Core Competences of Healthcare Assistants in Europe (CC4HCA) : an exploratory study into the desirability and feasibility of a common training framework under the professional qualifications directive : final report.
Date: 2018-02-21
Institutions: Consumers, Health, Agriculture and Food Executive Agency
Subjects: Europe, directive (EU), health care profession, health policy, professional qualifications, report, vocational training

Core Competences of 
Healthcare Assistants in 
Europe (CC4HCA) 

An exploratory study into the desirability and feasibility 
of a common training framework under the Professional 
Qualifications Directive 

Willemijn Schäfer, Marieke Kroezen, Johan Hansen, Walter Sermeus, Zoltan Aszalos & Ronald Batenburg 
October – 2016 

Public 
Health 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMISSION 

Consumers, Health, Agriculture and Food Executive Agency 
Unit DG SANTE.DDG1.B.3 

Contact: Directorate-General for Health and Food safety 

Unit B3 

E-mail:  SANTE-PUBLICATIONS@ec.europa.eu 

European Commission 
B-1049 Brussels 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Core Competences of 
Healthcare Assistants in 
Europe (CC4HCA) 

An exploratory study into the desirability and feasibility 
of a common training framework under the Professional 
Qualifications Directive 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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EUROPEAN COMMISSION 

Contents 

LIST OF ABBREVIATIONS ........................................................................................................................... 8 

1 

EXECUTIVE SUMMARY ON THE MAIN FINDINGS OF THE STUDY ................................... 9 

PART I: BACKGROUND   ......................................................................................................................................... 14 

2 

BACKGROUND TO THE CC4HCA STUDY ................................................................................... 15 

2.1 Rationale for the CC4HCA study............................................................................................................................................. 15 

2.2 Objectives of the CC4HCA study ............................................................................................................................................. 16 

2.3 What is a Common Training Framework? ......................................................................................................................... 18 

2.4 Research questions ...................................................................................................................................................................... 21 

2.5 Content of the report ................................................................................................................................................................... 22 

3  METHODS .............................................................................................................................................. 24 

3.1 Mapp of the current situation of healthcare assistants in each EU Member State and identification of 
competent authorities ........................................................................................................................................................................ 25 
3.1.1 Literature search ................................................................................................................................................................. 25 
3.1.2 Statistics search ................................................................................................................................................................... 26 
3.1.3 Development of the questionnaires ............................................................................................................................ 26 
3.1.4 Collecting responses .......................................................................................................................................................... 28 
3.1.5 Mapping exercise ................................................................................................................................................................ 28 

3.2 Expert consultation round among European organisations on Delphi study ................................................... 29 

3.3 Delphi study among national representatives ................................................................................................................. 30 
3.3.1 Delphi questionnaire development ............................................................................................................................. 30 
3.3.2 Selection procedure for participants Delphi study .............................................................................................. 31 
3.3.3 Participants in the Delphi study ................................................................................................................................... 32 

3.4 CC4HCA study workshops ........................................................................................................................................................ 32 
3.4.1 Goals of the CC4HCA workshops .................................................................................................................................. 32 
3.4.2 Starting point of the Brussels workshop .................................................................................................................. 33 
3.4.3 Programme and documentation of the Brussels workshop ............................................................................ 34 
3.4.4 Participation in the Brussels workshop .................................................................................................................... 34 
3.4.5 Online workshop ................................................................................................................................................................. 35 
3.4.6 Programme and documentation of the online workshop ................................................................................. 35 
3.4.7 Participation in the online workshop ........................................................................................................................ 35 

3.5 Preparation of the final report ................................................................................................................................................ 36 

PART II: THE ROLE, KNOWLEDGE, SKILLS AND COMPETENCES OF HCAS IN THE EU MEMBER 
STATES ............................................................................................................................................................................... 37 

4  HEALTHCARE ASSISTANTS: DEFINITIONS, JOB DESCRIPTIONS AND STATISTICS 38 

5 

 
 
 
4.1 Definitions and occupational titles ....................................................................................................................................... 38 
4.1.1 Internationally applied definitions and classifications of HCAs..................................................................... 38 
4.1.2 Occupational titles of HCAs as reported by country informants ................................................................... 40 

4.2 Statistical information on HCAs ............................................................................................................................................. 42 
4.2.1 Numbers of HCAs ................................................................................................................................................................ 42 
4.2.2 Additional information provided by country informants ................................................................................. 45 
4.2.3  Mobility  of  HCAs,  indicated  by  mobility  statistics  on  ‘second-level  nurses’  in  the  EU  Market 
Regulated Professions Database .............................................................................................................................................. 46 

5 

EDUCATION AND TRAINING SYSTEMS ..................................................................................... 52 

6  MAIN TASKS AND DUTIES OF HCAS ........................................................................................... 56 

7  KNOWLEDGE, SKILLS AND COMPETENCES OF HCAS ......................................................... 58 

8 

REGULATION AND REGISTRATION OF THE HCA PROFESSION AND EDUCATION . 61 

PART III: EXPLORATION OF A COMMON TRAINING FRAMEWORK FOR HCAS ................................. 62 

9 

THE VIEWS ON THE CONTENT OF A POTENTIAL CTF FOR HCAS ................................. 64 
 ........................ 65 
 .............................................................................................................. 65 
................................................................................................................. 71 

9.1 The level of support for a common set of knowledge, skills and competences for HCAs

9.1.1 Results from the Delphi study
9.2.2 Results from the workshops

 ............................................................................. 73 

9.2 Support for additional criteria to be included in a CTF

 ......................................................................................................... 76 

9.3 EQF level of a potential CTF for HCAs

 ............................................................................ 76 

9.4 Conclusions on the content of a potential CTF for HCAs

 .......... 78 

10. 

THE DESIRABILITY AND FEASIBILITY OF A CTF AS A LEGAL INSTRUMENT

 ................................................................................................... 78 
 ........................................................................................................................................ 78 
 ......................................................................................................................................... 79 

10.1 Drivers and barriers for a CTF for HCAs

10.1.1
10.1.2

Barriers
Drivers

 ............................................ 80 

10.2 Willingness among EU Member States to explore a CTF for HCAs further

 ................................................................................................................................................. 81 

10.3 Conclusions

 .......... 82 

11.

FURTHER EXPLORATION OF A CTF FOR HCAS AND POSSIBLE NEXT STEPS

 ................................................................ 82 

11.1 Starting point: willingness to explore a CTF for HCAs further

 ......................................... 82 

11.2 Exploration of possible future steps in the development of a CTF for HCAs

 ....................................................................... 86 

11.3 ‘Roadmap’ fora potential suggestions for a CTF for HCAs

 .............................................................................................................. 90 

11.4 Reflections on the CC4HCA study

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 ............................................................................................................................... 92 

ABSTRACT

 .......................................................................................................................... 93 

REFERENCES

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List of abbreviations 

Abbreviation 

CC4HCA 

Meaning 

 Core Competences of Healthcare Assistants in Europe 

CPD 

CTF 

EC 

EQF 

EU 

HCA 

MS 

 Continuous Professional Development 

Common Training Framework 

European Commission 

European Qualifications Framework 

European Union 

Healthcare Assistant 

Member State 

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1 

Executive summary on the main findings of the study 

The CC4HCA study 
This report presents the findings of the study ‘Core Competences of Healthcare Assistants in 
Europe’  (CC4HCA).  The  aim  was  to  map  the  position  of  healthcare  assistants  in  all  28  EU 
Member  States  and  to  explore  the  feasibility  and  interest  among  Member  States  for 
adopting  a  common  training  framework  for  this  professional  group  under  Directive 
2013/55/EU, amending the Professional Qualifications Directive (2005/36/EC). The CC4HCA 
study was carried out on behalf of the European Commission (DG SANTE) and funded by the 
European Union in the frame of the Third Health Programme 2014-2020. 

Healthcare assistants, a growing category of health professionals in Europe 
In  many  European  countries,  the  role  of  healthcare  assistants  (HCAs)  has  developed  over 
recent years and HCAs are becoming a significant part of healthcare teams, working closely 
with registered nurses and other health professionals. Because clarification of the roles and 
responsibilities  of  team  members  is  known  to  be  crucial  in  improving  multidisciplinary 
collaboration  and  efficient  care  delivery,  an  overview  of  the  knowledge,  skills  and 
competences  of  HCAs  is  needed.  Such  an  overview  can  help  define  HCAs’  roles  and 
responsibilities  and  give  a  clearer  understanding  of  their  position  in  healthcare  teams. 
Moreover, in the context of growing mobility of healthcare professionals across Europe, it is 
becoming ever more relevant that there should be clarification and definitions of HCAs’ core 
competences  across  EU  Member  States.  Such  an  overview  can  help  ensure  patient  safety 
while at the same time facilitating professionals' mobility. One specific instrument that can 
support this process is the common training framework (CTF), a new legal tool set out under 
Directive 2013/55/EU, amending Directive 2005/36/EC. 

What is a common training framework? 
A common training framework (CTF) is a legal tool that introduces a new way of recognising 
professional  qualifications  across  EU  countries  automatically.  A  CTF  will  let  EU  Member 
States expand the system of automatic recognition to professions that are not automatically 
recognised as part of Annex V of Directive 2005/36/EC. A CTF is based on a common set of 
core  (or  minimum)  knowledge,  skills  and  competences  needed  for  pursuing  a  specific 
profession.  A  CTF  has  to  comply  with  the  following  conditions  set  out  in  Directive 
2013/55/EU (Article 49a, paragraph 2), amending Directive 2005/36/EC: 
1.  The CTF shall facilitate mobility between Member States; 
2.  The profession or the education and training leading to the profession is regulated in at 

least one third of the Member States; 

3.  The  CTF  combines  knowledge,  skills  and  competences  required  in  at  least  one  third of 

the Member States; 

4.  The CTF is based on European Qualification Framework levels; 
5.  The  profession  concerned  is  not  covered  by  another  CTF  and  does  not  benefit  from 

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automatic recognition under another system; 

6.  Preparation of the CTF following a transparent due process; 
7.  The  CTF  permits  nationals  from  any  Member  State  to  acquire  the  professional 
qualification  under  such  framework  without  being  required  to  be  a  member  of-  or 
registered with any professional organisation. 

What were the objectives of the CC4HCA study?  
The central aim of the CC4HCA study was: 
To explore the level of consensus among all 28 EU countries concerning the desirability and 
potential content of a common training framework for healthcare assistants within the EU 

The three objectives that follow from this central aim were: 
1.  To  identify  the  competent  authorities  in  each  Member  State  and  the  representative 
national  or  European  professional  organisations  that  are  interested  in  working  on  a 
suggestion for a CTF for HCAs; 

2.  To set up a network that can establish a common position on a set of knowledge, skills 
and competences combining the knowledge, skills and competences required in at least 
12 Member States; 

3.  Provide input (a common position on the set of knowledge, skills and competences and 
a  feasible  roadmap)  for  interested  representative  European  or  national  professional 

organisations  (or  competent  authorities)  that  might  want  to  engage  in  working  on  a 

suggestion for a CTF for HCAs. 

What were the main components of the CC4HCA study? 
The study consisted of three main tasks: 
1.  Mapping out the position of HCAs in all 28 EU Member States; 
2.  A  Delphi  study  among  the  competent  authorities  and/or  representative  national 
professional organisations for HCA regulation and/or education in each Member State; 
3.  Two  workshops  for  further  exploration  of  a  common  position  on  the  desirability  and 

feasibility of a potential CTF for HCAs within the EU. 

All 28 EU Member States participated in all tasks, with the exception of Austria and Malta 
for the Delphi study. 

What  results  were  obtained  by  mapping  out  healthcare  assistants’  current  position  in 
Europe? 

Definition and position of HCAs in the EU Member States 
The occupational titles of HCAs used across EU Member States show that the terminology 
differs  considerably  between  countries.  In  some  countries  the  HCA  occupation  is  defined 
broadly,  while  in  others  its  scope  is  more  limited.  Generally,  HCAs  work  under  the 
supervision  of  nurses  but  they  are  sometimes  also  supervised  by  other  healthcare 

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professionals, most notably medical specialists. HCAs are employed in hospitals, home care 
and long term care and (to a lesser extent) in primary care and psychiatry as well.  
Regulation of healthcare assistants 
The HCA profession is regulated in 14 Member States, while HCA education and training is 
regulated in 22 out of the 28 EU Member States. One of the conditions for a potential CTF is 
that the profession, or the education and training leading to the profession, is regulated in 
at least one third (i.e. 10) of the EU Member States. Hence, this condition is met for HCAs. 
Education of healthcare assistants 
In nearly all EU Member States, the curriculum for HCA training and education is defined at 
the national level. Considerable variation was found in the entry requirements for training 
and  education  across  the  EU  (from  no  requirement  through  to  high  school  or  secondary 
school),  the  minimum  entry  age  (from  no  restriction  to  18  years)  and  duration  of  the 
education (from 3 months up to 2 or 3 years, with 6 years in Latvia as an exception). Most 
Member States have curricula stating that about 60% of the total education time should be 
spent in practical situations. In half of the Member States, HCAs are obliged to follow some 
sort of continuous professional development (CPD) programme. 
Core knowledge, skills and competences of healthcare assistants 
Knowledge, skills and competence items that are part of HCAs’ curriculum in most Member 
States  are  strongly  related  to  their  tasks  and  duties  in  everyday  practice.  This  means  that 
they are mainly focused on non-medical care provision, such as supporting patients in their 
activities of daily living (ADL), clerical and administrative knowledge, cleaning and washing, 
preparing meals and communication. 
Core tasks and duties of healthcare assistants 
In  most  EU  Member  States,  the  core  tasks  and  duties  of  HCAs  consist  of  monitoring  and 
measuring  patients’  vital  signs,  providing  non-medical  care  (e.g. cleaning,  washing, 
preparing  and  serving  meals),  supporting  other  health  professionals  and  applying  safety, 
quality and hygiene techniques. HCAs often only provide ‘basic care’ to patients. 

What are the results for the desirability and feasibility of a common training framework? 

The content and qualification level of a potential CTF for healthcare assistants 
The  results  from  the  Delphi  study  and  workshops  provided  the  foundations  for  drawing 
conclusions about the content and qualification levels that a potential CTF for HCAs within 
the  EU  should  have,  according  to  the  Member  States.  There  was  consensus  between  the 
Member  States  about  a  core  (or  minimum)  set  of  knowledge,  skills  and  competences  of 
HCAs. In two Delphi rounds, a list of 18 knowledge requirements plus 17 for skills and 4 for 
competences was judged to be relevant by at least one third of the Member States as part 
of a potential CTF for HCAs. However, it was also noted that further refinement of this set 
would be required. 

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At  the  same  time,  there  was  a  great  deal  of  discussion  about  the  differences  between 
Member States with regard to the qualification level that this combined set of knowledge, 
skills and competences for HCAs should have. During the workshops, both Member States 
and  European  stakeholders  feared  that  assigning  a  single,  universal  EQF  level  could  have 
severe  and  potentially  undesirable  consequences.  Determining  a  singlee  common  and 
appropriate EQF level for a potential CTF for HCAs therefore appears to be a sensitive and 
complicated topic at the moment, due to the many differences between Member States.  

The desirability and feasibility of a potential CTF for healthcare assistants 
The following can be concluded regarding the desirability and feasibility of a CTF for HCAs as 
currently  perceived  by  the  28  European  Member  States.  First  of  all,  there  appears  to  be 
consensus among EU Member States on the need to define the role of HCAs across Europe. 
Also, most study participants expressed a willingness to be engaged in a further exploration 
of a CTF for HCAs. In terms of feasibility of a CTF, however, Member States and European 
stakeholder  organisations  see  barriers  regarding  a  number  of  conditions  that  are  formally 
required  for  proposing  a  CTF.  Many  of  the  barriers  relate  to  the  existing  differences 
between  and  within  countries  and  sectors,  especially  related  to  the  levels  of  education, 
qualification  and  autonomy  of  HCAs.  Other  barriers  concern  the  perceived  uncertainty 
about a CTF as a new EU legal instrument that there is no practical experience with as yet. 
One important issue is the legal consequences that a CTF would have for national training, 
occupation and financing systems. Ongoing transformation of the national health workforce 
and  education  system  was  perceived  as  a  barrier  in  a  number  of  Member  States  too, 
although  others  perceived  this  as  an  opportunity.  Finally,  some  Member  States  and 
European stakeholders fear that a CTF may increase mobility, with negative effects for the 
countries of origin. 

Conclusion and discussion 

Further exploration of a CTF for healthcare assistants and potential follow-on steps 
Based  on  the  results  summarised  above,  we  conclude  that  there  is  a  common  position  of 
willingness to explore the desirability of a CTF for HCAs further – even though the perceived 
feasibility is currently uncertain. We have recapped the seven conditions below as set out in 
Directive 2013/55/EU, amending Directive 2005/36/EC, summarising the extent to which its 
‘building blocks’ are already in place so that the CTF development process for HCAs can be 
started, should interested parties wish to undertake such a further exploration. 

A  CTF  shall  comply  with  the  following  conditions 
(Dir.  2013/55/EU,  art.  49a)Error!  Bookmark  not 
efined.: 

Study results and description of the building blocks for 
further CTF compliance/exploration in place: 

a)  The  CTF  enables  more  professionals  to  move 

This cannot be predicted at this time. 

between Member States 

b)  The  profession  or  the  education  and  training 
leading to the professions is regulated in at least 

Currently, the HCA profession is regulated in 14 EU MSs 
and HCA education is regulated in 22 EU MSs. 

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one third of Member States  

c)  The  CTF  combines  knowledge,  skills  and 
competences  required  in  at  least  one  third  of 
the Member States  

d)  The  CTF  is  based  on  European  Qualification 

Framework levels 

e)  The  profession  concerned  is  not  covered  by 
from 

another  CTF  and  does  not  benefit 
automatic recognition under another system 

f)  Preparation of the CTF following a "transparent 
relevant 
including 
due 
stakeholders  from  Member  States  where  the 
profession is not regulated 

process", 

the 

g)  The  CTF  permits  nationals  from  any  Member 
State  to  acquire  the  professional  qualification 
under such a framework without being required 
to  be  a  member  of  or  registered  with  any 
professional organisation. 

This  study  showed  that  there 
is  consensus  on  a 
potential  set  of  knowledge,  skills  and  competences  of 
HCAs  (> one  third  MSs  agreeing),  but  the  levels  of 
autonomy, supervision and other aspects  need  further 
discussion. 

This  study  showed  that  it  is  currently  not  feasible  to 
level  for  HCA 
reach  agreement  on  a  single  EQF 
knowledge,  skills  and  competences  among  Member 
States. 
HCAs  are  not  covered  by  another  CTF  and  do  not 
benefit  from  automatic  recognition  under  another 
system. 

This  study  provides  an  initial  building  block  for  this 
through  a  mapping  of  representatives  from  all  28  EU 
MSs  and  a  number  of  European  professional 
organisations,  and  consulted  them  through  the  Delphi 
study and workshops. 

This would be an effect of an actual CTF and cannot be 
determined  at  this  time.  Some  participants  are 
concerned  about  the  representation  of  HCAs  by 
professional organisations. 

‘Roadmap to guide a potential suggestion for a CTF for healthcare assistants 
As  a  final  step  of  this  CC4HCA  study,  we  have  sketched  out  a  roadmap  that  may  guide 
interested  representative  European  or  national  professional  organisations  or  competent 
authorities  that  may  want  to  be  engaged  in  developing  a  CTF  for  HCAs.  Based  on  the 
conditions  for  a  CTF  as  set  out  in  Directive  2013/55/EU,  amending  Directive  2005/36/EC, 
and the outcomes of the CC4HCA study, the major tasks and their interrelationships can be 
depicted as follows:  

When  applying  this  roadmap,  one  important  recommendation  is  to  make  sure  that  the 
position of HCAs in Member States and the national discussion about their position in the 
healthcare system needs to be aligned with the CTF development process at the EU level. 
This requires the situation to be mapped out fully with involvement of stakeholders within 
every Member State, with all parties being kept informed accordingly throughout the whole 
CTF development process.  

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Part I:  
Background 

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2  

Background to the CC4HCA study 

This report presents the results of the study ‘Core Competences of Healthcare Assistants in 
Europe’ (CC4HCA) conducted between April 2015 and October 2016. The CC4HCA study was 
carried out on behalf of the European Commission (DG SANTE) and funded by the European 
Union in the frame of the Third Health Programme 2014-2020. The study is a follow-up of 
the  pilot  study  ‘Creating  a  Pilot  Network  of  Nurse  Educators  and  Regulators’  that  was 
conducted  between  2010  and  2013  (Braeseke  et  al.,  2013).  The  main  aim  of  the  CC4HCA 
study  was  to  explore  the  interest  among  all  Member  States  of  the  European  Union  in 
developing  a  common  position  on  the  knowledge,  skills  and  competences  of  healthcare 
assistants  (HCAs)  in  Europe.  In  this  first  chapter  we  explain  the  rationale,  objectives  and 
research questions that guided the study. 

2.1 Rationale for the CC4HCA study 
In  many  European  Union  (EU)  Member  States,  healthcare  assistants  (HCAs)  are  becoming 
increasingly  important.  A  number  of  factors,  such  as  the  ageing  of  both  citizens  and 
healthcare  personnel,  combined  with  sometimes  inadequate  workforce  planning  and 
recruitment and retention policies, have led to growing shortages in nursing (Ashby et al., 
2003; Gerrish & Griffith, 2004; Keeney, Hasson, McKenna, & Gillen, 2005; McKenna, Hasson, 
&  Keeney,  2004;  Spilsbury  &  Meyer,  2004;  Buchan  &  Aiken,  2008;  Sermeus  et  al.,  2011). 
Subsequently, this can lead to an increasing demand for HCAs, as they are often deployed to 
take over tasks from nurses and support medical staff in providing care (Spilsbury & Meyer, 
2004). At the organisational level, reasons for managers to employ HCAs are related to cost-
efficiency, as HCAs usually have lower qualifications and lower salaries (Thornley, 2000). It 
can  also  be  expected  that  the  role  of  HCAs  in  EU  Member  States  will  increase  with  the 
growing trend towards self-management and empowerment of patients and their informal 
carers.  HCAs  play  a  key  role  in  answering  the  increasing  need  for  better  communication 
between  patients  and  healthcare  professionals,  and  play  a  part  in  many  initiatives  to 
improve inter-professional cooperation to achieve people-centred care. 

The rationale behind the study can be summarised by the following line of reasoning:  
• 

In many European countries, the role of HCAs has developed over recent years as HCAs 
comprise  a  significant  part  of  healthcare  teams  (MacAlister,  1998;  Vail  et al,.  2011), 
working closely with registered nurses and other health professionals; 

•  At the same time, it has been found that clarifying the roles and responsibilities of team 
members  is  very  important  for  improving  multidisciplinary  collaboration  in  healthcare 
(Williams & Laungani, 1999); 

•  This  implies  that  an  overview  of  the  knowledge,  skills  and  competences  of  HCAs  is 
needed,  to  define  their  roles  and  responsibilities  and  to  achieve  a  clearer  overview  of 
their position in healthcare teams; 

15 

 
 
 
•  Consequently,  this  can  improve  the  delivery  of  high-quality  patient  care  based  on  the 

optimum division of tasks and responsibilities within the team; 

•  Healthcare  is  a  key  sector  for  employment,  driven  by  increasing  healthcare  demands. 
HCAs, like many other health professionals, are expected to become increasingly mobile 
in order to meet population needs in the EU; 

•  The CTF is one specific legal instrument that can support the goals described above; 

•  A  CTF  for  HCAs  across  Europe  may  also  facilitate  cross-border  mobility  of  HCAs  while 

safeguarding patient safety. 

Given  that  this  rationale  applies  to  all  countries  (i.e. Member  States  and  their  healthcare 
systems),  it  is  clear that  specific  added  value  can  be  achieved  by  comparing  the  roles  and 
responsibilities of HCAs in different countries. This will not only increase awareness among 
policy-makers  about the  existing  diversity  in  the  position  of  HCAs,  but will  also  encourage 
exploration  of  cross-national  collaboration.  This  can  be  done  for  example  by  exchanging 
best practices, formulating common challenges for the HCA profession and exploring what 
could  comprise  a  common  basis  for  training  and  professionalisation.  While  requiring  a 
longer horizon of preparation and action, a long-term goal of defining ‘core competences’ 
for HCAs across countries may also be able to facilitate cross-border mobility. 

One specific legal instrument that could potentially support the goals described above is the 
common  training  framework  (CTF).  The  background  and  design  of  this  instrument  is 
described in the next section. However, it is as yet unknown and unexplored  (1) whether a 
set of core competences for HCAs can be defined supra-nationally as the basis for a CTF and 
(2) whether  a  CTF  is  a  desirable  and  feasible  instrument  for  supporting  collaboration, 
exchange and cross-border mobility of HCAs across EU Member States. The CC4HCA study 
was therefore initiated in order to address the following main goal: 

To explore the level of consensus among all 28 EU Member States concerning the desirability 
and potential content of a common training framework (CTF) for healthcare assistants 
within the EU. 

2.2 Objectives of the CC4HCA study 
The main aim of the CC4HCA study was to explore the level of consensus among all 28 EU 
countries concerning the desirability and potential content of a common training framework 
(CTF) for healthcare assistants within the EU. We would like to emphasise that the CC4HCA 
study  was  exploratory  in  nature.  This  study  should  not  be  considered  as  a  first  step  in  a 
formal CTF process. The CC4HCA study presents the explored level of consensus among the 
stakeholders  consulted  and  the  building  blocks  from  which  an  actual  CTF  process  could 
potentially be started, should there be any parties interested in doing so. 

