Occupational Health Nursing in Hungary Henriett Éva Hirdi, RN, MSN, C-OHN; OiSaeng Hong, RN, PhD, FAAN
ABSTRACT This article is the first about occupational health nursing in Hungary. The authors describe the Hungarian health care and occupational health care systems, including nursing education and professional organizations for occupational health nurses. The Fundamental Law of Hungary guarantees the right of every employee to healthy and safe working conditions, daily and weekly rest times and annual paid leave, and physical and mental health. Hungary promotes the exercise of these rights by managing industrial safety and health care, providing access to healthy food, supporting sports and regular physical exercise, and ensuring environmental protection. According to the law, the responsibility for regulation of the occupational health service lies with the Ministry of Human Resources. Safety regulations are under the aegis of the Ministry of National Economy. [Workplace Health Saf 2014;62(10):421-430.]
H
ungary is located in central Europe, with a total population of approximately 9.9 million. Its area is 93,000 km2 (35,919 sq mi), comparable to the size of the state of Indiana. The capital city is Budapest, with approximately 1.7 million inhabitants, and the official language is Hungarian, part of the Finno-Ugric language family. Hungary has more than a 1,000-year-old history. Hungary became a full member of the United Nations in 1955, the Council of Europe in 1990, the World Trade Organization in 1995, the Organisation for Economic Co-operation and Development (OECD) in 1996, the North Atlantic Treaty Organization (NATO) in 1999, and the European Union in 2004 (Encyclopedia Britannica, 2012). HEALTH STATUS Annual national statistical data collection is governed by Act XLVI of 1993 on Statistics. This Act regulates the surveying, processing, storage, transfer, receiving, analysis, supply, communication, and publication of data by ABOUT THE AUTHORS
Ms. Hirdi is Vice President, Council of Hungarian Paramedical Professionals (MESZK), Budapest, Hungary. Dr. Hong is Professor, Occupational and Environmental Health Nursing Graduate Program, School of Nursing, University of California, San Francisco, California. Submitted: February 17, 2014; Accepted: July 21, 2014; Posted online: August 20, 2014 The authors have disclosed no potential conflicts, financial or otherwise. Correspondence: Henriett Éva Hirdi, RN, MSN, C-OHN, MESZK Országos Szervezet, Könyves K. krt.76., 1450 Bp., Pf.: 214., Budapest H-1087, Hungary. E-mail: [email protected] doi:10.3928/21650799-20140813-01
statistical methods. National statistical data are easily available, accessible in Hungarian and English in official publications and on the website of the Hungarian Central Statistical Office (HCSO; http://portal.ksh.hu). Based on the latest statistical data of the HCSO, Hungarians’ life expectancy is among the lowest in Europe: 71.5 years for men and 78.4 years for women. The main causes of death are circulatory system disease, malignant neoplasms of the trachea, bronchus, and lung, diseases of the liver, and external causes (motor vehicle accidents and intentional self-harm) (HCSO, 2012a). Lifestyle factors, especially the traditionally unhealthy Hungarian diet, alcohol consumption, and smoking, play a central role in shaping the overall health of the population. According to the European Health Interview Survey conducted in 2009, 21.5% of male respondents and 18.9% of female respondents reported that they were obese (body mass index ≥ 30), and 39.4% of men and 31.1% of women reported they were overweight (25 ≤ body mass index < 30). In 2009, an estimated 31.4% of the Hungarian population age 15 years and older were regular daily smokers. Approximately 15% of respondents in Hungary reported their health status to be “bad” or “very bad.” Approximately 70% of the respondents had a chronic disease affecting one or more organ systems (HCSO, 2010). To reduce the above risk factors, several national initiatives have been introduced in recent years. For example, public places, including restaurants, bars, and workplaces, became smoke-free in 2012. The government also
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prohibits smoking in bus stops, underpasses used by pedestrians, and playgrounds, and within 5 meters of their vicinity. Smoking is banned in schools, child welfare institutes, and health service provider offices, including their courtyards (Hungarian Government, 2012a). Another action of the Hungarian Parliament was to pass a public health product tax, or the so-called “chips tax.” The goal of the legislation was to reduce the consumption of unhealthy foods, to promote healthy diets, and to finance health services, especially public health programs. Taxed food products include soft drinks, energy drinks, pre-packaged sweet goods, salty snacks, and seasonings if sugar, salt, or caffeine content is above a pre-determined level (National Institute for Quality and Organizational Development in Healthcare and Medicines, 2012). HUNGARIAN HEALTH CARE SYSTEM The Hungarian national health care system is managed and supervised by the Ministry of Human Resources, which is also responsible for the welfare system, the development of educational systems, the protection of cultural heritage, the promotion of child and youth welfare, and the realization of government aims related to sports in Hungary (Hungarian Government, 2012b). The basic public health law is Act CLIV of 1997 on Health, which created the general framework for health care, including patient rights, the organization of the health care system, major factors, and responsibilities for health care. The law also identified the services financed by the central government and declared that every individual has a right to life-saving or life-preserving health care interventions and effective, continually accessible and equitable health services (Hungarian Government, 1997). Primary health care is the foundation of the publicly financed state health care system. Municipalities are responsible for providing primary care, which includes general practitioner and pediatric health care, primary dental services, health visitor nursing system, and school physician health services. In 2012, the provision of inpatient and outpatient specialist care became the responsibility of the state. Operation and property management are coordinated by the National Institute for Quality and Organizational Development in Healthcare and Medicines. Hungary’s health care system is financed through the Health Insurance Fund, which is primarily responsible for recurrent health care costs. Act LXXXIII of 1997 on the Services of Compulsory Health Insurance declared that participation in the non-risk–related health insurance program is compulsory for all Hungarian citizens living in Hungary. All citizens are covered by this plan, regardless of employment status, with the government paying contributions for groups such as unemployed adults, children, students, individuals who cannot work due to incapacity, and pensioners. The voluntary health insurance system currently does not play a significant role and has only supplementary and complementary functions (e.g., eligibility for higher levels of concierge service or perdiem-like wage supplement during hospital treatment). Since 1995, occupational health care has been excluded
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from statutory health insurance coverage (Gaál, Szigeti, Csere, Gaskins, & Panteli, 2011). Today, one of the most urgent health care needs is to provide a sufficient number of qualified health care workers; Hungary has a significant shortage of physicians and nurses, mainly due to extremely low salaries in the health care sector compared to other sectors of the economy. Moreover, low salaries encourage migration of Hungarian health care professionals to other western European countries. The Hungarian provider shortage will become more critical due to a recent government regulation. After March 1, 2013, public and civil servant health professionals, employed by government departments or agencies, cannot be employed after the retirement age of 62 years except for researchers and professors working in higher education (National Institute for Quality and Organizational Development in Healthcare and Medicines, 2013). OCCUPATIONAL HEALTH LEGISLATION European directives are binding in their entirety and oblige member states to transpose the directives into national law within set deadlines. European Union directives on safety and health at work have their legal foundation in Article 153 of the Treaty on the Functioning of the European Union (Article 137 TEC), which gives the European Union the authority to adopt directives in this field. A wide variety of European Union directives set