4.2 Human resources
4.2.1 Planning and registration of human resources
The Norwegian Authority for Health Personnel, which is part of the Directorate of Health, is responsible for the licensing and authorization of health care personnel in Norway. Currently, 29 categories of health personnel are licensed. The Directorate of Health and Statistics Norway share the responsibility for monitoring and evaluating health workforce trends.
Since the mid-1990s Statistics Norway has been modelling long-term supply and demand trends in health personnel. Its model (HELSEMOD) contains predictions for more than 20 different categories of health personnel groups (Statistics Norway, 2019b) and has informed human resources policies in the health sector.
The Directorate of Health issues certificates of specialization to medical doctors, in accordance with specific and transparent requirements. Except for GPs, there is no system for re-evaluation or re-authorization for medical doctors.
4.2.2 Trends in the health workforce
The number of physicians per 1000 inhabitants has been increasing over the last few decades. At 4.8 per 1000 in 2018, the ratio in Norway was higher than in all the comparator countries featured in Fig4.2.
In 2016, 17 606 physicians worked in Norway. Out of these, 4606 (26%) worked in the municipalities (as GPs or other), 12 000 (68%) worked as specialists in hospitals and 1000 (6%) worked as specialists outside hospitals. The proportion of physicians working for the municipalities increased by 13% between 2013 and 2016 (Norwegian Directorate of Health, 2016). Yet the distribution is uneven and some municipalities experience shortage of GPs (see Box4.2).
The ratio of nurses to inhabitants has also increased over recent years and at 17.8 nurses per 1000 inhabitants remains among the highest in the EU/EEA (Fig4.3). However, despite these high numbers, nurse shortages are predicted in the years to come (see section 7.3). Given these forecasts, since 2015 municipalities have had the opportunity to apply for state subsidies to employ more nurses and municipal health care workers. These subsidies are available until 2020.
The number of dentists in Norway has been stable over the past decade, and remains fairly high – at 0.9 per 1000 inhabitants in 2018. Although Statistics Norway projected a shortage of dentists by 2020, these projections have been met with scepticism from universities offering education in dentistry and there are currently no plans to increase the educational capacity at these universities. The number of pharmacists in Norway increased substantially between 2009 and 2018 to 0.8 per 1000 inhabitants, which is similar to the OECD average (OECD, 2019).
4.2.3 Professional mobility of health workers
Norway employs a large number of health workers trained abroad – a total of 18% of its health workforce in 2015. Out of 37 700 foreign workers within the health care sector, there were about 11 000 nurses (29%), 10 300 health care workers (27%) and 5200 doctors (14%) (Statistics Norway, 2019a).
The share of foreign-trained physicians was slightly above 40% of the total in 2018 and the respective figure for nurses was 9% (OECD, 2019). Among OECD countries, only Israel, New Zealand and Ireland have a higher share of foreign-trained doctors. Nearly half of foreign-trained doctors were Norwegian-born, but completed their medical studies abroad (Norwegian Medical Association, 2016). A majority of the foreign-trained nurses were trained in the other Nordic countries or in other EU/EEA countries.
Health personnel trained abroad whose native language is not Norwegian must pass a language proficiency test and prove that they have knowledge of Norwegian health and care services, health, social security and social rights, Norwegian culture, and key national issues. In addition, they must pass courses in the safe handling of medicines and a medical proficiency test, which is adapted to different professions.
4.2.4 Training of health personnel
An authorization from the Directorate of Health is required for all categories of regulated health professions in order to practise in Norway.
Medical study programmes are offered at four public universities in Norway (Oslo, Bergen, Trondheim and Tromsø), with a total educational capacity of 600 students in 2016. The curricula of the medical faculties have so far not been subject to detailed regulation and may differ, especially as regards teaching methods and the organization of the study programmes. Between 2005 and 2015 the government signalled several new requirements regarding medical competences for basic medical education. The suggestions covered a wide variety of areas from patient safety, innovation, teamwork, patient pathways, patient involvement and public health to disease prevention, and the universities have responded by implementing changes in the medical curricula (Frich, 2016).
