key: cord-0945833-jgrfkfhv
authors: Ungureanu, Marius-Ionuţ; Brînzac, Monica Georgiana; Forray, Alina; Paina, Ligia; Avram, Lucreţia; Crișan, Dana Alina; Donca, Valer
title: The geriatric workforce in Romania: the need to improve data and management
date: 2020-09-19
journal: Eur J Public Health
DOI: 10.1093/eurpub/ckaa127
sha: 69cd8e2893d20dafb0f7efa9d979886fac34d5bf
doc_id: 945833
cord_uid: jgrfkfhv

Facing severe under-funding and significant workforce maldistribution, the health system in Romania is challenged to provide adequate care for the ageing population. The aim of this article is to connect health labour market data of the geriatrics workforce in Romania with individual perceptions of front-line workers in geriatrics in order to better understand the ‘human’ factors of effective health workforce development. Comprehensive health workforce data are not available; we therefore used a rapid scoping review and interviews to combine quantitative and qualitative data sources, such as the ‘Healthcare Facility Activity Report’, policy documents and available reports. They show that despite a consistent increase in the overall number of geriatricians, their majority is based in Bucharest, the capital city. The initial review points to possible geriatrician burnout, caused in part by high workload. The geriatrics workforce in Romania is poorly developed. Significant efforts are still needed to create policies addressing inflows and outflows, training, maldistribution and inefficiencies related to their practice. Addressing burnout by improving teamwork and collaboration is vital for maintaining and improving the workforce morale and motivation. Two major policy recommendations emerged: an urgent need for better health workforce data in Romania and development of more effective workforce management.

R omania faces particularly difficult challenges in relation to its health workforce, specifically to establish a comprehensive monitoring system and to ensure sufficient numbers, equitable distribution and right skills. 1 For many years, Romania has been an important source of healthcare professionals-mainly doctors and nurses-for other countries. [1] [2] [3] [4] After formally acceding to the European Union (EU) in 2007, workforce mobility increased dramatically. 1 Data collected by the Romanian College of Physicians show a declining trend among the doctors requesting certificates of good standing, a mandatory document needed for getting one's qualifications recognized in another country and an indicator of intention to migrate. 5 The number of certificates issued decreased from 1819 in 2015 to 1462 in 2016 and 1126 in 2017. 5 There are major concerns about having sufficient numbers of health workers, and their distribution and skills mix particularly in light of current demographic trends. The proportion of elderly Romanians has grown significantly as a result of the combined effect of increases in life expectancy and in emigration flows of the young population. 6 By 2050, more than a quarter of Romanians (27.7%) will be older than 65 years, and the proportion of those older than 85 years is expected to increase to 8.5%, from 4.8% in 2019. 6 The complexity of care for the elderly calls for a health system with the right combination of services provided by qualified professionals. 7 Recent findings show that long-term care (LTC) services for the elderly are poorly developed and fragmented. 8 Shortages in LTC staff combine with poor management and with a lack of collaboration between health professionals and between the health and social care sectors. Insufficient numbers of professionals are only part of the problem, other factors must also be considered, for instance, increased pressure on health professionals often caused by heavy workloads. 8 Data on the status of the geriatrics workforce and geriatrics services in Romania are limited, as are data on the health workforce in general. It should also be noted that geriatrics is a relatively new specialty in Romania. 9,10 However, its importance is growing given the increasing proportion of elderly. In this context, and to build a more sustainable health workforce, policymakers, health workforce planners and researchers alike need to have a better understanding of both the labour market situation and the perceptions and needs of those who care for the elderly.

This article conducts an analysis of the geriatrics labour market and connects these results with individual perceptions of front-line workers to better understand the 'human' factors of effective health workforce development. To our knowledge, this is the first analysis of this kind on the geriatrics health workforce in Romania.

This research is explorative in nature and combines different sources and approaches to integrate qualitative data in a health labour market approach. First, we used yearly quantitative data provided by the National Institute of Statistics for the years between 2009 and 2018 to determine the number and distribution of geriatricians in Romania, in both public and private facilities. 11 Second, we conducted a rapid scoping review of the literature to identify scholarly articles on the geriatrics workforce in Romania and its challenges related to working conditions. We searched PubMed, ScienceDirect and Google Scholar using a combination of the following search terms: 'geriatrics', 'workforce', 'stress', 'burnout', 'Romania'. We limited the search to articles in Romanian and English, published since 2000. Six articles were retrieved based on their title and abstract. The full text was retained only of those that presented relevant information on challenges affecting the geriatrics health workforce in Romania.

Third, we complemented data from the first two sources with two individual examples, purposively selected-one geriatrician (male, more than 20 years of experience) and one geriatrics nurse (female, about 5 years of experience). These two key informants were asked to describe the specific challenges they are experiencing in their dayto-day work, the individual coping mechanisms and the suggestions for improvements and policy changes.

