The global financial crisis beginning in 2007 resulted in the introduction of austerity measures in most of the affected countries.1 Spain was one of the European countries hardest hit by the economic crisis,2,3 with austerity policies in public expenditure being introduced in 2010 affecting the resources available in Spanish National Health System (NHS).3,4 Austerity measures resulted in NHS personnel/public employees’ wage freezing and salary reductions (up to 5%), increasing working hours for existing staff, and a staff recruitment freeze.4,5 Between 2009 and 2014, staff expenditure of de NHS decreased from 31.223.857 to 27.766.868 euros, with a strong reduction on primary health care expenditure (from 8.366.581 to 6.997.544 euros) compared to hospital care (from 20.451.063 to 18.422.814 euros).6

Reductions on the national and regional budgets were applied from 2009 to 2016. Health expenditure in Spain followed an upward trend until 2009 when the trend reserved and health expenditure decreased each year until 2016.7 As a result of these consecutive decreases in funding, between 2009 and 2015, government expenditure on health decreased 5.3%.8 In April 2012, The “Royal Decree-Law 16/2012, of urgent measures to ensure the Sustainability of the National Health System and to improve the Quality and Security of its Provisions” (hereafter referred to as: RDL/2012) was approved. In this law, measures were introduced with the aim of undertaking a structural reform and achieving a more efficient healthcare system, although health expenditure in Spain is below the average within the European Union and its growth is 1.4% lower than the combined average of OECD countries.4,5,8 In 2012, health spending was reduced by 8% in comparison to the previous year,9,10,11 by reducing the free health coverage portfolio, establishing and increasing co-payments for certain benefits (e.g., ambulances, hospitalizations, and pharmaceutical assistance)and introducing restrictions to health care services.5,12,13 With this legislation, only the insured and their beneficiaries were entitled to full assistance, and people who are considered uninsured had restricted access to primary health care and specialized care; they could only access emergency services in cases of severe illness or in the event of an accident, and only women in pre-natal, natal and post-natal situations, and people under 18 years of age could have general access to health care services.

Previous studies have examined the impact of the financial crisis on the health of the population and the impact of austerity measures on access to the health services and to a lesser extent, on how these affect the daily work of health professionals, mainly physicians.2,12,14–16 However, little is known about how these legislative measures affected nurses’ daily work. Nurses account for 54.20% of the total health care professionals in Spain, they are the front-line health care providers and an important source of information to patients.17 The aim of this study is to ascertain the perspectives of nursing professionals on how the financial crisis and austerity measures affected their ability to provide care in such new circumstances.

35.1% of nurses attending the Congress answered the questionnaire. Out of all 123 surveys included in the final analysis 122 had all 14 main questions answered in full, and 85 had at least one or more unanswered auxiliary questions.

This research has highlighted nurses’ overall opposition to austerity measures imposed on the NHS as a response to the financial crisis. The main reasons reported include a perception that such health reforms were having negative consequences on nurses’ working conditions, the deterioration of the quality of health services, and that austerity measures were having a negative effect on the health of both nationals and migrants’ populations.

The implementation of the RDL/2012 during a time of deep economic crisis, brought about health staff reductions caused by the sudden reduction in employment offers, especially public recruitment, the main job generator among health care professions and nursing in particular.17,21 Potential long-term negative results, beyond the period of recession were evident in England, where decrease in NHS's human resources investment entailed a decrease in the nurse-patient ratio, work overload for nurses and a decrease in the quality of care, which had an impact in the health of the population.22–24

Nurses’ reported a decrease of patients in their practice, mainly due to the increase in waiting lists and delays. This could result on patients accessing private services to avoid long waiting times.2,4,25,26 Indeed, between mid-2009 and 2012, surgery waiting lists grew by 43% in number of patients, with an average increase in in waiting times from 63 days to 76 days (21%).27 Data from the Spanish Health Ministry shows that surgery waiting lists have gone slightly down from 614.101 to 592.175 during 2017, although unequally between Autonomous Regions28,29.

Nurses reported the precarization of their working conditions through salary reduction and increase in working hours, coinciding with official statistics.21 Precarious working conditions which nurses endured -manifested in the loss of job security, loss of social benefits, and night shift and weekend benefits, the increase in working hours, little time to devote to direct care, lack of job replacement following retirements, the increase in casual and temporary positions to the detriment of permanent positions, resulted in work overload and had a negative impact on the quality of care and on nurses’ own quality of life.5,30,31 The current situation can lead to an increase in the prevalence of burnout among nurses, whose figures ranged between 18% and 33% in 2013, while between 26.74% and 55% report emotional exhaustion.32

As a consequence of the global economic crisis, the organizational changes in the Spanish NHS, the reduction in public expenditure, and labour market reforms, more nurses than any other health professionals in Spain have migrated to work in other countries in search of better working conditions.33,34 Between 2010 and 2014 there was an increase in the migration of Spanish nurses, from 4580 to 9200 Spanish nurses working in other European countries, such as Great Britain and Germany33,35,36.

Creating and maintaining such a work environment to retain and support nurses is key in improving the quality of care and patient safety, so future measures ought to be considered. These include, among other, institutional measures to improve recruitment and retention of nurse; policies for preventing stress and burnout; ensuring a decrease of patient-nurse ratio; and promoting greater work stability.

Studies carried out in Spain based on primary health care services also showed that physicians’ perceptions were of disapproval of the austerity measures implemented in Spain to make the health system sustainable, considering them inappropriate and inefficient.14,15 A large number of health care professionals, with the support of their professional associations, unions, and the 15-M movement declared that they would refuse to stop giving care to foreign patients due to administrative irregularities, national agencies and scientific societies also seconded this rejection. As a consequence, constitutional challenges were filed to avoid complying with the restrictions of access for vulnerable groups in some Autonomous Regions.37 In 2018, new RDL 7/2018, of July 27, modifying the previous RDL/2012 and partially recovering the universal access to the NHS was implemented, so the effects of the changes introduced should be explored in the near future.

Our findings suggest that participating nurses’ overwhelmingly opposed austerity measures imposed on the NHS as a response to the financial crisis. To our knowledge this is the first study exploring nurses’ perceptions on the effects of austerity measures on health care in Spain, only one year after these measures were introduced. The results of this study are especially relevant, as nurses are the NHS’ primary workforce and with the closest contact with patients.

María Victoria Zunzunegui.

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

Falta.

We thank all nurses who provided support and helped in the acquisition of data. The authors are also grateful to Roland Pastells, who provided support with the documentation.

None.

One of the authors (EBV) belongs to the Gaceta Sanitaria editorial committee, but was not involved in the editorial process of the manuscript.