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To achieve the main aim, the overall scope and objectives of the study were operationalised 
as:  

1. 

To 

identify  the  competent  authorities 

in  each  Member  State  and  the 

representative  national  or  European  professional  organisations  that  are 

interested in working on a suggestion for a CTF for HCAs; 

2. 

To set up a network that can establish a common position on a set of knowledge, 

skills  and  competences  combining  the  knowledge,  skills  and  competences 

required in at least 10 Member States. 

3. 

Provide 

input  (a  common  position  on  the  set  of  knowledge,  skills  and 

competences and a feasible roadmap) for interested representative European or 

national professional organisations (or competent authorities) that might want to 

engage in working on a suggestion for a CTF for HCAs. 

To achieve these aims, the pilot study by Contec and partners (2013) provided an important 
starting point as it has already mapped out the position of HCAs in 14 EU Member States. 
This  CC4HCA  study  complemented  that  mapping  exercise  for  the  other  14  EU  Member 
States  (Croatia,  Cyprus,  Estonia,  France,  Greece,  Hungary,  Latvia,  Lithuania,  Luxembourg, 
Malta, Portugal, Romania, Slovakia and Sweden), based on the current situation of HCAs in 
these Member States (Braeseke et al., 2013). Figure 2.1 shows the countries included in the 
CC4HCA study (dark blue) and the countries included in the pilot study conducted by Contec 
(light  blue).  Data  from  the  pilot  study  was  updated  where  possible,  as  data  collection  for 
that study took place in 2011. This drew a full and up-to-date picture of the position of HCAs 
in all 28 EU Member States. 

17 

 
 
 
 
 
 
 
Figure 2.1: Countries included in the Contec pilot study in 2012/2013 and countries included 
in the CC4HCA mapping study in 2015/2016 

2.3 What is a Common Training Framework? 
A  common  training  framework  (CTF)  is  a  legal  construct  that  introduces  a  new  way  of 
automatic  professional  qualification  recognition  across  EU  countries.  With  a  CTF,  EU 
Member  States  can  expand  the  system  of  automatic  recognition  to  new  professions.  In 
Directive 2013/55/EU, amending Directive 2005/36/EC1, a CTF is described as: “a common 
set  of  minimum  knowledge,  skills  and  competences  necessary  for  the  pursuit  of  a  specific 
profession” (see Box 2.1 for the exact definitions of what is understood under ‘knowledge, 
skills and competences’). In other words, a CTF aims to define a benchmark in terms of what 
a person should know, understand and be able to do in order to practice a given profession. 
A  CTF  for  healthcare  assistants  (HCAs)  would  therefore  form  a  benchmark  for  the  HCA 
profession that EU Member States would have to adhere to when developing their own HCA 
training programmes. 

1 See for a full explanation of the CTF and all conditions: Directive 2013/55/EU of the European Parliament and 

of the Council of 20 November 2013, amending Directive 2005/36/EC. To be found here. 

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Box 2.1: Definition of ‘knowledge, skills and competences’ 
• 

‘Knowledge’  means  the  outcome  of  the  assimilation  of  information  through  learning. 
Knowledge is the body of facts, principles, theories and practices that is related to a field 
of work or study. In the context of the European Qualifications Framework, knowledge 
is categorised as theoretical and/or factual;  
‘Skills’ means the ability to apply knowledge and use know-how to complete tasks and 
solve  problems.  In  the  context  of  the  European  Qualifications  Framework,  skills  are 
categorised  as  cognitive  (involving  the use  of  logical  intuitive  and  creative  thinking)  or 
practical  (involving  manual  dexterity  and  the  use  of  methods,  materials,  tools  and 
instruments);  
‘Competence’  means  the  proven  ability  to  use  knowledge,  skills  and  personal  social 
and/or  methodological  abilities  in  work  or  study  situations  and  in  professional  and 
personal  development.  In  the  context  of  the  European  Qualifications  Framework, 
competence is described in terms of responsibility and autonomy. 

• 

• 

Source: https://ec.europa.eu/esco/portal/escopedia/       

Implications of a common training framework for EU Member States 

Suggestions  for  a  CTF  may  be  submitted  to  the  European  Commission  by  representative 
professional organisations at the EU level, as well as national professional organisations or 
competent  authorities  from  at  least  one  third  of  the  Member  States.  If  all  the  conditions 
described  in  Box  2.2  below  are  met,  the  Commission  will  be  empowered  to  adopt  a 
delegated  act  to  establish  a  CTF  for  a  given  profession.  This  means  that  the  CTF  would 
become  legally  binding  for  all  EU  Member  States.  However,  Member  States  can  be 
exempted from the obligation of introducing the CTF on their territory if they fulfil one of 
the following exemption conditions: 

•  There are no education or training institutions available in its territory to offer such 

training for the profession concerned; 

•  The introduction of the CTF would adversely affect the organisation of its system of 

education and professional training; 

•  There  are  substantial  differences  between  the  CTF  and  the  training  required  in  its 

territory, which entail serious risks. 

It  should  also  be  noted  that  a  CTF  is  voluntary  for  professionals  and  does  not  replace  a 
national  training  programme.  In  other  words,  a  CTF  is  neither  a  European  curriculum  or 
diploma nor a qualification. It is a common training framework.  

19 

 
 
 
 
Box 2.2: Conditions which every common training framework must meet 
A  common  training  framework  must  meet  the  following  conditions,  as  set  out  in  the 
Directive 2013/55/EU (Article 49a, paragraph 2), amending Directive 2005/36/EC: 

(a)  The CTF shall facilitate mobility across Member States  
(b) The  profession  or  the  education  and  training  leading  to  the  professions  is 

regulated in at least 1/3 of Member States  

(c)  The CTF combines knowledge, skills and competences required in at least 1/3 of 

the Member States  

(d) The CTF is based on European Qualification Framework levels2  
(e)  The  profession  concerned  is  not  covered  by  another  CTF  and  does  not  benefit 

from automatic recognition under another system  

(f)  Preparation  of  the  CTF  following  a  "transparent  due  process",  including  the 
relevant stakeholders from Member States where the profession is not regulated 
(g)  The  CTF  permits  nationals  from  any  Member  State  to  acquire  the  professional 
qualification under such framework without being required to be a member of- or 
registered with any professional organisation. 

Development process of a common training framework 

The adoption process of a CTF consists of several stages. Firstly, suggestions for a potential 
CTF are made by representative professional organisations at the EU level and/or national 
professional  organisations  or  competent  authorities  from  at  least  one  third  of  the  EU 
Member  States.  The  European  Commission  can  also  make  suggestions.  Secondly,  a 
proposed  CTF  is  checked  by  the  European  Commission  to  see  whether  it  meets  all 
conditions as set out in Directive 2013/55/EU (Article 49a, paragraph 2), amending Directive 
2005/36/EC. After the preparation of a proposed CTF - through a transparent due process - 
discussions will be held about the CTF by the Member States. The CTF will be transformed 
into  a  delegated  act  describing  the  CTF.  A  delegated  act  enters  into  force  only  if  no 
objections  are  expressed  either  by  the  European  Parliament  (EP)  or  the  Council  within  a 
period of 2 months after notification of that act to the EP and Council. The final step is the 
process  of  implementing  the  act,  including  listing  the  national  qualifications  and  national 
professional titles that comply with the common training framework adopted. 

2  A  qualifications  framework  is  an  instrument  for  classifying  qualifications  according  to  a  set  of  criteria  for 
specified  levels  of  learning  achieved,  aiming  to  integrate  and  coordinate  qualification  subsystems  and 
improve  the  transparency,  access,  progression  and  quality  of  qualifications  in  relation  to  the  labour 
market and civil society. 

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2.4 Research questions 
To  achieve  the  central  aim  of  this  study,  it  was  broken  down  in  two  main  parts  that 
structure the results section of this report and its chapters. 

The  first  part  of  this  study  was  carried  out  to  describe  the  role,  knowledge,  skills  and 
competences  of  HCAs  in  the  EU  Member  States.  The  following  research  questions  were 
answered: 

•  How  can  the  position  of  HCAs  be  described  in  each  of  the  14  Member  States  that 
were not included in the Contec study? Inter alia this was in terms of the following 
general aspects: 

o  occupational title 
o  the number of HCAs 
o  other 

elements 

such 

as 

their 

employment/unemployment 
international and vertical mobility 

rate, 

job 

age 

and 

gender  distribution, 
retention,  annual  wages  and 

•  How are these distributed within a Member State, inter alia in terms of the areas of 

employment? 

•  What are the tasks and duties of HCAs within the Member States? 
•  How  can  the  position  of  HCAs  be  described  in  each  of  the  28  Member  States,  in 

terms of the following aspects: 

o  their minimum age at the beginning of the education 
o  the duration of the education 
o  source of funding the education 
o  curriculum details, type of training 

•  Are the education and/or education objectives regulated in the Member States? And 

• 

• 

if so, is the curriculum and/or examination regulated? 
Is the profession regulated and registered in the Member States? And if so, how is it 
regulated? 
Is  this  registration  voluntary  or  obligatory,  and  if  the  first  applies,  what  is  the 
estimated registration coverage of healthcare assistants? 

•  How can the details and conditions of this regulation be described? 
•  What  is  the  set  of  the  knowledge,  skills  and  competences  of  HCAs  within  the 

Member States? 

The second part of the CC4HCA study aimed to explore the desirability and feasibility of a 
common training framework for HCAs, and provide input for a potential common position 
among  the  28  EU  Member  States  on  the  minimum  set  of  knowledge,  skills  and 
competences. As preparation for this part of the study, the following research needed to be 
answered first: 

•  For all 28 Member States, which organisations (or authorities) that are represented 
by  the  recruited  country  experts  for  the  first  part  of  the  study  are  authorised  to 

21 

 
 
 
define  the  national  set  of  knowledge,  skills  and  competences  or  training  tests  for 
HCAs in their country?  

•  What  is  the  content  of  these  national  sets  and  how  are  they  documented, 

implemented, controlled, communicated and versioned?  

•  For all 28 Member States, which organisations (or authorities) can ensure that their 
national  administrations  are  engaged  in  and  interested  in  working  on  a  suggestion 
for a CTF for HCA at the European level? 

Subsequently the following research questions were addressed: 

•  What  are  the  visions  of  the  representatives  of  the  organisations  identified,  and 

representatives of other EU Member States? 

•  What  consensus  emerges  from  group  discussions  on  a  potential  CTF  and  its 
components,  in  terms  of  applicability,  usefulness,  desirability  and  feasibility  of 
implementation? 

•  What  is  a  common  position  on  the  minimum  set  of  knowledge,  skills,  and 

competences of HCAs? 

•  What  further  steps  should  be  taken  to  reach  consensus  on  a  minimum  set  of 
knowledge, skills, and competences that can support a CTF proposal at the EU level? 
•  To  what  extent  did  the  one-day  workshop  lead  to  a  common  position  on  the 

minimum set of knowledge, skills and competences of HCAs? 

•  What are the views on this position of the stakeholders that were not present, and 

• 

can consensus among them be achieved? 
If no common position can be determined that is shared by a minimum of one third 
of the Member States, what steps need to be taken in additional Member States to 
reach such a position? 

•  What  are the  next  steps  for  a  suggestion for  a  CTF,  including  a  feasible timeline,  a 
relevant  legal  framework  and  the  plan  to  include  relevant  organisations  or 
authorities? 

2.5 Content of the report 
This  report  describes  the  results  of  the  CC4HCA  study  conducted  between  April  2015  and 
October 2016 and it is divided into three parts. 

Part  I  of  the  report  describes  the  background  of  the  study  (this  chapter),  as  well  as  the 
methods  and  processes  used  to  collect  the  data  for  answering  the  research  questions 
(Chapter 3). 

In Part II, the current position of HCAs in the 28 EU Member States is described. Chapters 5 
to 8 present the results of the Europe-wide mapping exercise, describing the education and 
training  systems,  and  the  main  tasks  and  duties  of  HCAs  (including  their  knowledge,  skills 
and  competences)  across  the  EU.  Separate  chapters  are  devoted  to  describing  the 

22 

 
 
 
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regulation  and  registration  of  the  profession  and  education  of  HCAs  in  the  EU  Member 
States. 

Part III of the report provides the exploration of a potential CTF for HCAs. Firstly, the content 
of  a  potential  CTF  for  HCAs  is  described  in  terms  of  a  set  of  core  competences  for  HCAs. 
Secondly,  the  desirability  and  feasibility  of  a  CTF  as  a  legal  instrument  is  elaborated, 
describing the drivers and barriers mentioned by the Member States and taking the position 
of European stakeholders into account. Part III also includes a conclusion and discussion of 
the results and the process of this study. 

23 

 
 
 
3 

Methods  

To  explore  the  feasibility  and  desirability  of  a  common  training  framework  (CTF)  for 
healthcare assistants in the European Union, we performed the following six main tasks: 
1.  Mapping out the current situation of HCAs in each EU Member State; 
2.  Identification of the competent authorities and/or representative national professional 

organisations for HCA regulation and/or education in each EU Member State;  

3.  An expert consultation round among European organisations on the completeness and 

comprehensibility of the planned Delphi study;  

4.  Building  a  shared  view  among 

interested  national  and  European  professional 
organisations (and/or competent authorities) on the minimum set of knowledge, skills 
and  competences  required  for  HCAs,  as  needed  for  preparing  a  suggestion  for  a  CTF, 
through  the  Delphi  study  (exploration  of  the  level  of  consensus)  among  competent 
authorities and national representatives; 

5.  Organisation  of  CC4HCA  study  workshops  to  explore  a  common  position  on  the 

minimum set of knowledge, skills and competences further; 

6.  Preparation  of  the  final  report  including  recommendations  for  stakeholders  willing  to 

prepare a suggestion for a CTF for HCAs by providing: 
a)  A  common  position  among 

interested  representative  national  or  European 
professional  organisations  (or  competent  authorities)  on  the  minimum  set  of 
knowledge,  skills  and  competences  of  an  HCA  required  for  preparing  a  suggestion 
for a CTF; 

b)  A  roadmap  for  preparing  a  suggestion  for  a  CTF,  including  a  feasible  timeline  and 
include  relevant  professional 
the  relevant 
organisations or competent authorities from Member States where the profession is 
not regulated. 

legal  framework  and  a  plan  to 

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Figure 3.1   Flowchart showing the main tasks and their interdependencies 

3.1  Mapp  of  the  current  situation  of  healthcare  assistants  in  each  EU 
Member State and identification of competent authorities 
To map out the current situation of HCAs and to identify competent authorities for HCAs in 
each EU Member State, the following tasks were performed:  

•  Literature search 
•  Statistics search 
•  Questionnaire research among country informants 
Each of these tasks will be described in more detail below.  

3.1.1 Literature search 
The  first  step  was  to  search  all  available  literature  in  the  European  languages  that  are 
mastered  by  the  consortium  partners  (English,  French,  German,  Dutch  and  Hungarian).  In 
addition, Italian was included in order to include a southern European language as well. Box 
3.1  includes  an  overview  of  the  search  terms  used  in  these  6  languages.  Various  search 
engines were used, including PubMed, Google Scholar and Google. The aim was to collect 
and assess as much relevant material as possible about the role of HCAs in all 28 Member 
States, so that this could be used as input for the country consultation rounds of Task 1 and 
Task 2.  The  following  sources  were  excluded:  documents  concerning  only  (national) 
competence  profile  descriptions;  documents  that  were  not  based  on  qualitative, 

25 

 
 
 
quantitative  or  literature  research;  and  documents  that  only  covered  a  very  specific  topic 
such as the role of elderly patients in the communication process of care. 

As  well  as  literature  database  research,  manual  searching  and  snowballing  were  used 
among  past  studies  as  reference  points.  Country  informants  from  all  28  Member  States 
were asked to identify relevant publications on healthcare assistants in their country and/or 
provide an English summary. This literature was used to support the answers to the survey 
on the national situations. 

Box 3.1: Search terms used for identifying literature in six European languages 

Dutch: helpende zorg en welzijn / zorghulp / verzorgende IG / taken 
English: healthcare assistants / HCAs / skills, knowledge and competences (of HCAs) 
French: aide soignante / tâches / compétences  
German: Pflegeassistent / Pflegehelfer, Heimhelfer / Aufgaben 
Hungarian: ápolási asszisztens / kompetenciák 
Italian:  operatore  socio-sanitario  /  operatori  socio-sanitari  /  OSS  /  competenze  / 
ruolo / conoscenze 

3.1.2 Statistics search 
In addition to the literature, we also consulted available international and national statistics 
about  HCAs.  First  of  all,  the  informants  from  the  14  ‘new’  Member  States  (i.e. those  not 
covered  in  the  pilot  study)  were  asked  to  collect  national  figures  on  the  following  topics: 
number and FTE of HCAs, unemployment rates, graduates per year, distributions by e.g. age, 
gender  and  country  of  birth,  number  of  HCAs  in  the  various  areas  of  employment  and 
mobility.  
In  addition,  the  Eurostat  database  and  EU  Single  Market  regulated  professions  database 
were studied for figures on healthcare assistants in all 28 EU Member States. 
It  must  be  noted  that  comparative  country  statistics  about  the  numbers  of  trained, 
employed or active HCAs are hard to extract due to different definitions and classifications, 
and  due  to  incomplete  or  missing  reliable  data  sources  and  registrations.  This  was  clearly 
inventoried  in  the  pilot  study  on  HCAs  (Braeseke  et al.,  2013).  The  figures  found  in  the 
databases  in  this  study  have  therefore  been  compared  to  the  figures  reported  by  the  14 
country  informants  from  the  ‘new’  countries.  The  fact  that  we  were  able  to  combine 
statistics from several sources id not only provide an initial starting point for the mapping 
exercise,  but  also  provided  an  external  reference  point  for  determining the  adequacy  and 
accuracy of the information that was provided by country informants. 

3.1.3 Development of the questionnaires 
The  final  step  of  data  collection  was  through  questionnaire  research  among  country 
representatives. The aim of the survey was twofold: 

1.  To  gain  insights  in  the  role  of  healthcare  assistants  in  14  EU  Member  States  not 

covered by the pilot study; 

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2.  To identify the representative organisations/ competent authorities of HCAs in all 28 

EU Member States. 

Various  sources  were  used  for  the  development  of  the  questionnaire.  In  order  to  achieve 
comparability with the data from the pilot study already collected, the basis for the item list 
was  the  questionnaire  used  in  the  pilot  study.  Replicating  this  questionnaire  for  the  14 
Member States provided a full picture of the EU with regard to these elements of the HCA 
position.  Moreover,  the  questionnaire  was  complemented  with  additional  elements  of 
interest. The aim was to collect more information about (1) the status of HCA registration 
per country, (2) whether this is voluntary rather than obligatory, and (3) the degree to which 
such a registration covers the active HCA workforce in a country. This is of interest as it can 
be  expected  that  voluntary  memberships  or  registration  figures  will  underestimate  the 
actual number of (active) HCAs. Another element added to the item list and data collection 
was the distribution of tasks and skills of HCAs within a country. This addressed the question 
of  whether  all  HCAs  are  trained  for  the  same  tasks  and  skills,  or  whether  these  differ 
between  subsectors  and  types  of  workplaces.  If the  latter  is  the  case, this  is  an  important 
aspect to take into account for the minimum set of knowledge, skills and competences. As 
these items were new in the CC4HCA study, this implies that it is not be possible to compare 
all  EU  countries  on  these  topics.  Because  of  this,  and  due  to  reasons  of  unavailability  of 
information, some of the tables in the next chapter contain empty cells for some countries. 

When making the new questionnaire, the findings from the literature search were used to 
formulate  the  new  items  concerning  the  position  of  HCAs.  Various  draft  versions  of  the 
questionnaire  were  discussed  among  the  study  partners  and  the  questions  were 
reformulated  or  items  added  where  this  was  deemed  necessary.  To  check  whether  the 
questions were comprehensible, the questionnaire was piloted among external experts not 
involved 
in  the  Netherlands  and  Hungary.  Finally,  before  the 
questionnaire was sent out to country experts of the 14 Member States, a draft version was 
sent to the project officers at DG SANTE/CHAFEA, to review its content and applicability. 

in  the  study 

itself, 

The final result was a questionnaire consisting of two parts:  

1.  An extensive questionnaire on the role of HCAs in each country, including questions 
on  definitions  and  job  descriptions  of  HCAs,  education,  regulation  and  registration 
and  employment  and  the  labour  market  (see  Appendix  A).  This  questionnaire  was 
only sent to the 14 Member States that are included in this study.  

2.  A  short  questionnaire  to  identify  the  representative  organisations/competent 
authorities of HCAs in all 28 EU Member States (see Appendix B). This questionnaire 
was  sent  to  e.g. national  contacts, 
including  chief  nursing  officers,  nursing 
associations,  and  university  departments  in  the  field  of  nursing.  Organisations  or 
countries  were  asked  to  indicate  whether  they  would  be  willing  to  sign  either  an 
Expression of Interest or a Letter of Commitment (see Box 3.2). 

27 

 
 
 
 
Box 3.2: Information provided to respondents concerning expressions of interest and letters 
of commitment 

An Expression of Interest implies that you will participate in the next steps of our study 
on behalf of your organisation and country. In practice, you will be invited to take part in 
an online consultation round later in autumn of this year, and a workshop in Brussels in 
the spring of 2016.  

A  Letter  of  Commitment  also  implies  that  you  will  participate  in  the  next  steps  of  our 
study on behalf of your organisation and country. In practice, you will be invited to take 
part  in  an  online  consultation  round  later  in  autumn  of  this  year,  and  a  workshop  in 
Brussels  in  the  spring  of  2016.  Additionally,  by  signing  the  Letter  of  Commitment,  you 
express your country’s commitment to support the development of a common training 
framework  for healthcare  assistants  at the  level of  a  minimum  set  of  knowledge,  skills 
and competences. This commitment and support is acknowledged provisionally and at a 
general  level.  The  content  of  a  potential  common  training  framework  will  be  explored 
and discussed further within this project involving the views of all EU Member States. 

3.1.4 Collecting responses  
Subcontractors  from  all  14  Member  States  served  as  country  informants  for  this  task. 
Appendix C gives an overview of these country informants. Hungary was covered by MESZK 
as member of the study consortium. Each country informant received instruction on how to 
complete the item list. To validate the information, country informants were also invited to 
share their preliminary information with other experts in their professional networks. This 
type of  ‘national  peer  review’  has been  shown to be  very  helpful  in  filling  blind  spots  and 
ensuring that information is cross-referenced. 

While the countries already covered in the pilot study were not formally part of this study, 
we  preferred  to  approach  the  country  informants  who  had  been  responsible  for  the  data 
collection in that pilot study. They were asked by e-mail if they would be willing to update 
the  data  on  their  country,  if  major  changes  had  taken  place  since  2011.  Updates  were 
received from Austria, Ireland, Italy, the Netherlands and Slovenia. 

3.1.5 Mapping exercise 
As  key  element  of  this  report,  the  information  provided  by  all  country  informants  is 
described in Part 2 of this report in order to answer the research questions concerning the 
first two aims of the study. Where possible, data is also presented for the 14 countries that 
were  the  subject  of  investigation  in  the  pilot  study.  This  provides  an  overview  of  the 
situation in all 28 EU Member States. For some topics, only data in the 14 ‘new’ countries 
was collected. Results of the countries are presented in tables, providing an overview of the 
countries. For a number of key topics, the information is aggregated and combined into an 
overall table, in order to allow information to be compared clearly. Finally, an overview is 

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provided  of  the  representative  organisations/competent  authorities 
countries.  

identified 

in  all 

The results from the mapping exercise and the identification of competent authorities in all 
EU Member States fed into the next stage of the CC4HCA study, namely the Delphi study. In 
order  to  conduct  a  high  quality  Delphi  study,  this  process  started  with  an  expert 
consultation among European organisations.   

3.2  Expert  consultation  round  among  European  organisations  on  Delphi 
study 
As a potential CTF for HCAs would become legally binding at the Member State level, it was 
decided  in  consultation  with  the  European  Commission  that  participants  in  the  CC4HCA 
Delphi  study  should  either  be  representatives  of  a  ‘competent  authority’  for  HCAs  at 
Member State level and/or representatives of Ministries of Health and/or representatives of 
national professional organisations. However, considering the important role that European 
organisations  play  in  the  current  landscape  surrounding  HCAs  and  the  knowledge  and 
expertise they have in this area, their insights were deemed highly important to the CC4HCA 
study as well. In September 2015, representatives of European organisations were therefore 
asked to participate in an expert consultation on the development of the Delphi study (see 
also Section 3.3 below).  

The  aim  of  the  expert  consultation  round  was  to  ensure  the  completeness  and 
comprehensibility of the Delphi survey, making sure it contained all relevant and important 
items surrounding a potential CTF for HCAs. Nine European experts in this area were asked 
to review and give advice about the design and contents of the Delphi questionnaire. More 
specifically, we asked them to comment on:  

•  The  completeness  of  the  Delphi, 

identifying  any  relevant  missing 

items  or 

superfluous items; 

•  The appropriateness of the question formats and response options; 

•  The comprehensibility of the Delphi (also where the level of English was concerned) 

We received responses from six of the experts within the set deadline (see Box 3.3). Their 
comments and suggestions were processed in the final version of the Delphi study. 