Romania has 13 public and private medical schools, yet only three geriatrics under-graduate departments, one of whom-the oldestbased in Bucharest. In 2018, there were 157 practicing geriatricians in Romania and 85 geriatricians in training. 11 There was a relevant and continuous increase between 2011 and 2018 with numbers nearly doubling during this time (figure 1). However, developments in the group of junior geriatricians did not mirror this trend; in 2018 their numbers were only slightly higher than in 2011 (figure 1). This is very alarming, because it indicates an even widening gap between demand and supply in future. Furthermore, the available professionals in geriatrics are not uniformly distributed across the country: 57 (36.3%) are based in Bucharest, where less than a fifth of the country's population lives. Geriatricians in training show a similar pattern, with 50 residents in Bucharest (58.8%) out of the 85 junior doctors nation-wide. 11 

Geriatrics care is provided in specially designated geriatrics hospital departments, staffed with geriatrics doctors (geriatricians), geriatrics nurses and nursing assistants. Geriatrics is a 4-year specialty which can be pursued by medical graduates in accordance with their results in the national ranking exam. However, geriatrics is not popular among medical school graduates. While solid research data are not available, a recent online survey among medical school graduates placed geriatrics in the bottom quarter of preferred medical specialties. 12 For nurses, no specialized training programmes exist.

Our search retrieved initially six results. After analyzing the full-text content of the articles, only one presented information focused on geriatrics care and a second one provided more general information partly relevant to our study. Vartan and Avadanei surveyed a small sample of 23 geriatrics Romanian nurses and found high levels of emotional exhaustion and reduced personal accomplishment. 13 In addition, Spânu et al. report findings from a study on burnout and quality of care, including Romanian 349 health professionals-doctors, nurses and resident doctors, of which 0.9% were working in geriatrics. 14 They concluded that the perceived job demands were correlated with emotional exhaustion and depersonalization.

Existing research may raise concern about the work conditions in geriatric care in Romania, but information is very limited and also not up-to-date. Boxes 1 and 2 introduce the perceptions of two front-line workers-a geriatric doctor and a geriatric nurse-thus providing some insights into hospital-based geriatrics care.

The two individual interviews illustrate that geriatricians and geriatrics nurses confronted a number of weaknesses and failures at the level of the system and the organization. Especially in the 

Working in a hospital geriatrics department is causing exhaustion and low levels of satisfaction, motivation and appreciation. The causes are related to the high complexity of elderly patients, due to their multiple conditions. Many times, patients present themselves late at the hospital, which causes additional complications. There is, generally, a poor formal collaboration with other specialties and with social workers. When collaboration is present, it is most frequently based on informal connections between individuals. Moreover, social care is poorly developed, which adds additional burden to the geriatricians: elderly with no family members or homeless need to remain hospitalized even after their medical condition has been resolved, especially during the cold season. During this time, the geriatricians need to cover patients' medical and social needs. The volume of work is high, because of the trend of population ageing and also because of the small number of geriatrics departments in the country. The planning and recruitment schemes of geriatrics departments do not take into account the specific situation of geriatrics; they do not discriminate between other specialties treating adults who are not functionally dependent. Therefore, staff numbers are estimated too low and do not meet the demand. There is a high turnover of personnel, because of the particular working conditions in geriatrics departments and insufficient mechanisms to motivate them. Junior doctors often face a shortage of training opportunities, thus they rely mostly on individual rather than institutional effort, as well as on-the-job training. Professional satisfaction is limited compared with other specialties, since geriatricians are most of the times caring rather than curing. Also, they face high and unrealistic expectation from patients, families and society at large. Source: Personal communication, information provided by geriatrics doctor (male, working in a hospital geriatrics department) case of nurses, this may be reinforced by poor education, often reduced to 'on-the-job training'. In the absence of institutional support and effective management and leadership structures, health professionals are forced to rely on personal strength and coping strategies as well as on support from peers. These conditions may generate high costs at a personal level, which might explain a high turnover rate of personnel in geriatrics departments.