minimum health and safety standards for the protection of workers. European Union member states are free to adopt stricter rules for the protection of workers when drafting national law from European Union directives (European Agency for Safety and Health at Work, 2013). In Hungary, many regulations relevant to health, safety, and welfare at work have been adopted and are easily accessible on the website: https://www.magyarorszag.hu. Two of the most important pieces of health and safety legislation are the above-mentioned Act CLIV of 1997 on Health and Act XCIII of 1993 on Labor Safety. These laws set the health and safety standards for all employees and others who may be affected by any work activity. The Labor Safety Act, in accordance with the recommendations of the Framework Directive on Safety and Health (European council 89/391 EC), regulates the necessary personal, material, and organizational conditions of non-hazardous and safe work to protect the health and abilities of employees, as well as to establish work conditions that prevent occupational injuries and diseases. All workers are protected by this Act, including employees, contractors, subcontractors, apprentices, trainees, student workers, volunteers, and employees who perform their work at home (Hungarian Government, 1993). Other regulations cover work activities that carry specific risks (e.g., lifting and carrying, computer work, and exposure to occupational noise, biological agents, electricity, asbestos, ionizing radiation, and sharps). MAJOR OCCUPATIONAL HEALTH PROBLEMS The economy of Hungary is medium-sized, a structurally, politically, and institutionally open economy in central Europe, part of the European Union’s single mar-
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TABLE 1
Economic Activity (in Thousands) of Population Aged 15 to 64 Years by Sex 2000 Age Group Employed population Registered unemployed population Economically inactive population
2010
2012
Male
Female
Male
Female
Male
Female
2,091.6 (62.7%)
1,740.4 (49.6%)
2,005.4 (60.4%)
1,744.7 (50.6%)
2,060.8 (62.5%)
1,782.0 (52.1%)
158.7 (4.8%)
104.5 (3.0%)
264.3 (8.0%)
210.3 (6.1%)
262.3 (8.0%)
212.4 (6.2%)
1,084.2 (32.5%)
1,661.3 (47.4%)
1,051.7 (31.6%)
1,492.9 (43.3%)
972.5 (29.5%)
1,425.6 (41.7%)
Data from Hungarian Central Statistical Office. (2012a). Statistical data of Hungary. Retrieved from http://portal.ksh.hu
ket. The private sector accounts for more than 80% of the Hungarian gross domestic product. Foreign ownership of and investment in Hungarian firms is widespread. Hungary’s main industries are heavy industry (i.e., mining, metallurgy, and machine and steel production), energy production, mechanical engineering, construction materials, processed foods, textiles, chemicals (especially pharmaceuticals), and automobile production. The agricultural sector, for which Hungary has especially favorable climate conditions, represents approximately 3.1% of the country’s gross domestic product. Cattle, pigs, poultry, and sheep are raised in Hungary; the most important crops include wheat, corn, sunflowers, potatoes, sugar beets, canola, and a wide variety of fruits, notably apples, peaches, pears, grapes, watermelons, and plums. Hungary also has several wine regions, producing the famous white dessert wine Tokaji and the red Bull’s Blood. Another traditional world-famous alcoholic drink produced in Hungary is the fruit brandy, pálinka. Within the service sector, private services include trade, tourism, finance, and other economic services. The Hungarian spa culture is world famous, with thermal baths and more than 50 spa hotels, each of which offer the opportunity for a pleasant, relaxing holiday and a wide range of quality health-related and beauty treatments. The state-run service sectors include health care, education, and public administration. Table 1 shows the economically active and inactive populations and their relation to the total population aged 15 to 64 years by sex. The economically active population includes all Hungarians who produce goods and services. The employment rate of individuals 15 to 64 years old was 57.2% in 2012; the unemployment rate for this age group was 11%. The economically inactive population, those who had no job on the reference year, or those who had not been looking for a job, comprised 31.8% of the total Hungarian population. Changes in the economically active population between 2000 and 2012 are displayed in Table 1. The annual rate (2011) for occupational accidents was 5.2 per 1,000 employees (HCSO, 2012a). The standard retirement age was 62 years for men and 58 years for women in 2002, reaching a unisex age of 62 years in
2009. However, a full pension was accessible as early as 60 years for men (with a minimum of 38 covered years) and 55 years for women (with 37 years of contributions). Just 14% of Hungarians between 60 and 64 years of age are still working; however, recent reforms have tightened the rules for early retirement. In 2009, the Hungarian government passed a pension bill to gradually raise the age of retirement to 65 years between 2016 and 2027 (OECD, 2011). The National Labor Office, a central public administrative body, operates within the statutory framework and takes action against employers who breach employment legislation. The Office is responsible for monitoring employers’ records of work-related accidents and, based on the findings, prepares annual reports on the state of occupational safety in Hungary. The reports (available in Hungarian) are presented to the government by the Ministry of National Economy that is responsible for ensuring occupational safety in the country’s labor market. The National Labor Office concluded that the total number of work-related accidents in 2012 was lower than in 2010 (Table 2). The report highlighted that the number of occupational accidents decreased in 2012 in all categories. By sector of economic activity, the largest proportion of work-related accidents in 2012 occurred in engineering (18.9% of the total), manufacturing (16.3%), wholesale and retail trade (12.8%), transportation and storage (12.4%), and education, public administration, and defense (10.1%). The number of fatal work-related accidents also decreased in 2012 compared to 2010; construction continued to report the highest proportion of fatal work-related accidents (29%), followed by agriculture, forestry and fishing (21%), and transportation and storage (16.1%). Deficiencies in investigating work-related accidents and occupational diseases were often found at companies where occupational health and safety professionals were employed only “on paper,” according to the report (Balogh, 2008). Common deficiencies included: the absence of a designated individual responsible for company-level occupational health and safety, and ambiguous accident records resulting in insurance cost avoidance by the company (Balogh, 2008). The estimated proportion of occupational accidents not recorded by the National
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TABLE 2
Number of Occupational Accidents and Fatalities by Sector Work-related Accidents Sector
Fatal Accidents at Work
2010
2012
2010
2012
814 (4.1%)
744 (4.4%)
12 (12.6%)
13 (21.0%)
Manufacturing
3,386 (17.0%)
2,773 (16.3%)
11 (11.6%)
4 (6.5%)
Wholesale and retail trade; repair of motor vehicles and motorcycles
2,553 (12.8%)
2,180 (12.8%)
6 (6.3%)
5, (8.1%)
Transportation and storage, information, and communication
2,492 (12.5%)
2,114 (12.4%)
19 (20.0%)
10 (16.1%)
Education, public administration and defense; compulsory social security
1,948 (9.8%)
1,726 (10.1%)
2 (2.1%)
4 (6.5%)
Human health and social work activities
1,330 (6.7%)
1,136 (6.7%)
2 (2.1%)
0 (0%)
Construction
1,053 (5.3%)
818 (4.8%)
25 (26.3%)
18 (29.0%)
Engineering
3,540 (17.7%)
3,214 (18.9%)
5 (5.3%)
3 (4.8%)
Other activities
2,832 (14.2%)
2,320 (13.6%)
13 (13.7%)
5 (8.1%)
Total
19,948 (100%)
17,025 (100%)
95 (100%)
62 (100%)
Agriculture, forestry, and fishing
Data from National Labor Office. (2013). Accidents at work tables. Retrieved from http://www.ommf.gov.hu/index.html?akt_menu=223 Figure 1. Work-related diseases by frequent causes between 2009 and 2012.
Labor Office remained at 35% to 40% (National Labor Office, 2013). Occupational exposures and resulting diseases are regulated by Decree 27/1996 (VIII. 28) of the Minister of Welfare. The List of Reported Occupational Diseases included 143 diseases classified by potential causal agents. The most frequently reported occupational diseases were infectious, respiratory, and skin. The number of respiratory diseases and industrial poisonings has continuously decreased. The number of occupational diseases caused by hazard exposures between 2009 and 2012 are shown in Figure 1. The annual rate (2012) of reported occupational diseases is approximately 0.5 per 10,000 employees.
