De-bureaucratization and Stabilization of Nursing: An Integrated Social Economy Model as an Alternative to the Reduction of Qualification Standards in Nursing Education in Slovakia

Introduction and Theoretical Framework

The starting point for an in-depth analysis of the genesis of the current crisis is the discrepancy between achieved education and the actual content of work in clinical practice. This paper, within a critical comparison, maps the legislative turbulence in Slovakia and confronts it with theoretical approaches to professional autonomy and structural differentiation in Italy, which strives for strict compliance with European Union directives.

The Italian precedent confirms that the solution to the personnel deficit should not be the devaluation of education, but the strengthening of the academic status of nurses in accordance with Directive 2005/36/EC. Instead of lowering qualification requirements, the Italian legislator chose the path of deepening the career structure of the support staff, thereby protecting the clinical autonomy of the nurse as a full partner of the physician.

The analysis focuses on deconstructing current efforts to change the educational standard and offers an alternative perspective based on successful foreign practice.

Competency Crisis in Slovak Nursing

The current discourse on stabilizing healthcare personnel in Slovakia shows signs of conceptual disorientation and systemic amnesia. The most striking manifestation of this state is the consideration of introducing an experimental educational model "1+4" (one year of post-secondary or other study plus four years of secondary nursing school), which aims to rapidly saturate the deepening deficit of nursing labor, regardless of qualitative impacts. The academic community, key professional organizations, and chambers of commerce rightfully perceive this step as a denigration of the status of nurses and as academic regression. Despite occasional institutional inconsistency, where a minority of professional representatives accepted the pragmatic pressure from the ministry, the vast majority of professional representation consensually rejects the model: they perceive it as a direct denial of European qualification standards, especially the European Parliament Directive on the recognition of professional qualifications.

The proposed legislative intent is contrary to the purpose and meaning of Directive 2005/36/EC, even though it does not formally violate it. The Directive requires that the education of nurses responsible for general care be based on a deep scientific foundation and correspond to at least three years of university preparation or the equivalent of a proper bachelor's degree. The true core of the crisis in Slovak nursing is not the inherent unwillingness of young people to study this field at universities, but the chronic overloading of university-educated nurses with auxiliary, hygienic-sanitary, and administrative tasks, tolerated by the system. In the environment of institutional healthcare in Slovakia, the position of the nurse as an autonomous expert in nursing diagnosis and process management is limited by persistent demansionarism (demansionamento - qualification undervaluation of the nurse due to personnel deficit). In practice, this means the concentration of a wide range of disparate activities in one job position - from professional pharmacotherapy to meeting the patient's basic needs and the sanitation or cleaning of the ward environment.

This structure of work generates a high degree of cumulative physical and psychological burden, which is identified in the professional literature as one of the main factors of professional burnout and subsequent departure from the system. Comparative findings show that without a fundamental structural reconstruction of clinical workload and the relief of nurses from auxiliary tasks, even increasing the number of new graduates does not represent a sustainable solution for the stability of nursing teams.

Foreign experience, especially from Italy, clearly demonstrates that the solution to the personnel crisis does not lie in the declassification of the profession, but in its exact opposite: in deepening the qualification structure of the support staff, culminating in the introduction of a new category of nurse's assistant (assistente infermiere) by decree in February 2025. This modern approach does not involve lowering standards for nurses, but creating a professional intermediate link, directly subordinate to the clinical leadership of the nurse, relieving her of unskilled work. Based on this analogy, the presented study therefore posits the thesis that the way out of the Slovak crisis does not lie in the competence of the Ministry of Health of the Slovak Republic nor in the deformation of the school system through the "1+4" model, but in a radical structural reconstruction of the clinical workload of nursing personnel through clearly defined support levels, such as the nurse's assistant.

Theoretical Framework

Unlike the Italian system, the Slovak nursing care system has so far retained a taxatively defined work structure in which a university-educated nurse performs, alongside clinical-managerial tasks (pharmacotherapy, invasive procedures, nursing diagnosis), also basic hygiene, sanitation, and service activities. The absence of a formalized intermediate qualification layer (analogous to OSS/ASA) means that the entire range of activities - from highly specialized to manual - remains concentrated in one job position.

This concentration has two immediate consequences. First, it generates a cumulative physical and psychological burden that is structurally different from the burden of clinically specialized work and is repeatedly identified as one of the main predictors of burnout syndrome and personnel turnover. Second, it weakens the position of the nurse as a clinical partner of the physician: while the Italian infermiere, after the legislative reform of 1999, acts as a bearer of independent professional responsibility within a multidisciplinary team, the Slovak model - and especially the proposed reductionist educational standard "1+4" - systematically weakens this equality, since a graduate of a shortened educational program cannot bear the same scope of clinical responsibility as a nurse with completed university education in accordance with Directive 2005/36/EC.

Evidence of the absence of systemic reflection on this problem is also the course of the legislative process for adopting the "1+4" model. According to available information, the positions of relevant professional entities, including the Slovak Chamber of Nurses and Midwives (SKSaPA) and the Trade Union Association of Nurses and Midwives (OZ SaPA), were marginalized in the decision-making process, despite these being entities with a direct mandate to defend the professional interests of nursing staff. This lack of participation by professional and trade union organizations contrasts with the Italian case, where the 1999 reform arose in direct cooperation with professional colleges (today the Ordini delle Professioni Infermieristiche) and was the result of a long-term legislative process, not an administratively expedited measure. The involvement of trade union organizations, such as OZ SaPA, in commenting on the "1+4" model should take place in accordance with Act No. 2/1991 Coll. on Collective Bargaining, which regulates the status and participation of trade unions in the process of creating labor law standards.

The Slovak case thus represents not only a question of a qualification standard, but a broader problem of the absence of a structural mechanism for distributing the workload among differentiated categories of personnel - a problem that the "1+4" model not only fails to solve, but potentially deepens by lowering the qualification level for entry, as it shifts part of the clinical-control responsibility to the physician and continues to leave part of the manual workload within the competence of the nurse.