Data and knowledge on the geriatrics workforce in Romania are overall poorly developed and reduced to quantitative data collected with the help of nation-wide tools. Qualitative information seems to be largely absent, and there are no signs that health workforce policy and management are interested in the 'human face' of the health workforce. There is a need to systematically increase the quantity and quality of data in order to improve empirically based health workforce development and to provide policy recommendations on recruitment, retention and motivation of healthcare workers in geriatrics. 15 Our exploratory study suggests that the increased risk of burnout, stress and exhaustion is one of the major challenges related to the geriatrics workforce in Romania. Even though many of these effects have been informally reported for long periods of time, the policy responses lacked to address them properly. The National Health Strategy 'Health for Prosperity' 2014-20 lists human resources for health strategy among its objectives, 16 but a strategic document developed in 2016 has never been adopted. 17 The Government's efforts were limited to financial issues, including significantly increased wages for numerous categories of health professionals. However, they failed to address the complexity of workforce challenges related, for instance, to working conditions, informal healthcare payments, personal and professional development, [18] [19] issues repeatedly reported to act as push factors contributing to health professionals' decisions to emigrate. 1, 20 To address these complex issues, decision-makers need to employ a whole-of-Government approach. 21, 22 Specifically, measures taken in the health sector must be complemented with decisions in the educational, labour and financial domains. [23] [24] [25] This would involve educational policies addressing the selection and motivation of geriatrics residents, assessment of the needed numbers and their distribution by means of adequate planning tools, as well as the connection with the variety and quality of geriatrics services needed for the elderly.

The transnational European dimension is also highly relevant, 26 as Romania is still losing high numbers of qualified health professionals and carers. No functional governance mechanisms are in place at a European level to manage these trends and, as a consequence, the Romanian health system continues to be at high risk of losing the very few professionals providing geriatrics care. This would even worsen the current situation: with 2.9 practising doctors per 1000 population Romania has the third lowest number of practising doctors in the EU, which achieved on average 3.6 practising doctors per 1000 population. 4 Finally, there is a need to give greater attention to the organizational conditions and the individual situation, including the health and wellbeing of health professionals. Furthermore, improvements in education and competences in inter-professional work could potentially lead to reduced feelings of exhaustion, over-burdening and limited communication between doctors and nurses.

This study is an exploratory effort and the scarcity of data does not allow for generalization. The findings must be viewed with high caution, in particular, those related to the work conditions and the views of individual professionals. The study primarily highlights significant gaps and a future 'direction of travel' in health workforce policymaking. It shows that research should not only focus on getting more data on geriatrics but also expand on knowledge and understanding of the qualitative dimensions of work in geriatric care.

This article set out to explore the situation the geriatrics workforce in Romania. The findings highlight an urgent need for improving monitoring systems and data sources and for establishing more effective management. The complexity of challenges and the institutional weaknesses on different levels call for fundamentally novel direction in Romania's health workforce policy and research, which moves beyond mere health labour market analysis and also acknowledges the healthcare worker as an individual. Health workforce policy must address working conditions, inter-professional collaboration, education and care coordination to improve the work situation in geriatrics and to mitigate further emigration and job drop-outs because of stress and burnout. In the absence of measures in these areas, and with the added impact of the COVID-19 pandemic, the health system might be in danger to lose even more of its professionals, leaving few available to care for the elderly citizens.

Many nurses working in geriatrics departments feel unappreciated and stigmatized, because people generally do not understand the specifics of their work and workload, and underestimate it both in terms of quantity and quality. Training does not prepare geriatric nurses adequately for the clinical and administrative tasks they need to perform. Moreover, the division between administrative and clinical work is often unbalanced with over-burdening administrative tasks, which do not leave them with enough time to provide clinical care. Since there is generally a shortage of staff, the psychological pressure as well as turnover among nurses are high. As a result, it is common for nurses to feel guilty for not being able to do more, not being able to provide enough attention and presence for their patients. To maintain a human touch to the care they are providing, nurses often are imagining that those cared for are their parents or family members.

Nurses often feel that doctors do not appreciate their work and accurately estimate the workload, and that the management ignores their needs or lacks understanding of the situation. They also believe that the organization of work and the communication with doctors should be improved. Interestingly, nurses seek to mitigate managerial and communication problems by helping each other through verbal encouragement and maintaining a positive attitude. As institutional support is provided only for serious problems, they take action and seek to offer help to whoever is in need or struggling with a particular situation. Gratitude expressed by patients and seeing patients recover may also counterbalance negative perceptions; e.g. if patients who could not walk when admitted, leave the hospital on their own feet upon discharge. Source: Personal communication, information provide by geriatrics nurse (female, working in a hospital-based geriatrics department)

iv30 European Journal of Public Health

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We wish to thank the two key informants, who contributed to this study, for their availability and time. We are also grateful for the guest editors' kind support during the manuscript development.Conflicts of interest: None declared.

• Access to and availability of the geriatrics workforce in Romania is poor and unevenly distributed. • Geriatricians and geriatrics nurses in specialized hospitalbased departments seem to be at risk of stress and burnout. • The geriatrics health professionals' work experiences need to be researched more carefully and taken into account in workforce policies. • A novel approach to health labour market data and policy is needed, which includes greater attention to the individual professional.Geriatric workforce in Romania iv31