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As Nagy et al. (2011, 2013b) presented in a detailed analysis, the number of occupational diseases and increased hazard exposures are generally underreported because reporting interferes with employers’ interests, potential funding of the occupational health service, and, in many cases, the interests of employees who fear being fired or disciplined. Many employers fear increasing workers’ compensation costs or having less chance of winning contracts. OCCUPATIONAL HEALTH CARE Occupational health nursing and occupational medicine have a long-standing tradition in Hungary. Historically, the roots of Hungarian occupational medicine came from the
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era of the founder of the Hungarian state, King Stephen I (Saint Stephen). The “Ius regale” of 1030 (on the royal land with mineral resources) included the rules for employment of miners. Hospitals, relief funds, and health insurance were available for miners from the 12th century. The first hospital was founded in Selmec, in the northern part of the Kingdom of Hungary, in 1224. Its primary purpose was to treat injured miners (Ungváry, 1994; Ungváry & Morvai, 2010). From the 15th century, groups of miners joined together to create their own mutual assistance fund to cover the costs of sickness and injuries, including physician fees. The first known mutual assistance fund dates back to 1496 (Sárdi, 2003). Almost a thousand years later, in compliance with the Labor Safety Act and the sectorial decrees, every employer must provide occupational health care for all employees; however, the law does not differentiate between sectors, areas, or size of enterprises. Nevertheless, a government decree regulates the services: one setting with one full-time physician and one full-time nurse may cover 1,000 to 2,000 workers, depending on health risks (Hungarian Government, 1995). In 1995, the responsibility for financing occupational health service was shifted to employers by Government Decree No. 89/1995 (VII. 14). The employer can organize occupational health care in different ways; whereas larger employers manage their own services, smaller employers can contract with occupational health care providers (Gaál et al., 2011). The main tasks of occupational health services include (Minister of Welfare, 1995): 1. Determining the amount of work an individual can handle safely, whether the employee is fit to work in a given position or occupation, and defining the conditions under which the worker may be employed; 2. Qualifying a worker as fit or unfit to do a given job and determining the type of work environments and conditions under which the individual is fit to work; 3. Determining the frequency with which fitness examinations are required based on the workplace environment and the nature of the job; 4. Detection and analysis of risk factors connected with work and the work environment, and recommendations for risk factor elimination; 5. Promotion of healthy work conditions, prevention of the harmful impact of work and work environments, and elimination of hazards accompanying new technologies; 6. Organization of first aid facilities in the workplace and training of first aid personnel; 7. Management of accident response and first aid; 8. Monitoring the health of working minors, women, pregnant women, nursing mothers, elderly individuals, and workers with chronic diseases and disabilities; 9. Initiating occupational rehabilitation for injured workers; and 10. Prevention or early detection of occupational and work-related diseases. The current national occupational health service is structured to provide services to all employees. Occupational health care providers must be licensed to practice
by the National Public Health and Medical Officer Service. Before issuing a license, medical officers from the National Public Health and Medical Officer Service inspect the facilities and ascertain whether minimum standards for infrastructure, hygiene, personnel, and material supplies have been met (Gaál et al., 2011). The Decree 27/1995 (VII. 14.) of the Minister of Welfare states that occupational health physicians must be qualified to practice occupational medicine. In parallel, either registered nurses or nurses with occupational health nursing specialist certification are allowed to work in occupational health settings. According to a recent survey by Hirdi et al. (2013), almost half (45.9%) of nurses working in the field had earned occupational health nursing specialist certification. In 2012, occupational health services covered almost 80% of workers in an organized employment setting. The number of employees by industry is presented in Table 3. The actual coverage is dependent on several factors, including availability of occupational health units, the size of the enterprise, and economic factors. In Hungary, the occupational health coverage of companies and workforces differs by sector. The coverage is highest in human health and social work activities (89%). In the relatively low-risk sectors, such as finance, insurance, administrative, and support service activities, the coverage is lower (64%). In general, 20% of the workforce does not have occupational health services, typically in some sectors of industry, agriculture, the self-employed, travelling workers, construction, small-scale enterprises, and the informal sector called the black market. In the past 12 months, 3,161,785 employees received occupational health services, of which 59% received fitness-for-job examinations. In Hungary, participation in pre-employment examinations is compulsory for any candidate and after employment the examination must be repeated annually or biannually. After 30 days of sick leave absence, a return-to-work examination for employees is also compulsory. The examination typically includes a health examination or a work capacity evaluation aimed at appropriate decisions regarding return-towork. These services are managed by 978 full-time physicians, approximately one-third of the total number of physicians in the field. In addition to this, 1,676 part-time physicians are also providing these services. On the other hand, 2,274 of these 2,654 physicians specialize in occupational medicine. Their work is supported by 195 industrial hygienists, psychologists, and ergonomists, complementing this interprofessional service. A total of 2,649 nurses were employed in Hungarian occupational health services (Nagy et al., 2013a). Nurses provide services under the supervision of a physician; they are not allowed to practice independently regardless of their qualifications. The number of nurses working in occupational settings has dropped by 25% in recent years, from 3,472 in 2000 to 2,649 in 2012. Figure 2 presents the Hungarian employment trend for nurses in occupational health from 1997 to 2012, the most recent 15 years for which data are available. The number of nurses has actually decreased over the past
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TABLE 3
Number of Employees Total and Provided Occupational Health Services by Sector (2012) Number of Employed Individuals (%)
Number of Employed Individuals Covered by Occupational Health Services (%)
Occupational Health Coverage of Workers by Sectors (%)
77,800 (2.9%)
66,812 (3.2%)
86%
Mining and quarrying, manufacturing, electricity, gas, steam, and air conditioning supply, water supply; sewage, waste management, and remediation activities
678,000 (25.4%)
509,325 (24.7%)
75%
Construction
112,500 (4.2%)
88,236 (4.3%)
78%
Wholesale and retail trade, repair of motor vehicles and motorcycles, transportation and storage, accommodation and food service activities
596,500 (22.3%)
519,105 (25.1%)
87%
Information and communication, financial and insurance activities, real estate activities, professional, scientific and technical activities, administrative and support service activities, public administration and defense, compulsory social security
637,100 (23.8%)
407,851 (19.8%)
64%
Human health and social work activities
263,800 (9.9%)
235,594 (11.4%)
89%
Education, arts, entertainment and recreation, other activities
308,700 (11.5%)
237,161 (11.5%)
77%
2,674,400
2,064,084
77.2%
Sector Agriculture, forestry, and fishing
National economy, total
Data from Nagy, I., Grónai, É., Nagy, Z. S., & Brunner, P. (2013a). The work of Hungarian occupational health in 2012 [article in Hungarian]. Foglalkozás-egészségügy, 17, 59-73.
Figure 2. Nurses practicing occupational health between 1997 and 2012.
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two decades. In 1997, 3,565 nurses were working in occupational health units. After a slight year-on-year decrease or increase between 1997 and 2007, the number of nurses decreased sharply in 2008 and 2009, when the occupational health sector was affected by the global financial crisis. As a result of the crisis, the numbers of occupational health nurses fell by 12.9% between 2007 and 2008, and by 13.9% between 2008 and 2009. From 2010, the loss of occupational health nurses is attributable to a variety of factors, including emigration, retirement, and nurses leaving the profession.
Basic nursing education (except nurse assistant) can be followed by clinical specialization courses, but only through on-the-job training within the framework of NQR education. Nurses who want to develop their professional skills have a choice of more than 13 nursing specialties, including: oncology, geriatrics, hospice, psychiatry and mental hygiene, diabetology, anesthesiology and intensive care, and occupational health (Balogh, 2008). However, due to the lack of specializations in higher education, BSc and MSc nurses earn the same specialized certificate as the advanced vocational diploma nurses.
NURSING EDUCATION Nurse education in Hungary is consistent with European Union requirements at this time. Nurses can be educated in two ways: National Qualification Register (NQR) training or higher education at several levels. Basic nursing education (except nursing assistant) is based on a high school (post-secondary level) diploma. The education of nurses is described below (Balogh, 2008):
Occupational Health Nursing Specialist Education
1. Nurse Assistant (two-year-program, vocational training); 2. Diploma Nurse with an NQR nursing qualification (3-year program of advanced level vocational training based on high school qualification); 3. BSc nurse (4-year program, university); 4. MSc nurse (5-year program, or a supplementary basic 1.5-year program post BSc degree, university); and 5. PhD (at least 3-year education in the field of nursing and health care education, university graduate school). Unfortunately, the nursing profession is not an attractive career opportunity in Hungary due to low wages, excessive workload, and unclarified professional areas of competence, which has led to fewer nursing students during the past decade. A further problem is lack of mobility between the 3-year diploma nursing qualification and the 4-year BSc or higher level education (Stubnya, Csetneki, & Balogh, 2011), meaning diploma-prepared nurses with an NQR nursing qualification must enter the BSc degree program at the beginning, receiving no credit for prior education or experience. The BSc program is 4 or more years compared to 3 years for the NQR qualification. The diploma-prepared nurse completes the same application procedure as a high school graduate. To gain a BSc, language skills and final thesis are also required. Typically, basic Hungarian nursing education programs do not have specific occupational health content in their curricula; community health courses might include some elements of occupational health nursing practice. For example, the Faculty of Health Science of Semmelweis University provide an additional elective course in occupational health nursing for BSc nursing students. This two-credit (60-hour) course includes an introduction to occupational health nursing in Hungary and Europe, laws and regulations related to occupational health and safety, workplace health promotion programs, roles and functions of occupational health nurses, developing occupational health services, application of conceptual models to occupational health nursing practice, and risk assessment.