Deconstruction of Counterarguments

The Italian nursing system is defined by a robust infrastructure which, compared to the Slovak network, faces significantly higher pressure on personnel capacities. Despite this massive burden, the Italian model did not resort to lowering qualification requirements for entry into the profession, but rather to a strict differentiation of clinical work from service and support activities. The successful implementation of this model in a substantially larger system is direct evidence of its high degree of scalability. The argument about the specificity or smaller scope of Slovak healthcare therefore does not hold as a reason for an exception, as the Italian precedent confirms that a systemic division of competencies is a functional and transferable solution also for the needs of the Slovak Republic.

For Slovak macro-management practice, it is therefore crucial to analyze the historical precedent of the Italian Republic, which at the turn of the 1980s and 1990s was undergoing an identical structural crisis. The Italian health system (Servizio Sanitario Nazionale – SSN) during this period showed a significant personnel deficit in the nursing segment, which generated intense political pressures to deregulate qualification standards with the aim of rapidly saturating the labor market with low-cost professional categories. Institutional decision-makers faced a systemic dilemma: either accept a concessionary approach associated with the devaluation of the qualification structure, or proceed to redefine the status of the nursing profession in line with trends in the modernization of clinical practice.

The Italian legislator chose the second path, and did so in two phases. The first step was not adding personnel, but increasing the attractiveness of university nursing studies themselves: by moving education exclusively to universities (Laurea Triennale/Magistrale), expanding career and specialization paths, and legally recognizing the nurse as a full-fledged, autonomous healthcare professional. This step was legislatively completed with the adoption of Law No. 42/1999 (Legge 42/1999), which definitively removed nursing from the list of so-called "auxiliary professions" (professioni sanitarie ausiliarie) and elevated it to an independent profession (professione sanitaria autonoma), an equal partner to the physician in the multidisciplinary team. The increase in prestige, autonomy, and career prospects represents a motivational (pull) factor acting in the opposite direction to the Slovak strategy of lowering qualification requirements. While the Italian model relies on the long-term strengthening of the profession's attractiveness, the Slovak approach can be characterized as a short-term, emergency solution, the sustainability of which in terms of professional stability is not proven.

The second, complementary step was the thorough separation of nursing competencies from service, sanitary, and hygiene activities. The introduction of this model was the result of a nationwide legislative consensus with regional acceptance, which ensured the unification of standards across all Italian regions: on February 22, 2001, a unified profile of the socio-healthcare operator - OSS (Operatore Socio-Sanitario) was created, supplemented by the ASA (Ausiliario Socio-Assistenziale) profile in the social field. These categories took over complete basic nursing care - including total hygienic care of the patient, dressing them, assistance with feeding and positioning, as well as sanitation of the ward environment. The nurse's agenda was thus not only partially freed up; it was separated from any manual, unskilled work, so that she could fully devote herself to the management, diagnosis, and execution of the nursing process.

Demographics and Personnel Deficit: Asymmetric Aging as a Systemic Pressure

After defining the theoretical framework of the competency crisis, it is necessary to support this problem with data - at the level of demographic pressure, personnel density, and the architecture of inpatient care in both countries.

The first element of structural homogeneity between the Italian Republic and the Slovak Republic is the demographic transition, characterized by progressive and asymmetric aging of the population. This phenomenon generates linear and unsustainable pressure on both healthcare systems.

Tab. 1: Comparison of Countries

Source: Own processing by the author based on data from the Statistical Office of the Slovak Republic, ISTAT, and Eurostat.

Basic Demographic and Systemic Indicators

From a demographic scale perspective, Italy, with 58.9 million inhabitants, represents a macro-nation of the European Union, while Slovakia, with 5.41 million residents, forms a medium-sized system (approximately 9.1% of Italy's demographic volume); however, development trends are almost identical. In Italy, the share of the population over 65 reached a European maximum of 25.1% (14.8 million people). In Slovakia, this quota has so far stopped at the level of 19.0% (1.02 million people), but the growth rate of the geriatric component over the last four years (+11%) indicates an extremely rapid convergence with the Italian standard.

In parallel, the segment of the "oldest old" (over 80 years) is growing. Italy records 4.6 million people in this category, which translates into more than 12 million patients with chronic multimorbidity. In Slovakia, the average age of the population reached 43.3 years, accompanied by a massive expansion of chronic-degenerative pathologies. The result is an anomaly in the form of 11 outpatient examinations per citizen per year (one of the highest values in the EU), which points to a massive demand for basic care that the poorly developed community-based infrastructure is unable to filter.

Tab. 2: Statistical indicators of personnel deficit

Source: Own processing by the author based on data from OECD, WHO and Corte dei Conti (2025).

Key finding: Despite the higher deficit of nurses, Italy chose competency differentiation (OSS/ASA), not a reduction in qualifications. The transfer of support tasks guarantees a safe ratio of approximately 6 patients per nurse, while in Slovakia the absence of auxiliary staff forces nurses to handle all tasks under a critical load of 15 to 20 patients. (Conferenza permanente Stato-Regioni, 2001; Dimensione Infermiere, 2025; OECD, 2025).

A comparison of the demand for care with the actual supply of professional workforce reveals a deep personnel crisis in both countries. Italy has long faced a structural deficit with a value of 6.5 nurses per 1,000 inhabitants, which is well below the OECD average (approaching a value of 10) (OECD, 2025; European Observatory on Health Systems and Policies, 2024). Slovakia is in an even more alarming position, where this indicator has fallen to 5.7 nurses per 1,000 inhabitants (OECD, 2025; OECD / European Observatory on Health Systems and Policies, 2025). In other words: Italy has a lower ratio of nurses per capita than the OECD average, but higher than Slovakia – despite its lower relative deficit, it chose a more radical solution (complete removal of support tasks), while Slovakia, with a deeper deficit, resorts to a solution that deepens the problem in the long term.

A key indicator of organizational inefficiency and threat to the safety of provided care is the ratio of doctors to nurses. The European safety standard requires a minimum of 2.5 nurses per doctor (European Parliament and Council of the EU, 2005). In Italy, this ratio is critically low – 1.4 to 1 (Ferraro, 2025). In Slovakia, the situation is almost identical (approximately 1.3 to 1) (VReduMED, 2024), which in practice generates a destructive chain effect.