Basic medical education lasts six years, after which all medical school graduates may obtain an authorization to practise. Since 2013 medical students applied for available residency positions and hospitals selected the candidates they wanted to employ. A new system of competence training was introduced in 2017. The previous system with internships has been replaced by a system of specialization called “LIS” (Leger i spesialisering – Physicians in specialization). LIS1 (Part 1) consists of one year of hospital training and six months of training in primary care (in the municipalities). LIS2 (Part 2) introduces shared competence platforms for groups of specialties (such as internal medicine and surgery) (36 months), while LIS3 (Part 3) covers training unique to each specialty (24 months). LIS2 only applies to 17 specialties, which means that medical students pursuing these specialties must complete all three parts of the training. Students enrolled in the remaining 25 specialties must complete only part 1 and 3 of the training. The LIS education programme takes 6.5 years in total. The new competence training system is coordinated nationally, with a regional coordinating centre in each RHA. All GPs working in primary care are required to become specialists in general medicine by 2022.
A degree in dentistry (Masters in Dentistry) is awarded after five years of study. The first two years of this programme are integrated with the medical study programme. Dental specialization programmes are offered by the University of Oslo and last three or five years (longer for oral surgery and oral medicine).
Studies in pharmacology are divided into a three-year Bachelor’s and a two-year Master’s degree. The Master’s programme usually includes six months’ practical training in a hospital or community pharmacy.
There are two types of nursing practitioners in Norway: registered nurses (RNs) and licensed practical nurses (LPNs). The latter are not included in the figures shown in Fig4.3.
There are 10 educational institutions in Norway offering basic RN education at more than 35 locations, mainly in universities. An increasing number of colleges offer decentralized (e.g. web-based training or training in local educational institutions) or part-time study programmes. The minimum requirement for entering the RN programme is a general study competence, which usually means that the applicant has completed three years of upper secondary education. The basic RN degree takes three years or 180 ECTS points and nurses who have completed it are awarded a Bachelor’s degree and are authorized to practise. Half of the study time is devoted to clinical training, organized by the RHAs and the municipalities. After completing the Bachelor’s degree, RNs can subsequently pursue a Master’s degree or enter a specialization programme in nursing (60–90 ECTS points), for example in intensive care or operating theatre nursing. Specialization programmes are not part of the Bologna system; however, these programmes are now being included in Master’s degree programmes at university colleges (Råholm et al., 2013). Nurses undergoing full-time specialist education are usually paid an allowance by their employer for the duration of their studies and, in exchange, commit to work for the same employer for a certain number of years after finishing the specialization. Master’s degree curricula can differ as there is no single national standard in this area. However, streamlining the Master’s degree is part of the planned educational reforms for the welfare sector.
LPNs are classified as health care workers and obtain a certificate upon completion of vocational training in upper secondary school. This system was introduced in 2008, replacing the former auxiliary nurse and care worker education. In order to receive a certificate and to be able to apply for a licence to practise, the nurse must complete two years of secondary vocational education and two years of training. LPNs may undertake further specialization, e.g. in mental health nursing or music-based therapy, and might qualify for an intake to nursing schools to become RNs.
Given the predicted shortages of nurses (see section 6.1), in 2016 the government set out an action plan, the Competence Lift 2020 (Kompetanseløft 2020), to increase recruitment and improve the competences and professional development of the health workforce in the municipalities (Norwegian Directorate of Health, 2017c).
Other health care professionals
Besides physicians, dentists, psychologists and nurses, several other professional work titles within the health sector are protected by law. These include midwife, medical secretary (providing administrative support), ambulance worker and physiotherapist. All these professions need an issued authorization in order to practise.
4.2.5 Physicians’ career paths
Physicians and nurses can pursue a clinical career (with or without managerial responsibility), an academic career or a combination of both (in which case they usually base their research on clinical practice). Most physicians and a large number of nurses choose to continue their studies in order to qualify as specialists after receiving their authorization to practise. For nurses, an academic career is more difficult to combine with clinical practice.
Graduate medical education requires a minimum of four to five years of residency (see section 4.2.4). Upon completing the residency training, residents are usually employed as specialists at the hospital where they completed their residency training.
4.2.6 Other health workers’ career paths
Nurses’ career paths
Like physicians, nurses can pursue a clinical career, an academic career or a combination of both. A large number of nurses choose to continue their studies in order to qualify as specialists after receiving their authorization to practise. For nurses, an academic career is more difficult to combine with clinical practice.
Strengthening education in general management has been a national policy priority since the 1990s. An analysis of managers in the municipal care sector, based on data from the KS, reveals a shift in management from 2007 to 2015, with an increase of managers for home services and a decrease in managers for institution-based services. The majority, nearly 70% of all managers, have a background in nursing. Since 2015 the Norwegian Business School has been contracted by the Directorate of Health and the KS to offer management education for health leaders in the primary care sector. The capacity in 2018 was 216 places.