29 

 
 
 
 
Box 3.3: Participants in the expert consultation round for the CC4HCA Delphi survey 

•  EPSU - European Federation of Public Service Unions 
•  ESNO - European Specialist Nurses Organisations 
•  FEPI - European Council of Nursing Regulators 
•  FINE - European Federation of Nurse Educators 
•  HOSPEEM - European Hospital & Healthcare Employers' Association 
• 

ICN - International Council of Nurses 

3.3 Delphi study among national representatives 
The aim of the Delphi study was to explore (1) to what extent EU Member States are willing 
to  support  a  CTF  proposal  for  HCAs,  and  (2)  to  what  extent  consensus  can  be  reached 
among EU Member States on a minimum set of knowledge, skills and competences that a 
potential  CTF  for  HCAs  should  include.  The  Delphi  study  was  conducted  from  November 
2015 to February 2016 and involved three Delphi rounds.  

3.3.1 Delphi questionnaire development 
In  total,  three  Delphi  rounds  were  conducted.  During  the  first  two  rounds,  similar 
questionnaires  were  used.  During  the  third  round,  a  different  set  of  questions  was 
developed to gain a deeper insight in participants’ viewpoints.   

Round 1 Delphi questionnaire  
As a first step, a questionnaire was developed based on the results of the mapping exercise. 
For each of the 28 EU Member States the relevant items from the mapping exercise were 
listed under either the knowledge, skills or competences category.  

Subsequently,  we  formulated  additional  categories  for  items  that  were  identified  in  the 
mapping  exercise,  but  which  did  not  fall  within  the  three  core  categories.  These  could  be 
relevant and be part of a CTF as well. This resulted in in matrices for each of the countries as 
displayed below: 

Table 3.1: Schematic display of the resulting matrix for one country 

CATEGORIES 

Knowledge 

Skills 

Competences 

EQF definition: the 
outcome of the 
assimilation of 
information through 
learning. Knowledge is 
the body of facts, 
principles, theories and 
practices that is related 
to a field of work or 
study. In the context of 

EQF definition: the ability 
to apply knowledge and 
use know-how to complete 
tasks and solve problems. 
In the context of the EQF, 
skills are described as 
cognitive (involving the 
use of logical, intuitive and 
creative thinking) or 
practical (involving 

EQF definition: the proven 
ability to use knowledge, 
skills and personal, social 
and/or methodological 
abilities, in work or study 
situations and in 
professional and personal 
development. In the 
context of the EQF, 
competence is described in 

Addit. 
cat. 

Addit. 
cat. 

…. 

…. 

30 

 
 
 
EUROPEAN COMMISSION 

CATEGORIES 

Knowledge 

Skills 

Competences 

Addit. 
cat. 

Addit. 
cat. 

the EQF, knowledge is 
described as theoretical 
and/or factual 

manual dexterity and the 
use of methods, materials, 
tools and instruments) 

terms of responsibility and 
autonomy 

Q item 1  

Q item 2  

Q item 3  

Q item 4  

Q item 5  

Q item 6  

Q item 7  

Q item 8  

The items were translated into learning outcomes, which have been defined as ‘a statement 
of what a learner is expected to know, understand, or be able to do at the end of a learning 
process’. Based on these steps, a first-round questionnaire was developed focusing on the 
desired  content  of  a  potential  CTF  according  to  the  national  stakeholders.  The  items 
concerned  the  skills,  knowledge  and  competence  items,  additional  criteria  that  should  be 
part  of  a  CTF  (e.g. minimum  level  of  education)  and  questions  on  the  desired  European 
Qualification  Framework  (EQF)  levels.  The  first  round  of  the  Delphi  study  started  in 
November 2015. The participants had two weeks to complete the questionnaire.   

Round 2 Delphi questionnaire 
The  second  round  of  the  Delphi  study  started  in  December  2015,  again  with  an  official 
runtime of two weeks. In this round, the participants were given a summary report from the 
previous  round  in  which  they  could  compare  their  own  response  to  the  responses  of  the 
other countries (anonymised). They were then asked for each item of the questionnaire of 
round 1 if they wanted to change their answers based on the answers of other countries. 
The second round questionnaire was largely similar to the one used in the first round. Six 
additional  knowledge  and  skills  items  were  added  based  on  suggestions  from  Delphi 
participants in the first round.  

Round 3 Delphi questionnaire 
Compared to the first round, only a few changes were made in respondents’ answers in the 
second  round.  This  indicated  that  the  second  round  did  not  lead  to  further  consensus 
building  among  the  participants.  It  was  therefore  decided  to  issue  a  questionnaire  with 
different  questions  in  the  third  round.  This  questionnaire  was  based  on  the  results  of  the 
first  two  rounds  and  asked  for  clarification  on  a  number  of  findings.  The  third  and  final 
round of the Delphi survey ran from January to February 2016.  

3.3.2 Selection procedure for participants Delphi study 
As a potential CTF for HCAs would become legally binding at the Member State level, it was 
decided  (in  consultation  with  the  European  Commission  and  based  on  Directive 

31 

 
 
 
 
 
 
 
 
 
2013/55/EU) that participants in the CC4HCA Delphi study should either be representatives 
of  a  ‘competent  authority’  for  HCAs  at  Member  State-level  and/or  representatives  of 
Ministries  of  Health  and/or  representatives  of  national  professional  organisations.  The 
scheme below was used to select participants in each EU Member State:  

Is the HCA profession or 
the education and 
training leading to the 
profession regulated in 
the MS?  

Yes 

No 

Invite competent 
authority or national 
professional organisation 

Invite relevant 
stakeholder(s) 

An extensive description of the selection procedure can be found in Appendices D and E.  

3.3.3 Participants in the Delphi study  
High participation rates were obtained for all Delphi rounds, for instance through the use of 
phone and regular e-mail reminders for those who had not yet completed the Delphi study. 
Only two Member States that were invited did not participate in any of the Delphi rounds: 
Austria and Malta. All other MSs have participated in at least one of the three rounds.    

Table 3.2: Participation in the three Delphi rounds 

No. of 
competent 
authorities 
invited 

No. of 
Member 
States 
invited1 
22 
26 
26 

No. of competent 
authorities that 
completed the 
survey 
27 
29  
31 

Round 1  27 
Round 2  33 
Round 3  33 
1  As  some  countries  have  multiple  competent  authorities  for  healthcare  assistants  (HCAs),  the 
number of competent authorities invited is greater than the number of Member States represented. 

100% 
87,9% 
93,3%% 

22 
25 
25 

Response 
rate 

No. of Member 
States 
represented 

The  results  of  the  Delphi  study  are  described  in  Part  III  of  this  report,  ‘Exploration  of  a 
common training framework for HCAs’.  

3.4 CC4HCA study workshops  

3.4.1 Goals of the CC4HCA workshops 
At  the  start  of  the  CC4HCA  study,  one  CC4HCA  workshop  was  envisioned  with  the  aim  of 
discussing the desirability of a potential CTF for HCAs, and its core set of knowledge, skills 

32 

 
 
 
 
 
EUROPEAN COMMISSION 

and competences with all EU Member States. These discussions would start from a national 
point  of  view,  taking  into  account the  current  definition,  position  and  situation  of  HCAs  in 
the different countries.  

The  CC4HCA  workshop  was  organised  on  6-7  April  2016  in  Brussels  (Belgium).  For  this 
workshop,  competent  authorities  from  all  EU  Member  States  and  a  number  of  European 
experts and stakeholder organisations were invited to participate in an open discussion and 
almost  all  agreed  to  come.  However,  due  to  the  tragic  terrorist  attacks  in  Brussels  in 
March 2016  and  the  subsequent  limited  operation  of  Brussels  Airport,  many  flights  were 
cancelled and a significant number those invited were unable to attend. In consultation with 
the  EC,  it  was  decided  to  go  ahead  with  the  workshop  and  organise  an  additional  online 
workshop at a later point in time for those participants who could not come. After all, it is a 
fundamental aim of the CC4HCA study to get a full and complete overview of the position of 
competent authorities of all EU Member States, and of all relevant European stakeholders. 
This online workshop took place on the 10 June 2016. While both workshops had largely the 
same  aim,  structure  and  discussion  questions,  for  the  sake  of  clarity  we  will  discuss  them 
separately in this methodology section.  

3.4.2 Starting point of the Brussels workshop 
To  ‘set  the  scene’  for  the  Brussels  workshop,  the  consortium  prepared  a  list  of  starting 
points  for  the  discussion  that  were  also  shared  with  the  workshop 
invitees  and 
complemented by the Commission's presentation. The starting points read: 
•  The desirability and feasibility of a CTF for HCAs at the European level is explored. Hence, 
during  this  workshop,  no  actual  CTF  will  be  proposed  nor  is  the  actual  decision  to 
propose a CTF for HCAs decided upon or proposed; 

•  A CTF for HCAs at the European level contains several elements (i.e. requirements) that 

participants are invited to discuss; 

•  A  CTF  is  part  of  Directive  2013/55/EU  (amending  Directive  2005/36/EC),  focusing  on 
automatic recognition of the basis of common training principles. This is one of the first 
studies concerning this instrument; 

•  A CTF for HCAs at the European level is legally binding for all EU Member States, but MSs 
can  opt  out  if  this  is  adequately  substantiated;  which  in  any  case  calls  for  a  thorough 
discussion about the advantages and disadvantages of a CTF; 

•  A  CTF  shall  not  replace  national  training  programmes  unless  a  Member  State  decides 

otherwise under national law; 

•  For those not complying with the CTFs, the general system of recognition of professional 

qualifications will continue to apply; 

•  Labour regulations of the host Member State prevail; 
• 

‘HCAs’  is  used  as  an  umbrella  term  throughout  the  CC4HCA  study  as  well  as  in  the 
workshop; it is recognised (and described in the project reports) that there are a large 
variety of professional titles, education and training in the various countries; 

33 

 
•  The aim of the workshop is to discuss a potential CTF for HCAs and its various/potential 
core  competences  from  the  point  of  view  of  national  situations,  in  particular  the 
definition, position and situation of HCAs in the various countries; 

•  All participants are invited to discuss the desirability and feasibility of a CTF for HCAs and 
its requirements, while recognising the standpoints of other EU Member States, as well 
as the stakeholders at the European level. 

3.4.3 Programme and documentation of the Brussels workshop 
Prior  to  the  workshop  and  in  consultation  with  the  EC,  the  consortium  prepared  a 
programme  for  the  workshop.  All  invitees  received  a  discussion  paper  allowing  them  to 
prepare  for  the  various  discussion  rounds,  including  the  programme  of  the  day  (see 
Appendix F).  During  the  workshop,  the  input  from  all  stakeholders  was  documented  by  at 
least  two  members  of  the  research  team  at  the  same  time.  Moreover,  rapporteurs  were 
appointed  for  each    round  two  subgroup  discussion,  responsible  for  documenting  the 
discussions and summarising them. 

3.4.4 Participation in the Brussels workshop  
The Brussels workshop was attended by 15 participants from 14 EU Member States and 6 
participants from 4 European-level organisations (see Table 3.3). 

Table 3.3: Overview of participating organisations in the CC4HCA workshop 6-7 April 

Country 
Austria 
Belgium 

France 
Germany, Lower Saxony 
Greece 
Ireland 

Italy  
Lithuania 
Luxembourg 
Malta 

Netherlands 

Organisation 
Federal Ministry of Health (Bundesministerium für Gesundheit) 
Federal Public Service Health, Food Chain Safety and Environment 
The Directorate-General of Healthcare Provision (DGOS - La direction générale de 
l’offre de soins) 
Ministry of Education and Cultural Affairs in Lower Saxony  
Greek Regulatory Body of Nurses 
Office of Nursing and Midwifery Services Director, Health Service Executive (HSE)  
National Federation of Colleges of Nursing (Ipasvi -Federazione Nazionale Collegi 
Infermieri professionali)  
Lithuanian Nurses Organisation  
Ministry of Health  
Regulation and Standards Directorate 
Cooperation  Organisation  for  Vocational  Education,  Training  and  the  Labour 
Market (SBB) 
National Agency for Qualification and Vocational Education and Training (ANQEP, 
I.P.) 
Kommunal 
Health Education England (HEE) 
ESNO - European Specialist Nurses Organisations 

Portugal 
Sweden 
UK 
European representation 
European representation   HOSPEEM - European Hospital & Healthcare Employers' Association 
European representation 
European representation 

EPSU - European Federation of Public Service Unions 
EFN - European Federation of Nurses Associations 

34 

 
 
 
 
EUROPEAN COMMISSION 

In total 27 people from 18 countries and 6 people from 6 European organisations were not 
able to attend the event.  

3.4.5 Online workshop 
Those invitees who could not attend the Brussels workshop were invited to participate in an 
online workshop. The online workshop was designed in two stages: 
1)  First,  the  invitees  received  a  Summary  Document  (see  Appendix G)  that  informed  them 
about  the  discussion  questions  and  results  of  the  subgroup  discussion  rounds  that  took 
place  during  the  two-day  workshop  in  Brussels.  Participants  were  invited  to  share  the 
document with their colleagues and other stakeholders in their country.  
2) Second, the representatives were invited to participate in an online group workshop. This 
online  teleconference  was  held  in  two  subgroups  of  6  to  7  participants  on  Friday 
10 June 2016. Each participant was assigned to one of the two subgroups and thereby to a 
timeslot in the morning or the afternoon of Friday 10 June.  

Each web group conference took 2.5 hours. With this online workshop, we aimed to consult 
all participants through a group discussion that was as similar as possible to the workshop 
subgroup meetings we held in Brussels in April.  

3.4.6 Programme and documentation of the online workshop 
The programme of the online meeting consisted of three parts: 

1.  A  general  introduction  to  the  CC4HCA  study  by  DG  SANTE  of  the  European 
Commission,  a  presentation  on  the  common  training  framework  by  DG  Internal 
Market, Industry, Entrepreneurship and SMEs (DG Growth) and an overview of the 
CC4HCA  study  design  and  results  so  far.  Slides  were  presented  through  the  web 
application. 

2.  After  the  presentations,  there  was  time  for  questions  and  answers  from  all 

participants. 

3.  All participants were then asked to contribute to a group discussion. All participants 
were  invited  to  express  their  views  and  positions  regarding  two  main  discussion 
questions.  The  two  questions  were  described  in  the  Summary  Document  and  are 
similar  to  those  posed  in  the  Brussels  workshop.  Input  and  comments  were 
documented during the session. The aim was to provide an open atmosphere for all 
participants to express and exchange opinions.. 

During  the  online  workshop,  the  input  from  all  stakeholders  was  documented  by  at  least 
two members of the research team at the same time.  

3.4.7 Participation in the online workshop 
The  web  conference  was  organised  through  a  (simple)  online  system  for  which  each 
participant  received  a  link  and  logon  details.  The  online  workshop  was  attended  by  13 
participants from 13 countries and 2 participants from 2 European level organisations (see 
table 3.4). 

35 

 
 
 
Table 3.4: Overview of participating organisations in the CC4HCA online workshop 10 June 2016 
Country 
Bulgaria 
Croatia 
Czech Republic 
Estonia 

Organisation(s) 
Ministry of Health 
Croatian Nursing Council (Hrvatska komora medicinskih sestara) 
Czech National association of Nurses 
Estonian Nurses Union 
The  Finnish  National  Board  of  Education;  the  Ministry  of  Social  Affairs 
and Health 
Chamber of Hungarian Health Care Professionals (MESZK) 
Ministry of Health, Department of science and higher education 
Romanian Nursing Association (RNA)  
Nurses and Midwives Association of Slovenia  
Faculty of Nursing Jesenice 
Ministry of Health 
Health Education England 
Department of Health Social Services and Public Safety 

Finland 
Hungary 
Poland 
Romania 
Slovenia 
Slovenia 
Spain 
UK, England 
UK, Northern Ireland 
European representation  FEPI - European Council of Nursing Regulators 
European representation  EPSU - European Federation of Public Service Unions 

3.5 Preparation of the final report 
After  the  workshop  and  web  conference,  the  study  consortium  processed  the  outcomes 
from all steps into this final report. In order to produce a report that accurately reflects the 
outcomes  of  the  study,  we  invited  the  Member  States  and  European  organisations  that 
participated in the workshops to provide comments on a draft version of the report. They 
were  invited  to  check  whether  the  facts  were  correct  and  whether  the  findings  and 
conclusions  reported  reflected  the  discussions  and  conclusions  during  the  workshops.  For 
this  consultation,  representatives  from  24  Member  States  and  5  European  organisations 
were invited. We received responses from 16 Member States 4 European organisations. The 
feedback was taken on board in this final version of the report. 

36 

 
 
 
 
 
 
EUROPEAN COMMISSION 

Part II: 

The role, knowledge, skills and competences of HCAs in 
the EU Member States 

37 

 
 
 
 
 
 
 
 
4 

Healthcare assistants: definitions, job descriptions and statistics 

In this chapter we describe the position of HCAs in all 28 EU Member States in terms of the 
following aspects: 

•  definition and occupational title 
•  number registered and employed 
•  age, gender, employment/unemployment rate, annual wages 
•  cross-border mobility 
•  areas of employment 

Various  data  sources  have  been  used  for  this  and  the  subsequent  chapters.  The  primary 
sources are the data collected by the CC4HCA study on 14 EU Member States and the data 
that  were  previously  collected  by  the  Contec  pilot  study  on  the  14  other  Member  States, 
which was updated, extended and complemented by the CC4HCA study where possible. In 
addition, other internationally acknowledged data sources were used. 

4.1 Definitions and occupational titles 

4.1.1 Internationally applied definitions and classifications of HCAs 
The  definitions  and  classifications  of  healthcare  assistants  that  are  commonly  used 
internationally are based on the International Standard Classification of Occupations (ISCO, 
2008 revision), a system for classifying and aggregating occupational information obtained 
by  means  of  population  censuses,  (labour)  statistical  surveys,  as  well  as  administrative 
records.  The  three  ISCO  codes  presented  in  Table  4.1  correspond  the  profession  of 
healthcare  assistants  (code  5321  and  5322),  or  are  closely  related  to  the  HCA  profession 
(code 3221).  

Table 4.1: ISCO-08 codes with relevance to the HCA profession  
ISCO 
code 
ISCO-codes corresponding with the profession of healthcare assistants 
5321  Health care 

Occupation 
group 

Definition 

assistants 

5322  Home-based 
personal care 
workers 

Health care assistants provide direct personal care 
and assistance with activities of daily living to 
patients and residents in a variety of health care 
settings such as hospitals, clinics and residential 
nursing care facilities. They generally work in 
implementation of established care plans and 
practices, and under the direct supervision of 
medical, nursing or other health professionals or 
associate professionals 
Home-based personal care workers provide 
routine personal care and assistance with activities 
of daily living to persons who are in need of such 
care due to effects of ageing, illness, injury, or 
other physical or mental conditions, in private 
homes and other independent residential settings 

Examples of 
occupations  

▪ Birth assistant (clinic 
or hospital) 
▪ Nursing aide (clinic 
or hospital) 
▪ Patient care 
assistant 
▪ Psychiatric aid 

▪ Home birth 
assistant 
▪ Home care aide 
▪ Nursing aide (home) 
▪ Personal care 
provider 

38 

 
 
 
EUROPEAN COMMISSION 

Definition 

Occupation 
group 

ISCO 
code 
ISCO-codes closely related to profession of healthcare assistants 
3221  Nursing 

associate 
professionals 

Nursing associate professionals provide basic 
nursing and personal care for people in need of 
such care due to effects of ageing, illness, injury, or 
other physical or mental impairment. They 
generally work under the supervision of, and in 
support of, implementation of health care, 
treatment and referrals plans established by 
medical, nursing and other health professionals 

Examples of 
occupations  

▪ Assistant nurse 
▪ Associate 
professional nurse  
▪ Enrolled nurse 
▪ Practical nurse 

of 

the 

profession 

healthcare 

corresponding  with 

ISCO-codes 
assistants 
When reporting on HCAs, the main international statistical organisations combine ISCO-08 
codes 5321 and 5322 as can been seen in the ‘Joint Questionnaire on Non-Monetary Health 
Care  Statistics’  (OCED/Eurostat/WHO).  This  questionnaire  combines  codes  5321  and  5322 
and does not collect separate data for the separate codes. The main argument behind this is 
that home-based personal care workers (5322), according to the ISCO definition, are doing 
essentially the same things as health care assistants (5321), with the main difference being 
they  are  providing  their  services  in  the  home  of  patients  rather  than  in  institutions.  Both 
ISCO codes are combined in the Joint Questionnaire and are used to measure the following 
two variables: 

•  The  number  of  ‘Practising  caring  personnel  (personal  care  workers)’,  that  includes 
both health care assistants in institutions (ISCO-08 5321) and home-based personal 
care workers (ISCO-08 5322) providing services for patients, and 

•  The number of ‘Professionally active caring personnel (personal care workers)’, that 
includes  professionally  active  caring  personnel  include  practising  caring  personnel 
and  other  caring  personnel  for  whom  their  education  is  a  prerequisite  for  the 
execution of the job (covering ISCO-08 codes 5321 and 5322). 

ISCO-codes related to the profession of healthcare assistants 
As  stated  before,  this  study  built  upon  the  results  of  the  Contec  study  conducted  in 
2011/2012.  In  the  Contec  study,  healthcare  assistants  were  defined  by  the  ISCO-08  codes 
5321 (healthcare assistants) and 3221 (nursing associate professionals), but not by the ISCO-
08  code  5322  (home-based  personal  care  workers).  Compared  to  the  current  state  of 
international data (collection), ISCO-08 code 3221 is not part of the profession of healthcare 
assistants  but  –  as  shown  by  Tabel  4.1  –  it  is  closely  related  to  the  HCA  profession. 
Therefore, and to maintain comparability with the data from the 14 Member States covered 
by  the  Contec  study,  we  decided  to  similarly  use  ISCO-08  code  3221  and  5321  to  define 
HCAs in the 14 Member States covered by this study.  

39 

 
 
4.1.2 Occupational titles of HCAs as reported by country informants 
Table  4.2  provides  an  overview  of  the  occupational  titles  belonging  to  HCAs  as  identified 
through country informants in all 28 EU Member States. The first half of Table 4.2 is based 
on the information collected through CC4HCA country experts, the second half is based on 
information collected through the Contec study. We asked the country informants of the 14 
Member States covered in our study to describe the “(…) appropriate occupational name or 
title for HCAs” in their national language. In order to maintain comparability with the Contec 
study, the ISCO-08 code 5321 and 3221 were presented to the informants as a starting point 
(see Appendix A). Given this, the country experts were requested to describe in free format 
the  occupational  titles  for  healthcare  assistants  in  their  country  and  language.  All 
information sources provided by the informants that support the occupational title and job 
description of HCAs within the Member States can be found in Appendix J. 

Table 4.2 shows that the occupational title and terminology for HCAs – as translated from 
the  national  languages  back  into  English  by  the  study  consortium  –  differs  considerably 
between  Member  States.  In  some  countries,  HCAs  appear  to  be  broader  or  at  least  more 
extensively  described  than  in  others  (e.g. ward  or  dentists  assistants  in  Cyprus,  versus  a 
range of titles in Malta). In a number of countries, e.g. Greece and Latvia, the term explicitly 
refers to HCAs being assistants to nurses. In other countries, this is left unspecified, implying 
that  HCAs  can  also  work  under  supervision  of  e.g. GPs  or  other  doctors.  For  Germany,  it 
should  be  noted  that  the  information  provided  in  Table  4.2  concerns  only  the  HCA  in  the 
federal state of Lower Saxony. The occupation of the HCA in Germany varies at the federal 
include  Krankenpflegehelfer  / 
state  (Bundesland) 
Krankenpflegehelferin 
/ 
Altenpflegehelferin (certified assistant in elderly care). 

in  other  states 
assistant) 

level.  Job  titles 
(certified 

Altenpflegehelfer 

nursing 

and 

Table 4.2: Occupational titles of HCAs in national language and English (back)translation in 
28 MSs, provided by CC4HCA country informants in 2015 and Contec country informants in 
2011/2012 

Occupational title 

English (back)translation 

Member States consulted by CC4HCA country informants in 2015 
Croatia a 
Cyprus 

Medicinska sestra; medicinski tehničar 
Bοηθός Θαλάμου; Βοηθός Οδοντιατρείου 

Estonia 

France 

Isikuhooldustöötajad; Hooldustöötajad 
tervishoius;Hooldajad tervishoiuasutustes 
Aide soignante hospitalière; aide à domicile 

Greece 
Hungary 

βοηθοί νοσηλευτών or νοσοκόμοι 
Ápolási asszisztens 

Latvia 
Lithuania 
Luxembourg  Aide-soignant 

Māsas palīgs 
Slaugytojo padėjėjas 

Nurse; nurse technician 
Ward assistants dentist 
assistant 
Care worker, healthcare 
assistant 
Hospital and home 
healthcare assistant  
Nurse’s assistants 
Nursing associate 
professional 
Assistant of nurse 
Nurse assistant 
Care assistant 

40 

 
 
 
 
 
EUROPEAN COMMISSION 

Malta 

Portugal 
Romania 
Slovakia 
Sweden 

Occupational title 
Nursing Aides, Health Assistants, Paramedic Aides, 
Carers, Assistant Carers, Care Workers, Assistant Care 
Workers, Care and Support Workers, Social Assistants 
Técnico Auxiliar de Saúde 
Infirmiera 
Zdravotnícky asistent 
Undersköterska, vårdbiträden 

Member States consulted in the Contec pilot study in 2011/2012 
Austria  

Pflegehelfer; Heimhelfer 

Belgium  
Bulgaria  
Czech 
Republic  
Denmark  

Finlandc  
Germany 
(Lower 
Saxony) 
Ireland  
Italy  

Aide Soignante, Zorgkundige, Pflegehelfe a 
Sanitaries 
Not reported 

Social- og sundhedsassisten  

Lähihoitaja 
Staatlich geprüfter Pflegeassistent 

Health care Assistant  
OSS – Operatore Socio-sanitario 

Netherlands  Verzorgende IG, Helpende zorg en welzijn, Zorghulp 

Poland  
Sloveniab, d     Not reported 

Opiekun medyczny 

English (back)translation 
Ibid 

Technical Health Assistant 
Healthcare assistants 
Healthcare assistants 
Assistant nurse, nursing 
assistant 

Care assistant, home 
helper  
Healthcare assistant 
Health Assistants  
Medical Assistants  

Social/ Healthcare 
Assistant  
Practical nurse 
Certified Care Assistant  

Ibid  
Auxiliary Staff, Social and 
Health Auxiliary Workers  
Individual healthcare 
carers, health and welfare 
assistants,  care assistant  
Medical Carer 
Nurse assistant, healthcare 
technician, practical nurse 
Nursing assistants 

Spain  

UKb, e 

Técnico en cuidados auxiliares de enfermería 

Healthcare Assistants, Health Care Support Workers, 
Nursing Assistants, Nursing Auxiliaries, Clinical Support 
Workers 

Ibid- 

a  The  Crotian  Ministry  of  Health  states  that  ‘caregiver’  is  close  to  healthcare  assistants,  in  Croatian  translated 
„njegovatelj/njegovateljica“, who are employed in the social welfare system for homes of elderly people and persons with 
disabilities.  In  addition,  ‘ordely’  („bolničar/bolničarka“)  are  close  to  healthcare  assistants,  who  perform  tasks  in  the 
hospitals.  Both  occupations  are  not  health  professions  however,  and  not  regulated.  It  should  finally  be  noted  that 
‘healthcare assistants’ as such currently do not exist in Croatia, but the MoH is considering introducing them in the health 
system as ‘assistant profession to nurses’. 
b Updated after the Contec pilot study. 
c This is how the HCA was defined in the pilot Contec study. Updated information after the pilot study showed that the HCA 
in  Finland  can  be  defined  as  “hoiva-avustaja”  (Care  Assistant).  The  care  assistant  only  follows  a  part  of  practical  nurse 
training. 
d Slovenia started with reform of education on secondary level in 2014. Competences of the Practical Nurse will be reduced 
and the title will be changed. The new title proposed by the National Council for Nursing is Healthcare Assistant (HCA).  
e In the United Kingdom, the Healthcare Assistants form the occupational group in focus of this project because they work 
under  the  supervision  of  RNs  as  indicated  in  the  definition  of  the  target  group.  In  terms  of  working  tasks  performed, 
Assistant Practitioners (who are a level above the HCAs) are also relevant and comparable to examples given from other 
countries. Assistant practitioners work with greater independence and may in some cases even supervise HCAs. 