A key indicator of organizational inefficiency and threat to the safety of provided care is the ratio of doctors to nurses. The European safety standard requires a minimum of 2.5 nurses per doctor. In Italy, this ratio is critically low – 1.4 to 1. In Slovakia, the situation is almost identical (approximately 1.3 to 1), which in practice generates a destructive chain effect: doctors are overloaded with bureaucratic agenda and nurses are exposed to enormous physical and psychological pressure due to the accumulation of unrelated activities. However, while the Italian doctor has in the nurse a full-fledged, academically equal partner capable of independent diagnosis and decision-making within the nursing process, the Slovak "1+4" model systematically declines this relationship: a nurse with a secondary school level of training cannot bear the same degree of clinical responsibility, and therefore part of the decision-making and control burden inevitably shifts back to the doctor – the exact opposite of the declared goal of relieving the healthcare system (European Parliament and Council of the EU, 2005; Ferraro, 2025; OECD, 2025; VReduMED, 2024).

In the area of care for the chronically ill, Italy shows a share of 1.5 dedicated operators (i.e., qualified professional staff for social-health care, primarily in the category of Operatore Socio-Sanitario – OSS) per 100 seniors. In Slovakia, this indicator reveals an almost complete absence of formalized support staff directly in wards and residential care facilities. The Slovak nurse thus remains isolated in clinical practice, without the existence of a hierarchically lower, subordinate assistance layer that would relieve her of physically and mentally exhausting manual work. (European Observatory on Health Systems and Policies, 2024; OECD, 2025; OECD / European Observatory on Health Systems and Policies, 2025; VReduMED, 2024)

These comparative findings lead to the fundamental conclusion that the solution to the personnel crisis in Slovak nursing cannot lie in the legislative devaluation of educational standards, but in a radical reconstruction of the clinical workload of staff. The Italian model proves that exact competency differentiation and the institutionalized removal of basic support tasks from the hands of nurses allows for the establishment of a safe and medically sustainable norm at the level of six patients per nurse. In stark contrast to this stands the Slovak reality of permanent triple overload (15 to 20 patients per nurse), which is a direct consequence of the absence of any support personnel segment.

A key transformation tool for relieving healthcare staff and delegating support tasks is offered by the social economy through integration social enterprises (in the Slovak Republic according to Act No. 112/2018 Coll., following the model of Italian type B social enterprises – cooperative sociali di tipo B). Their primary goal is the work integration of disadvantaged persons (inserimento lavorativo) and their involvement in auxiliary assistance services. Through the systematic, legislatively regulated deployment of assistant workforce, generated and managed through registered integration social enterprises (within the meaning of Act No. 112/2018 Coll.), it is possible in Slovakia to protect the intellectual status of the nurse, eliminate her overload, and simultaneously address the secondary, yet equally acute structural problem of inclusion of disadvantaged persons in the labor market.

This proposed inter-ministerial synergy between the Ministry of Health of the Slovak Republic and the Ministry of Labour, Social Affairs and Family of the Slovak Republic represents a Slovakia-specific alternative to the Italian OSS model. While Italy had to create an entirely new professional category tied to the healthcare system for the transformation of nursing, the Slovak Republic can effectively utilize the already existing and legislatively anchored institute of integration social enterprises.

By allocating disadvantaged or vulnerable persons who undergo targeted, modular professional training for performing low-skilled auxiliary, sanitary, and logistical tasks in the hospital environment, an immediate relief of overloaded nursing units will occur. This approach also addresses the financial barrier: the wage costs and management of auxiliary staff would not primarily burden the resources of public health insurance, but would be largely refunded and stimulated through instruments of active labor market policy and funds designated for the development of social entrepreneurship. The result of such a conceptual transformation is not only an approximation to safe European standards of patient care, but also systematic protection of university-educated nurses from professional burnout and premature departure from the system.

Architecture of inpatient care and the paradox of Slovak hospitalization

Absorption capacity of both healthcare systems (Italian and Slovak) in managing chronic critical patients directly depends on the configuration of hospital and social-health networks. Italy has a network of 996 hospitals and over 8,000 residential long-term care (LTC) facilities (public, accredited private), which in absolute numbers creates an acute deficit of nursing workforce – while Slovakia records 78 (including university and specialized institutes). This gap in network volume means that Italy needs, in absolute numbers, an order of magnitude more nursing staff than Slovakia – and yet it faces a structural shortage of nurses. Thus, if a country with an incomparably greater personnel pressure managed to solve the problem through professionalization, and not its opposite, the argument about a "different" Slovak situation loses weight (European Observatory on Health Systems and Policies, 2024; MarkNtel Advisors, 2026; OECD / European Observatory on Health Systems and Policies, 2025).

Tab. 3: Systemic indicators of bed capacity and the LTC segment

Source: own processing based on aggregated statistics and Italy: Health System Summary, 2024.

The structural imbalance of Slovak healthcare in comparison with the Italian model reveals a deep paradox in the management of bed capacity and the financing of follow-up care. While Slovakia shows an excessive rate of hospitalizations on acute beds due to the absence of community alternatives, Italy invests in a robust network of residential facilities (LTC), which effectively relieve the acute sector. This situation is directly related to a deficit of auxiliary staff, forcing the system to meet the needs of geriatric patients in an expensive hospital environment instead of targeted community or assistive care.

The Italian case serves in this paper as a comparative precedent because it addresses a structurally identical problem – chronic overload of nurses with service tasks – in a system with a greater volume of pressure on personnel. The following section describes the Italian subsystem, its legislative evolution, and the precise definition of competencies that emerged from the reform.

Italian subsystem: SSN and personnel deficit

The Italian Servizio Sanitario Nazionale (SSN) provides a useful comparative framework precisely because its solution to the personnel crisis did not arise under conditions of personnel surplus, but on the contrary – in the context of a persistent and still unresolved deficit of nursing staff. While Italy, to manage the pressure of an aging population, legislatively established in 2001 the profession of OSS (Operatore Socio-Sanitario), whose role is to meet the patient's primary biological needs and protect nurses from professional regression (demansionamento), Slovakia has preserved a rigid, outdated model.

