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

Nursing Personnel Convention, 1977 (No. 149) - Malta (Ratification: 1990)

Article 2 of the Convention. National policy concerning nursing services and nursing personnel. The Committee welcomes the detailed information provided by the Government in its report. In particular, the Committee notes the implementation of the “National Health Systems Strategy for Malta 2014-20” (NHSS), which aims to provide every individual with the opportunity to lead a healthy and active life, and to benefit from equitable access to sustainable quality health care. The NHSS was developed with the technical assistance of the WHO, following an extensive consultation process with a wide range of stakeholders, including health care workers, health care organisations and health authorities. The NHSS is based on a “people-centred” approach, which recognizes four major groups of stakeholders involved in its implementation, including health practitioners (such as nursing personnel). In this regard, the NHSS envisages the involvement of health workers in health care governance and policy decision- making. The NHSS includes among its main objectives the improvement of the quality of care available, by ensuring consistency of care delivered by competent health workers. With a view to achieving this goal, the NHSS establishes a set of initiatives to raise standards for the professional development of health workers in the framework of a patient-centered approach. These initiatives include: strengthening the provision of training, including providing for training in relation to specialization and for the continued professional development of all health workers; moving forward with the development and implementation of the competency programmes for all groups of health care workers; piloting a mentoring programme for newly recruited employees; and supporting associations of health workers in taking steps to improve their continued professional development to in turn improve career advancement opportunities. The Committee also notes the information provided by the Government in relation to the “Health Workforce Planning Framework for Malta 2010-20”, which includes a detailed analysis of the impact of the different components of policy interventions implemented with respect to nursing personnel and nursing services. The Framework evaluates the policy interventions implemented in relation to: nursing workforce planning (planning capacity and stakeholder information); recruitment and retention (including financial and non-financial incentives, career structure and opportunities, nurse involvement in decision making); the deployment and performance of nurses (financial and non-financial incentives, data on activity and workforces, allocation of necessary equipment and material); and effective utilisation of their qualifications in the various health-care establishments (effective strategic management, financial and non-financial incentives, nurse involvement in decision making). Based on this evaluation, the Framework establishes projections of the number of nurses needed and of those available for the period 2010-20 and calculates the minimum standard nurse-to patient ratios needed to deliver adequate hospital services in the country. The Government does not indicate whether the Framework was developed in consultation with the employers’ and workers’ organizations concerned. The Committee requests the Government to provide detailed updated information on the nature and impact of measures implemented in the framework of the “National Health Systems Strategy for Malta 2014-20” and the “Health Workforce Planning Framework for Malta 2010-20”, particularly with respect to measures taken to improve the working conditions, career opportunities and professional competencies of nursing personnel. It also requests the Government to indicate whether the employers' and workers' organisations concerned, including the Malta Union of Midwives and Nurses (MUMN), were consulted in the development of measures taken or envisaged. In the context of the global COVID-19 pandemic, the Committee invites the Government to provide updated information on the impact of the pandemic on nursing personnel and nursing services, including measures taken to mitigate these impacts and to ensure the occupational safety and health of this essential category of frontline workers.

Article 3(1). Nursing education and training. The Committee notes the detailed information provided by the Government concerning the educational system established for nursing personnel in the country. The Government indicates that the courses offered by the University of Malta’s Institute of Health Care were transferred to the Faculty of Health Sciences in 2010, which includes a Nursing Department and a Mental Health Nursing Department. The Faculty offers full-time courses at undergraduate level in general nursing, leading to registration with the Council for Nurses and Midwives as well as degree and postgraduate courses. It works in collaboration with national public and private health care institutions, including the Mater Dei Hospital, which provide on-the-job training in diverse clinical settings. The Faculty promotes faculty exchanges through the Erasmus programme as well as lifelong learning courses for practicing nurses. Moreover, the Government indicates that, to address the increasing demand for qualified nurses, in October 2017, Northumbria University developed a new degree programme in Nursing Studies with the support of the Malta Enterprise and the MUMN. The Committee notes the information provided on the number of graduates accepted into the new programme. The Committee notes from the information provided by the Government that the Maltese Nursing Conversion Programme and the introduction of specialist nurse training have increased the skills, competencies and size of the nursing workforce. It further notes that the number of practicing nurses has increased by more than one-third over the past decade, to reach 7.9 per 1 000 population in 2018, slightly below the EU average of 8.5. The Committee requests the Government to continue to provide updated detailed information on the content and impact of the measures adopted to ensure that nursing personnel are provided with education and training appropriate to the exercise of their functions.