41 

 
 
 
The  Contec  study  and  our  consultation  of  the  country  informants  provided  information 
about protection of the occupational title of HCAs as well. From Table 4.3 it can be seen that 
country informants in 11 of the 28 EU Member States reported that the professional names 
of HCAs are protected. For a total of 10 out of 28 Member States, it is unknown whether the 
job  title  is  protected  (i.e.  this  was  not  reported  by  country  informants)  while  7  Member 
States do not protect the occupational titles of HCAs.  

Not protected 
•  Estonia 
•  Germany (Lower Saxony) 
• 
Ireland 
•  Malta 
•  Portugal 
•  Romania 
•  Sweden 

Table  4.3:  Title  protection  of  HCAs  in  28  MSs,  as  (not)  reported  by  CC4HCA  informants  in 
2015 and Contec country informants in 2011/2012 
Protected 
•  Croatiaa  
•  Cyprus 
•  Finland 
•  France 
•  Greece 
•  Hungary 
• 
Italy 
• 
Lithuania 
• 
Luxembourg 
•  Netherlands 
•  Slovakia 
a  Applies  to  ‘Medicinska  sestra;  medicinski  tehničar’.  The  Crotian  Ministry  of  Health  states  that  ‘caregiver’  is  close  to 
healthcare assistants, in Croatian translated „njegovatelj/njegovateljica“, who are employed in the social welfare system 
for  homes  of  elderly  people  and  persons  with  disabilities.  In  addition,  ‘ordely’  („bolničar/bolničarka“)  are  close  to 
healthcare assistants, who perform tasks in the hospitals. Both occupations are not health professions however, and not 
regulated. It should finally be noted that ‘healthcare assistants’ as such currently do not exist in  Croatia, but the MoH is 
considering introducing them in the health system as ‘assistant profession to nurses’. 

Not reported 
•  Austria 
•  Belgium 
•  Bulgaria 
•  Czech Republic 
•  Denmark 
• 
Latvia 
•  Poland 
•  Slovenia 
•  Spain 
•  United Kingdom 

4.2 Statistical information on HCAs 

4.2.1 Numbers of HCAs 
To describe the number of HCAs in all 28 MSs, we start by presenting the statistics of the 
international  statistical  reporting  bodies  and  offices.  As  explained  in  paragraph  4.1.1,  the 
OECD/Eurostat/WHO 
‘Joint  Questionnaire  on  Non-Monetary  Health  Care  Statistics’ 
combines ISCO-08 codes 5321 (healthcare assistants) and 5322 (home-based personal care 
workers) to measure two variables:  

•  The number of ‘Practising caring personnel (personal care workers)’, and  
•  The number of ‘Professionally active caring personnel (personal care workers)’. 

Table 4.4 shows the most recent OECD/Eurostat statistics on practising caring personnel and 
professionally active caring personnel. It shows that the variation between countries for the 
two  variables  is  very  large.  For  example,  Austria,  Croatia,  Bulgaria  and  Greece  have  fewer 
than 60 practising caring professionals per 100,000 inhabitants, while the Netherlands and 
Finland have 1,441 resp. 2,063  practising caring professionals per 100,000 inhabitants.  

42 

 
 
 
 
 
 
 
 
 
EUROPEAN COMMISSION 

For reasons of comparison with the Contec pilot study, we also included a third column in 
Table  4.4  with  the  numbers  of  practising  nursing  associate  professionals  (ISCO  3221). 
Looking at the statistics for this professional category, we note that the variation between 
countries  in  terms  of  number  of  practising  nursing  associate  professionals  per  100,000 
inhabitants  is  considerable  (e.g.  16  in  Cyprus  and  667  in  Denmark)  –  but  still  smaller 
compared to the cross-national variation for the two caring personnel variables.  

Table  4.4:  Statistics  on  practising  caring  personnel,  professionally  active  caring  personnel 
and practising nursing associate professionals, in numbers and per 100,000 inhabitants 

Practising caring personnel  
(ISCO-08 5321 and ISCO-08 
5322)1 

Professionally active caring 
personnel  
(ISCO-08 5321 and ISCO-08 
5322)2 

Practising nursing 
associate professionals 
(ISCO-08 3221)1 

No. 

No. 

Country 

No. 

No. per 
100,000  
inhabitants 
. 
1,014 
. 
. 
. 
. 
962 
. 
2,611 
609 
. 
. 
. 
. 
. 
. 
. 
616 
. 
. 
. 
. 
. 

No. per 
100,000  
inhabitants 
53 
. 
2 
11 
. 
238 
. 
272 
2,063 
: 
. 
59 
278 
505 
. 
105 
239 
591 
708 
1,441 
. 
270 
305 
91 
193 
918 
. 
1,046 

4,561 
. 
139 
455 
. 
25,048 
51,663 
3,569 
111,704 
. 
. 
6,389 
27,457 
23,938 
. 
2,102 
7,015 
3,415 
3,058 
243,000 
. 
28,103 
60,647 
4,935 
3,976 
426,533 
. 
675,532 

Austria  
Belgium 
Bulgaria 
Croatia 
Cyprus 
Czech Republic 
Denmark  
Estonia 
Finland 
France 
Germany 
Greece 
Hungary 
Ireland  
Italy 
Latvia 
Lithuania 
Luxembourg 
Malta 
Netherlands 
Poland 
Portugal 
Romania 
Slovakia 
Slovenia 
Spain 
Sweden 
UK 
1 Source: Eurostat (online data code: hlth_rs_prsns); 2 Source: OECD.Stat (code: Professionally active caring 
personnel), data retrieved on 24 October 2016 for the most recent years available (2010-2015); . = Data not 
available. 

10,312 
. 
0 
19,473 
140 
. 
37,442 
0 
24,673 
. 
164,000 
15,398 
14,685 
. 
. 
0 
0 
0 
0 
. 
0 
. 
111,599 
. 
12,628 
0 
. 
94,926 

. 
114,209 
. 
. 
. 
. 
54,041 
. 
141,346 
403,856 
. 
. 
. 
. 
625,464 
2,102 
. 
3,468 
. 
. 
. 
. 
. 
8,894 
4,016 
432,233 
. 
. 

No. per 
100,000  
inhabitants 
121 
. 
0 
460 
16 
. 
667 
0 
456 
. 
203 
141 
149 
. 
. 
0 
0 
0 
0 
. 
0 
. 
561 
. 
612 
0 
. 
152 

. 
. 

43 

 
 
 
 
 
 
We close this section by comparing the total number of employed HCAs as reported by our 
country  informants  with  the  number  of  (1)  practising  caring  personnel,  (2)  professionally 
active  caring  personnel  and  (3)  practising  nursing  associate  professionals  as  provided 
OECD/Eurostat and collected by their Joint Questionnaire. Table 4.5 presents the results of 
this comparison, that can be made for 9 Member States. Great caution is needed, however, 
in interpreting these numbers. The numbers in Table 4.4 (copied in the last three columns in 
Table  4.5  for  the  9  Member  States)  concern  the  number  of  practising  caring  personnel, 
professionally  active  caring  personnel  and  practising  nursing  associate  professionals  as 
provided by the statistical offices and agencies of the Member States. The numbers in the 
first column of Table 4.5 are reported by our country informants.  

Table 4.5: Comparison number of HCAs as reported by country informants and classified as 
practising  caring  personnel,  professionally  active  caring  personnel  and  practising  nursing 
associate professionals 
Country 

No. of HCAs as 
reported by 
country 
informants 

No. of 
professionally 
active caring 
personnel 
(ISCO-08 5321 and 
ISCO-08 5322)2 

No. of practising 
nursing associate 
professionals (ISCO-08 
3221)1 

23,000a 
376 
3,465 
14,617 
3,300 
918 
26,040 
60,130 
2,352 

19,473 
Croatia 
140 
Cyprus 
. 
Estonia 
15,398 
Greece 
. 
Luxembourg 
. 
Malta 
. 
Portugal 
111,599 
Romania 
Slovakia 
. 
1  Source:  Eurostat  (online  data  code:  hlth_rs_prsns);  2  Source:  OECD.Stat  (code:  Professionally  active  caring  personnel), 
data  retrieved  on  24  October  2016  for  the  most  recent  years  available  (2010-2015);  .  =  Data  not  available. 
a  Applies  to  ‘Medicinska  sestra;  medicinski  tehničar’.  The  Crotian  Ministry  of  Health  states  that  ‘caregiver’  is  close  to 
healthcare assistants, in Croatian translated „njegovatelj/njegovateljica“, who are employed in the social welfare system 
for  homes  of  elderly  people  and  persons  with  disabilities.  In  addition,  ‘ordely’  („bolničar/bolničarka“)  are  close  to 
healthcare assistants, who perform tasks in the hospitals. Both occupations are not health professions however, and not 
regulated. It should finally be noted that ‘healthcare assistants’ as such currently do not exist in  Croatia, but the MoH is 
considering introducing them in the health system as ‘assistant profession to nurses’. 

. 
. 
. 
. 
3,468 
. 
. 
. 
8,894 

No. of 
practising 
caring 
personnel 
(ISCO-08 5321 
and ISCO-08 
5322)1 
455 
. 
. 
6,389 
3,415 
3,058 
28,103 
60,647 
4,935 

For some countries, the numbers as reported by country informants are quite close to the 
numbers of caring personnel or practising nursing associate professionals as reported in the 
Eurostat and OECD database. But for Member States such as Cyprus, Malta and Slovakia the 
differences are considerable, which might be a result of other definitions and classifictions 
applied  for  HCAs  by  the  country  informants.  This  demonstrates  the  strong  influence  of 

44 

 
 
 
EUROPEAN COMMISSION 

definition and sources on this type of statistics, and the importance of obtaining agreement 
on them, within and between countries. 

4.2.2 Additional information provided by country informants 
We  asked  our  country  informants  to  provide  a  number  of  additional  statistics  on  HCAs  as 
well,  but  the  data  which  we  received  was  often  incomplete  and  not  all  countries  could 
provide this information. The annual wages of HCAs (either as a range or an average) and 
unemployment rates of HCAs could not be provided by all country informants, as Table 4.6 
shows. The numbers presented in the table show a large variation between countries, but 
this should be interpreted with caution. Numbers are presented in absolute terms and not 
corrected for e.g. size of the population (as in the Eurostat/OECD statistics in Table 4.4) or 
gross national income (in relation to their annual wage). 

Unemployment rate 
6% 
. 
. 
. 
82% 
approx. 10% 
. 
. 
. 
. 
. 
. 
. 
. 

Table  4.6:  Unemployment  rates  and  annual  wages  of  HCAs  as  reported  by  country 
informants 
Country 
Croatia a 
Cyprus 
Estonia 
France 
Greece 
Hungary 
Latvia 
Lithuania 
Luxembourg 
Malta 
Portugal 
Romania 
Slovakia 
Sweden 
.= Data not available 
a  Applies  to  ‘Medicinska  sestra;  medicinski  tehničar’.  The  Crotian  Ministry  of  Health  states  that  ‘caregiver’  is  close  to 
healthcare assistants, in Croatian translated „njegovatelj/njegovateljica“, who are employed in the social welfare system 
for  homes  of  elderly  people  and  persons  with  disabilities.  In  addition,  ‘ordely’  („bolničar/bolničarka“)  are  close  to 
healthcare assistants, who perform tasks in the hospitals. Both occupations are not health professions however, and not 
regulated. It should finally be noted that ‘healthcare assistants’ as such currently do not exist in  Croatia, but the MoH is 
considering introducing them in the health system as ‘assistant profession to nurses’. 

Annual wage 
EUR 12,000-24,000 
EUR 8,172 -8,820 
EUR 5,592 
EUR 16,920 
EUR 6,600 – 12,000 
EUR 4,080 – 7,200 
. 
. 
EUR 33,156 – 57,000 
EUR 8,000 -13,000 
. 
EUR 2,400 -2,600 
. 
EUR 22,832 -32,600 

Table  4.6  shows  that  the  unemployment  rate  was  reported  or  estimated  for  only  three 
Member  States.  The  annual  wage  is  reported  for  more  countries,  showing  (again) 
considerable  differences  between  e.g. Sweden  (over  22,000  euros)  and  Romania  (about 
2,500 euros). 

Additional  statistical  information  collected  through  the  country  informants  (not presented 
in Table 4.6) concerns a small number of countries. For example, the average age of HCAs is 
known for three countries: in Croatia it is 42, in Cyprus 50 and in Estonia it is situated in the 
age  category  50-59.  The  three  countries  that were  able  to  provide  information  on  gender 

45 

 
 
 
distribution  also  indicate  that  the  profession  is  strongly  female-dominated;  in  Croatia  the 
proportion of women working as HCAs is 95%, in Cyprus it is 90% and in Estonia 95%. This is 
most  likely  also  the  case  in  other  countries.  A  final  statistic,  which  is  only  known  for  two 
countries, is the number of graduates per year: in Croatia it is 1,200 and in Slovakia 1,250. 

4.2.3 Mobility of HCAs, indicated by mobility statistics on ‘second-level nurses’ in the EU 
Market Regulated Professions Database 
One  driver  of  a  potential  common  training  framework  (CTF)  for  HCAs  is  that  EU  Member 
States can collaborate on the training, recruitment and the mobility of HCAs. Indicators for 
the mobility of HCAs are not available from the Eurostat/OECD statistics, nor could these be 
retrieved through our country informants in a comparable and reliable manner.  

As  an  alternative,  figures  from  the  EU  Single  Market  Regulated  Professions  Database, 
governed  by  DG Growth,  can  be  used.  In  this  database,  healthcare  assistants  are  not 
included under the title ‘healthcare assistants’. The profession that partly corresponds with 
the  occupational  title  and  definition  of  healthcare  assistants  is  the  ‘second-level  nurse’. 
‘Second-level  nurses’  as  defined  in  the  EU  Single  Market  regulated  professions  database 
under  Directive  2005/36/EC  are  part  of  the  general  system  of  recognition  (primary 
application). 

To demonstrate the correspondence between HCAs and ‘second-level nurses’, a specific job 
title  or  category  in  the  EU  database,  Table 4.7  provides  a  comparison  between  the 
translations  of  ‘second-level  nurse’  according  to  the  regulated  professions  database  and 
‘healthcare assistants’ for the CC4HCA database in the countries for which data is available. 
As  can  be  seen,  the  professional  titles  are  identical  for  8  of  the  16  countries  (indicated  in 
green).  Slight  deviations  are  found  for  5  countries:  for  Austria  and  the  Netherlands,  the 
definition in the CC4HCA study is broader, while for Finland, Germany (Lower Saxony) and 
Slovakia,  the  definition  in  the  Regulated  Professions  Database  is  broader  (indicated  in 
yellow).  For  the  remaining  three  countries  it  could  not  be  decided  if  the  definitions  are 
comparable. 

Table  4.7:  Comparison  between  translations  of  ‘second-level  nurse’  (regulated  professions 
database) and ‘healthcare assistant’ (CC4HCA study) 
Translation of 'second-level nurse' 
(regulated professions database) 

Translation of 'healthcare assistant' in the 
CC4HCA study 

Austria 

Belgium 

Pflegehelferin / Pflegehelfer 

Pflegehelfer; Heimhelfer 

Aide-soignant, 

Aide-Soignant, Zorgkundige, Pflegehelfer 

Czech Republic 

Ošetřovatel; Sanitář; Zdravotnický asistent 

Medical Assistants 

Denmark 

Finland 

Social- og sundhedsassistent 

Social- og sundhedsassisten  

Lähihoitaja/ Närvårdarea 

Lähihoitaja 

46 

 
 
 
 
 
 
 
EUROPEAN COMMISSION 

France 

Aide soignant 

Aide soignant 

Kranken-pflegerhelfer/in; Rettungsassistent 

Staatlich geprüfter Pflegeassistent 

Germany 
(Lower Saxony) 
Greece 

Italy 

Latvia 

Assistant nurse 

Assistente sanitaria 

Māsas palīgs 

Luxembourg 

Aide soignant 

Malta 

Registered nurse (second level); State 
enrolled nurse 

Nurse’s assistants 

OSS – Operatore Socio-sanitario 

Māsas palīgs 

Aide soignant 

Nursing Aides, Health Assistants, Paramedic 
Aides, Carers, Assistant Carers, Care Workers, 
Assistant Care Workers, Care and Support 
Workers, Social Assistants 
Verzorgende IG, Helpende zorg en welzijn, 
Zorghulp 
Zdravotnícky asistent 

Netherlands 

Slovakia 

Spain 

Verzorgende individuele gezondheidszorg 
(formerly ziekenverzorgende) 
Sanitár; Zdravotnícky asistent 

Auxiliar de enfermería 

Técnico en cuidados auxiliares de enfermería 

United Kingdom  Nurse Admitted to Sub-Part 2 of the Register 

maintained by the Nursing & Midwifery 
Council 

Healthcare Assistants, Health Care Support 
Workers, Nursing Assistants, Nursing 
Auxiliaries, Clinical Support Workers 

Green: Same definition; yellow: (slight) deviations; white: unknown 
 a Updated information after the Contec pilot study: hoiva-avustaja  
Taking these similarities and differences into account, the numbers on mobility as provided 
in the Regulated Professions Database can be used as an indicator for the mobility of HCAs 
for the majority of countries. 

The  first  number  that  can  be  shown  is  the  number  of  second-level  nurses  who  were 
permanently established in another EU Member State between 2005 and 2014. Figure 4.1 
shows that this number fluctuated between 7 in 2005/2006 to 479 in 2011. There is no clear 
trend of increase or decrease of mobility visible for this professional group.  

Figure 4.1: Number of second-level nurses from EU Member States who were  permanently 
established in another MS between 2005 and 20143 

3 Source: http://ec.europa.eu/growth/tools-databases/regprof/index.cfm. 

47 

 
 
                                                 
500

450

400

350

300

250

200

150

100

50

0

2005/6

2007

2008

2009

2010

2011

2012

2013

2014

Next,  Table 4.8  and  figures  4.2  and  4.3  show  the  countries  where  the  second-level  nurses 
obtained their qualifications between 2005/6 and 2013/2014. The highest absolute number 
of  second-level  nurses  settling  in  other  countries  comes  from  Germany  (1,022  nurses), 
Belgium  (974  nurses)  and  France  (778  nurses).  The  German  second-level  nurses  mostly 
settled in Austria, Luxembourg and Denmark. Almost all second-level nurses from Belgium 
who  emigrated  settled  in  France  and  a  large  proportion  of  French  second-level  nurses 
settled  in  Belgium  or  Luxembourg.  Countries  which  serve  the  most  as  host  countries  are 
Austria (1,516 nurses), France (1,431) and Belgium (1,074). The fact that Austria, Germany, 
France  and  Belgium  share  common  languages  is  a  possible  explanation  for  the  higher 
mobility numbers between these four countries.  

Table 4.8: Permanent settlement of second-level nurses in 26 EU Member States in 2005-13, 
sorted by number of number of nurses from the country of origin 4 
Recognition in host country: 

Qualification 
obtained in: 

Germany  
France  
Sweden 
Slovakia 
Slovenia 
Romania 

a
i
r
t
s
u
A

365 
1 
5 
331 
423 
92 

i

m
u
g
e
B

l

61 
523 
7 
0 
1 
77 

h
c
e
z
C

c
i
l

b
u
p
e
R

1 
0 
0 
88 
0 
0 

k
r
a
m
n
e
D

129 
0 
648 
1 
0 
5 

e
c
n
a
r
F

13 
0 
6 
0 
0 
81 

y
n
a
m
r
e
G

0 
12 
7 
10 
2 
41 

e
c
e
e
r
G

21 
0 
2 
0 
0 
1 

g
r
u
o
b
m
e
x
u
L

414 
241 
0 
0 
0 
1 

a
i
k
a
v
o
S

l

0 
0 
0 
0 
0 
0 

a
t
l
a
M

0 
1 
1 
0 
0 
2 

l

a
t
o
T

1,022 
778 
682 
430 
426 
306 

K
U

18 
0 
6 
0 
0 
6 

4 Source: http://ec.europa.eu/growth/tools-databases/regprof/index.cfm > Second level nurses > 
Establishment > Geography of mobility > 2005-2013 > In all EU Countries, retrieved 2015 

48 

 
 
 
 
 
                                                 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMISSION 

Netherlands 
Poland 
Italy  
Spain 
Hungary  
Bulgaria 
Czech  
Republic  
Finland  
Greece 
UK 
Portugal 
Austria  
Lithuania  
Latvia  
Denmark  
Ireland  
Luxembourg 
Cyprus  
Estonia 
Malta 
Total 

3 
100 
11 
3 
106 
19 
48 

0 
4 
1 
0 
0 
2 
0 
0 
0 
0 
0 
0 
0 
1,516 

251 
43 
43 
32 
3 
9 
1 

3 
1 
7 
8 
1 
1 
0 
0 
1 
1 
0 
0 
0 
1,074 

0 
0 
0 
0 
0 
0 
0 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
89 

13 
14 
1 
0 
4 
0 
1 

10 
24 
122 
117 
3 
5 
6 

2 
67 
7 
13 
42 
6 
8 

6 
0 
3 
0 
0 
9 
6 
0 
0 
0 
0 
0 
0 

2 
1 
31 
30 
5 
2 
0 
4 
2 
1 
2 
0 
0 
840  1431  288 

0 
31 
3 
0 
21 
5 
3 
4 
0 
3 
0 
1 
0 

0 
0 
0 
0 
0 
1 
1 

1 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
27 

1 
2 
0 
0 
1 
0 
1 

0 
0 
0 
0 
2 
0 
0 
0 
1 
0 
0 
0 
0 
671 

0 
1 
1 
0 
1 
13 
2 

0 
0 
5 
0 
1 
2 
3 
0 
1 
0 
0 
0 
0 
35 

0 
1 
0 
0 
0 
0 
2 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
3 

3 
0 
0 
7 
1 
36 
1 

48 
17 
0 
0 
0 
2 
2 
0 
0 
0 
0 
1 
2 
150 

283 
252 
185 
172 
161 
89 
71 

60 
54 
50 
38 
30 
23 
14 
8 
5 
5 
2 
2 
2 
6,124 

Figure  4.2:  Country  of  qualification  of  permanently  settled  second-level  nurses  in  25  EU 
Member States, 2005-145 

5 Source: http://ec.europa.eu/growth/tools-databases/regprof/index.cfm > Second level nurses > 
Establishment > Geography of mobility > 2005-2013 > In all EU Countries, retrieved 2015. 