Italy, moreover, still records its own deficit of nursing staff, which according to the Rapporto Ministero della Salute and Corte dei Conti exceeds 60,000 nurses, and the remuneration of Italian nurses is approximately 20% below the European average. The Italian model, therefore, does not constitute proof that the division of competencies solves the personnel deficit in absolute numbers – its function is the structural distribution of workload, which prevents the accumulation of clinical, administrative, and manual activities in a single job position.

This pragmatic approach to the division of labor is based on the broader Italian policy of integrating disadvantaged persons, the foundations of which were laid by Framework Law No. 104/1992. This paved the way for the key Legge 68/1999, which, through the institution of "targeted employment mediation" (collocamento mirato) – created a legislative bridge between social inclusion and healthcare. It is precisely this mechanism that allows hospitals to legally and effectively draw auxiliary labor (OSS/ASA) from social entities, thereby making the state's social policy a direct tool for relieving nurses in clinical practice – which is exactly the functional logic that the law on social economy offers for Slovak conditions.

Historical evolution and norms

Legislative development in Italy occurred in two waves – the academization of the nursing profession and the parallel establishment of a supportive qualification layer – and continued in 2025 with the introduction of another intermediate link.

The Italian nursing system underwent a fundamental legislative transformation at the turn of the 20th and 21st centuries, aimed at overcoming the so-called catalog model of job duties (Italian mansionario) – that is, a system in which the professional activity of a nurse was defined by a strict list of tasks without clinical autonomy and without a clear separation from auxiliary activities (Repubblica Italiana, 1999; Tobruk, 2016). Law No. 42/1999 (Legge 42/1999, "Disposizioni in materia di professioni sanitarie") abolished the categorization of nursing among the so-called auxiliary healthcare professions (professioni sanitarie ausiliarie) and reclassified it among independent healthcare professions (professioni sanitarie), the practice of which is defined by a professional profile, a code of deontology, and a specific study program, not by an exhaustive list of tasks. This change meant the legal recognition of the nurse's clinical autonomy in the management of the nursing process.

Tab. 4: Establishment and development of the chamber of nurses - competencies and institutionalization

Source: Own processing by the author based on Italian and Slovak legislation.

Parallel to the academization of the profession, the agreement between the state and regions of February 22, 2001 (Provvedimento 22 febbraio 2001) introduced the unified qualification category Operatore Socio-Sanitario (OSS), supplemented in the social field by the profile Ausiliario Socio-Assistenziale (ASA). The introduction of this category enabled the structural separation of the clinical-managerial component of nursing work from its manual, service component without reducing the educational requirements for the nurse. Legislative development continued with Law No. 3/2018 (the so-called Legge Lorenzin), which brought further organization of healthcare professions in Italy and confirmed the direction towards professionalization and autonomy of individual categories of healthcare workers.

The institutional and sociological prerequisite for promoting, protecting, and expanding the professional competencies of nursing staff is the level of representativeness of the professional chamber. Comparative analysis shows that mandatory membership (the Italian FNOPI model subject to Law No. 3/2018) establishes an absolute consolidation of the professional status. This comprehensive representativeness generates not only significant economic self-sufficiency for the organization but, above all, high institutional legitimacy in partnership with the ministry and state authorities. The national regulatory mandate enables the chamber to effectively assert competency claims, guarantee legal protection, and prevent qualification devaluation (so-called demansionamento). Conversely, the voluntary membership model leads to fragmentation of the profession, limits in resource allocation, and inherently weakens the chamber's bargaining power regarding systemic interventions into the competency framework (Repubblica Italiana, 2018; Tobruk, 2016).

The development of the competency model in Italy continues to the present day. By decree of the Prime Minister (DPCM) of 28 February 2025, a new qualification category, assistente infermiere (nursing assistant), was introduced, representing a further level of qualification following the OSS after completing an additional educational program. The Federation of Professional Nursing Chambers (FNOPI) justifies the introduction of this category as a tool to reduce the risk of qualification undervaluation, i.e., the renewed overburdening of nurses with unskilled tasks due to staff shortages.

Regional implementations (for example, in Lombardy) explicitly condition the introduction of this category on the fact that it must not lead to a reduction in the number of qualified nurses nor to their replacement by personnel with lower qualifications. As of the date of preparation of this contribution, the model is in the implementation phase, and its effectiveness is subject to ongoing monitoring by both regional and professional bodies; part of the professional and political community (for example, an opposition representative in the Lombardy Regional Council) expresses concern about the risk of repeating a previous, less successful attempt to introduce the so-called "super OSS". Despite this open discussion, the direction of change is clear: the response to the persistent staff shortage is the addition of another qualified intermediate link in the care structure, not a lowering of qualification requirements for the entry-level nursing position.

Competencies of OSS and ASA: Mapping and Strict Delineation of Boundaries

Based on a comparison of both systems, the competency spectrum of nursing care can be divided into three clearly separated levels, which reflect the modern development of the Italian model towards strengthening the nursing team.

  1. Clinical-Managerial Tasks (Nurse / infermiere):

  • Nursing diagnosis and planning of the nursing process,

  • Administration of pharmacotherapy and management of invasive procedures,

  • Evaluation of clinical data and decision-making within the nursing process,

  • Coordination with the physician and other members of the multidisciplinary team. (Conferenza permanente Stato-Regioni, 2001; Dimensione Infermiere, 2025; Repubblica Italiana, 1999; Tobruk, 2016)

  1. Advanced Assistance Level (assistente infermiere – 2025 novelty): In 2025, the Italian model introduced this new qualification category (DPCM of 28 February 2025) as a tool to further reduce the risk of overburdening nurses with unskilled tasks (demansionamento).

  • Qualification: This is not an entry-level position but a career progression for experienced OSS operators (requiring a minimum of 24 months of practice and an additional 500-hour training course).

  • Relationship to the Nurse: The "assistente infermiere" performs their activities exclusively in coordination with the nurse's instructions and in accordance with the nursing care plan. They work under the nurse's direct clinical supervision, and the existence of this position must not lead to a reduction in the number of qualified nurses nor to their replacement (Conferenza permanente Stato-Regioni, 2025; Presidenza del Consiglio dei Ministri, 2025).