The earliest known document regarding industrial health nursing in Hungary shows that between 1883 and 1917 a nurse, Mária Csermák, cared for Rudabánya ore miners and their families with a physician, Dr. Fábry. Meanwhile, Jánosné Gábor practiced as a midwife in the same location, the Miner’s Medical Center founded in 1883, a ward with 16 beds (Papp, 2010; Rudabánya Town, 2012). The industrial nursing profession in Hungary evolved with the growth of industry at the beginning of the 20th century because factories employed nurses. The first factory-nurse course was offered in 1933 by Dr. Mária Baloghy in Budapest. Students of the 2-year full-time course studied health, social, legal, and cultural topics for 45 hours each week for a total of 2,400 hours. During the following 10 years, more than 150 students completed the factory-nurse course. Dr. Baloghy also introduced a monthly continuing education seminar series, so qualified factory nurses could maintain and update their knowledge and skills throughout their work lives (Hirdi, 2013). After World War II, a new “Industrial Nurse” course was initiated in 1953, which awarded a vocational qualification after a 10-month program. The training and examination were free of charge (Minister of Health, 1953); the last course was offered in 1997. This qualification is still used today. The system of industrial (factory) health services was more than four decades old when it was transformed into the Occupational Health Care Service in 1993. The first Occupational Health Nurse Specialist course was offered in 1997. Further changes were introduced to this course in 1999 and 2012. Figure 2 shows the effect of legislative change, Decree 27/1995 (VII. 14.) of the Minister of Welfare, on the total number of occupational health nurses practicing in Hungary. The regulation required nurses to earn the occupational health nursing qualification within a prescribed time. This regulation has been revoked, resulting in a decrease in occupational health nurses again. Currently, this specialization course can be accessed only after completing a minimum 3-year basic nursing education program at the post-secondary level. Experience in occupational health nursing is not required. Rather, the course includes on-the-job training within the framework of NQR training. The specialist study curriculum for nurses includes one classroom day per week and can be completed in a few months (500 to 720 hours) (Hungarian Government, 2012c).
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Figure 3. Nurses earning occupational health nurse qualification between 1997 and 2013.
Specific courses are based on national regulations related to worker health and safety, occupational toxicology, prevention methodology, administration of occupational health services, occupational diseases, industrial hygiene, health screenings and examinations, work psychology, ergonomics, work physiology, physical examinations (e.g., electrocardiography, audiometry, spirometry, and vision testing), emergency health care, and basic computer skills (Béleczky, 2000). The number of nurses currently attending this specialization course is extremely low (i.e., less than 50 per year) (Nagy et al., 2013a; OHAAP, 2013) (Figure 3). One of the reasons for this decline in registrations is that nurses with basic nursing qualifications are allowed to work in occupational health settings without specialization. Another driving force is that after earning the occupational health nursing specialist qualification, nurses’ staff level, wage, and competencies do not change. Finally, these nurses are already working in health services because during their year of training they must arrange time away from their jobs for training days and examinations. In addition, nurses must pay relatively high tuition, examination fees, and incidental expenses that are incongruent with the low wages of nurses. The course is only offered centrally, requiring many nurses to travel to course sites. Registration and Continuing Education
The Health Act regulates registration and licensing of health care professionals, including recognition of foreign diplomas, and established the Health Care Professional Training and Continuing Education Council. All nurses with qualifications from a recognized educational institution within Hungary are entered in the basic registry (diploma register) after conferral of the degree or certificate. Nurses can practice only if they have completed professional training, are listed in the basic and operational (relevant in continuous professional development) registries, and become members of the Council of the
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Hungarian Paramedical Professional Nurses (Hungarian Government, 1997). To ensure the quality of training and minimum standards of service, all nurses are expected to continue their professional education by earning a minimum of 150 credit points by completing accredited courses in a 5-year continuing education cycle. The minimum requirement for renewal is 3 years of professional practice in a position for which the nurse is registered and collection of points from theoretical continuing education. In optimal situations, 100 points of practice (20 points per year) can be awarded by practicing in a particular specialization, supplemented by 50 theoretical points (30 points for compulsory topics and 20 points for voluntary topics). Theoretical points can be earned by participating in continuing vocational education for either 1 day or 40 hours, participating in conferences, attending professional lectures, publishing articles, or participating in “mobility” initiatives that enable nurses to learn or train in other European countries (Minister of National Resources, 2011). Special congresses, conferences, workshops, and study days focused on occupational medicine, occupational health nursing, and labor safety and hygiene are organized by the Council of the Hungarian Paramedical Professional Nurses, the Hungarian Nursing Association, and the Hungarian Scientific Society for Occupational Health and Medicine. These organizations hold three regularly scheduled meetings each annually. The number of participants in each event ranges from 50 to 100. Relevant professional and scientific journals are published in Hungary to provide professional development for nurses. The periodicals most applicable for occupational health nurses are the “Hungarian Journal of Nursing Theory and Practice,” the “Journal of Occupational Health,” and the “Journal of Health Development,” issued by the Council of the Hungarian Paramedical Professionals, the National Labor Office, and the National Institute for Health Development, respectively.
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The Office of Health Authorisation and Administrative Procedures (OHAAP) is responsible for the compulsory registration and licensing of health care workers (OHAAP, 2013). Through the webpage of the OHAAP, anyone can access the database of Hungarian health workers, including name, type of professional qualification, date of continuing education completion required by statute, language skills, work restrictions, and employer or worksite (Hungarian Government, 1997). PROFESSIONAL ASSOCIATIONS FOR OCCUPATIONAL HEALTH NURSES Several professionals and scientific associations for health care professionals have been organized in Hungary, including the Hungarian Medical Chamber (http://www. mok.hu), the Hungarian Scientific Society for Occupational Health and Medicine (http://www.mutt.hu), the Occupational Safety and Health Association (http://www. mufosz.hu), and the Foundation for Worker’s Representatives (http://www.mvkepviselo.hu/). Unfortunately, Hungarian occupational health nurses have not yet organized an association. Occupational health nurses are usually members of the two largest professional organizations for nurses: the Hungarian Nursing Association (http://www. apolasiegyesulet.hu) and the Council of Hungarian Paramedical Professionals (MESZK, http://www.meszk.hu). The Hungarian Nursing Association was established in 1989, the first independent organization to represent the professional interests of Hungarian nurses. The Association represents 10 different sections working within the framework of the Association, including an occupational health nursing section (Hungarian Nursing Association, 2012). The Council of Hungarian Health Care Professionals was formed in 2004 to represent almost all paramedical health care workers, including nurses, midwives, physiotherapists, health visitors, and dietitians. Membership in the Council was initially mandatory, became voluntary in 2006, but today is again mandatory for every nurse, which has raised the profile of issues affecting paramedical professionals and nurses in Hungary. The Council operates as a public body capable of engaging in constructive dialogue with the Ministry of Human Resources, municipalities, and health care institutions. The Council provides professional and ethical support for individuals practicing in paramedical fields as they evolve into professions in their own right, independently address issues affecting associated groups, determine and represent the professional, economic, and social interests of paramedical professionals, and contribute commensurately to members’ roles and status in society, the development of health policy, and the creation of standards for health care provided to the public (Balogh, 2008). Training courses and professional conferences are held at county, regional, and national venues, independently or in partnership with other professional organizations (Balogh et al., 2008). The Council currently has 18 professional sections (e.g., Nursing, Midwifery, Physiotherapy, Dietetitian, Community Health Care), which include all paramedical health professionals working in the Hungarian health care sector. Based on mandatory membership, every nurse who
IN SUMMARY Occupational Health Nursing in Hungary Hirdi, H. É., Hong, O. Workplace Health and Safety 2014;62(10):421-430.
1
Hungary has an almost 1,000-year history of occupational health care, which is now converging with other international partners.
2 3
In Hungary, occupational health nurses have enrolled in specialized education for 80 years.
Despite the need for specialized knowledge and skills, occupational health nurses are not encouraged to complete occupational health nursing education programs due to permissive legislation.
4
In 2012, the Council of Hungarian Paramedical Professionals conducted a membership profile survey of occupational health nurses, the first such national survey in Hungary.
works in occupational health is a member of the Council of Hungarian Health Care Professionals. In 2009, to represent these nurses, the Council became a member of the Federation of Occupational Health Nurses within the European Union (FOHNEU). More detailed information on FOHNEU has been published by Staun (2012). The future development of occupational health nursing, at both individual and community levels, is strongly emphasized by the Council. The first national survey of occupational health nurses was conducted in 2012 by Hirdi et al. (2013) to assess working conditions, health status, lifestyle, and health behaviors. A report of this study will be published in the near future. CONCLUSION In this article, the authors provided an overview of the Hungarian health care and occupational health care systems, including nursing education and professional organizations for occupational health nurses. Hungary has an almost 1,000-year-old history of occupational health care and labor safety, which was revolutionary at the turn of the 19th and 20th centuries. Since the industrial revolution, companies hired nurses; the formal education of industrial nurses began 60 years ago. In accordance with European Union directives, a major revision of occupational health and safety legislation and the health care system occurred in the 1990s. Currently, Hungary is committed to enhancing occupational health nursing. The Council of Hungarian Health Care Professionals took the first steps in this direction by becoming a member of the FOHNEU and collaborating with other international associations. In parallel, the Council explored the status of nurses working in occupational health and safety by conducting an online national membership survey.