Articles 5 (2) and 6. Collective bargaining concerning employment and working conditions of nursing personnel.  Since 2001 the Committee has been requesting the government to provide more detailed information regarding collective agreements for nursing personnel. It notes with interest the information provided by the Government in respect of the set of collective and sectoral agreements signed between 2000 and 2018 with a view to improving the working conditions and career prospects for nursing personnel in the public and the private sectors. The Government indicates that working conditions for nursing personnel are established mainly in two types of agreements: the collective agreements for all public service employees, including nurses working within the public services; and sectoral agreements that are negotiated specifically for nurses and midwives. The Government indicates that both collective and sectoral agreements establish a specific time frame for their implementation. Prior to the expiry of the agreements, workers’ organizations, including the MUMN, submit their proposals concerning working conditions. The Government also adds that the collective agreements concluded between 2000 and 2013 introduced, among other measures, the establishment of a clinical specialist nursing framework (2000) a Continuous Professional Development allowance for all nurses (2006) and a special long service leave scheme for nurses with at least 30 years of full-time service (2013). The Government reports on the conclusion of the fifth Collective Agreement for Public Sector Employees in 2017, including nurses in the public sector, for the period 2017-24. The new collective agreement was signed by, among other actors, the MUMN, the General Workers’ Union (GWU), UĦM – Voice of the Workers, the Malta Union of Teachers (MUT), and the Medical Association of Malta (MAM). The agreement provides for an increase in salaries and certain allowances for Public Administration employees. In particular, the agreement introduces increments on the “shift allowance” for those employees working on a shift basis, a “qualification allowance” for those employees who have acquired additional qualifications beyond those required for the exercise of their duties. The Government adds that the most recent sectoral agreement has been concluded, covering Public Service Nurses for the period 22 November 2018 to 31 December 2022. It sets out a basic salary scale for the different categories of nursing personnel, providing for double pay on Sundays and triple pay on Public Holidays. The 2018 sectoral agreement also provides for different allowances, such as the “Nursing Premium” (varying from €3,843 to €8,960 depending on years of service and working conditions, and a “Continuous Professional Development Allowance” (consisting of €700 per annum for professional educational activities). The Government does not provide information on the current collective agreements covering the employment and working conditions of nursing personnel in the private sector. The Committee requests the Government to continue to provide updated detailed information on the content and impact of collective and sectoral agreements concluded concerning the working conditions (including remuneration and training opportunities) of nursing personnel in public and private hospitals, nursing homes and medical centres. It further requests the Government to provide copies of such agreements in its next report.

Article 5 (3). Procedures for the settlement of disputes arising in connection with the determination of terms and conditions of employment. The Committee notes the information provided by the Government concerning the different procedures contemplated in the Collective Agreement for Public Service Employees 2017-2024 in case of dispute and/or disagreement between the parties arising in connection with the determination of terms and conditions of employment. The Government indicates that such procedures provide for negotiation between the parties through a conciliation mechanism (section 10), as well as for a panel of arbitrators (section 11). Noting that the information provided by the Government concerns the public sector, the Committee requests the Government to also provide information on the procedures for the settlement of disputes arising in connection with the determination of terms and conditions of employment of nursing personnel in the private sector.

Article 6 (g). Social security. The Committee notes that the Government refers to the introduction of a pension reform raising the retirement age of nursing personnel to 65, with a view to increasing their retention in the profession and maintaining the number of nurses in the workforce. The Government also indicates that an agreement was concluded between the Government and the MUMN, which provides the possibility for nurses to continue to work post-retirement age. The Committee requests the Government to provide detailed information on the pension reform introduced raising the retirement age of nurses and the content and impact of its agreement with the MUMN. It further requests the Government to indicate whether, following the pension reform, nursing personnel enjoy conditions with regard to social security that are at least equivalent to those of other workers.