  • Status: This position creates an intermediate link in the team, allowing the nurse to delegate more technical assistance tasks to a qualified worker, thereby protecting their clinical competency scope. (Conferenza permanente Stato-Regioni, 2025; Presidenza del Consiglio dei Ministri, 2025).

  1. Basic Assistance Tasks (OSS/ASA):

  • Total hygienic care of the patient, including dressing,

  • Positioning and mobilization,

  • Distribution of meals and assistance with feeding,

  • Sanitization of the immediate bedside area and handling of medical materials and aids (Conferenza permanente Stato-Regioni, 2001; Tobruk, 2016).

This division does not represent a hierarchization of the value of individual activities, but a functional differentiation of responsibility: while the nurse category requires university education and bears full legal responsibility for clinical decisions, the OSS/ASA category is suitable precisely as an entry point for the guided labor integration of disadvantaged population groups within the meaning of Act No. 112/2018 Coll. (Zákon č. 112/2018 Z. z.). The addition of the assistente infermiere category only underscores the consistent Italian direction: even in a crisis, the system addresses the shortage by deepening qualifications and expanding the career path of support staff, rather than lowering the bar for entry into the nursing profession (Conferenza permanente Stato-Regioni, 2025; Presidenza del Consiglio dei Ministri, 2025).

Tab. 5: Contrast between accumulation and differentiation of clinical workload in nursing practice

Source: own processing based on comparison of SR and IT systems

Application Proposal for the Conditions of the Slovak Republic

The transition from theoretical comparison to practical implementation requires abandoning isolated departmental thinking and adopting a deep structural change that links the acute needs of healthcare with existing tools of the social economy. The following proposal defines a specific legislative and operational mechanism through which a key goal can be achieved - relieving nurses of manual workload and stabilizing nursing teams through interdepartmental synergy.

Normative Transposition: The Tripartite Agreement Mechanism

The aim of the proposed mechanism is not merely the extensive creation of new job positions in the social economy sector, but above all the systemic reconstruction of the nursing team in its fully functional and competency-differentiated form. This model envisions the reconstruction of the team so that the nurse performs exclusively the clinical-managerial component of care, while the primary assistance tasks are carried out by their direct co-worker from the support staff, analogous to the Italian OSS/ASA profile. The innovative tool that allows this tandem to be truly established without direct and unbearable financial burden on hospital budgets is a contractual mechanism inspired by the Italian model of "targeted employment" (collocamento mirato), anchored in Articles 12 and 14 of Law No. 68/1999.

However, it is essential to emphasize that while this legislative framework offers effective incentives for the inclusion of disadvantaged and vulnerable persons, the position of assistant helper is not exclusively limited to these categories. It represents a universal competency layer that can be filled by all job seekers possessing the necessary degree of empathy and willingness to perform the defined scope of tasks (mansionari), with the institute of social enterprise serving as a flexible platform for their systematic integration into clinical practice under the direct supervision of a nurse. The proposed model thus primarily addresses the structural deficit of personnel and the protection of the professional status of nurses, while the aspect of social inclusion represents a significant, but not the only, benefit of this interdepartmental solution.

The Italian legislative precedent allows the employer to fulfill its legal obligation to employ disadvantaged persons by concluding a contract with an external entity, typically a social cooperative (cooperativa sociale) or a social enterprise. This external entity duly employs the person and subsequently assigns them to perform work directly at a specific hospital ward under the institute of the "integrated employment agreement" (convenzione di inserimento lavorativo). For the nurse in clinical practice, this means gaining a permanent work partner for basic care, with whom they daily coordinate the needs of assigned patients, while being completely relieved of the partner's labor law management or administrative coverage, as these competencies remain under the responsibility of the social enterprise.

Tab. 6: Legislative development of the position of nurses and auxiliary staff in Italy and Slovakia

Source: Own processing by the author based on Italian and Slovak legislation.

This systemic change requires precise legislative clarification in two key areas to avoid legal uncertainty and ensure the functionality of the model:

  1. Explicit definition of the professional category: It is necessary to add the category "service assistant in a healthcare facility, working under the clinical supervision of a nurse" to the text of Act No. 112/2018 Coll. as a legitimate job position for disadvantaged and vulnerable persons.

  2. Adjustment of contractual conditions: It is necessary to legislatively define the conditions under which a public healthcare provider can conclude a contract with a social enterprise for the provision of assistance services, so that this relationship is considered a contractual-supplier relationship for the provision of services in the public interest. This clarification will prevent the risk that the model could be mistakenly interpreted as a temporary assignment of an employee to perform work (so-called personnel outsourcing). The professional setting of this relationship must guarantee that while the social enterprise bears full administrative responsibility, the hospital receives a service that is operationally managed directly by the nurse on the ward.

Key actors and Act No. 112/2018 Coll.

The proposed mechanism works only if the roles of the three types of actors are clearly separated - the nurse and their working tandem with the OSS/ASA, however, remain the operational core of the entire model.

The Offices of Labour, Social Affairs and Family (ÚPSVaR) identify and register persons belonging to disadvantaged or vulnerable categories within the meaning of § 2 of Act No. 112/2018 Coll., who are capable, after preparation, of performing basic assistance tasks in cooperation with the nurse. ÚPSVaR may also provide contributions to support the creation of these jobs under Act No. 5/2004 Coll. on Employment Services.

Registered integration social enterprises (third sector) are the formal employer of the assistant and bear their labor law and administrative responsibility. This very structure is key from the nurse's perspective: their work partner on the ward has a stable labor law background outside the hospital, which reduces turnover in this position and allows the nurse to build a long-term working routine with them instead of repeatedly training new people.

Public healthcare providers (hospitals) define the organization of elementary activities in individual wards, while the clinical leadership of this cooperation remains exclusively within the competence of the nurse in accordance with their professional autonomy in managing the nursing process: the nurse determines the patient's needs at a given time and the assistant staff (OSS/ASA) ensures the performance of the service tasks themselves.