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ABSTRACT This article is the first about occupational health nursing in Hungary. The authors describe the Hungarian health care and occupational health care systems, including nursing education and professional organizations for occupational health nurses. The Fundamental Law of Hungary guarantees the right of every employee to healthy and safe working conditions, daily and weekly rest times and annual paid leave, and physical and mental health. Hungary promotes the exercise of these rights by managing industrial safety and health care, providing access to healthy food, supporting sports and regular physical exercise, and ensuring environmental protection. According to the law, the responsibility for regulation of the occupational health service lies with the Ministry of Human Resources. Safety regulations are under the aegis of the Ministry of National Economy. [Workplace Health Saf 2014;62(10):421-430.]
H
ungary is located in central Europe, with a total population of approximately 9.9 million. Its area is 93,000 km2 (35,919 sq mi), comparable to the size of the state of Indiana. The capital city is Budapest, with approximately 1.7 million inhabitants, and the official language is Hungarian, part of the Finno-Ugric language family. Hungary has more than a 1,000-year-old history. Hungary became a full member of the United Nations in 1955, the Council of Europe in 1990, the World Trade Organization in 1995, the Organisation for Economic Co-operation and Development (OECD) in 1996, the North Atlantic Treaty Organization (NATO) in 1999, and the European Union in 2004 (Encyclopedia Britannica, 2012). HEALTH STATUS Annual national statistical data collection is governed by Act XLVI of 1993 on Statistics. This Act regulates the surveying, processing, storage, transfer, receiving, analysis, supply, communication, and publication of data by ABOUT THE AUTHORS
Ms. Hirdi is Vice President, Council of Hungarian Paramedical Professionals (MESZK), Budapest, Hungary. Dr. Hong is Professor, Occupational and Environmental Health Nursing Graduate Program, School of Nursing, University of California, San Francisco, California. Submitted: February 17, 2014; Accepted: July 21, 2014; Posted online: August 20, 2014 The authors have disclosed no potential conflicts, financial or otherwise. Correspondence: Henriett Éva Hirdi, RN, MSN, C-OHN, MESZK Országos Szervezet, Könyves K. krt.76., 1450 Bp., Pf.: 214., Budapest H-1087, Hungary. E-mail: [email protected] doi:10.3928/21650799-20140813-01
statistical methods. National statistical data are easily available, accessible in Hungarian and English in official publications and on the website of the Hungarian Central Statistical Office (HCSO; http://portal.ksh.hu). Based on the latest statistical data of the HCSO, Hungarians’ life expectancy is among the lowest in Europe: 71.5 years for men and 78.4 years for women. The main causes of death are circulatory system disease, malignant neoplasms of the trachea, bronchus, and lung, diseases of the liver, and external causes (motor vehicle accidents and intentional self-harm) (HCSO, 2012a). Lifestyle factors, especially the traditionally unhealthy Hungarian diet, alcohol consumption, and smoking, play a central role in shaping the overall health of the population. According to the European Health Interview Survey conducted in 2009, 21.5% of male respondents and 18.9% of female respondents reported that they were obese (body mass index ≥ 30), and 39.4% of men and 31.1% of women reported they were overweight (25 ≤ body mass index < 30). In 2009, an estimated 31.4% of the Hungarian population age 15 years and older were regular daily smokers. Approximately 15% of respondents in Hungary reported their health status to be “bad” or “very bad.” Approximately 70% of the respondents had a chronic disease affecting one or more organ systems (HCSO, 2010). To reduce the above risk factors, several national initiatives have been introduced in recent years. For example, public places, including restaurants, bars, and workplaces, became smoke-free in 2012. The government also
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prohibits smoking in bus stops, underpasses used by pedestrians, and playgrounds, and within 5 meters of their vicinity. Smoking is banned in schools, child welfare institutes, and health service provider offices, including their courtyards (Hungarian Government, 2012a). Another action of the Hungarian Parliament was to pass a public health product tax, or the so-called “chips tax.” The goal of the legislation was to reduce the consumption of unhealthy foods, to promote healthy diets, and to finance health services, especially public health programs. Taxed food products include soft drinks, energy drinks, pre-packaged sweet goods, salty snacks, and seasonings if sugar, salt, or caffeine content is above a pre-determined level (National Institute for Quality and Organizational Development in Healthcare and Medicines, 2012). HUNGARIAN HEALTH CARE SYSTEM The Hungarian national health care system is managed and supervised by the Ministry of Human Resources, which is also responsible for the welfare system, the development of educational systems, the protection of cultural heritage, the promotion of child and youth welfare, and the realization of government aims related to sports in Hungary (Hungarian Government, 2012b). The basic public health law is Act CLIV of 1997 on Health, which created the general framework for health care, including patient rights, the organization of the health care system, major factors, and responsibilities for health care. The law also identified the services financed by the central government and declared that every individual has a right to life-saving or life-preserving health care interventions and effective, continually accessible and equitable health services (Hungarian Government, 1997). Primary health care is the foundation of the publicly financed state health care system. Municipalities are responsible for providing primary care, which includes general practitioner and pediatric health care, primary dental services, health visitor nursing system, and school physician health services. In 2012, the provision of inpatient and outpatient specialist care became the responsibility of the state. Operation and property management are coordinated by the National Institute for Quality and Organizational Development in Healthcare and Medicines. Hungary’s health care system is financed through the Health Insurance Fund, which is primarily responsible for recurrent health care costs. Act LXXXIII of 1997 on the Services of Compulsory Health Insurance declared that participation in the non-risk–related health insurance program is compulsory for all Hungarian citizens living in Hungary. All citizens are covered by this plan, regardless of employment status, with the government paying contributions for groups such as unemployed adults, children, students, individuals who cannot work due to incapacity, and pensioners. The voluntary health insurance system currently does not play a significant role and has only supplementary and complementary functions (e.g., eligibility for higher levels of concierge service or perdiem-like wage supplement during hospital treatment). Since 1995, occupational health care has been excluded
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from statutory health insurance coverage (Gaál, Szigeti, Csere, Gaskins, & Panteli, 2011). Today, one of the most urgent health care needs is to provide a sufficient number of qualified health care workers; Hungary has a significant shortage of physicians and nurses, mainly due to extremely low salaries in the health care sector compared to other sectors of the economy. Moreover, low salaries encourage migration of Hungarian health care professionals to other western European countries. The Hungarian provider shortage will become more critical due to a recent government regulation. After March 1, 2013, public and civil servant health professionals, employed by government departments or agencies, cannot be employed after the retirement age of 62 years except for researchers and professors working in higher education (National Institute for Quality and Organizational Development in Healthcare and Medicines, 2013). OCCUPATIONAL HEALTH LEGISLATION European directives are binding in their entirety and oblige member states to transpose the directives into national law within set deadlines. European Union directives on safety and health at work have their legal foundation in Article 153 of the Treaty on the Functioning of the European Union (Article 137 TEC), which gives the European Union the authority to adopt directives in this field. A wide variety of European Union directives set minimum health and safety