a threat to the quality of care and creates uncertainty, not least because many home carers look after of people with multiple ailments. 

“Municipalities are hiring more and more unskilled people, but the employers should hire trained assistant nurses – not least when you consider they have to deal with medication. They should also to a greater degree be able to allocate work according to skills,” says Mari Huupponen.

Would like a nationally coordinated training programme

At SKR, Katarina Storm Åsell has been part of the expert group assisting in the work on the government proposal. SKR’s input to the consultation underlines the importance of creating a nationally coordinated training programme for assistant nursing. Today’s system has far too many variations both in scope, quality and content. That is why it is important to start with the training before considering creating a protected title. SKR therefore opposes the proposed legitimation and the alternative – a protected title.

“We believe it is important that the training is of good quality, that it is national and that these prerequisites are clear before you consider protecting the title. A majority of those who train to be an assistant nurse do this through adult education, so the ability for adult education to deliver quality is crucial here,” says Katarina Storm Åsell. 

SKR also opposed the idea of linking a certain number of working tasks to the role of assistant nurses. 

“It would be difficult to make this work in the workplace. For employers it is important to be able to use the existing competencies in the best possible way,” says Katarina Storm Åsell. 

“We want the training to be regulated rather than the profession itself. Such regulation of for instance the “job package” offered by adult education should make it more transparent and help employers’ organise work in the best possible manner. It would also allow them to work systematically with for instance career development models. It is important that employers know what those who have passed the exam can do,” she says.