49 

 
  
 
 
 
 
 
 
 
 
 
 
                                                 
Figure 4.3: Host countries of HCAs permanently settled in other countries 2005-2014  

Another indicator providing insight into the mobility of second-level nurses in the EU Market 
Regulated  Professions  Database  is  the  number  of  decisions  taken  on  recognition  of 
professional qualifications for the purpose of permanent settlement within the EU Member 
States. These decisions are taken by host countries on professionals qualified in one country 
who  apply  for  recognition  in  another  country  to  practice  there  on  a  permanent  basis. 
Limited to intra-EU mobility in the period 2005-2015 (i.e. since Directive 2005/36/EU came 
into existence), data that can be retrieved from the EU Single Market regulated professions 
Database  shows  that  62%  (n=5341)  of  the  decisions  with  regard  to  second-level  nurses 
taken  by  host  countries  were  positive  (8%  were  negative  (n=660)  and  30%  were  neutral 
(n=2558)). When we compare these numbers with the intra-EU mobility numbers for nurses, 
as  a  comparable  profession  over  the  same  period,  we  see  that the percentage  of  positive 
decisions is higher at 89%. While this difference could have several causes, it is likely that 

50 

 
 
 
 
 
 
EUROPEAN COMMISSION 

this is related to the fact that automatic recognition has been established for nurses, but not 
for second-level nurses (in particular by Directive 2005/36/EU).  

51 

 
 
 
 
5 

Education and training systems 

This chapter describes the variation in the position of HCAs in terms of education and entry 
requirements  in  the  EU  Member  States.  The  descriptions  are  mostly  limited  to  the  14 
countries  for  which  new  data  was  collected  (Croatia,  Cyprus,  France,  Greece  Hungary, 
Latvia,  Lithuania,  Luxembourg,  Malta,  Portugal,  Romania,  Slovakia  and  Sweden),  but  an 
additional  description  has  been  provided  of  the  results  of  the  pilot  study  where  available 
(Braeseke  et al.,  2013),  in  order to provide  an  EU-wide  overview of the variation  between 
Member States.  

For all these 14 Member States, it was stated that the geographical level of the curriculum is 
the  national  level.  Currently,  only  Malta  has  no  curriculum  defined.  In  the  pilot  study  this 
was the case for the UK and Germany, as both countries are regulated at the regional rather 
than national level. In the third round of the Delphi study, participants were also asked to 
answer questions relating to their national qualification framework. Of the 25 participating 
Member  States,  22  indicated  that  they  had  a  national  qualification  framework.  In  19  of 
these Member States HCAs’ education is effectively linked to this framework. In most cases 
(n=15),  these  national  qualification  frameworks  are  linked  to  the  European  Qualifications 
Framework. Sometimes this is a direct link, such as in Bulgaria, but sometimes the link can 
be indirect, as is the case for Hungary, where the national qualification framework level 5.2 
is comparable to EQF level 3.  

There  is  a  wide  variation  in  entry  requirements  for  education  between  the  14  Member 
States. This varies from no entry requirements in Latvia to high school or secondary school 
in e.g. Cyprus and Lithuania. The minimum age for starting education as an HCA also varies 
widely  between  the  countries.  In  Cyprus,  Greece  and  Portugal  there  is  no  minimum  age, 
whereas in other countries the minimum age varies between 15 and 18. The variation in the 
minimum  age  was  also found  in the  pilot  study, with  Ireland,  the Netherlands and  the  UK 
having no minimum age requirements. It should be noted that the variation in age may be 
related  to  the  variation  in  entry  requirements  regarding  previous  education.  The  age 
requirement may be less important than the education requirement. 

Finally,  differences  can  be  found 
in  the  extent  to  which  continuous  professional 
development  is  required.  In  Croatia,  Estonia,  France,  Latvia,  Luxembourg,  Romania  and 
Slovakia, HCAs are obliged to do some form of CPD, whereas in the other countries this is 
optional or not mandatory (information for pilot countries unavailable). 

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EUROPEAN COMMISSION 

Table  5.1:  Definition  of  curricula  and  entry  requirements  for  the  education  of  HCAs  in  14 
Member States (data based on the CC4HCA mapping study only) 
Country 

Min. age 

CPD 

Entry requirement for 
education 

Geographical 
level of 
curriculum 
National 
National 
National 

Croatia b 
Cyprus 
Estonia 

France 

National 

Greece 
Hungary 

National 
National 

Latvia 
Lithuania 

National 
National 

Luxembourg 

National 

Qualifications 
framework to which 
HCAs are linkeda 
No 
Not reported 
A national 
qualifications 
framework 
A national 
qualifications 
framework 
No 
A national 
qualifications 
framework, EQF (level 
3) 
No 
A national 
qualifications 
framework 
A national 
qualifications 
framework 

Malta 

Portugal 
Romania 

No curriculum 
definedc 
National 
National 

N/A 

EQF (level 4) 
No 

Slovakia 

National 

EQF (level 4) 

Elementary school (planned) 
Secondary school 
Basic education (9 yrs) or 
secondary education (12 yrs) 

15 
No 
18 

Yes 
No 

Before high school diploma or 
“baccalauréat” 

17 

Yes 

Basic education (12 years) 
Elementary school 

No 
16 

No 
No 

No entry requirement 
After secondary school 

Finalisation of a 9th grade 
class, a favourable opinion to 
a healthcare profession in the 
9th grade class; entry test of 
competences 
N/A  

9 years of school 
Graduate of eight classes 
minimum 
Basic school + entrance exam 
or high school 

18 
18 

15 

Yes 
Optional 

Yes 

N/A 

N/A 

No 
16 

Optional 
Yes 

15 for 
fulltime, 
18 for 
part-time 
No 

Yes 

No 

Sweden 

National level 
with regional 
differences in 
special courses 

A national 
qualifications 
framework 

No 

N/A= Not Applicable  
a Source: Delphi study, round 3.  
b  Applies  to  ‘Medicinska  sestra;  medicinski  tehničar’.  The  Crotian  Ministry  of  Health  states  that  ‘caregiver’  is  close  to 
healthcare assistants, in Croatian translated „njegovatelj/njegovateljica“, who are employed in the social welfare system 
for  homes  of  elderly  people  and  persons  with  disabilities.  In  addition,  ‘ordely’  („bolničar/bolničarka“)  are  close  to 
healthcare assistants, who perform tasks in the hospitals. Both occupations are not health professions however, and not 
regulated. It should finally be noted that ‘healthcare assistants’ as such currently do not exist in  Croatia, but the MoH is 
considering introducing them in the health system as ‘assistant profession to nurses’. 
c Since the time of data collection (September 2015) a set of national minimum standards for training has been established. 
The standards essentially note that training for HCAs needs to be at least EQF level 3. Requirement for education remains 
unidentified and so are age and CPD (source: https://activeageing.gov.mt/en/Documents/NMS_ENG.pdf ) 

Table  5.2  gives  an  overview  of  some  characteristics  of  the  training  and  education 
programmes  of  HCAs  in  the  28  EU  Member  States,  i.e. including  the  14  pilot  countries.  In 
more  than  half  of  European  Member  States  (n=15),  the  education  of  HCAs  is  publicly 

53 

 
 
 
funded. In five more countries there is the option of choosing between publicly or privately 
funded education or a mix. In Romania, Lithuania and the UK, funding is mainly private. In 
the UK, funding can also be covered by the employer. There is a high variation between the 
countries in the duration of the education programmes. In Romania, the duration is shortest 
with 3 months or 360 hours and in Latvia the main programme has a duration of 6 years. 
Depending on the country, there are also differences in the minimum percentage or number 
of  hours  from  the  total  period  of  education  when  HCA  students  have  to  be  trained  in 
practical situations. In France, Malta, the Netherlands and the UK, the minimum number of 
hours to be spent in practical work is not defined. In the other countries, the percentage is 
up  to  around  60%  of  the  total  duration  of  the  education.  It  is  worth  noting  that  these 
dimensions are related, i.e. the duration of educational programmes tends to be shorter in 
countries with private funding of education. 

Table 5.2: Education/ training programmes for HCAs 
Country 

Funding education 

Duration of main programme(s) 

Public 
Mixed 
Public 
Mixed 
96% public 
Public 
Mostly private 
Public 
Public 

Member States consulted by our country informants in 2015 
Croatia a 
Cyprus 
Estonia 
France 
Hungary 
Latvia 
Lithuania 
Luxembourg 
Malta 

Not reported 
1 or 2 years 
2 years 
11 months 
2 years, 1100-1400 hours 
6 years (from the age of 15) 
9 weeks, 360 hours 
3 years 
6 months (EQF level 1), 1- 2 
years (EQF 2-4) 
3 years  
Mixed 
Portugal 
3 months (360 hours) 
Private 
Romania 
4 years, 4224 hours 
Public 
Slovakia 
Sweden 
120 weeks 
Public 
Member States consulted in the Contec pilot study in 2012 
Austria  

1600 hours  

Public, private or 
mixed 
Public or private 

Public 
Public 
Public 
Public 

1 year 

Not reported 
4 years 
86 weeks (approx. 1,5 year)c 
3 years 

Belgium b 

Bulgaria  
Czech Republic  
Denmark 
Finlandd  

Germany (Lower 
Saxony) b 
Ireland  
Italy  
Netherlands  
Poland  
Slovenia  
Spain  

Percentage spent in 
practical work 

Not reported 
Not defined 
20% 
Not defined 
50% 
Not reported 
>60% 
>50% 
Not defined 

420 hours 
240 hours  
Varying per year 
12.5% 

50% 

Not defined by law, 
generally 50% 
Not defined 
33% 
62% 
All parts of the 
curricula are divided 
into practical and 
theoretical periods. 
> 960 hours (43%) 

Public 

> 2,220 hours (approx. 2 yrs)c 

Public 
Mixed 
Public 
Public or private 
Public or private 
Public or mixed 

Not reported 
1000 hours (approx. 6 months)c 
1, 2 or 3 years 
880 hours (approx. 4-5 months)c 
2718 hours (approx.16 months)c 
1400 hours (approx. 8 months)c 

Not reported 
45% 
Not defined 
18% 
37% 
31% 

54 

 
 
EUROPEAN COMMISSION 

Not defined 

Private or employer 

Information not availabe 

UK 
a  Applies  to  ‘Medicinska  sestra;  medicinski  tehničar’.  The  Crotian  Ministry  of  Health  states  that  ‘caregiver’  is  close  to 
healthcare assistants, in Croatian translated „njegovatelj/njegovateljica“, who are employed in the social welfare system 
for  homes  of  elderly  people  and  persons  with  disabilities.  In  addition,  ‘ordely’  („bolničar/bolničarka“)  are  close  to 
healthcare assistants, who perform tasks in the hospitals. Both occupations are not health professions however, and not 
regulated. It should finally be noted that ‘healthcare assistants’ as such currently do not exist in  Croatia, but the MoH is 
considering introducing them in the health system as ‘assistant profession to nurses’. 
b Updated after the Contec study 
c Own calculations, assuming a 40-hour/week 
d Updated information after the Contec study: The training for the care assistant is only a part of practical nurse training. 
Normally it is 2 modules (‘Support and guidance of growth’ and ‘Rehabilitation support’) from practical nurse training plus 
a free choice module from some other vocational qualification or further qualification. Care assistant is not a qualification. 

55 

 
 
 
6 

Main tasks and duties of HCAs 

This  chapter  describes  the  main  tasks  and  duties  of  HCAs  within  the  EU  Member  States. 
Appendix H  provides  an  extensive  description  of  HCAs’  tasks,  collected  by  the  current 
CC4HCA study and the Contec pilot study. Table 6.1 below lists the most common tasks and 
duties of HCAs across Europe and the number of countries where they are part of the role of 
HCAs. There are a number of core tasks that belong to the tasks and duties of HCAs in most 
Member States. These are mainly related to monitoring and measuring patients’ vital signs, 
providing non-medical care for patients (e.g. preparing and serving food and drinks, sanitary 
care  support),  applying  safety,  quality  and  hygiene  techniques,  and  providing  some  ‘basic 
care’. The latter task is often not further specified. Another important task of HCAs in the 
majority  of  Member  States  is  assisting  other  healthcare  professionals.  In  a  minority  of 
countries, HCAs provide first aid to patients, assist in moving and transferring patients and 
provide support in activities of daily living (ADL). Tasks and duties that HCAs perform in just 
a few countries are supporting patients’ relatives and providing education, supervision and 
professionalisation.  When  evaluating  these  texts,  it  appeared  that  a  number  of  tasks  are 
identified in most countries. These concern tasks that relate to supporting activities such as 
applying  cleaning  and  washing  techniques  for  equipment,  monitoring  and  measuring  vital 
parameters and preparing and serving food and drinks to clients/patients. 

Table 6.1: Main tasks of HCAs in each country 
Tasks and duties 

Monitor and measure vital parameters 
Apply cleaning and washing techniques (manual and mechanical) for equipment 
Prepare and serve food and drinks to clients/patients 
Apply quality and safety procedures 
Support other health professionals 
Apply hygiene techniques 
Sanitary care support for patients 
Communicate clearly in interacting with patients/clients 
Provide basic care 
Apply cleaning and washing techniques (manual and mechanical) for patients 
Preventive care and first aid 
Assist in moving and transferral of patients 
Support in activities of daily living 
Patient intake/discharge and documentation of care 
Provide education/supervision/professionalisation 
Support for relatives 

Part of HCA role  
in N countries 
21 
16 
16 
15 
15 
14 
14 
13 
13 
9 
9 
8 
8 
6 
5 
3 

56 

 
 
 
 
 
EUROPEAN COMMISSION 

The  health  professionals  to  which  HCAs  are  accountable  in  practice  varies  between 
countries.  In  all  countries,  nurses  are  among  the  professionals  to  which  HCAs  are 
accountable,  indicating  the  strong  linkage  between  he  professions.    In  seven  countries, 
reference is made only to nurses, while in other countries the list of professionals to whom 
HCAs are accountable is broader, also including medical professions. 

Table  6.2:  Professionals  to  whom  HCAs  are  accountable  in  practice  (data  based  on  the 
CC4HCA mapping study only) 
Country 

HCAs accountable to  

Croatia 
Cyprus 

Estonia 
France 
Greece 
Hungary 
Latvia 
Lithuania 

Head nurse of the department or physician 
Ward assistants: to a personnel lead of the hospital; Dentist assistants: to the 
dentist 
Head nurse of staff nurse* 
Mostly a nurse for clinical practice, but also a doctor if they work at the hospital. 
Nurses* 
A healthcare assistant works under the supervision of nursing staff * 
Nurses, chief nurses, head of nursing* 
Chief nurse/ nursing administrator of the department or unit of healthcare 
institution.  
Direct supervision of nurse who is implementing nursing plan* 

Luxembourg  Doctors, chef nurses, nurses, physiotherapist, ergo therapist, diet assistants, speech 

Malta 

therapists social worker, assurance dependence evaluators 
Accountable to the qualified nurse working in the same context. In the absence of a 
nurse, such as at a radiology department or a social work clinic, the HCAs are 
accountable to the health professional present in the specific context. 
Nurses* 
Nurse in charge or the chief nurse* 
Nurses, midwives, doctors 
Not reported 

Portugal 
Romania 
Slovakia 
Sweden 
* Only refer to nurses as the profession HCAs are accountable to 

57 

 
 
 
7 

Knowledge, skills and competences of HCAs 

The  central  question  addressed  in  this  chapter  concerns  the  common  set  of  fields  of 
knowledge, skills and competences of HCAs: can this common set be defined and what does 
it look like? Based on the feedback from the country experts from all 28 Member States, a 
common  set  of  the  main  knowledge,  skills  and  competences  of  HCAs  could  indeed  be 
constructed. To do this, the various terms and vocabulary provided by the country experts 
were  interpreted,  classified  and  allocated  into  different  knowledge  areas,  skills  and 
competences. In total, we identified 18 items related to knowledge, 16 related to skills and 
4 related to competences. The skills of HCAs in practice were discussed in Chapter 6.  

Table 7.1a shows the list of the 18 extracted common fields of knowledge of HCAs. It can be 
seen  that  “support  in  activities  of  daily  living  (ADL)”  and  “clerical/administrative/planning 
knowledge”  are  identified  as  part  of  the  curriculum  in  most  of  the  Member  States.  Other 
items of knowledge that were identified in at least 10 of the MS are “communication and 
interaction  with  patients  and  co-workers”,  “patient  rights  and  rights  and  duties  of  HCAs”, 
“legislation  that  falls  within  the  scope  of  HCAs”,  “end-of-life  and  post-mortem  care”, 
“ethical  principles  of  care  provision”,  “positioning,  lifting  and  transportation  of  patients 
(manually and mechanically)” and “inter-professional healthcare and teamwork”. Items that 
are  mentioned  in  four  countries  only  (France,  Latvia,  Luxembourg  and  Portugal)  are 
“knowledge of cleaning equipment” (manual and mechanical) and “specific patient groups”.  

Table  7.1a:  Overview  of  knowledge  items  of  HCAs  commonly  mentioned  by  country 
informants as being part of the HCA curriculum 
Knowledge 

Part of curriculum in countries 

Part of 
curriculum  
in N 
countries 
19 

Support in activities of daily living (basic and 
instrumental) 

Clerical/administrative/planning knowledge 

Communication and interaction with patients 
and co-workers 
Patient rights and rights and duties of HCAs 

Legislation that falls within the scope of HCAs /  
healthcare system knowledge 
End-of-life and post-mortem care 

Ethical principles of care provision 

17 

14 

12 

11 

11 

10 

AT, BE, BG, CY, DE, DK, EE, ES, 
FR, HU, IE, IT, LV, LU, NL, PL, PT, 
RO, UK 
AT, BE, BG, CY, CZ, DE, EE, ES, 
HR, LU, LV, MT, PL, PT, SK, SI, UK 
BE, CY, EE, DE, FR, HR, HU, IT, 
LU, LV, PL, PT, SI, UK 
BE, DE, ES,  FR, HR, LV, LT, LU, 
PL, PT, RO, UK 
AT, DE, ES, FR, HR, IE, LV, LU, PL, 
PT, SK 
AT, FR, LV, LT, LU, MT, NL, PL, 
PT, RO, SI 
AT, BG, CY, EE, FR, HR, LV, PL, 

58 

 
 
 
 
 
EUROPEAN COMMISSION 

Knowledge 

Part of curriculum in countries 

Part of 
curriculum  
in N 
countries 

Positioning, lifting and transportation of patients 
(manually and mechanically) 
Interprofessional healthcare and teamwork 

10 

10 

8 
8 
8 
8 

Human anatomy, physiology and pathology 
Cultural/gender/personal sensitivities  
Hygiene rules and procedures in patient care 
Pharmacology and non-pharmacological 
treatments 
Storage and organisation of equipment and 
materials 
7 
Safe practice environment 
Specialist areas of care 
5 
Cleaning equipment (manually and mechanically)  4 
4 
Specific patient groups 

8 

PT, SI 
AT, BE, BG, CY, FR, HU, IT, LV, 
LU, PT 
EE, DE, FR, HR, IT, LU, LV, PL, PT, 
SK 
BG, CY, EE, FR, HU, LV, LT, PL, PT 
BE, CY, EE, ES, IT, LV, LU, PT 
AT, BE, BG, FR, HU, LV, LU, PT 
AT, CZ, EE, LT, LU, MT, SK, UK 

BG, CY, CZ, GR, LU, LV, MT, PT 

AT, BE, FR, HR, HU, PL, PT 
CY, FR, GR, LU, PT 
FR, LV, LU, PT 
FR, LV, LU, PT 

Table 7.1b provides an overview of the skills of HCAs that were extracted and classified from 
the  country  informant  information.  Among  the  many  items,  “monitor  and  measure  vital 
parameters”,  “prepare  and  serve  food  and  drinks  to  clients/patients”  and  “support  other 
health  professionals”  are  common  skills  within  the  curriculum  in  a  larger  set  of  countries. 
Even  though  knowledge  of  the  activities  of  daily  living  (ADL)  was  identified  as  the  most 
common item of knowledge in the majority of countries, it is not necessarily identified as a 
skill in all of these countries. 

Table 7.1b: Overview of skills items of HCAs commonly mentioned by country informants as 
being part of the HCA curriculum 
Skills 

Part of curriculum in 
countries 

Part of 
curriculum  
in N 
countries 
21 

Monitor and measure vital parameters 

Prepare and serve food and drinks to 
clients/patients 
Support other health professionals 

Apply quality and safety procedures 

16 

15 

14 

AT, BE, BG, CZ, EE, ES, FR, GR, 
HR, HU, IE, IT, LU, LV, LT, MT, 
NL, PL, SK, SI, UK 
AT, BE, CZ, EE, HR, HU, IT, LU, 
LV, LT, MT, NL, PL, PT, RO, SK 
AT, CZ, DE, EE, ES, FR, HR, IE, 
LT, LU, MT, PL, RO, SK, SI 
BE, CY, EE, FR, HR, IE, IT, LU, 
LV, MT, NL, PL, PT, SK 

59 

 
 
 
 
Skills 

Apply cleaning techniques (manual and mechanical) 
for equipment 
Sanitary care support for patients 

Basic care 

Apply washing techniques (manual and mechanical) 
for patients 
Apply hygiene techniques 

Communicate clearly when interacting with 
patients/clients 
Preventive care and first aid 

Assist in moving and transferring of patients 
Support in activities of daily living 

Admission, discharge and transfer (ADT) of patients 
and documentation of care 
Education/supervision/professionalisation 
Support for relatives 

Part of 
curriculum  
in N 
countries 
14 

14 

14 

13 

13 

13 

10 

8 
8 

6 

5 
3 

Part of curriculum in 
countries 

AT, BE, CZ, ES, GR, IE, LV, LU, 
MT, NL, PL, PT, RO, SK 
CZ, FR, GR, HR, HU, IT, LU, LV, 
LT, MT, PL, PT, RO, SK 
AT, BE, CZ, ES, GR, HR, LT, LU, 
MT, NL, PL, SK, SI, UK 
AT, BE, CY, CZ, EE, FR, GR, HU, 
IT, LV, LU, MT, UK 
AT, BE, CZ, EE, ES, FR, LU, LV, 
LT, PL, PT, RO, SK 
BG, DE, HR, CZ, FR, HU, IE, IT, 
LU, MT, PT, RO 
AT, BE, CY, EE, ES, HR, LV, LU, 
PL, SK 
AT, LU, LV, LT, MT, PL, RO, SK 
AT, DK, FR, HR, HU, LU, LV, 
RO 
AT, BE, CZ, HR, IE, NL 

DK, HR, LU, LV, NL 
EE, FR, LT 

Finally, Table 7.1.c presents the four common HCA competences identified regarding a “care 
plan”,  “patient  needs”,  “patients’  safety  and  autonomy”  and  “communication”.  These 
competences were only identified in 4 or 5 countries.  

Table  7.1c:  Overview  of  competence  items  of  HCAs  commonly  mentioned  by  country 
informants as being part of the HCA curriculum 
Competences 

Part of curriculum in countries 

Part of curriculum  
in N countries 

Care plan 
Patient needs 
Patients’ safety and autonomy 
Communication 

5 
4 
4 
4 

BE, BG, FR, LT, LU 
BE, FR, LT, PT 
BE, BG, FR, PT 
BG, FR, PT, LU 

60 

 
 
 
 
 
 
 
 
 
EUROPEAN COMMISSION 

8 

Regulation and registration of the HCA profession and education 

In this chapter we answer the following questions: 
• 

Is the HCA profession regulated and registered in the Member States? And if so, how is it 
regulated? 
Is this registration voluntary or obligatory, and if the first applies, what is the estimated 
registration coverage of healthcare assistants? 

• 

•  How can the details and conditions of this regulation be described? 

Directive 2005/36/EC defines a ‘regulated profession’ as follows: 

“A professional activity or group of professional activities, access to which, the pursuit of 
which, or one of the modes of pursuit of which is subject, directly or indirectly, by virtue of 
legislative, regulatory or administrative provisions to the possession of specific professional 
qualifications; in particular, the use of a professional title limited by legislative, regulatory or 
administrative provisions to holders of a given professional qualification shall constitute a 
mode of pursuit. Where the first sentence of this definition does not apply, a profession 
referred to in paragraph 2 shall be treated as a regulated profession” 
Directive 2005/36/EC, article 3, paragraph 1a 

This  definition  is  also  used  in  the  European  Commission’s  regulated  professions  database, 
which contains information on the regulated professions covered by Directive 2005/36/EC. 
As explained in Chapter 4, the regulated professions database uses “second-level nurse” as 
the  generic  name  referring  to  healthcare  assistants.  A  comparative  analysis  between  the 
national names for the HCA profession as reported by countries in the regulated professions 
database  and  the  names  as  submitted  by  our  country  informants  showed  a  high  level  of 
correspondence (see also Table 4.4 in this report). Based on the data in this database, we 
conclude  that  the  HCA  profession  is  regulated  in  14  EU  Member  States,  namely  Austria, 
Belgium,  Czech  Republic,  Denmark,  Finland,  France,  Germany,  Greece,  Italy,  Latvia, 
Luxembourg,  the  Netherlands,  Slovakia  and  Spain.  While  Malta  is  also  included  in  the 
database, the database also notes that its level of recognition under Directive 2005/36/EC 
needs to be checked. For the moment, we have therefore considered the HCA profession as 
unregulated in Malta. It is worth noting that for a CTF to be possible, one of the conditions 
that have to be fulfilled is that “the profession or the education and training leading to the 
profession  should  be  regulated  in  at  least  one  third  of  Member  States  (Directive 
2013/55/EU,  Article 49a,  paragraph 2,  amending  Directive  2005/35/EC).  Looking  at  the 
regulation rules in the 28 MSs, this criterion would be fulfilled.  