standards for the protection of workers. European Union member states are free to adopt stricter rules for the protection of workers when drafting national law from European Union directives (European Agency for Safety and Health at Work, 2013). In Hungary, many regulations relevant to health, safety, and welfare at work have been adopted and are easily accessible on the website: https://www.magyarorszag.hu. Two of the most important pieces of health and safety legislation are the above-mentioned Act CLIV of 1997 on Health and Act XCIII of 1993 on Labor Safety. These laws set the health and safety standards for all employees and others who may be affected by any work activity. The Labor Safety Act, in accordance with the recommendations of the Framework Directive on Safety and Health (European council 89/391 EC), regulates the necessary personal, material, and organizational conditions of non-hazardous and safe work to protect the health and abilities of employees, as well as to establish work conditions that prevent occupational injuries and diseases. All workers are protected by this Act, including employees, contractors, subcontractors, apprentices, trainees, student workers, volunteers, and employees who perform their work at home (Hungarian Government, 1993). Other regulations cover work activities that carry specific risks (e.g., lifting and carrying, computer work, and exposure to occupational noise, biological agents, electricity, asbestos, ionizing radiation, and sharps). MAJOR OCCUPATIONAL HEALTH PROBLEMS The economy of Hungary is medium-sized, a structurally, politically, and institutionally open economy in central Europe, part of the European Union’s single mar-
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TABLE 1
Economic Activity (in Thousands) of Population Aged 15 to 64 Years by Sex 2000 Age Group Employed population Registered unemployed population Economically inactive population
2010
2012
Male
Female
Male
Female
Male
Female
2,091.6 (62.7%)
1,740.4 (49.6%)
2,005.4 (60.4%)
1,744.7 (50.6%)
2,060.8 (62.5%)
1,782.0 (52.1%)
158.7 (4.8%)
104.5 (3.0%)
264.3 (8.0%)
210.3 (6.1%)
262.3 (8.0%)
212.4 (6.2%)
1,084.2 (32.5%)
1,661.3 (47.4%)
1,051.7 (31.6%)
1,492.9 (43.3%)
972.5 (29.5%)
1,425.6 (41.7%)
Data from Hungarian Central Statistical Office. (2012a). Statistical data of Hungary. Retrieved from http://portal.ksh.hu
ket. The private sector accounts for more than 80% of the Hungarian gross domestic product. Foreign ownership of and investment in Hungarian firms is widespread. Hungary’s main industries are heavy industry (i.e., mining, metallurgy, and machine and steel production), energy production, mechanical engineering, construction materials, processed foods, textiles, chemicals (especially pharmaceuticals), and automobile production. The agricultural sector, for which Hungary has especially favorable climate conditions, represents approximately 3.1% of the country’s gross domestic product. Cattle, pigs, poultry, and sheep are raised in Hungary; the most important crops include wheat, corn, sunflowers, potatoes, sugar beets, canola, and a wide variety of fruits, notably apples, peaches, pears, grapes, watermelons, and plums. Hungary also has several wine regions, producing the famous white dessert wine Tokaji and the red Bull’s Blood. Another traditional world-famous alcoholic drink produced in Hungary is the fruit brandy, pálinka. Within the service sector, private services include trade, tourism, finance, and other economic services. The Hungarian spa culture is world famous, with thermal baths and more than 50 spa hotels, each of which offer the opportunity for a pleasant, relaxing holiday and a wide range of quality health-related and beauty treatments. The state-run service sectors include health care, education, and public administration. Table 1 shows the economically active and inactive populations and their relation to the total population aged 15 to 64 years by sex. The economically active population includes all Hungarians who produce goods and services. The employment rate of individuals 15 to 64 years old was 57.2% in 2012; the unemployment rate for this age group was 11%. The economically inactive population, those who had no job on the reference year, or those who had not been looking for a job, comprised 31.8% of the total Hungarian population. Changes in the economically active population between 2000 and 2012 are displayed in Table 1. The annual rate (2011) for occupational accidents was 5.2 per 1,000 employees (HCSO, 2012a). The standard retirement age was 62 years for men and 58 years for women in 2002, reaching a unisex age of 62 years in
2009. However, a full pension was accessible as early as 60 years for men (with a minimum of 38 covered years) and 55 years for women (with 37 years of contributions). Just 14% of Hungarians between 60 and 64 years of age are still working; however, recent reforms have tightened the rules for early retirement. In 2009, the Hungarian government passed a pension bill to gradually raise the age of retirement to 65 years between 2016 and 2027 (OECD, 2011). The National Labor Office, a central public administrative body, operates within the statutory framework and takes action against employers who breach employment legislation. The Office is responsible for monitoring employers’ records of work-related accidents and, based on the findings, prepares annual reports on the state of occupational safety in Hungary. The reports (available in Hungarian) are presented to the government by the Ministry of National Economy that is responsible for ensuring occupational safety in the country’s labor market. The National Labor Office concluded that the total number of work-related accidents in 2012 was lower than in 2010 (Table 2). The report highlighted that the number of occupational accidents decreased in 2012 in all categories. By sector of economic activity, the largest proportion of work-related accidents in 2012 occurred in engineering (18.9% of the total), manufacturing (16.3%), wholesale and retail trade (12.8%), transportation and storage (12.4%), and education, public administration, and defense (10.1%). The number of fatal work-related accidents also decreased in 2012 compared to 2010; construction continued to report the highest proportion of fatal work-related accidents (29%), followed by agriculture, forestry and fishing (21%), and transportation and storage (16.1%). Deficiencies in investigating work-related accidents and occupational diseases were often found at companies where occupational health and safety professionals were employed only “on paper,” according to the report (Balogh, 2008). Common deficiencies included: the absence of a designated individual responsible for company-level occupational health and safety, and ambiguous accident records resulting in insurance cost avoidance by the company (Balogh, 2008). The estimated proportion of occupational accidents not recorded by the National
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TABLE 2
Number of Occupational Accidents and Fatalities by Sector Work-related Accidents Sector
Fatal Accidents at Work
2010
2012
2010
2012
814 (4.1%)
744 (4.4%)
12 (12.6%)
13 (21.0%)
Manufacturing
3,386 (17.0%)
2,773 (16.3%)
11 (11.6%)
4 (6.5%)
Wholesale and retail trade; repair of motor vehicles and motorcycles
2,553 (12.8%)
2,180 (12.8%)
6 (6.3%)
5, (8.1%)
Transportation and storage, information, and communication
2,492 (12.5%)
2,114 (12.4%)
19 (20.0%)
10 (16.1%)
Education, public administration and defense; compulsory social security
1,948 (9.8%)
1,726 (10.1%)
2 (2.1%)
4 (6.5%)
Human health and social work activities
1,330 (6.7%)
1,136 (6.7%)
2 (2.1%)
0 (0%)
Construction
1,053 (5.3%)
818 (4.8%)
25 (26.3%)
18 (29.0%)
Engineering
3,540 (17.7%)
3,214 (18.9%)
5 (5.3%)
3 (4.8%)
Other activities
2,832 (14.2%)
2,320 (13.6%)
13 (13.7%)
5 (8.1%)
Total
19,948 (100%)
17,025 (100%)
95 (100%)
62 (100%)
Agriculture, forestry, and fishing
Data from National Labor Office. (2013). Accidents at work tables. Retrieved from http://www.ommf.gov.hu/index.html?akt_menu=223 Figure 1. Work-related diseases by frequent causes between 2009 and 2012.
Labor Office remained at 35% to 40% (National Labor Office, 2013). Occupational exposures and resulting diseases are regulated by Decree 27/1996 (VIII. 28) of the Minister of Welfare. The List of Reported Occupational Diseases included 143 diseases classified by potential causal agents. The most frequently reported occupational diseases were infectious, respiratory, and skin. The number of respiratory diseases and industrial poisonings has continuously decreased. The number of occupational diseases caused by hazard exposures between 2009 and 2012 are shown in Figure 1. The annual rate (2012) of reported occupational diseases is approximately 0.5 per 10,000 employees.