While the relationship between ÚPSVaR and the social enterprise is activation-supportive, the relationship between the social enterprise and the assistant is labor law-based, and the relationship between the social enterprise and the hospital is contractual-supplier based, the actual quality of care provided is determined by the daily operational relationship between the nurse and their assistant directly on the ward.

Education and mentoring: guided transition

The success of the proposed model depends not only on the legal construction of the contractual relationship, but primarily on the quality of the assistant's preparation and the speed of creating a functional working tandem with the nurse.

Division of competencies in management:

  • Integration and labor law role (Case Manager / Disability & Diversity Manager - DDM): This is an external worker of the registered social enterprise (not a hospital employee) who accompanies the integration process, handles labor law matters, and continuously monitors the assistants supplied to the hospital.

  • Clinical role (Nurse on the ward): Provides daily clinical guidance to the assistant directly on the ward. While the DDM handles the integration and contractual aspects, the nurse directs the clinical performance of service tasks.

Phases of guided transition:

  • Preparation before entry: Basic training covering the competency profile of the assistant helper (hygienic care, patient handling, principles of occupational safety and hygiene, communication principles), carried out by the social enterprise in cooperation with an educational institution or directly with the hospital.

  • Guided entry to a specific ward: The assistant is assigned to a specific nurse or nursing team. Under their direct clinical supervision and in cooperation with the case manager, they undergo an initial period of work performance during which the key working tandem is formed.

  • Stabilized integration with ongoing support: After the initial phase is completed, the case manager continues to maintain contact with both the assistant and the ward. This ensures the timely identification of difficulties and the stability of the nurse-assistant tandem, the potential disruption of which (e.g., by the assistant's premature departure) would again transfer the burden onto the nurse.

The role of the social worker in this model goes beyond traditional job placement: it involves ongoing case management functionally comparable to supported employment used in the work integration of persons with disabilities within the EU. The target state of the model is not merely fulfilling a quota of jobs in the social economy, but creating a stable, repeatedly functioning nurse–OSS/ASA working pair on each ward that genuinely addresses competency overload.

Discussion and economic evaluation

Before this study on the given issue engages in a broader professional discussion, it is necessary to explicitly name the core difference between the two approaches, which is also the main thesis of this paper: the Slovak and Italian systems solve an identical problem - the nursing shortage - with opposing strategies on the side of entry into the profession. The Slovak "1+4" model addresses the deficit by shortening and simplifying the educational pathway to the nursing profession compared to the current university standard, i.e., an intervention on the side of expanding access routes into the profession. The Italian model solves the same problem in the opposite way - by expanding and diversifying the university educational pathway (bachelor's, master's and specialization studies, coordination and managerial career positions) and simultaneously removing basic tasks from the nurse in favor of OSS/ASA, i.e., an intervention on the side of the attractiveness and sustainability of the profession. These two strategies have different time horizons for their effect and different consequences for the quality of care, which are discussed in the following subchapters.

Fiscal sustainability: absence of inter-ministerial coordination

The central finding of this paper extends beyond the framework of nursing issues itself: the current state reveals an absence of coordination not between two, but between three ministries, whose agendas directly overlap in this area. The Ministry of Health of the Slovak Republic (MZ SR) addresses the personnel deficit with its own, sectorally isolated legislative instrument (the "1+4" model), while the implementation of this model itself - i.e., the educational aspect - is provided by the Ministry of Education, Research, Development and Youth of the Slovak Republic (MŠVVaM SR) through a network of secondary medical schools. Concurrently and independently of both, the Ministry of Labour, Social Affairs and Family of the Slovak Republic (MPSVR SR) manages the agenda of activating the unemployed and integrating vulnerable groups into the labor market through social economy instruments.

These three agendas are not substantively independent - they concern the same population observed in three different life phases and through three different, mutually unconnected instruments. MŠVVaM SR is already addressing the integration of marginalized and disadvantaged children from preschool age - precisely the target group that the proposed model plans to later, in adulthood, place into positions of assistant helpers through social enterprises (MPSVR SR). Finally, MZ SR uses this same population as a cheap educational shortcut for entry into the nursing profession, without any connection to anything that happened to them previously in the education or social integration system. Registered social enterprises, including social cooperatives, which already work with marginalized children and young people in cooperation with the education system, are the same type of entity that, according to the proposed model, should employ assistants in healthcare - the infrastructure thus partially exists and functions, it is simply not used across ministries. The current state, in which all three ministries proceed in parallel and without mutual interconnection, represents an inefficient use of public resources and a missed opportunity for a systemic solution.

This absence of inter-ministerial coordination has a direct impact on the professional sustainability of nursing. The current Slovak model places a dual, structurally incompatible demand on the nurse: on the one hand, management of the nursing process, clinical decision-making, and responsibility corresponding to a university-educated intellectual professional; on the other hand, physically demanding manual work corresponding to an unskilled or low-skilled position. This combination has no parallel in any other profession with a comparable level of education - a university-educated professional is generally expected to have either predominantly cognitive or predominantly manual workload, not both to a full extent simultaneously. As long as this structural contradiction persists, it is likely to continue acting as one of the main factors driving young graduates out of the profession, regardless of how entry into education is legislatively regulated.

At the same time, the "1+4" model offers no answer to the question of how the profession is to be attractive to a generation of applicants who choose their studies and occupation based on career prospects and social status, not just on the immediate availability of a job. Lowering the qualification entry requirement may temporarily increase the number of formally qualified persons, but it does not address the cause of current staff leaving nor does it offer a motivational framework for future generations.

Cost-benefit analysis (Social Return on Investment – SROI)

The fiscal justification for the proposed model of synergy with the social economy is based on the transformation of a passive social transfer into active income from employment - i.e., on transfer efficiency, which is a standard criterion for evaluating activation policy in the labor market. A person belonging to a disadvantaged or vulnerable category within the meaning of Act No. 112/2018 Coll., who, without proper labor market integration, would receive a benefit in material need or other transfers, becomes, upon employment in the position of assistant helper, a payer of contributions and income tax. This is a two-way fiscal effect: a decrease in the expenditure side of the public budget is accompanied by an increase in its revenue component, which on a macroeconomic scale represents a high rate of social return on investment.