61 

 
 
 
 
 
In addition, the CC4HCA study also examined how many countries entry to the profession is 
regulated  in.  For  the  14  countries  (Croatia,  Cyprus,  France,  Greece  Hungary,  Latvia, 
Lithuania,  Luxembourg,  Malta,  Portugal,  Romania,  Slovakia  and  Sweden)  that  were  the 
subject  of  the  mapping  study,  we  see  that  entry  into  the  HCA  profession  is  regulated  in 
eight. In five countries it is not and for one country (Latvia) the information is not available. 

Table 8.1: Regulation and registration HCAs into practice in 14 Member States (data based 
on the CC4HCA mapping study only) 
Re-entry 
Country 
regulation 
Yes 

Insurance 
requirements 
Voluntary 

Regulation 
coverage  
100% 

Entry 
regulation 
Yes 

Registration body 

Croatiaa 

Cyprus 
Estonia 
France 
Greece 
Hungary 

Latvia 
Lithuania 
Luxembourg 
Malta 
Portugal 

Romania 
Slovakia 

Yes 
No 
Yes 
Yes 
Yes 

- 
No 
Yes 
No 
No 

No 
Yes 

No 
- 
No 
No 
Yes 

- 
- 
Yes 
- 
- 

- 
No 

90% 
- 
N/A 
100% 
100% 

- 
- 
N/A 
- 
- 

- 
N/A 

Croatian Nursing 
Council (CNC) 
Ministry of Health 
No 
No 
No 
Chamber of Hungarian 
Health care 
Professionals + Health 
Registration and 
Training Centre 
Health Inspection 
No 
Ministry of Health 
No 
At the institutional 
level, by the employer 
No 
Slovak Chamber of 
Medical and Technical 
Staff 
- 

No 
No 
No 
No 
TBC 

No 
Voluntary 
No 
No 
Yes 

No 
No 

- 

No 

Yes 
Sweden 
- : Information not received or not available. 
a  Applies  to  ‘Medicinska  sestra;  medicinski  tehničar’.  The  Crotian  Ministry  of  Health  states  that  ‘caregiver’  is  close  to 
healthcare assistants, in Croatian translated „njegovatelj/njegovateljica“, who are employed in the social welfare system 
for  homes  of  elderly  people  and  persons  with  disabilities.  In  addition,  ‘ordely’  („bolničar/bolničarka“)  are  close  to 
healthcare assistants, who perform tasks in the hospitals. Both occupations are not health professions however, and not 
regulated. It should finally be noted that ‘healthcare assistants’ as such currently do not exist in  Croatia, but the MoH is 
considering introducing them in the health system as ‘assistant profession to nurses’. 

No 

62 

 
 
 
EUROPEAN COMMISSION 

Part III: 

Exploration of a common training framework for HCAs 

63 

 
 
 
 
 
 
 
 
 
 
 
9 

The views on the content of a potential CTF for HCAs 

In the previous part of this report, a common set of knowledge, skills and competences of 
HCAs  was  investigated  and  defined,  based  on  survey  and  consultation  rounds  among 
informants and representatives of the 28 EU Member States. The following three chapters 
describe the results of the Delphi study and the workshops for identifying whether there is a 
shared  view  for  establishing  a  common  position  on  a  set  of  knowledge,  skills  and 
competences:  what  willingness  is  there  across  the  EU  to  take  this  common  set  of  core 
competences  and  follow  a  roadmap  to  start  working  on  a  suggestion  for  a  CTF  for  HCAs? 
What is the desirability and feasibility of a CTF for HCAs within the EU? 

The research questions related to this aim are: 

•  What  are  the  visions  of  the  representatives  of  the  organisations  identified,  and 

representatives of other EU Member States? 

•  What  consensus  emerges  from  group  discussions  on  a  potential  CTF  and  its 
components,  in  terms  of  applicability,  usefulness,  desirability  and  feasibility  to 
implement? 

•  What  is  a  common  position  on  the  minimum  set  of  knowledge,  skills,  and 

competences of HCAs? 

•  What are further steps that should be taken to reach consensus on a minimum set of 
knowledge,  skills,  and  competences  that  could  support  a  CTF  proposal  at  the  EU 
level? 

•  To what extent did the workshops lead to a common position on the minimum set of 

knowledge, skills and competences of HCAs? 

•  What are the views of stakeholders who were not present on this position, and could 

• 

consensus among them be achieved? 
If no common position can be determined that is shared by a minimum of one third 
of the Member States, what steps need to be taken in additional Member States to 
reach such a position? 

•  What are the next steps for a suggestion for a CTF, including a feasible timescale, a 
relevant  legal  framework  and  a  plan  for  including  relevant  organisations  or 
authorities?  

To  answer these  questions, Chapter 9 focuses  on  the  views  of  the  EU Member  States  and 
European organisations regarding the content of a potential CTF for HCAs, while Chapter 10 
goes into the views of these stakeholders regarding the desirability and feasibility of a CTF 
as a legal instrument to facilitate recognition of qualifications and examines the drivers and 
barriers  that  were  identified.  Chapter 11  focuses  on  the  last  two  research  questions 
mentioned above by discussing the potential further steps for exploration of a CTF for HCAs 
that  can  be  taken  by 
interested  representative  European,  national  professional 
organisations or competent authorities.  

64 

 
 
 
EUROPEAN COMMISSION 

9.1  The  level  of  support  for  a  common  set  of  knowledge,  skills  and 
competences for HCAs  
To  explore  the  level  of  support  for  a  common  training  framework  -  a  common  set  of 
knowledge,  skills  and  competences  -  for  healthcare  assistants,  the  Delphi  study  and  the 
workshops  asked  representatives  from  all  EU  Member  States  about  their  views  on  this 
matter. Article 49a of Directive 2013/55/EU, amending Directive 2005/36/EC, explains that a 
CTF  “combines  the  knowledge,  skills  and  competences  required  in  the systems  of  training 
applicable in at least one third of the Member States”. On this basis, we took the threshold 
of  one  third  of  the  Member  States,  i.e. 10  Member  States,  to  denote  a  sufficient  level  of 
support for a knowledge, skills or competence item to be potentially included in a CTF. As 
will be explained in detail below, this threshold was exceeded for all knowledge, skills and 
competence  items  that  we  asked  about,  showing  a  high  level  of  agreement  among 
competent  authorities  from  the  Member  States  about  the  content  of  a  potential  CTF  for 
HCAs.  

9.1.1 Results from the Delphi study  
In the first two rounds of the Delphi study, competent authorities from 26 Member States 
were asked to indicate what knowledge, skills and competence items should or should not 
be  included  in  a  potential  CTF  for  healthcare  assistants.  In  total  48  items  were  presented 
and participants also had the option of adding additional items themselves. In Table 9.1, all 
items addressed in the Delphi are ranked according to the number of Member States that 
indicated they would include it in a CTF.  

Table 9.1: Proposed CTF items in the Delphi rounds sorted by level of agreement to include 
them in a CTF (Category: S=skills item, K= knowledge item, C=competence item) 

Category 
S 
S 
S 
K 
K 
K 
K 
K 
K 
K 
K 
C 
S 
S 
S 
S 
K 
K 
K 
K 
S 
K 
S 
S 

Label of the item 
Apply cleaning techniques (manual and mechanical) for equipment 
Apply washing techniques (manual and mechanical) for patients 
Attend to sanitary needs of clients/patients 
Cultural, gender and other personal factors of the patient that impact upon patient care 
Ethical principles in healthcare and awareness of these principles 
First aid in emergency situations 
Hygiene and infection rules and procedures in patient care 
Manually and mechanically cleaning equipment 
Principles of (manually and mechanically) positioning, lifting and transportation of patients 
Rights and duties of HCAs 
Supporting patients/clients in activities of daily living (basic and instrumental) 
Work under the supervision of other healthcare professionals to assist them in care provision 
Apply body hygiene procedures in patient care 
Apply quality and safety procedures in patient care 
Assist other healthcare professionals and have the required S to do so (depending on the type of other 
Communicate clearly in interacting with clients/patients and family 
Communication and interaction with patients and co-workers 
Cooperation in a multi-professional team 
Health and safety in the workplace and quality management systems 
Legislation that regulates the professional activities of HCAs 
Move and transfer patients 
Patient rights 
Prepare and serve food and drinks to clients/patients 
Support patients in activities of daily living, including hygiene, comfort, mobility and feeding needs 

65 

 
 
 
 
C 
S 
S 
K 
K 
K 
K 
S 
K 
S 
K 
S 
C 
S 
K 
K 
K 
C 
K 
K 
K 
C 
C 
S 

Take responsibility for their actions and justify them professionally and ethically 
Apply first aid in emergency situations 
Conduct basic care activities 
Storage and transportation of equipment and materials 
The national health system and social insurance system 
Basic knowledge on public health 
Human anatomy, physiology and pathology 
Support patients’/clients’ relatives in patient care related activities 
Specific patient groups, e.g. elderly 
Conduct (delegated) activities related to ADT (admission, discharge, transfer) and documentation of care 
ICT use and use of technological applications 
Monitor and measure vital parameters and overall patient condition 
Assess basic patient vital signs and care needs and requirements without supervision and report to other 
Carry out social activities for specific age groups 
Palliative care and pain management and post-mortem care provision 
Chronic disease management 
Specialist areas of care, e.g. diabetes care, at basic level 
Assess the need for basic healthcare assignments without supervision 
Clerical, administrative and care planning issues 
Psychological support 
Pharmacology, administration of medicines and non-pharmacological treatments 
Show entrepreneurship 
Carry out care assignments according to a care plan without supervision 
Supply and distribute medicines 

There  was  much  agreement  among  Delphi  respondents  on  the  knowledge  requirements 
that  should  be  part  of  a  potential  CTF  for  healthcare  assistants  at  the  European  level. 
Moreover, individual respondents’ views on this remained consistent and few changes were 
observed  between  the  various  Delphi  rounds.  All  knowledge  requirements  that  we  asked 
about  exceeded  the  threshold  of  a  minimum  of  10  Member  States  (i.e. one  third  of  the 
Member States), which implies that it could be part of a potential CTF for HCAs. In Table 9.2, 
an  overview  is  given  of  all  knowledge  requirements  that  were  surveyed.  A  significant 
number  of  respondents  made  a  distinction  between  the  levels  of  knowledge  that  HCAs 
should have on certain issues. For some requirements they indicated ‘basic knowledge’, for 
others they stated ‘in-depth knowledge’.  

There  was  considerable  agreement  among  Delphi  respondents  on  the  skills 
requirements  that  should  be  part  of  a  potential  CTF  for  HCAs.  Similarly  to  the  knowledge 
requirements,  individual  respondents’  views  remained  consistent  through  the  various 
Delphi  rounds  and  all  skills  requirements  exceeded  the  threshold  of  a  minimum  of  10 
Member States (see Table 9.3). Most respondents indicated that the skills requirements in a 
potential  CTF  for  HCAs  should  stem  from  the  duties  that  HCAs  have  in  their  everyday 
practice. More frequently and explicitly than for the knowledge requirements, respondents 
commented  that  the  skills  requirements  should  be  further  specified  in  terms  of  ‘basic 
activities’ or ‘specialised activities’. 

The degree of agreement among Delphi respondents on the competence requirements 
that should be part of a potential CTF for HCAs was lower than for knowledge and skills, and 
respondents  showed  little  inclination  to  change  their  views.  However,  all  competence 
requirements  that  we  asked  about  exceeded  the  threshold  of  a  minimum  of  10  Member 
States agreeing that it should be part of a potential CTF for HCAs (see Table 9.4 below). 

66 

 
 
 
 
 
 
 
Table 9.2: Results of the CC4HCA Delphi rounds 1 and 2 for the minimum set of knowledge requirements for Healthcare Assistants  

EUROPEAN COMMISSION 

HCAs should have knowledge about.... 

ROUND 1 
N of MSs that 
said ‘yes’6  

ROUND 2 
N of MSs that 
said ‘yes’7  

Most 
consensus 

Rights and duties of HCAs 

Ethical principles in healthcare and awareness of these 
principles  
Cultural, gender and other personal factors of the patient 
that impact upon patient care 
Principles of (manually and mechanically) positioning, 
lifting and transportation of patients 
Supporting patients/clients in activities of daily living 
(basic and instrumental) 
Hygiene- and infection rules and procedures in patient 
care 
First aid in emergency situations 
Legislation that regulates the professional activities of 
HCAs 
Manually and mechanically cleaning equipment 
Communication and interaction with patients and co-
workers 
Cooperation in a multi-professional team 
The national health system and social insurance system 
Patient rights 
Health and safety in the workplace and quality 
management systems 

22 

22 

22 

22 

22 

22 

Not asked in R1 
22 

21 
22 

22 
19 
21 
21 

24 

24 

24 

24 

24 

24 

24 
24 

24 
23 

23 
23 
23 
22 

ROUND 1 
% of Delphi 
respondents  
who said ‘yes’ 
100 

ROUND 2 
% of Delphi 
respondents  
who said ‘yes’ 
100 

100 

100 

100 

100 

100 

Not asked in R1 
96,3 

96,3 
100 

100 
88,9 
96,3 
96,3 

100 

100 

100 

100 

100 

100 
96,6 

100 
96,6 

96,6 
93,1 
96,6 
93,1 

CHANGE 
Between 
R1 and 
R28 

= 

= 

= 

= 

= 

= 

N/A 

+ 

+ 

– 

– 
+ 
+ 

– 

6 Member states with multiple competent authorities were aggregated to ‘one vote’. We applied the following rule: if ≥ 50% of the competent authorities in a MS ticked 

‘yes’, the answer for the MS as a whole was considered ‘yes’. 

7 Member states with multiple competent authorities were aggregated to ‘one vote’. We applied the following rule: if ≥ 50% of the competent authorities in a MS ticked 

‘yes’, the answer for the MS as a whole was considered ‘yes’. 

8 Key: = unchanged, + increase, – decrease 

67 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
Least 
consensus 

Threshold for CTF 

HCAs should have knowledge about.... 

ROUND 1 
N of MSs that 
said ‘yes’6  

ROUND 2 
N of MSs that 
said ‘yes’7  

Storage and transportation of equipment and materials 
Basic knowledge of public health 
Human anatomy, physiology and pathology 
Specific patient groups, e.g. elderly 
ICT use and use of technological applications 
Palliative care and pain management and post-mortem 
care provision 
Specialist areas of care, e.g. diabetes care, at basic level 
Clerical, administrative and care planning issues 
Chronic disease management 
Psychological support 
Pharmacology, administration of medicines and non-
pharmacological treatments 

19 
Not asked in R1 
17 
19 
18 
16 

15 
14 
Not asked in R1 
Not asked in R1 
12 

22 
21 
21 
20 
19 
17 

16 
14 
13 
13 
12 

ROUND 1 
% of Delphi 
respondents  
who said ‘yes’ 
92,6 
Not asked in R1 
77,8 
88,9 
85,2 
77,8 

74,1 
70,4 
Not asked in R1 
Not asked in R1 
59,3 

ROUND 2 
% of Delphi 
respondents  
who said ‘yes’ 
93,1 
89,7 
86,2 
86,2 
79,3 
72,4 

69 
58,6 
65,5 
65,5 
55,2 

CHANGE 
Between 
R1 and 
R28 

+ 
N/A 
+ 
– 
– 

– 

– 
– 
N/A 
N/A 

– 

Threshold for CTF 

68 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 9.3: Results of the CC4HCA Delphi rounds 1 and 2 for the minimum set of skills requirements for Healthcare Assistants 

EUROPEAN COMMISSION 

HCAs should be able to…. 

ROUND 1 
N of MSs that 
said ‘yes’9 

ROUND 2 
N of MSs that 
said ‘yes’10 

Most 
consensus 

Apply washing techniques (manual and mechanical) for patients 

Attend to sanitary needs of clients/patients 
Apply cleaning techniques (manual and mechanical) for equipment 
Communicate clearly in interacting with clients/patients and family 
Apply quality and safety procedures in patient care 
Move and transfer patients 
Support patients in the activities of daily living, including hygiene, 
comfort, mobility and feeding needs 
Prepare and serve food and drinks to clients/patients 
Assist other healthcare professionals and have the required skills to 
do so (depending on the type of other healthcare professionals) 
Apply body hygiene procedures in patient care 
Conduct basic care activities 
Apply first aid in emergency situations 
Support patients’/clients’ relatives in patient care related activities 
Monitor and measure vital parameters and overall patient condition 
Conduct (delegated) activities related to ADT (admission, discharge, 
transfer) and documentation of care 
Carry out social activities for specific age groups 
Supply and distribute medicines 

Least 
consensus 

Threshold for CTF 

22 

22 
20 
22 
21 
21 
21 

20 
20 

20 
18 
20 
16 
15 
15 

Not asked in 1 
Not asked in 1 

24 

24 
24 
23 
23 
23 
23 

23 
22 

22 
22 
21 
21 
18 
18 

17 
12 

ROUND 1 
% of Delphi 
respondents  
who said ‘yes’ 
100 

ROUND 2 
% of Delphi 
respondents  
who said ‘yes’ 
100 

100 
92,6 
100 
96,3 
96,3 
96,3 

92,6 
92,6 

92,6 
85,2 
92,6 
77,8 
74,1 
74,1 

100 
100 
96,6 
96,6 
96,6 
96,6 

96,6 
93,1 

93,1 
89,7 
89,7 
89,7 
75,9 
79,3 

Not asked in 1 
Not asked in 1 

72,4 
51,7 

CHANGE 
Between 
R1 and 
R211 

= 

= 
+ 
– 
+ 
+ 

+ 

+ 

+ 

+ 
+ 
– 
+ 
+ 

+ 

N/A 

/A 

Threshold for CTF 

9 Member states with multiple competent authorities were aggregated to a single vote. We applied the following rule: if ≥ 50% of the competent authorities in a MS ticked 

‘yes’, the answer for the MS as a whole was considered ‘yes’. 

10 Member states with multiple competent authorities were aggregated to a single vote. We applied the following rule: if ≥ 50% of the competent authorities in a MS ticked 

‘yes’, the answer for the MS as a whole was considered ‘yes’. 

11 Key:  = unchanged, + increase, – decrease 

69 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
Table 9.4: Results of the CC4HCA Delphi rounds 1 and 2 for the minimum set of competences for Healthcare Assistants 

HCAs should be able to…. 

ROUND 1 
N of MSs that 
said ‘yes’12 

ROUND 2 
N of MSs that 
said ‘yes’13 

Most 
consensus 

Least 
consensus 

Threshold for CTF 

Work under the supervision of other healthcare professionals to 
assist them in care provision 
Take responsibility for their actions and justify them professionally 
and ethically 
Assess basic patient vital signs and care needs and requirements 
without supervision and report to other healthcare professionals as 
appropriate 
Assess the need for basic healthcare assignments without 
supervision 
Show entrepreneurship 
Carry out care assignments according to a care plan without 
supervision 

21 

20 

15 

14 

11 
10 

24 

23 

14 

13 

11 
10 

ROUND 1 
% of Delphi 
respondents  
who said ‘yes’ 
96,3 

ROUND 2 
% of Delphi 
respondents  
who said ‘yes’ 
100 

92,6 

70,4 

66,7 

55,6 
51,9 

96,6 

58,6 

58,6 

51,7 
48,3 

CHANGE 
Between 
R1 and 
R214 

+ 

+ 

– 

– 

– 

– 

Threshold for CTF 

12 Member states with multiple competent authorities were aggregated to a single vote. We applied the following rule: if ≥ 50% of the competent authorities in a MS said 

‘yes’, the answer for the MS as a whole was considered ‘yes’. 

13Member states with multiple competent authorities were aggregated to a single vote. We applied the following rule: if ≥ 50% of the competent authorities in a MS said 

‘yes’, the answer for the MS as a whole was considered ‘yes’. 

14 Key: = unchanged, + increase,– decrease 

70 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
9.2.2 Results from the workshops  
Based  on  the  outcomes  of  the  Delphi  study,  a  common  set  of  skills,  knowledge  and 
competence  items  that  could  be  considered  as  the  ‘core’  for  the  HCA  profession  was 
explored  further  during  the  Brussels  workshop  in  April 2016  and  online  workshop  in 
June 2016.  During  these  workshops,  not only  were  Member  State representatives  present, 
but  representatives  of  a  number  of  relevant  European  organisations  participated  in  the 
discussions as well. As a basis for the discussions, we used the broad set of knowledge, skills 
and  competence  items  that  resulted  from  the  Delphi  study.  The  first  main  question 
addressed  during  the  workshop  was  to  explore  if  this  list  of  knowledge,  skills  and 
competences  (see  Table 9.5  below)  can  indeed  be  considered  as  a  ‘core’  for  the  HCA 
profession. In a round table setting, the participants were invited to share their viewpoints 
and answer the following questions: 

•  Can you point out items that definitely should be included in a CTF – why? 
•  Can you point out items that definitely should not be included in a CTF – why not? 

Table 9.5: Proposed CTF items in the Delphi rounds sorted by level of agreement for including 
them in a CTF (Category: S=skills item, K= knowledge item, C=competence item) 

Category 
S 
S 
S 
K 
K 
K 
K 
K 
K 
K 
K 
C 
S 
S 
S 
S 
K 
K 
K 
K 
S 
K 
S 
S 
C 
S 
S 
K 
K 
K 
K 
S 
K 
S 
K 
S 
C 
S 

Label of the item 
Apply cleaning techniques (manual and mechanical) for equipment 
Apply washing techniques (manual and mechanical) for patients 
Attend to sanitary needs of clients/patients 
Cultural, gender and other personal factors of the patient that impact upon patient care 
Ethical principles in healthcare and awareness of these principles 
First aid in emergency situations 
Hygiene and infection rules and procedures in patient care 
Manually and mechanically cleaning equipment 
Principles of (manually and mechanically) positioning, lifting and transportation of patients 
Rights and duties of HCAs 
Supporting patients/clients in activities of daily living (basic and instrumental) 
Work under the supervision of other healthcare professionals to assist them in care provision 
Apply body hygiene procedures in patient care 
Apply quality and safety procedures in patient care 
Assist other healthcare professionals and have the required S to do so (depending on the type of other 
Communicate clearly in interacting with clients/patients and family 
Communication and interaction with patients and co-workers 
Cooperation in a multi-professional team 
Health and safety in the workplace and quality management systems 
Legislation that regulates the professional activities of HCAs 
Move and transfer patients 
Patient rights 
Prepare and serve food and drinks to clients/patients 
Support patients in the activities of daily living, including hygiene, comfort, mobility and feeding needs 
Take responsibility for their actions and justify them professionally and ethically 
Apply first aid in emergency situations 
Conduct basic care activities 
Storage and transportation of equipment and materials 
The national health system and social insurance system 
Basic knowledge on public health 
Human anatomy, physiology and pathology 
Support patients’/clients’ relatives in patient care related activities 
Specific patient groups, e.g. elderly 
Conduct (delegated) activities related to ADT (admission, discharge, transfer) and documentation of care 
ICT use and use of technological applications 
Monitor and measure vital parameters and overall patient condition 
Assess basic patient vital signs and care needs and requirements without supervision and report to other 
Carry out social activities for specific age groups 

 
 
 
 
 
 
 
 
 
K 
K 
K 
C 
K 
K 
K 
C 
C 
S 

Palliative care and pain management and post-mortem care provision 
Chronic disease management 
Specialist areas of care, e.g. diabetes care, at basic level 
Assess the need for basic healthcare assignments without supervision 
Clerical, administrative and care planning issues 
Psychological support 
Pharmacology, administration of medicines and non-pharmacological treatments 
Show entrepreneurship 
Carry out care assignments according to a care plan without supervision 
Supply and distribute medicines 

The  discussions  in the two  workshops  showed  that  in  general the  participants  agreed that 
items ranked highest on the list are essential elements in a potential CTF. As the workshop 
was  intended  to  let  participants  exchange  their  views  and  experiences  in  an  open 
atmosphere,  no  voting  was  organised  to  actually  ‘measure’  the  number  of  participants 
agreeing with the CTF list and its various items. In fact, this was already done during the two 
Delphi study rounds. The aim of the workshop was to have a more in-depth discussion of the 
items. Various reasons why certain items should not be included or needed redrafting could 
be identified: 

•  Many participants indicated that they thought certain items should not be included, 
because they fall under the responsibility of other professions. These were generally 
the  items  at  the  bottom  of  the  list  (see  Table 9.5).  For  example,  many  country 
representatives  stated  that  HCAs  in  their  country  do  not  administer  medicines.  On 
the other hand, in some countries HCAs are expected to carry out this task. In other 
countries  there  are  differences  in  the  administration  of  medicines  according  to  the 
settings in which HCAs work: in some settings HCAs are allowed to do this, in others 
not. Another example of an item that was considered to be outside the responsibility 
of HCAs was ‘monitoring the overall patient condition’ which is only done by nurses 
in certain countries. Various participants considered chronic disease management to 
be too specialised for HCAs.   

•  A  second  main  reason  for  excluding  or  redrafting  items  was  that  they  were 
considered  to  require  too  high  a  level  of  knowledge  or  to  be  at  a  specialised  level. 
This,  for  example,  applied  to  having  specific  knowledge  of  human  anatomy.  Other 
participants  indicated  that  they  thought  HCAs  needed  to  have  only  a  basic  level  of 
knowledge in this field. ‘Showing entrepreneurship’ was also not considered to be an 
appropriate competence for HCAs by various stakeholders. 

•  Thirdly, it was also stated that certain items could only be included when the tasks 
were  performed  under  supervision.  Views  on  the  level  of  autonomy  of  HCAs, 
however, varied between stakeholders. In some countries, for example ‘carrying out 
care assignments according to a care plan without supervision’ is out of the question 
and HCAs should always be supervised. Another example is that HCAs in one of the 
countries work under the supervision of nurses or other healthcare professionals for 
at least three years. Also, it can be the case that HCAs work without supervision, but 
only performing delegated tasks. 