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As Nagy et al. (2011, 2013b) presented in a detailed analysis, the number of occupational diseases and increased hazard exposures are generally underreported because reporting interferes with employers’ interests, potential funding of the occupational health service, and, in many cases, the interests of employees who fear being fired or disciplined. Many employers fear increasing workers’ compensation costs or having less chance of winning contracts. OCCUPATIONAL HEALTH CARE Occupational health nursing and occupational medicine have a long-standing tradition in Hungary. Historically, the roots of Hungarian occupational medicine came from the
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era of the founder of the Hungarian state, King Stephen I (Saint Stephen). The “Ius regale” of 1030 (on the royal land with mineral resources) included the rules for employment of miners. Hospitals, relief funds, and health insurance were available for miners from the 12th century. The first hospital was founded in Selmec, in the northern part of the Kingdom of Hungary, in 1224. Its primary purpose was to treat injured miners (Ungváry, 1994; Ungváry & Morvai, 2010). From the 15th century, groups of miners joined together to create their own mutual assistance fund to cover the costs of sickness and injuries, including physician fees. The first known mutual assistance fund dates back to 1496 (Sárdi, 2003). Almost a thousand years later, in compliance with the Labor Safety Act and the sectorial decrees, every employer must provide occupational health care for all employees; however, the law does not differentiate between sectors, areas, or size of enterprises. Nevertheless, a government decree regulates the services: one setting with one full-time physician and one full-time nurse may cover 1,000 to 2,000 workers, depending on health risks (Hungarian Government, 1995). In 1995, the responsibility for financing occupational health service was shifted to employers by Government Decree No. 89/1995 (VII. 14). The employer can organize occupational health care in different ways; whereas larger employers manage their own services, smaller employers can contract with occupational health care providers (Gaál et al., 2011). The main tasks of occupational health services include (Minister of Welfare, 1995): 1. Determining the amount of work an individual can handle safely, whether the employee is fit to work in a given position or occupation, and defining the conditions under which the worker may be employed; 2. Qualifying a worker as fit or unfit to do a given job and determining the type of work environments and conditions under which the individual is fit to work; 3. Determining the frequency with which fitness examinations are required based on the workplace environment and the nature of the job; 4. Detection and analysis of risk factors connected with work and the work environment, and recommendations for risk factor elimination; 5. Promotion of healthy work conditions, prevention of the harmful impact of work and work environments, and elimination of hazards accompanying new technologies; 6. Organization of first aid facilities in the workplace and training of first aid personnel; 7. Management of accident response and first aid; 8. Monitoring the health of working minors, women, pregnant women, nursing mothers, elderly individuals, and workers with chronic diseases and disabilities; 9. Initiating occupational rehabilitation for injured workers; and 10. Prevention or early detection of occupational and work-related diseases. The current national occupational health service is structured to provide services to all employees. Occupational health care providers must be licensed to practice
by the National Public Health and Medical Officer Service. Before issuing a license, medical officers from the National Public Health and Medical Officer Service inspect the facilities and ascertain whether minimum standards for infrastructure, hygiene, personnel, and material supplies have been met (Gaál et al., 2011). The Decree 27/1995 (VII. 14.) of the Minister of Welfare states that occupational health physicians must be qualified to practice occupational medicine. In parallel, either registered nurses or nurses with occupational health nursing specialist certification are allowed to work in occupational health settings. According to a recent survey by Hirdi et al. (2013), almost half (45.9%) of nurses working in the field had earned occupational health nursing specialist certification. In 2012, occupational health services covered almost 80% of workers in an organized employment setting. The number of employees by industry is presented in Table 3. The actual coverage is dependent on several factors, including availability of occupational health units, the size of the enterprise, and economic factors. In Hungary, the occupational health coverage of companies and workforces differs by sector. The coverage is highest in human health and social work activities (89%). In the relatively low-risk sectors, such as finance, insurance, administrative, and support service activities, the coverage is lower (64%). In general, 20% of the workforce does not have occupational health services, typically in some sectors of industry, agriculture, the self-employed, travelling workers, construction, small-scale enterprises, and the informal sector called the black market. In the past 12 months, 3,161,785 employees received occupational health services, of which 59% received fitness-for-job examinations. In Hungary, participation in pre-employment examinations is compulsory for any candidate and after employment the examination must be repeated annually or biannually. After 30 days of sick leave absence, a return-to-work examination for employees is also compulsory. The examination typically includes a health examination or a work capacity evaluation aimed at appropriate decisions regarding return-towork. These services are managed by 978 full-time physicians, approximately one-third of the total number of physicians in the field. In addition to this, 1,676 part-time physicians are also providing these services. On the other hand, 2,274 of these 2,654 physicians specialize in occupational medicine. Their work is supported by 195 industrial hygienists, psychologists, and ergonomists, complementing this interprofessional service. A total of 2,649 nurses were employed in Hungarian occupational health services (Nagy et al., 2013a). Nurses provide services under the supervision of a physician; they are not allowed to practice independently regardless of their qualifications. The number of nurses working in occupational settings has dropped by 25% in recent years, from 3,472 in 2000 to 2,649 in 2012. Figure 2 presents the Hungarian employment trend for nurses in occupational health from 1997 to 2012, the most recent 15 years for which data are available. The number of nurses has actually decreased over the past
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TABLE 3
Number of Employees Total and Provided Occupational Health Services by Sector (2012) Number of Employed Individuals (%)
Number of Employed Individuals Covered by Occupational Health Services (%)
Occupational Health Coverage of Workers by Sectors (%)
77,800 (2.9%)
66,812 (3.2%)
86%
Mining and quarrying, manufacturing, electricity, gas, steam, and air conditioning supply, water supply; sewage, waste management, and remediation activities
678,000 (25.4%)
509,325 (24.7%)
75%
Construction
112,500 (4.2%)
88,236 (4.3%)
78%
Wholesale and retail trade, repair of motor vehicles and motorcycles, transportation and storage, accommodation and food service activities
596,500 (22.3%)
519,105 (25.1%)
87%
Information and communication, financial and insurance activities, real estate activities, professional, scientific and technical activities, administrative and support service activities, public administration and defense, compulsory social security
637,100 (23.8%)
407,851 (19.8%)
64%
Human health and social work activities
263,800 (9.9%)
235,594 (11.4%)
89%
Education, arts, entertainment and recreation, other activities
308,700 (11.5%)
237,161 (11.5%)
77%
2,674,400
2,064,084
77.2%
Sector Agriculture, forestry, and fishing
National economy, total
Data from Nagy, I., Grónai, É., Nagy, Z. S., & Brunner, P. (2013a). The work of Hungarian occupational health in 2012 [article in Hungarian]. Foglalkozás-egészségügy, 17, 59-73.
Figure 2. Nurses practicing occupational health between 1997 and 2012.
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two decades. In 1997, 3,565 nurses were working in occupational health units. After a slight year-on-year decrease or increase between 1997 and 2007, the number of nurses decreased sharply in 2008 and 2009, when the occupational health sector was affected by the global financial crisis. As a result of the crisis, the numbers of occupational health nurses fell by 12.9% between 2007 and 2008, and by 13.9% between 2008 and 2009. From 2010, the loss of occupational health nurses is attributable to a variety of factors, including emigration, retirement, and nurses leaving the profession.
Basic nursing education (except nurse assistant) can be followed by clinical specialization courses, but only through on-the-job training within the framework of NQR education. Nurses who want to develop their professional skills have a choice of more than 13 nursing specialties, including: oncology, geriatrics, hospice, psychiatry and mental hygiene, diabetology, anesthesiology and intensive care, and occupational health (Balogh, 2008). However, due to the lack of specializations in higher education, BSc and MSc nurses earn the same specialized certificate as the advanced vocational diploma nurses.
NURSING EDUCATION Nurse education in Hungary is consistent with European Union requirements at this time. Nurses can be educated in two ways: National Qualification Register (NQR) training or higher education at several levels. Basic nursing education (except nursing assistant) is based on a high school (post-secondary level) diploma. The education of nurses is described below (Balogh, 2008):
Occupational Health Nursing Specialist Education
1. Nurse Assistant (two-year-program, vocational training); 2. Diploma Nurse with an NQR nursing qualification (3-year program of advanced level vocational training based on high school qualification); 3. BSc nurse (4-year program, university); 4. MSc nurse (5-year program, or a supplementary basic 1.5-year program post BSc degree, university); and 5. PhD (at least 3-year education in the field of nursing and health care education, university graduate school). Unfortunately, the nursing profession is not an attractive career opportunity in Hungary due to low wages, excessive workload, and unclarified professional areas of competence, which has led to fewer nursing students during the past decade. A further problem is lack of mobility between the 3-year diploma nursing qualification and the 4-year BSc or higher level education (Stubnya, Csetneki, & Balogh, 2011), meaning diploma-prepared nurses with an NQR nursing qualification must enter the BSc degree program at the beginning, receiving no credit for prior education or experience. The BSc program is 4 or more years compared to 3 years for the NQR qualification. The diploma-prepared nurse completes the same application procedure as a high school graduate. To gain a BSc, language skills and final thesis are also required. Typically, basic Hungarian nursing education programs do not have specific occupational health content in their curricula; community health courses might include some elements of occupational health nursing practice. For example, the Faculty of Health Science of Semmelweis University provide an additional elective course in occupational health nursing for BSc nursing students. This two-credit (60-hour) course includes an introduction to occupational health nursing in Hungary and Europe, laws and regulations related to occupational health and safety, workplace health promotion programs, roles and functions of occupational health nurses, developing occupational health services, application of conceptual models to occupational health nursing practice, and risk assessment.