Article 7. Occupational safety and health of nursing personnel. The Committee notes that, according to the European Commission 2019 Country Health Profile on Malta, in 2017, the country reported the third highest notification rate of new HIV cases in the European Union (EU). The report points out that rates of newly diagnosed cases overall have increased by more than 50 per cent since 2008, in contrast to a general downward trend observed across the EU. In this context, the Committee notes the information provided by the Government regarding the measures taken to prevent occupational transmission of HIV among nurses, including the specialization of nurses working in multidisciplinary teams in decontamination, infection control and HIV to contain infectious diseases, and the implementation of plans for post-exposure management of health care personnel. In this respect, the Committee draws the Government’s attention to the Joint ILO/WHO Guidelines on Health Services and HIV/AIDS, 2005, which contains guidance on the effective prevention of occupational transmission of HIV. The Committee also notes the Government’s indication that national legislation mandates the use of personal protective equipment (PPE) when the risks to the health and safety of workers cannot be avoided or sufficient limited by technical means of collective protection or by measures, methods or procedures of work organization. The legislation further establishes that PPE should be provided free of charge by the employer, who must ensure that the equipment provided is adequate and in a satisfactory hygienic condition. Workers and workers’ representatives are also provided with training in the proper used of PPE. The Government adds that such training must be provided at the expense of the employer and take place during working hours. The Committee notes from the website of the Government that health workers at Mount Carmel Hospital, as well as staff working in Community Mental Health Services have received training on the use of PPE and the management of COVID-19 positive patients. The Committee refers in this regard to paragraph 49 of Recommendation No. 157, which establishes 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 notes that the NHSS provides for the adoption of measures to maintain the physical and mental health and well-being of health workers, calling for the necessary infrastructure, including access to psychological support services, to be provided to address stress and burn-out of nursing staff working within the health care system, especially in those areas where staff are dealing with critically-ill or terminally ill patients. Noting that nursing personnel, often in close contact with patients, are at high risk of being infected while treating patients with suspected or confirmed COVID-19 when infection control precautions are not strictly practiced, the Committee requests the Government to provide updated information on all the safety measures taken or envisaged, including the provision of sufficient quantity of appropriate personal protective equipment (PPE) and adequate rest breaks during their shifts, with a view to protecting the health and wellbeing of nurses and limit as much as possible their risk of contracting COVID-19. The Committee also requests the Government to provide information on the measures implemented to prevent and reduce psychosocial risks, including burn-out, violence and harassment, in addition to preventing the risk of long-term repercussions on nurses’ wellbeing. It further requests the Government to indicate whether nurses and/ or their representatives were consulted or participated in the formulation and implementation of such measures.

Application in practice. The Committee observes that, according to the European Commission 2019 Country Health Profile on Malta, the reforms undertaken in education, training and employment conditions have increased the number of nurses. The Committee notes in this respect the information provided by the Government regarding the trends during the period 2003-18 in the number of nurses entering in the profession as well as in those leaving the profession, due to retirement or for other reasons, such as career changes or emigration. The Government reports that in 2018 there were 3,420 nurses in the public sector (73.2 per cent were women and 26.8 per cent men). With regard to their qualifications, the Government indicates that 91.9 per cent were first- level nurses, 5.8 per cent were second-level nurses and 2.3 per cent were registered in the mental health part of the register. Nevertheless, the Committee notes from the cited report of the European Commission that, despite these efforts, the country continues to experience a shortage of nursing personnel in hospitals and long-term care and the nursing workforce in these settings is increasingly reliant on migrant workers, posing challenges for recruitment and retention. The Committee requests the Government to continue to continue to provide updated detailed information on the application of the Convention in practice, including statistics disaggregated by sex, age and region, on the ratio of nursing personnel to the population, the number of persons enrolled in nursing schools, the number of men and women nurses who enter and leave the profession each year, the organization and the operation of all institutions in the public and the private sector which provide healthcare. It also requests the Government to provide any official studies, surveys and reports addressing health workforce issues in the health sector, including those that might have been developed in the context of the COVID-19 pandemic.