Various  points  were  also  raised  that  needed  further  specification  in  the  view  of  the 
participants, for example: 

•  Conduct basic activities  

72 

 
 
 
•  Clerical, administrative care planning issues 
•  Preparing meals: one participant indicated that if this includes cooking then it’s not 
part of the training, but if the task is just to assemble and heat the food, then it is. 

Sometimes the meaning was not clear to the participants of the workshop: e.g. one of the 
participants wanted to know what was meant by “mechanical cleaning”.  

In  addition,  some  further  issues  for  discussion  were  raised  related  to  the  content  of  a 
potential CTF:  
•  There was a general consensus that the core objective of a CTF should be patient safety 

• 

and quality, besides promoting mobility; 
In line with the previous point, participants pointed out that if a potential CTF is set at 
too  low  a  level,  this  may  threaten  patient  safety.  On  the  other  hand,  if  the  set  of 
knowledge, skills and competences is at too high a level, this may be a barrier preventing 
countries from supporting a CTF; 

•  The items included in a potential CTF should be mutually coherent;  
•  Additionally,  participants  stated  that  a  list  of  knowledge,  skills  and  competence  items 

should take account of: 

o  The legal regulations at the country level with regard to knowledge, skills and 
competences.  For  example,  in  various  countries  there  is  legislation  about 
which healthcare professionals are allowed to diagnose and prescribe. 

o  The  sectors  in  which  HCAs  are  active,  e.g.  the  hospital  sector,  home  care, 

long-term care and, to a lesser extent, primary care and psychiatry.  
Initial professional training and continuous vocational training 

o 
o  Patient perspective, including patient empowerment 

The participants also raised a number of questions that may need further exploration: 

•  Should  the  items  be  categorised  as  having  a  low,  average  or,  high  level  of 

complexity? 

•  Does the framework focus on general or specific settings, patient groups, levels and 

legislation? 

•  There is a need for further definition of what HCAs are, given the range of different 

definitions across the EU, and what CTFs are.  

9.2 Support for additional criteria to be included in a CTF 
A common training framework (CTF) is not limited to a minimum set of knowledge, skills and 
competences,  but  may  include  other  additional  criteria  as  well.  We  asked  the  Delphi 
participants to indicate which other criteria should be part of a potential CTF for HCAs (e.g. 
entry requirements for HCA education, language proficiency, and so on). There was a high 
level of agreement among Delphi respondents about the minimum set of other CTF criteria 
for Healthcare Assistants and all requirements that we asked about exceeded the threshold 

 
 
 
 
 
 
 
of  a  minimum  of  10  Member  States  agreeing  that  it  should  be  part  of  a  potential  CTF  for 
HCAs.  

Table  9.6:  Results  of  the  CC4HCA  Delphi  round  1  on  the  minimum  set  of  other  criteria  for 
HCAs 

Criterion should be part of CTF? 

Most consensus  3. Duration of HCA education 

6. Appropriate level of national language 
proficiency 
4. Theory-practice ratio of HCA education 
1. Entry requirements for HCA education 
2. Minimum age to enter HCA education 
5. Continuing Professional Development 
requirements for HCAs 

Least consensus 

Threshold for CTF 

% of Delphi 
respondents  
who said ‘yes’ 
92,6 
88,9 

N of MSs 
that said 
‘yes’15 
21 
19 

85,2 
77,8 
77,8 
77,8 

19 
17 
17 
17 

Threshold for CTF 

Duration of HCA education  
92,6%  of  the  Delphi  respondents,  representing  21  EU  Member  States,  believed  that  a 
potential common training framework for healthcare assistants at the European level should 
include the duration of HCA education. There was little agreement between the respondents 
who  agreed  with  this  statement  on  what  that  duration  should  be;  durations  mentioned 
ranged from 3 months to 48 months, with an average of 17,4 months. The most frequently 
mentioned duration was 12 months (N=7), closely followed by 24 months (N=6). 

Appropriate level of national language proficiency   
88,9%  of  the  Delphi  respondents,  representing  19  EU  Member  States,  believed  that  a 
potential common training framework for healthcare assistants at the European level should 
include  the  appropriate  level  of  national  language  proficiency  which  HCAs  should  have. 
There was little agreement among the respondents who agreed with this  on what that level 
should  be,  based  on  the  Common  European  Framework  of  Reference  for  Languages.  The 
threshold of 10 Member States agreeing was exceeded for none of the levels (see below). 

Level based on the Common European  
Framework of Reference for Languages 

N (%) of Delphi respondents  
who said ‘yes’ 

A1- Basic 

A2- Elementary 

B1- Intermediate 

B2- Upper intermediate 

C1- Effective operational proficiency or advanced 

0 (0%) 

1 (4,2%) 

7 (29,2%) 

5 (20,8%) 

6 (25%) 

15  For  member  states  with  multiple  competent  authorities,  we  applied  the  following  rule:  if  ≥  50%  of  the 

competent authorities said ‘yes’, the answer for the MS as a whole was considered ‘yes’. 

74 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
C2- Mastery or Proficiency 

Don't know 

Total who believe that a CTF should include  
level of national language proficiency 

1 (4,2%) 

4 (16,7%) 

24 (100%) 

Theory/practice ratio of HCA education  
85,2%  of  the  Delphi  respondents,  representing  19  EU  Member  States,  believed  that  a 
potential common training framework for healthcare assistants at the European level should 
include  the  theory/practice  ratio  that  HCA  education  should  have.  There  was  little 
agreement  among  the  respondents  who  agreed  with  this  on  what  the  ideal  ratio  between 
the theoretical and practical components in the education/training for HCAs should be. Eight 
respondents preferred a 50-50 ratio. A small majority of respondents (N=10) believed that 
the practical part should be greater than the theoretical part, but there was variation in the 
exact  ratio,  ranging  from  a  90:10  ratio  to  60:40.  Only  a  small  minority  (N=3)  believed  the 
theoretical part should be more extended.   

Entry requirements for HCA Education 
77,8%  of  the  Delphi  respondents,  representing  17  EU  Member  States,  believed  that  entry 
requirements for HCA education should be part of a potential common training framework 
for healthcare assistants. All respondents who agreed with this were asked to specify their 
answer:  

Entry requirements that should be part of a 
potential CTF for HCAs at European level 

Most 
consensus 

Secondary school graduation 

N Delphi 
respondents  
who said ‘yes’ 
18 

Successfully passing a health check 
Successfully passing an entry test 
Elementary school graduation 
Graduation at other school level 
Relevant work experience 

15 
15 
13 
10 
5 

Threshold for CTF 

Least 
consensus 

% 

No. of MSs 
that said 
‘yes’ 

85,7  16 

71,4  13 
71,4  13 
61,9  11 
47,6  9 
23,8  3 

Threshold for CTF 

Most respondents agreed that elementary and secondary school graduation should be entry 
requirements, just as successfully passing of a health check and entry test. For graduation at 
other  school  levels  and  work  experience,  the  threshold  of  one  third  of  all  Member  States 
agreeing was not exceeded. 

Minimum age for entering HCA education  
77,8%  of  the  Delphi  respondents,  representing  17  EU  Member  States,  believed  that  a 
potential CTF for healthcare assistants at the European level should include a minimum age 
for  entering  HCA  education.  Among  the  respondents  who  agreed  with  this,  there  was 
considerable  agreement  on  what  age  this  should  be.  The  most  frequently  mentioned  age 

 
 
 
 
 
 
 
 
 
 
 
 
 
was  18  (N=12),  exceeding  the  threshold of 10 Member States  agreeing. However,  answers 
provided ranged from age 15 to 20, with an average of 17,3..  

Continuing professional development requirements for HCAs  
77,8%  of  the  Delphi  respondents,  representing  17  EU  Member  States,  believed  that  a 
potential  CTF  for  healthcare  assistants  at  European  level  should  include  Continuing 
Professional  Development  (CPD)  requirements  for  HCAs.  Ideas  about  what  these  CPD 
requirements  should  look  like  vary.  While  most  respondents  opt  for  learning  credits  to  be 
obtained  per  time  period,  there  are  different  ideas about  the  minimum  number  of  credits 
and what time period should be used, ranging from 8 hours of CPD per year to 50 hours per 
year.  

9.3 EQF level of a potential CTF for HCAs 
Another  condition  that  a  common  training  framework  should  fulfil,  according  to  Directive 
2013/55/EU, amending Directive 2005/36/EC  16, is that it is based on European Qualification 
Framework  levels.  We  therefore  also  asked  our  Delphi  respondents  at  which  EQF  level  a 
potential CTF for HCAs should be positioned. Even though a potential CTF would only have 
one  EQF  level,  we  asked  respondents  for  the  desired  EQF  levels  for  knowledge,  skills  and 
competences separately, as we expected there could be differences in their views on these 
dimensions  (see  Table 9.7).  The  degree  of  agreement  among  Delphi  respondents  on  the 
appropriate  EQF  level  was  low  for  all  three  dimensions  (i.e. knowledge,  skills  and 
competences).  There  was  no  common  opinion  about  the  ‘right’  EQF  level.  Respondents’ 
views  on  EQF  levels  for  knowledge  and  skills  were  most  similar,  with  most  respondents 
opting for either EQF level 3 or 4, but the degree of agreement was low with 41.4% being the 
highest percentage of respondents agreeing on any given EQF level. For the minimum set of 
competences,  we  found  that  more  respondents  would  prefer  a  lower  EQF  level,  but  again 
there was no agreement on the exact level.  

Table  9.7:  Desired  EQF  level  for  the  minimum  set  of  knowledge,  skill  and  competence 
requirements (based on round 2 of the Delphi study) 

EQF level for minimum  
set of knowledge 
EQF level for minimum  
set of skills 
EQF level for minimum  
set of competences 

EQF level 1  EQF level 2  EQF level 3  EQF level 4  EQF level 5  Total 
0 
0% 
0 
0% 
0 
0% 

2 
6,9% 
2 
6,9% 
7 
24,1% 

10 
34,5% 
12 
41,4% 
10 
34,5% 

11 
37,9% 
10 
34,5% 
6 
20,7% 

4 
13,8% 
5 
17,2% 
4 
13,8% 

29 
100% 
29 
100% 
29 
100% 

9.4 Conclusions on the content of a potential CTF for HCAs 
Following  the  results  from  the  Delphi  survey  and  the  CC4HCA  workshops,  various 
conclusions can be drawn regarding the views of the stakeholders consulted on the content 

16 The full Directive 2013/55/EU including all required conditions can be found here. 

76 

 
 
 
 
 
 
 
                                                 
of  a  potential  CTF.  The  Delphi  study  showed  that  there  seems  to  be  a  general  consensus 
among the competent authorities of the EU Member States about what the core knowledge, 
skills  and  competences  of  HCAs  should  be.  This  is  most  true  for  the  knowledge  items  and 
least true for the competence items. Nevertheless, the threshold of one third of the Member 
States agreeing was exceeded for all three categories.  

While there is a fair level of consensus on the content of a potential CTF, the level at which 
these  content  items  should  be  situated  was  a  topic  of  substantial  discussion  between 
Member States, with little agreement reached. First of all, there is the issue of whether the 
required  knowledge,  skills  and  competences  should  be  formulated  at  a  ‘basic’  or  more 
specialised or in-depth level. Member States had different views on this. This became even 
clearer  when  looking  at  the  second  requirement  for  a  CTF,  that  the  knowledge,  skills  and 
competence items should be based on the levels of the European Qualification Framework. 
The degree of agreement among Delphi respondents on the appropriate EQF level was low 
for  all  three  dimensions.  Moreover,  there  were  discrepancies  between  the  views  of  the 
consulted  stakeholders  regarding  the  level  of  autonomy  that  HCAs  should  have  and  the 
required level of supervision, for example by nurses.  

A  final  conclusion  that  can  be  drawn  is  that  all  stakeholders  are  of  the  opinion  that  a 
for  example  concerning  the 
potential  CTF  should  have  additional  requirements, 
theory/practice ratio in training and the language requirements, but again there is a lot of 
variation in the views on exactly what these requirements should be. 

 
 
 
 
 
 
10.   The desirability and feasibility of a CTF as a legal instrument 

This  chapter  presents  the  views  of  EU  Member  States  and  European  professional 
organisations  on  the  desirability  and  feasibility  of  a  common  training  framework  for 
healthcare assistants as a legal instrument. Naturally, the desirability and feasibility of a CTF 
as  a  legal  instrument  are  related  to  its  content,  as  there  is  little  point  in  discussing  an 
abstract concept. However, the outcomes of the discussions presented here are at a broader 
level than merely the content of a CTF (as presented in Chapter 9). In the first section we will 
go into the drivers and barriers which were raised during two phases of the data collection 
(Delphi  and  workshops)  as  well  as  Member  States’  willingness  to  explore  a  CTF  for  HCAs 
further.  Subsequently,  we  will  outline  what  these  findings  mean  for  the  feasibility  and 
desirability of a potential CTF for HCAs.  

10.1 Drivers and barriers for a CTF for HCAs 

10.1.1  Barriers 
From the Delphi study and the workshops, various barriers for a potential CTF for HCAs could 
be identified: 
•  One barrier is the lack of a uniform Europe-wide accepted definition of what an HCA is. 
This  was  often  mentioned  at  the  beginning  of  discussions  and  was  acknowledged  as  a 
problem by all stakeholders. However, it did not prevent further discussions about a CTF 
from taking place.  

•  The main barrier seems to be the differences between and within countries concerning 
the level of HCAs and their education. During the workshop it was indicated that there 
are  huge  differences  in  the  levels  of  education  across  Europe  and  this  was  seen  as  a 
major barrier to establishing a CTF. Participants expressed the view that they would not 
be able to agree to a CTF if it was not in line with their own national framework. Related 
to this, concerns were expressed that if a CTF were to be adopted with a very minimal 
set of knowledge, skills and competences and a low EQF level, this would downgrade the 
level of HCAs. This was mentioned by various workshop participants as a reason for not 
backing a CTF. In the Delphi study, 5 out of 31 participants indicated that if the final level 
of knowledge, skills and competences adopted in a CTF was too low compared to what 
there  is  now  at  the  national  level,  this  could  even  be  a  ‘deal  breaker’  in  terms  of 
supporting a CTF for HCAs. On the other hand, the authorities from some countries were 
concerned  that  the  level  of  requirements  for  HCA  in  their  country  could  become  ‘too 
high’, so that potential conflicts could arise with the nursing role. 

•  The  potential  threat  of  HCAs’  knowledge,  skills  and  competences  overlapping  with  the 
scope  of  practice  of  other  health  professions,  particularly  nurses,  was  also  deemed 
problematic and a potential barrier for a CTF. For example, one particular item that was 
mentioned  in  the  workshop  was  the  administration  of  medicines,  which  is  often  only 
done by nurses or doctors and not by HCAs. This is related to difficulties surrounding the 
need for definition of what an HCA is, in particular in terms of the level of autonomy and 
supervision. For three Delphi participants, it would be a ‘deal breaker’ if they were asked 

78 

 
 
 
 
to  support  a  CTF  that  does  not  include  the  requirement  that  HCAs  must  work  under 
nurse  supervision  or  nursing  quality  control  of  their  activities.  Other  participants  also 
indicated that it is important that HCAs are supervised in their work, mainly by nurses. A 
related discussion point is that nurses might need new or additional supervisory skills to 
do this. 

•  Another  potential  barrier  is  the  current  educational  and  regulatory  frameworks  in 
various countries. These could potentially conflict with any CTF that is adopted. To study 
the  level  of  discrepancy  between  the  set  of  knowledge,  skills  and  competences  that 
country  representatives  could  agree  on  and  the  current  educational  and  regulatory 
frameworks, we included some questions about this in the final Delphi round. We found 
that for the complete set of knowledge, skills and competences, 15 to 17 Member States 
(depending on the specific item) indicated that their current educational and regulatory 
frameworks would match this set. Some 9 to 11 Member States indicated that there was 
a moderate or limited match and 1 to 4 Member States indicated that there would be no 
match  with this  set (for a  complete overview  of the  results  see  Appendix I).  Related to 
this, there were uncertainties about the future development of the HCA role at national 
level  and  how  this  would  be  affected  by  a  CTF.  Two  participants  also  specifically 
indicated that legislation in their own country would need to be changed in order to be 
able to adopt the CTF. 

•  Before a CTF for HCAs could be adopted, a number of the Delphi participants indicated 
that consultation with all relevant stakeholders about a potential CTF would be needed. 
For  two  Delphi  participants,  not  involving  all  stakeholders  would  be  a  deal  breaker 
stopping support for a CTF. During the workshops, it was also emphasised that the views 
of HCAs themselves and patients on this issue should be considered as well. A difficulty is 
that there is no European level organisation exclusively representing HCAs. 

•  A final but important barrier that participants mentioned when discussing a CTF for HCAs 
was  the  uncertainty  about  the  potential  consequences  once  it  is  implemented.  One  of 
the uncertainties centres on the issue of cross-border mobility. As no CTF for any sector 
has  been  implemented  yet,  workshop  participants  expressed  their  concerns  about 
whether a CTF would change mobility patterns or not. For countries where HCAs receive 
low  salaries,  this  uncertainty  is  accompanied  by  concerns  regarding  an  unintended 
increase in outflow and therefore a declining workforce. Related concerns regarded the 
traceability  and  quality  control  of  HCAs  working  across  borders,  in  particular  if  HCAs 
move  from  a  state  with  no  regulation  to  a  state  with  regulation.  Finally,  uncertainties 
were discussed about the conditions for a country to opt out from a potential CTF and 
what the economic consequences would be.  

10.1.2  Drivers 
Apart  from  the  barriers,  most  country  representatives  and  some  representatives  from 
European  organisations  also  saw  multiple  benefits  of  having  a  CTF  and  discussed  various 
drivers needed for a CTF to come into existence.  

 
 
 
 
•  First of all, the development of a CTF was seen as an opportunity to improve the national 
situation regarding HCAs. For example, a CTF may create the possibility of upgrading and 
optimising  skill  mixes  within  countries.  In  other  countries,  where  HCAs  are  not  yet 
regulated, it was mentioned that national regulation processes could be accelerated and 
supported  through  a  CTF.  A  couple  of  countries  are  also  in  the  process  of  defining  or 
redefining  the  role  of  HCAs  or  developing  qualifications  for  HCAs,  and  these  processes 
could be supported by a CTF as well.  

•  Benefits and drivers were also seen at the European level. As there is no clear vision yet 
on the role of HCAs at the European level, a CTF could create more transparency about 
what  the  standards  are  or  should  be  across  Europe.  During  the  workshop,  one 
participant  indicated  that  there  is  a  need  for  a  European-level  definition  of  HCAs:  who 
they are, what they do, and the basic levels of those workers. 

•  Another  important  driver  for  a  CTF  to  come  into  existence  is  its  potential  to  facilitate 
cross-border mobility. As stated earlier in this report as one of the rationales, a CTF may 
contribute  to  cross-national  collaboration  and  hence  to  a  solution  for  healthcare 
assistant  shortages  in  certain  countries.  At  the  same  time,  as  was  discussed  earlier,  a 
counter-effect may be that this leads to (greater) shortages in source countries.  

•  Finally, participants agreed that there is a growing need for healthcare assistants in many 
countries  as  a  key  healthcare  profession.  Awareness  is  high  in  all  countries  that  more 
people  need  special  care  and  the  amount  of  chronic  diseases  is  growing.  This  makes 
clarifying the position of HCAs in all MSs critical, in order to benefit fully from the HCA 
capacity in relation to the healthcare teams they are part of. This is an important result 
in  its  own  right,  regardless  of  the  controversies  as  to  whether  a  CTF  is  the  right 
instrument  at  this  moment  for  positioning  the  core  competencies  of  HCAs  and  to 
exploring its development. 

10.2 Willingness among EU Member States to explore a CTF for HCAs further 
If there is one clear finding that stands out from this study, it is the willingness of Member 
States  and  European  stakeholders  to  be  involved  in  exploring  a  potential  CTF  for  HCAs; 
however,  there  is  as  yet  no  common  position  on  making  a  formal  suggestion  to  the 
European  Commission.  This  was  evident  from  the  high  participation  rates  in  the  various 
steps of the study: the mapping exercise, the Delphi study and both workshops. In the final 
round of the Delphi study, we asked participants whether their country would be willing to 
engage in further exploration of developing a CTF for HCAs at the European level. Of the 31 
respondents, 29 answered “yes”, one answered “no” and one did not reply. The respondents 
also  indicated  in  what  way  their  country  would  be  willing  to  engage  in  further  steps.  The 
main ways they selected were: 

•  Further discussion about HCA regulation and education (n=7) 
•  Sharing experiences about HCA regulation and education (n=6) 
•  Via conferences, networking, workshops, etc. (n=5) 
•  Being involved in this and other studies on the same topic and play a ‘consultant role’ 

(n=5) 

80 

 
 
 
These  results,  from  before  the  workshop  discussions,  indicated  that  the  competent 
authorities across all MSs recognise the potential importance of a CTF for HCAs within the 
EU.  

10.3 Conclusions 
Based  on  the  results  of  the  Delphi  study  and  workshops,  there  is  still  a  large  gap  to  be 
overcome  when  we  explore  the  desirability  of  a  CTF  for  HCAs  on  the  one  hand  and  its 
feasibility on the other hand. While there is a clear need for the role of HCAs across Europe 
to be strengthened (inter alia in view of the common challenges facing healthcare systems 
across Europe) and a CTF could make more transparent what the standards are or should be, 
many  difficulties  will  have  to  be  overcome  before  a  CTF  would  actually  be  feasible.  These 
difficulties are mainly related to the current differences between countries, especially in the 
level of education and autonomy of HCAs. Furthermore, there are a number of uncertainties 
with  regard  to  a  CTF  that  make  countries  hesitant  to  embrace  the  instrument  at  this 
moment. These are for example related to the potential effects of a CTF on mobility, as well 
as the legal consequences of a CTF and the option of opting out. A first important step that 
should  be  taken  in  further  exploration  of  a  potential  CTF  for  HCAs  is  to  include  all 
stakeholders  in  the  countries  in  the  formal  decision-making  process,  including  HCAs 
themselves  and  hospital  employers  and  trade  unions,  and  to  ensure  that  stakeholders  are 
fully informed.  

 
 
 
 
 
 
11.  Further exploration of a CTF for HCAs and possible next steps  

As described in this report, the CC4HCA study aims to explore the desirability and feasibility 
of  a  potential  common  training  framework  for  healthcare  assistants  within  the  EU  as 
perceived by all 28 EU Member States. As a final step in this exploration process, this chapter 
sketches  a  roadmap  of  what  further  exploration  of  a  CTF  for  HCAs  may  entail  and  what 
issues  may  be  encountered,  should  interested  parties  decide  to  undertake  further 
exploration  of  a  CTF  for  HCAs.  It  does  this  by  first  providing  a  short  reflection  on  the 
willingness  for  such  an  exploration  among  the  Member  States  versus  their  perceptions  of 
the  feasibility  of  a  CTF  for  HCAs.  Subsequently,  we  discuss  potential  further  steps.  To 
structure  this  discussion,  we  started  from  Directive  2013/55/EU,  amending  Directive 
2005/36/EC, and the considerations that entered our study through various stakeholders. 

It should be noted that this chapter and its discussion should not be considered as an actual 
first step on the road towards a formal CTF process. We would like to stress once again that 
the exploratory nature of this CC4HCA study means that it merely presents the possibilities 
and the building blocks from which an actual CTF process may potentially be started, should 
there be parties interested in doing so. In other words, an actual CTF development process 
should have a bottom-up approach and originate from the interested parties, namely either 
one or more Member States or European-level stakeholders.  

We  conclude  this  chapter  with  some  reflections  on  the  design  and  route  of  the  CC4HCA 
study itself.  

11.1 Starting point: willingness to explore a CTF for HCAs further 
Based  on  the  Delphi  study  and  during  the  workshops,  we  observed  willingness  among  EU 
Member  States  and  European  stakeholders  to  be  engaged  in  further  exploration  of  a 
potential  CTF  for  HCAs.  At  the  same  time,  as  the  previous  chapters  showed,  the  actual 
feasibility  of  a  CTF  for  HCAs  is  challenged  by  a  substantial  list  of  barriers  perceived  by 
different authorities and stakeholders. This study shows that the desirability and feasibility 
of  a  CTF  for  HCAs  are  conditional  and  context-sensitive,  and  there  is  no  full  or  integral 
consensus among all Member States on all elements for supporting a CTF for HCAs. As a final 
step in our exploratory study, we have sketched possible future steps in the development of 
a CTF for HCAs, should a number of organisations or authorities from different EU MSs be 
willing to start such a process. 

11.2  Exploration  of  possible  future  steps  in  the  development  of  a  CTF  for 
HCAs 
To identify potential future steps in the development of a CTF for HCAs and the issues that 
interested  parties  may  encounter,  we  started  our  exploration  by  analysing  the  formal 
conditions  set  out  in  Art. 49a  of  Directive  2013/55/EU,  amending  Directive  2005/36/EC. 
Because every common training framework must comply with the conditions set out in this 

82 

 
 
 
 
 
Directive,  we  analysed  the  extent  to  which  ‘building  blocks’  are  in  place  that  could  be  a 
starting point for fulfilling the formal requirements of the Directive in the case of healthcare 
assistants.  Table 11.1  summarises  the  results  of  the  CC4HCA  study  against  the  seven  CTF 
requirements.  