The earliest known document regarding industrial health nursing in Hungary shows that between 1883 and 1917 a nurse, Mária Csermák, cared for Rudabánya ore miners and their families with a physician, Dr. Fábry. Meanwhile, Jánosné Gábor practiced as a midwife in the same location, the Miner’s Medical Center founded in 1883, a ward with 16 beds (Papp, 2010; Rudabánya Town, 2012). The industrial nursing profession in Hungary evolved with the growth of industry at the beginning of the 20th century because factories employed nurses. The first factory-nurse course was offered in 1933 by Dr. Mária Baloghy in Budapest. Students of the 2-year full-time course studied health, social, legal, and cultural topics for 45 hours each week for a total of 2,400 hours. During the following 10 years, more than 150 students completed the factory-nurse course. Dr. Baloghy also introduced a monthly continuing education seminar series, so qualified factory nurses could maintain and update their knowledge and skills throughout their work lives (Hirdi, 2013). After World War II, a new “Industrial Nurse” course was initiated in 1953, which awarded a vocational qualification after a 10-month program. The training and examination were free of charge (Minister of Health, 1953); the last course was offered in 1997. This qualification is still used today. The system of industrial (factory) health services was more than four decades old when it was transformed into the Occupational Health Care Service in 1993. The first Occupational Health Nurse Specialist course was offered in 1997. Further changes were introduced to this course in 1999 and 2012. Figure 2 shows the effect of legislative change, Decree 27/1995 (VII. 14.) of the Minister of Welfare, on the total number of occupational health nurses practicing in Hungary. The regulation required nurses to earn the occupational health nursing qualification within a prescribed time. This regulation has been revoked, resulting in a decrease in occupational health nurses again. Currently, this specialization course can be accessed only after completing a minimum 3-year basic nursing education program at the post-secondary level. Experience in occupational health nursing is not required. Rather, the course includes on-the-job training within the framework of NQR training. The specialist study curriculum for nurses includes one classroom day per week and can be completed in a few months (500 to 720 hours) (Hungarian Government, 2012c).
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Figure 3. Nurses earning occupational health nurse qualification between 1997 and 2013.
Specific courses are based on national regulations related to worker health and safety, occupational toxicology, prevention methodology, administration of occupational health services, occupational diseases, industrial hygiene, health screenings and examinations, work psychology, ergonomics, work physiology, physical examinations (e.g., electrocardiography, audiometry, spirometry, and vision testing), emergency health care, and basic computer skills (Béleczky, 2000). The number of nurses currently attending this specialization course is extremely low (i.e., less than 50 per year) (Nagy et al., 2013a; OHAAP, 2013) (Figure 3). One of the reasons for this decline in registrations is that nurses with basic nursing qualifications are allowed to work in occupational health settings without specialization. Another driving force is that after earning the occupational health nursing specialist qualification, nurses’ staff level, wage, and competencies do not change. Finally, these nurses are already working in health services because during their year of training they must arrange time away from their jobs for training days and examinations. In addition, nurses must pay relatively high tuition, examination fees, and incidental expenses that are incongruent with the low wages of nurses. The course is only offered centrally, requiring many nurses to travel to course sites. Registration and Continuing Education
The Health Act regulates registration and licensing of health care professionals, including recognition of foreign diplomas, and established the Health Care Professional Training and Continuing Education Council. All nurses with qualifications from a recognized educational institution within Hungary are entered in the basic registry (diploma register) after conferral of the degree or certificate. Nurses can practice only if they have completed professional training, are listed in the basic and operational (relevant in continuous professional development) registries, and become members of the Council of the
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Hungarian Paramedical Professional Nurses (Hungarian Government, 1997). To ensure the quality of training and minimum standards of service, all nurses are expected to continue their professional education by earning a minimum of 150 credit points by completing accredited courses in a 5-year continuing education cycle. The minimum requirement for renewal is 3 years of professional practice in a position for which the nurse is registered and collection of points from theoretical continuing education. In optimal situations, 100 points of practice (20 points per year) can be awarded by practicing in a particular specialization, supplemented by 50 theoretical points (30 points for compulsory topics and 20 points for voluntary topics). Theoretical points can be earned by participating in continuing vocational education for either 1 day or 40 hours, participating in conferences, attending professional lectures, publishing articles, or participating in “mobility” initiatives that enable nurses to learn or train in other European countries (Minister of National Resources, 2011). Special congresses, conferences, workshops, and study days focused on occupational medicine, occupational health nursing, and labor safety and hygiene are organized by the Council of the Hungarian Paramedical Professional Nurses, the Hungarian Nursing Association, and the Hungarian Scientific Society for Occupational Health and Medicine. These organizations hold three regularly scheduled meetings each annually. The number of participants in each event ranges from 50 to 100. Relevant professional and scientific journals are published in Hungary to provide professional development for nurses. The periodicals most applicable for occupational health nurses are the “Hungarian Journal of Nursing Theory and Practice,” the “Journal of Occupational Health,” and the “Journal of Health Development,” issued by the Council of the Hungarian Paramedical Professionals, the National Labor Office, and the National Institute for Health Development, respectively.
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The Office of Health Authorisation and Administrative Procedures (OHAAP) is responsible for the compulsory registration and licensing of health care workers (OHAAP, 2013). Through the webpage of the OHAAP, anyone can access the database of Hungarian health workers, including name, type of professional qualification, date of continuing education completion required by statute, language skills, work restrictions, and employer or worksite (Hungarian Government, 1997). PROFESSIONAL ASSOCIATIONS FOR OCCUPATIONAL HEALTH NURSES Several professionals and scientific associations for health care professionals have been organized in Hungary, including the Hungarian Medical Chamber (http://www. mok.hu), the Hungarian Scientific Society for Occupational Health and Medicine (http://www.mutt.hu), the Occupational Safety and Health Association (http://www. mufosz.hu), and the Foundation for Worker’s Representatives (http://www.mvkepviselo.hu/). Unfortunately, Hungarian occupational health nurses have not yet organized an association. Occupational health nurses are usually members of the two largest professional organizations for nurses: the Hungarian Nursing Association (http://www. apolasiegyesulet.hu) and the Council of Hungarian Paramedical Professionals (MESZK, http://www.meszk.hu). The Hungarian Nursing Association was established in 1989, the first independent organization to represent the professional interests of Hungarian nurses. The Association represents 10 different sections working within the framework of the Association, including an occupational health nursing section (Hungarian Nursing Association, 2012). The Council of Hungarian Health Care Professionals was formed in 2004 to represent almost all paramedical health care workers, including nurses, midwives, physiotherapists, health visitors, and dietitians. Membership in the Council was initially mandatory, became voluntary in 2006, but today is again mandatory for every nurse, which has raised the profile of issues affecting paramedical professionals and nurses in Hungary. The Council operates as a public body capable of engaging in constructive dialogue with the Ministry of Human Resources, municipalities, and health care institutions. The Council provides professional and ethical support for individuals practicing in paramedical fields as they evolve into professions in their own right, independently address issues affecting associated groups, determine and represent the professional, economic, and social interests of paramedical professionals, and contribute commensurately to members’ roles and status in society, the development of health policy, and the creation of standards for health care provided to the public (Balogh, 2008). Training courses and professional conferences are held at county, regional, and national venues, independently or in partnership with other professional organizations (Balogh et al., 2008). The Council currently has 18 professional sections (e.g., Nursing, Midwifery, Physiotherapy, Dietetitian, Community Health Care), which include all paramedical health professionals working in the Hungarian health care sector. Based on mandatory membership, every nurse who
IN SUMMARY Occupational Health Nursing in Hungary Hirdi, H. É., Hong, O. Workplace Health and Safety 2014;62(10):421-430.
1
Hungary has an almost 1,000-year history of occupational health care, which is now converging with other international partners.
2 3
In Hungary, occupational health nurses have enrolled in specialized education for 80 years.
Despite the need for specialized knowledge and skills, occupational health nurses are not encouraged to complete occupational health nursing education programs due to permissive legislation.
4
In 2012, the Council of Hungarian Paramedical Professionals conducted a membership profile survey of occupational health nurses, the first such national survey in Hungary.
works in occupational health is a member of the Council of Hungarian Health Care Professionals. In 2009, to represent these nurses, the Council became a member of the Federation of Occupational Health Nurses within the European Union (FOHNEU). More detailed information on FOHNEU has been published by Staun (2012). The future development of occupational health nursing, at both individual and community levels, is strongly emphasized by the Council. The first national survey of occupational health nurses was conducted in 2012 by Hirdi et al. (2013) to assess working conditions, health status, lifestyle, and health behaviors. A report of this study will be published in the near future. CONCLUSION In this article, the authors provided an overview of the Hungarian health care and occupational health care systems, including nursing education and professional organizations for occupational health nurses. Hungary has an almost 1,000-year-old history of occupational health care and labor safety, which was revolutionary at the turn of the 19th and 20th centuries. Since the industrial revolution, companies hired nurses; the formal education of industrial nurses began 60 years ago. In accordance with European Union directives, a major revision of occupational health and safety legislation and the health care system occurred in the 1990s. Currently, Hungary is committed to enhancing occupational health nursing. The Council of Hungarian Health Care Professionals took the first steps in this direction by becoming a member of the FOHNEU and collaborating with other international associations. In parallel, the Council explored the status of nurses working in occupational health and safety by conducting an online national membership survey.
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