To this direct fiscal effect is added a third, qualitatively different mechanism, which concerns the hospital as an employer. According to § 63 of Act No. 5/2004 Coll. on Employment Services, every employer with more than 20 employees - including healthcare facilities - is bound by a mandatory quota for employing citizens with disabilities amounting to 3.2% of the total number of employees, which, if not met, is addressed through substitute performance (placing an order with an integration enterprise or sheltered workshop), or a levy amounting to 0.9 times the total labor cost for each missing person. A contractual relationship with a registered social enterprise thus brings the hospital not only the missing personnel but also constitutes direct fulfillment of this legal obligation through a substantively related contract for assistance services - instead of substituting it by procuring goods unrelated to clinical operations, or paying the levy. The proposed mechanism thus combines three separate obligations of three different actors into a single instrument: the hospital's personnel deficit, its legal quota for employing disadvantaged persons, and the state's fiscal activation.

At the microeconomic level of a healthcare facility, the model does not increase wage costs within its own staffing structure, as the registered social enterprise remains the formal employer of the assistant; the hospital acts as a service buyer, the price of which, when correctly set, is lower than the hourly rate of a university-qualified nurse performing the same range of manual tasks. The benefit of the model therefore does not lie in an absolute reduction of personnel costs, but in the allocative efficiency of the budget: qualified nursing work is reserved for clinical and managerial tasks, while the service component is paid at a rate corresponding to lower qualifications. For an exact quantification of benefits using the SROI methodology, empirical data from pilot testing are crucial, as without verified parameters of wage costs and systemic savings, the economic estimate would remain at the level of hypotheses and would weaken the overall scientific relevance of the analysis.

Gender and intergenerational benefits of the proposed model

Given that nursing is a profession with a dominant representation of women in both the Slovak and Italian contexts, the consequences of overload from manual work acquire a clear gender dimension. The model of strict differentiation of competencies, inspired by the Italian example, directly contributes to the long-term sustainability of women's employment in healthcare. By removing physically devastating primary tasks, more favorable conditions are created for remaining in the profession until retirement age, as well as for a smoother return of nurses to the system after maternity or parental leave, when clinical, intellectually oriented work is substantially more compatible with family life than accumulated physical strain.

Part of this structural transformation in the Italian environment was also a reassessment of professional terminology, initiated by professional organizations with the aim of eliminating gender barriers to entry into the profession. The historical designation, referring to the era of religious sisters and their irreplaceable charitable contribution to hospital care, was replaced with a gender-neutral and clinically oriented term from sestra to infermiere. This shift from a traditional gender role to the status of an "autonomous healthcare professional" was also one of the strategic steps towards increasing the lucrativeness and attractiveness of the nursing field for men as well. Nursing thus began to be defined primarily through the level of academic competence, thereby successfully breaking down the social stereotype of the nurse as an exclusively female profession.

From an intergenerational perspective, the difference between the models is determined by the expectations they shape in future candidates. The Italian reform confirms that the key motivating factor is not only the initial salary level, but especially a visible career trajectory. Expanding the education system with specialized master's programs (Laurea Magistrale) and diversified professional competencies with an emphasis on new technologies creates a spectrum of opportunities that transforms the profession into a prestigious choice. For the younger generation, seeking status, progress, and professional perspective, nursing thus becomes an attractive field with a clear vision of growth, and not just a place for performing routine work. In contrast, the Slovak "1+4" model lacks this perspective; by shortening training, it de facto confirms the low status of the profession and does not remove the primary cause of graduate departure - overload from manual work. From the perspective of long-term system stability, the "1+4" model therefore represents a risk of cyclical recurrence of the personnel crisis, as it addresses the current deficit at the expense of the profession's attractiveness for future generations.

Synthesis of results and implications for public policy

The presented analysis demonstrates that the Slovak and Italian nursing care systems face structurally similar challenges - a critical shortage of personnel in the context of increasing demographic burden. However, these systems respond to this situation with different, at times even contradictory, strategies. While Italy, through education and technological progress, seeks to stabilize and professionally elevate the profession, the reality for both countries remains a worrying outflow of qualified nurses abroad. This brain drain confirms that as long as the profession in the domestic system does not offer an adequate degree of status, career perspective, and internal stability, healthcare personnel - whether Slovak or Italian - perceive exodus as the only rational alternative to persistent systemic rigidity and the inability of national institutions to innovate the conditions for practicing the profession. The Italian model, validated by the legislative reform of 1999 and confirmed by its continuation in the form of the assistente infermiere category introduced in 2025, addresses the personnel deficit by expanding and differentiating the qualification structure: the nurse retains full clinical-managerial autonomy, while service and assistance activities gradually transition to independently qualified mid-level personnel of the OSS, ASA, or assistente infermiere type. The proposed Slovak "1+4" model addresses the same deficit in the opposite direction - by lowering the qualification entry into the nursing profession, while maintaining its original, undifferentiated, and overloaded job description.

This analysis also identified that a simple wage comparison of the two countries does not support the argument in favor of the Italian model - Italian nursing personnel are remunerated below the EU average, and Italy records its own, quantitatively larger deficit of nurses. The true distinguishing factor is therefore not the level of salary, but the structure of the workload: the distribution of clinical, administrative, and manual tasks among differentiated qualification levels instead of their accumulation in a single position. The work further identified a specific application mechanism by which this principle can be transferred to the Slovak environment without the need to create a new systematized category within the healthcare sector: through Act No. 112/2018 Coll. on Social Economy and Social Enterprises. This mechanism enables the employment of disadvantaged persons in the positions of assistant helpers through a contractual relationship, thereby simultaneously addressing two deficits of Slovak public policy - the shortage of nursing personnel and the insufficient rate of labor integration of disadvantaged groups.