Table  11.1:  Main  study  results  and  description  of  the  building  blocks  for  further  CTF 
compliance/exploration already in place 
A CTF must comply with the following 
conditions (Dir. 2013/55/EU, art. 49a): 

Main study results and description of the building 
blocks for further CTF compliance/exploration 
already in place: 
This cannot be predicted at the time. Some 
participants are concerned about the intended 
consequences of cross-border mobility of HCAs. 

The CC4HCA study found  that:  
HCA profession is regulated in 14 EU MSs and HCA 
education is regulated in 22 EU MSs 

The CC4HCA study showed that there is consensus on 
what the knowledge, skills and competences of HCAs 
could comprise (>  one third of the MSs agreeing), but 
the formulation of the level (basic versus specialised) 
and level of autonomy/supervision and other issues 
need further discussion. 
The CC4HCA study showed that it would currently not 
be feasible to reach agreement among the MSs on a 
single EQF level, but provided MSs with alternative 
interpretations of this condition. These could be 
explored further. 
HCAs are not covered by another CTF and do not 
benefit from automatic recognition under another 
system. 

The CC4HCA Study provided an initial building block 
for this by including representatives from all 28 EU 
Member States and a number of European 
professional organisations through the Delphi study 
and workshops. 
This would be an effect of an actual CTF and cannot 
be determined at the time. Some participants are 
concerned about the representation of HCAs by 
professional organisations. 

(a) The CTF enables more professionals to 
move across Member States   

(b) The profession or the education and 
training leading to the professions is 
regulated in at least one third of Member 
States  
(c) The CTF combines knowledge, skills and 
competences required in at least one third 
of the Member States  

(d) The CTF is based on European 
Qualification Framework levels  

(e) The profession concerned is not 
covered by another CTF and does not 
benefit from automatic recognition under 
another system 
(f) Preparation of the CTF following a 
"transparent due process", including the 
relevant stakeholders from Member States 
where the profession is not regulated 

(g) The CTF permits nationals from any 
Member State to acquire the professional 
qualification under such framework 
without being required to be a member of- 
or registered with any professional 
organisation. 

 
 
 
 
 
When looking at the formal requirements that every CTF must fulfil, we see that for two out 
of the seven conditions the building blocks for the HCA profession are already in place. This 
is  the  case  for  the  conditions  on  regulation (b)  and  the  lack  of  coverage  by  another 
automatic  recognition  system (e).  These  two  conditions  may  be  referred  as  “checkboxes”, 
for  which  a  clear  answer  can  be  provided.  For  the  other  five  conditions,  determining  the 
extent to which building blocks are already in place is more complex. This is partly due to the 
fact that these conditions cannot be predicted (conditions a and g), are harder to quantify or 
judge (condition f), but also because the discussions during the workshops revealed a large 
number  of  complex  discussion  points  associated  with  them  (conditions  c  and  d).  Parties 
interested  in  starting  a  formal  development  process  for  a  CTF  for  HCAs  will  therefore 
probably  encounter  difficulties  with  these  conditions  in  the  development  process.  We  will 
therefore  discuss  the  issues  with  regard  to  these  particular  conditions  as  found  in  our 
exploratory study on a CTF for HCAs.    

Condition  (a)  The  CTF  enables  more  professionals  to  move  across  Member  States  
The nature of this condition precludes any comments being made about it, as the CTF itself is 
the legal instrument that (through automatic recognition) will enable more professionals to 
move across borders. This study did not investigate cross-border mobility as such, but we do 
note  that  there  is  discussion  and  specific  doubts  among  stakeholders  (notably  among 
European-level organisations as well) about the intended or desired mobility of HCAs. These 
doubts  are  deepened  by  the  lack  of  valid  and  reliable  numbers  on  HCAs’  mobility.  As 
described  in  Chapter 4.3,  mobility  statistics  are  only  available  for  ‘second-level  nurses’,  an 
occupational title that largely but not fully overlaps with the group of HCAs. 

The lack of information about cross-border mobility as such does not necessarily have to be 
a barrier to creating a CTF. Still, it shows that is highly important to establish uniform data 
sources and statistics about HCAs across Europe to improve the monitoring of HCA mobility.  

Conditions (c) The CTF combines knowledge, skills and competences required in at least one 
third of the Member States, and (d) The CTF is based on European Qualification Framework 
levels  
We  came  across  a  number  of discussion  points among Member  States and  European  level 
organisations about these conditions. The two main discussion points are: 

•  How  should  autonomy  and  supervision  of  HCAs  be  defined  with  regard  to  the  set  of 
knowledge,  skills  and  competences  that  are  selected  for  a  potential  CTF?  And  how  are 
autonomy and supervision related to the other professions with which HCAs collaborate 
in practice?  

•  Can  or  should  consensus  be  reached  with  regard  to  the  qualification  level  of  the 
knowledge,  skills  and  competences  of  HCAs,  if  this  is  based  on  the  European 
Qualification  Framework?  Can  an  ‘appropriate’  consensus-based  educational  level  for 
HCAs at European level also be based on compliance with the MSs’ national qualification 
system for HCAs and related professions? 

With  regard  to  these  discussion  points  that  most  Member  States  are  involved  in,  the 
CC4HCA  report  provides  the  basis  from  where  these  discussions  can  potentially  be  taken 

84 

 
 
forward.  First,  there  is  the  set  of  knowledge,  skills  and  competences  that  came  out  of  the 
Delphi study, with more than one third of the Member States agreeing on their inclusion in a 
potential  CTF.  This  list  can  be  taken  as  a  starting  point  for  discussions  at  both  the  EU  and 
national  level  about  the  qualification  level,  autonomy  and  supervision  of  HCAs.  We  found 
that discussions are pending in half of the Member States about the position of HCAs. This 
implies  that  national  discussions  should  be  taken  into  account,  as  qualifications  and 
autonomy  of  occupations  are  determined  by  national-level  legislation.  In  this  context,  it 
should also be noted that a CTF does not include or apply a certain level of autonomy. The 
level of HCAs’ autonomy or supervision depends on the labour market in which they work. 
However,  MSs  and  European  stakeholders  see  this  as  a  point  to  be  kept  in  mind  already 
when discussing/drafting a CTF. This is because it would make no sense to draft a core set of 
knowledge, skills and competences for HCAs if the required level of autonomy to actually use 
or  put  the  content  of  this  core  set  into  effect  is  missing  in  practice.  In  other  words,  the 
current  differences  between  countries  in  terms  of  the  level  of  autonomy/supervision  of 
HCAs are already influencing the discussion on the content of a CTF. This is why autonomy 
and  supervision  of  HCAs  is  one  of  the  issues  to  be  discussed  further,  should  parties  be 
interested to work further on a CTF for HCAs. The outcomes of discussions at the European 
level and the exchange of practices among MSs may provide input for the discussions at the 
national level. 

The CC4HCA study showed that the condition that a CTF should be based on the European 
Qualification Framework is a complex issue. The Delphi study showed us that there is a low 
level  of  consensus  among  Member  States  on  defining  the  appropriate  EQF  level.  It  is  also 
important to note that not all countries have a national qualification system that is linked to 
the  EQF  system.  Moreover,  during  the  course  of  the  study,  it  also  became  clear  that 
alternative  interpretations  of  this  condition  for  a  CTF  are  possible,  which  makes  the  issue 
more complex. This issue will be explored further in the following section (11.3). 

Condition  (f)  Preparation  of  the  CTF  following  a  "transparent  due  process",  including  the 
relevant stakeholders from Member States where the profession is not regulated 

The  CC4HCA  study  provides  a  starting  point  for  fulfilling  this  condition  if  a  CTF  for  HCAs 
would  be  proposedin  future.  It  brought  together  representatives  from  all  28  EU  Member 
States  and  a  number  of  European  stakeholders  through  the  Delphi  study  and  workshops. 
However,  during  the  interactive  discussions  at  the  workshops  it  was  also  noted  that  a 
potential  further  exploration  of  a  CTF  for  HCAs  would  require  a  broader  involvement  of 
stakeholders.  This  includes  the  national  and  European  health  employers  and  health 
employee  organisations,  patient  organisations,  and  potentially  healthcare  insurers  and 
Ministries  of  Health  and  Education,  insofar  as  they  are  not  (or  do  not  overlap  with)  the 
competent authorities in each MS. 

Condition (g) The CTF permits nationals from any Member State to acquire the professional 
qualification under such framework without being required to be a member of- or registered 
with any professional organisation 

 
 
 
This condition is beyond the scope of the CC4HCA study. The condition implies the effect of a 
CTF  that  was  not  investigated  and  cannot  be  determined  until  a  CTF  for  HCAs  is  actually 
prepared  or  proposed.  This  is  a  reminder  that  our  study  concerns  the  exploration  of  the 
pathway towards a potential CTF, including its desirability and feasibility. 

11.3 ‘Roadmap’ fora potential suggestions for a CTF for HCAs 
In this section we sketch out a ‘roadmap’ that may guide interested representative European 
or national professional organisations (or competent authorities) that may want to work on 
a  suggestion for  a  CTF  for  HCAs.  This  roadmap  forms  the final  step  of  the  CC4HCA  study’s 
exploratory process and presents a number of recommendations. 

At this point, it should be noted once again that these recommendations should not in any 
way  be  seen  as  the  actual  start  of  a  formal  CTF  development  process.  The  CC4HCA  study 
remains  exploratory,  mapping  out  the  position  of  HCAs  in  the  EU  Member  States,  and 
mapping out the positions of Member States with regard to the desirability and feasibility of 
a CTF for HCAs. 

Figure 11.1 provides a schematic overview of the roadmap. Its elements will be described in 
more  detail  below.  The  timeline  presents  an  estimate  of  the  time  the  different  steps 
(building  blocks)  would  require.  Experience  of  CTF  proposals  that  are  currently  in 
preparation should confirm whether these estimates are realistic and feasible. 

Figure 11.1 Schematic overview of roadmap to help guide interested parties that may want 
work on a suggestion for a CTF for HCAs 

11.3.1 Major tasks 
Based on the outcomes of the CC4HCA study, the roadmap recommends the following major 
tasks to be performed by interested parties to work on a suggestion for a CTF: 

I. National-level stakeholder analysis and/or consultation  
Before  any  further  steps  can  be  taken,  a  prerequisite  is  involvement  of  all  relevant 
stakeholders at the national level in the development process of a CTF at the European level. 
This  requirement  was  particularly  emphasised  by  the  European  stakeholder  organisations 
that  participated  in  the  study,  stressing  the  point  that  the  current  and  future  position  of 

86 

 
 
 
 
 
 
 
HCAs  is  often  not  solely  defined  by  competent  authorities.  In  many  cases  and  practices, 
health employer and employee organisations are developing and implementing policies with 
regard  to  the  training,  occupation,  allocation  and  development  of  HCAs.  Competent 
authorities  within  each  Member  State  should  explore  the  need  to  consult  and  involve 
stakeholders  in  the  development  process  of  a  CTF  for  HCAs.  In  those  countries  where  the 
HCA profession and/or education are not regulated (on not yet), it will be critical that such a 
stakeholder analysis should be performed first to identify all the relevant parties. This also 
applies for Member States that have regions or countries with independent authorities for 
health  policy  and  regulations  (e.g. Germany, 
Italy,  Spain,  Sweden,  UK).  Obviously, 
stakeholder analysis at the national level will be more complex in Member States that have a 
decentralised or devolved healthcare system. 

After  all  relevant  national  stakeholders  have  been  identified,  a  stakeholder  consultation 
process at national level can be conducted. Whether this is necessary, and whether it should 
have a formal or more informal character, will depend on the Member State situation. We 
recommend a stakeholder consultation to: 

a.  generally  explore  the  willingness  at  Member  State  level  to  be  engaged  in  a  CTF 

development process, and 

b.  specifically  explore  the  ‘critical’  conditions  or  a  CTF  (see  section  11.2)  and  their 

implications for the national situation. 

The first task recommended as part of the roadmap is ensuring that competent authorities 
and all other national stakeholders are fully informed and feel confident that they support 
the countries’ standpoints at the EU level where applicable. 

IIa.  Define  a  common  position  on  the  knowledge,  skills  and  competences  as  pre-defined 
learning outcomes 
A second proposed step is that a common position is defined on the knowledge, skills and 
competences  that  a  CTF  should  include.  This  consensus  process  should  be  initiated  and 
supported  by  those  representative  European  or  national  professional  organisations  or 
competent authorities that are interested in developing a CTF for HCA.  

While  this  CC4HCA  study  actually  found  a  high  level  of  consensus  on  a  set  of  generally 
defined knowledge, skills and competences of HCAs, the Delphi rounds and workshops also 
showed a critical discussion on the contextual factors that are relevant for the content of a 
CTF  as  well.  This  concerned  the  qualification  level  of  the  CTF  elements,  and  the  level  of 
autonomy  and  supervision  of  HCAs.  For  example,  while  Member  States  agree  that  HCAs 
should have knowledge of the “principles of (manually and mechanically) positioning, lifting 
and transporting patients”, there was no consensus on whether this knowledge should be at 
a  basic  level  (to  support  other  health  professionals  in  the  process)  or  more  specialised 
knowledge (to independently transport all patient types). With regard to this second step of 
the  roadmap,  it  can  be  noted  that  the  list  of  knowledge,  skills  and  competences  resulting 
from  this  CC4HCA  study  is  a  useful  base  for  further  exploration.  However,  there  is  no 
common position among EU Member States on all elements of a CTF of HCAs.   

 
 
 
To  execute  this  second  task  of  the  roadmap,  and  to  overcome  the  barriers  found  in  this 
study,  it  is  recommended  that  formulating  learning  outcomes  for  HCAs  should  also  be  an 
aim. Learning outcomes can be considered as a key pillar of the content of a CTF, from which 
the  desired  knowledge,  skills  and  competences  can  subsequently  be  derived.  It  can  be  an 
alternative  route  for  exploring  whether  EU Member  States agree  on  the  learning  outcome 
definitions for HCAs in a potential CTF. If this is the case, these learning outcomes may be 
adjusted more easily to the national (legal) context of Member States. This might also lower 
the barriers with regard to the allocation of qualifications and the application of the EQF (see 
step III). 

IIb. MS level feedback 
Achieving a common position on the content of a CTF for HCAs should preferably be done 
iteratively. As noted before, it is critical that all representative actors at the European level 
and the national stakeholders are involved in this process. The desirability at the MS level of 
a CTF for HCAs should be monitored, as well as the feasibility of proposals made at the EU 
level.  Continuous  feedback  to  the  MS  level  will  allow  problems  or  conflicts  with  national 
legislation to be identified at an early stage and taken back into the EU-level discussions.  

III. Define the educational level of a CTF  
If  a  common  position  on  the  knowledge,  skills  and  competences  has  been  defined,  the 
qualification level of a CTF can be defined. It became clear from the Delphi rounds within the 
CC4HCA study that there is little agreement among the Member States on the EQF level that 
can (or should) be associated with the core knowledge, skills and competences of an HCA. 
Also during the workshop rounds, the assignment of an EQF level to the HCA profession and 
its  core  competences  generated  critical  discussions.  These  centred  around  the  risk  of 
underemployment  or  overeducation  of  HCAs,  the  financial  consequences  for  national 
healthcare  budgets  and  healthcare  employers  if  HCAs  were  to  be  'upgraded',  and 
unintended  competition  between  professions  on  domains  and  positons.  Again,  the 
alignment between national and European qualifications was a general point of concern. In 
several  countries,  debates  are  currently  ongoing  on  the  risk  of  restructuring  the  national 
system of education (including health education), and the associated time and budgets that 
need to be allocated for European harmonisation.  

One  solution  for  overcoming  this  discussion  that  was  discussed  during  the  CC4HCA 
workshops  is  to  interpret  the  requirement  that  a  CTF  should  be  based  on  European 
Qualification Framework levels in the following way:   
•  Make the CTF a reference for national qualifications; 
•  Link HCAs’ national qualifications to a national qualification framework; and 
•  Link  the  national  qualification  frameworks  to  the  European  Qualification  Framework 

(which is often already the case). 

This  allows  the  Directive’s  conditions  for  a  CTF  to  be  fulfilled,  while  each  Member  State’s 
specific national context can be taken into account. Obviously this implies that the proposed 
roadmap explicitly changes between the MS and EU levels, as addressed in step IIb. 

IV. Submit the application of a CTF for HCAs to the European Commission 

88 

 
 
After  steps  I  to  III  have  been  completed,  the  interested  parties  can  formally  submit  a 
proposal for a CTF for HCAs to the European Commission. A number of CTF applications are 
currently being prepared, as well as a further description of the guidelines that need to be 
followed. For this final step, it should be remembered that the results of this CC4HCA study 
are  not  aimed  at  actually  submitting  or  preparing  a  CTF  application  for  HCAs.  The  study 
provides  information  about  (and  insights  into)  the  barriers  actors  can  encounter  when 
following the roadmap proposed in this section. The same needs to be remembered for the 
recommendations  for  overcoming  these  barriers  based  on  the  CC4HCA  study  results. 

11.3.2 Recommendations for process management 
The  proposed  roadmap  consists  of  a  number  of  core  tasks  to  be  undertaken,  should 
interested parties be willing to start a formal CTF development process for HCAs. As this is a 
complex process including many stakeholders with different interests and acting at different 
levels, this needs to be managed if it is to succeed. The recommendations below are not part 
of the formal CTF process as such, but are listed to assist parties interested in developing a 
CTF  for  HCAs.  The process  management  recommendations  are  based  on  the results  of the 
CC4HCA study.  

Ensure fully informed stakeholders to enable informed decision-making 
An  important  barrier  that  was  identified  by  the  CC4HCA  study  was  the  uncertainty  among 
stakeholders  regarding  a  CTF  as  a  legal  instrument.  Uncertainties  were  related  to  the 
potential  effects  of  a  CTF  for  HCAs  and  the  legal  and  financial  implications  of  CTF  at  the 
national level. This uncertainty can make Member States reluctant to explore a CTF, even if 
they  could  potentially  agree  on  its  content  and  educational  level.  Care  must  therefore  be 
taken  that  as  much  detailed  information  as  possible  about  a  CTF  is  available  for  all 
stakeholders.   

To  achieve  this,  the  European  Commission  could  develop  more  in-depth  background 
information on CTFs, apart from the (restricted) information that is available in Art. 49a of 
Directive 2013/55/EU, amending Directive 2005/36/EC, for example on the legal status of a 
CTF,  opt-out  possibilities  for  Member  States  and  the  possibility  of  adjusting  a  CTF  to 
changing health workforce needs. At the national level, our study showed that stakeholders 
are uncertain about the financial consequences, consequences for national health systems, 
health workforce structures, and so on. National-level stakeholder consultations can only be 
organised effectively and better-informed decisions can only be taken about the implications 
of adopting a CTF for HCAs if the stakeholders are properly informed.  

Ensure that potential language barriers are removed  
A  second  important  aspect  of  the  CTF  development  process  that  was  brought  up  by  the 
CC4HCA  study  participants  is  language  proficiency.  The  discussion  about  a  CTF  and  the 
definition  of  a  core  set  of  knowledge,  skills  and  competences  may  be  very  specific.  In  the 
CC4HCA study, stakeholders from 28 MSs participated, most of which do not have English as 

 
 
 
 
 
a  first  language.  During  the  Delphi  rounds  and  the  workshop,  this  sometimes  hindered  a 
thorough discussion of the meaning of knowledge, skills and competences sets and terms. In 
taking next steps for proposing a CTF and formulating its content, interpreters may need to 
be used at critical points in the process, e.g. in the formulation of learning outcomes.  

Time management 
Finally,  time  and  momentum  are  essential  and  strategic  conditions  in  the  development 
process of new legal instruments such as a CTF. This is specifically the case for EU decision-
making that take place in complex political and trans-national settings. As the CC4HCA study 
shows, it takes considerable time to collect all the relevant information for a CTF. Investment 
in  networks  and  contacts  is  needed  for  identifying  the  right  stakeholders  and  competent 
authorities  for  all  Member  States,  and  bringing  them  together  to  explore  whether  the 
conditions  for  a  CTF  can  be  met.  This  study  shows  what  the  current  status  and  consensus 
are, but this can obviously change over time.  

11.4 Reflections on the CC4HCA study 
In terms of deliverables, the CC4HCA study had three main objectives:  

1. 

2. 

3. 

To identify the representative national or European professional organisations (or 
competent authorities) that would be interested in working on a suggestion for a 
common training framework (CFT) for healthcare assistants (HCAs)  
To set up a network that can establish a common position on a set of knowledge, 
skills  and  competences  combining  the  knowledge,  skills  and  competences 
required in at least 12 Member States.  
To  provide  input  (a  common  position  on  the  set  of  knowledge,  skills  and 
competences and a feasible roadmap) for interested representative European or 
national professional organisations (or competent authorities) that might want to 
engage in working on a suggestion for a CTF for HCAs. 

These objectives have been achieved to a large extent, but also appeared ambitious. This is 
largely  due  to  the  lack  of  standardised  information  about  HCAs  across  Europe,  the  large 
diversity  found  across  Member  States,  and  the  complexity  of  exploring  all  the  relevant 
conditions for a potential CTF for HCAs.  

Nevertheless,  the  CC4HCA  study  was  successful  in  identifying  and  consulting  the  main 
country experts, competent authorities and relevant stakeholders in all EU Member States 
that exist specifically for healthcare assistants. This took a considerable time and it was not 
always clear who was the actual competent authority in a Member State, or for countries or 
regions  within  Member  States.  The  actual  ‘measurement’  of  the  two  key  concepts  of  the 
study – the ‘desirability’ and ‘feasibility’ of a CTF for HCAs among Member States –, was a 
challenging  task.  Different  methods  and  sources  were  applied  that  led  to  the  conclusions 
described in this report, but a number of options for additional research remain. 

Another  reflection  at  this  stage  is  that  it  is  hard  to  identify  the  network  or  a  group  of 
Member  States  that  represents  a  common  position  for  actually  proposing  a  CTF  for  HCAs. 

90 

 
 
 
We have provided the building blocks and a roadmap for such a group or network, but, as 
noted  in  this  report,  the  actual  proposal  or  preparation  of  a  CTF  for  HCAs  is  outside  the 
scope  of  this  study.  We  would  like  to  stress  once  more  that  an  actual  CTF  development 
process  should  have  a  bottom-up  approach  and  originate  from  the  interested  parties, 
namely either one or more Member States or European-level stakeholders. 

Reflections on the study approach 
The approach taken by the CC4HCA study in exploring a potential CTF development process 
should  not  be  considered  as  a  ‘golden  standard’  or  ‘blueprint’  on  how  to  conduct  a  CTF 
development  process.  Other  approaches  could  also  be  taken  and  the  choice  of  a  certain 
approach  depends  partly  on  the  profession  concerned.  For  example,  the  European 
Association  of  Hospital  Pharmacists  is  currently  developing  a  CTF  for  hospital  pharmacists 
and  included  an  exercise  for  gathering  existing  evidence  in  their  approach.  This  exercise 
includes  an  exploration  of  the  experience  and  attitudes  of  hospital  pharmacists  to  labour 
mobility (EAHP, 2016).  

Finally,  it  should  be  remembered  at  this  point  that  HCAs,  as  an  occupation,  have  weak 
representation and limited organisational strength in many Member States and especially at 
the European level. The rationale of this study was to explore the desirability and feasibility 
of a CTF from a European and governmental perspective. Improving the position of all health 
occupations – including those that are poorly represented – is a collective responsibility. 

 
 
 
 
 
 
Abstract 

Background: This report presents the findings of the study ‘Core Competences of Healthcare 
Assistants  in  Europe’  (CC4HCA),  which  aimed  to  map  out  the  position  of  healthcare 
assistants in all 28 EU Member States and explore the feasibility to adopt a common training 
framework  for  this  professional  group  under  Directive  2013/55/EU,  amending  the 
Professional  Qualifications  Directive  (2005/36/EC),  and  interest  among  Member  States  for 
doing so.  
Methods: Firstly, the roles of HCAs in all 28 EU Member States were mapped out, including 
identification  of  competent  authorities  and  European  stakeholder  organisations.  Next,  a 
Delphi study of three rounds was organised with the competent authorities, followed by two 
interactive workshops with the Delphi participants and European stakeholder organisations. 
Results:  Country  informants  and  Delphi  participants  from  all  28  Member  States  actively 
participated  in  all  parts  of  the  study.  The  map  of  the  current  situation  shows  substantial 
variation between European countries in HCAs’ roles in terms of education, regulation and 
the  tasks  they  perform.  There  appears  to  be  consensus  among  EU  Member  States  on  the 
need  to  define  the  role  of  HCAs  across  Europe.  There  was  also  consensus  between  EU 
Member  States  on  the  core  knowledge,  skills  and  competences  of  HCAs  that  could  be 
included in a CTF, although further refinement would be required. At the same time, there 
was a great deal of discussion on the differences between Member States with regard to the 
qualification level that this set should have. In terms of feasibility of a CTF, Member States 
and European stakeholder organisations see barriers regarding a number of conditions that 
are formally required for proposing a CTF. There is also perceived uncertainty about a CTF as 
a new EU legal instrument and its potential consequences for national training, occupation 
and financing systems. 
Conclusion:  There  is  willingness  among  Member  States  and  European  stakeholders  to  be 
involved  in  further  exploration  of  a  potential  CTF  for  HCAs.  A  possible  roadmap  has  been 
sketched  out  for  stakeholders  at  the  national  and  European  level  who  are  interested  in 
developing a CTF for HCAs. 

92 

 
 
 
 
 
 
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doi: 10.2818/49804