Concluding reflection: The Italian precedent as proof of direction, not as a ready-made solution

It is necessary to emphasize that Italy has not solved the crisis of nurse shortage either – on the contrary, the current deficit exceeding 60,000 nurses ranks the Italian system among the most affected in Europe. However, the crucial point is not whether Italy has solved the problem, but the direction it has taken in addressing it. By adopting the Agreement between the State and Regions of 3 October 2024 (implemented by the DPCM decrees of 28 February and 25 March 2025), Italy introduced the qualification category of assistente infermiere, which cannot be understood as a lowering of standards, because this position cannot be held by a fresh secondary school graduate, but exclusively by a qualified and experienced OSS operator (in the Slovak context equivalent to the category ofsanitár, i.e., orderly in a healthcare facility) with a prescribed length of practice and having completed a minimum 500-hour training course.

The definition of the status of this new category is unequivocal: the assistente infermiere performs activities in coordination with the nurse's instructions and works under her/his supervision, not instead of her/him. This reform is therefore significant not as proof of a solved problem, but as evidence of a consistent direction: even a quarter of a century after the introduction of the OSS profession, Italy is addressing the personnel crisis by deepening the career structure of support staff, not by lowering the qualification standard of the nurse. This is a deliberate correction of its own previous step, not a first and only attempt. The Italian example thus serves as evidence that even in conditions of a persistent crisis, it is possible to adhere to the principle of deepening qualifications instead of lowering them.

Conclusions and recommendations for public policy makers

The current state reveals a critical absence of coordination between ministries whose agendas directly overlap in this area. The Ministry of Health of the Slovak Republic addresses the personnel deficit with the isolated "1+4" instrument, while the Ministry of Labour, Social Affairs and Family of the Slovak Republic independently manages the social economy agenda, even though these are two sides of the same structural problem. As long as the nurse is simultaneously required to perform intellectual clinical work and physically demanding manual work, this structural contradiction will act as the main factor driving graduates away from the profession.

The analysis confirmed that the Slovak and Italian nursing care systems face identical structural challenges related to demographic transition. The Italian model, oriented towards competence differentiation and deepening specialization, shows a different methodological trajectory compared to the current Slovak proposal (the "1+4 model"). The identified absence of horizontal coordination between the ministries of the MZ SR, MŠVVaM SR and MPSVR SR limits the possibilities for comprehensive utilization of the available social economy infrastructure. Synergistic interconnection of these ministerial agendas represents a prerequisite for the effective transformation of nursing teams.

Based on the comparative analysis, the following measures are recommended for public policy makers:

  • Reassessment of the legislative proposal for the "1+4" model: Replacing quantitative adjustments to the educational standard with a model based on competence differentiation and optimization of nursing workload.

  • Creation of an inter-ministerial working platform: Ensuring legislative complementarity between Act No. 112/2018 Coll. on Social Economy and the healthcare system, with the aim of integrating support staff into clinical teams.

  • Legislative anchoring of the "support assistant" category:

  • Defining the position within Act No. 112/2018 Coll. for the purpose of financing from non-ministerial sources.

  • Amendment of Act No. 578/2004 Coll. for the purpose of defining the clinical subordination of the assistant to the head nurse, thereby ensuring the continuity and safety of nursing care.

  • Pilot verification of the model: Testing the proposed organizational changes in clinical practice, followed by quantification of benefits using the SROI methodology (Social Return on Investment).

  • Application of international knowledge: Utilizing implementation experience from the Italian assistente infermiere model (DPCM / Decreto del Presidente del Consiglio dei Ministri of 3 October 2024) when setting up the long-term Slovak competence framework.

Coordinated interconnection of healthcare and the social economy represents a systemically available, yet so far criminally underutilized opportunity for stabilizing Slovak nursing. Instead of lowering the requirements for entry into the profession, we must restore professional dignity to nurses by creating conditions for them to perform their true, highly qualified expert work. This model thus effectively transforms passive social transfers into active income from employment while simultaneously protecting the professional status of the nurse by removing the physically devastating manual burden. It is precisely the thorough differentiation of tasks that represents the only sustainable path towards stabilizing nursing in Slovakia.

Author: Mgr. Andrea Podešvová Garatti, MBA, LL.M.

List of abbreviations ASA - Ausiliario Socio-Assistenziale (It.) - auxiliary social-care worker; Italian qualification profile for basic nursing care in the social field, introduced in 2001 alongside the OSS profile. DDM - Disability & Diversity Manager (Eng.) - manager for disability and diversity; position responsible for guiding the process of work integration of disadvantaged persons. DPCM - Decreto del Presidente del Consiglio dei Ministri (It.) - decree of the President of the Council of Ministers of the Italian Republic; legal instrument by which the category of assistente infermiere was introduced on 28 February 2025. EU - European Union. FNOPI - Federazione Nazionale degli Ordini delle Professioni Infermieristiche (It.) - National Federation of Orders of Nursing Professions; umbrella professional organization of nurses in Italy. IT — Italy (Italian Republic) — abbreviation used in table comparisons. LTC - Long-Term Care (Eng.) - long-term care; social and healthcare for persons with permanently reduced self-sufficiency. Model "1+4" - experimental Slovak educational model (2026), combining one year of post-secondary or other study with four years of secondary nursing school as an alternative pathway to performing part of nursing activities. MPSVR SR - Ministry of Labour, Social Affairs and Family of the Slovak Republic. MŠVVaM SR - Ministry of Education, Science, Research and Sport of the Slovak Republic. MZ SR - Ministry of Health of the Slovak Republic. OECD - Organisation for Economic Co-operation and Development (Eng.) - Organisation for Economic Co-operation and Development. OSS - Operatore Socio-Sanitario (It.) - social-healthcare operator; Italian qualification profile for basic patient nursing care. OZ SaPA - Trade Union Association of Nurses and Midwives. RSA - Residenze Sanitarie Assistenziali (It.) - healthcare-social residential facilities; Italian type of long-term care facilities, equivalent to Slovak social service homes/facilities for the elderly. SKSaPA – Slovak Chamber of Nurses and Midwives.

SR - Slovak Republic - abbreviation used in table comparisons. SROI - Social Return on Investment; methodology for quantifying the fiscal and social benefits of a publicly funded intervention. SSN - Servizio Sanitario Nazionale (Italian) - National Health Service; the public health system of the Italian Republic, analogous to the Slovak system of public health insurance. ÚPSVR - Central Office of Labour, Social Affairs and Family.

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