Ordem dos Enfermeiros

Ordem dos Enfermeiros Green Paper: Modernising the Directive on the Recognition of Professional Qualifications Regarding the modernisation process of the Directive on the Recognition of Professional Qualifications, the European Commission published a document [COM(2011)367/4], entitled Green Paper - Modernising the Directive on the Recognition of Professional Qualifications According to the planned scheduled up to the end of this year, a proposal for a revised directive to modernize the existing Directive 2005/36/EC will be presented. The Ordem dos Enfermeiros is a public association established in 1998, free and autonomous in the scope of its attributions, with juridical personality, independent of the State, competent authority and representative of nursing and midwifery graduates who practice in Portugal, in compliance with the principles of their constitution and the applicable legislation. The main aim of the Ordem dos Enfermeiros is to promote the defence of the quality of nursing and midwifery care rendered to the population, as well as to develop, regulate and control the practice of nursing and midwifery, guaranteeing that ethical and professional deontology rules are respected. In the above mentioned capacity we would like to provide some general comments which we believe will contribute to a better understanding of the detailed contributions submitted as answers to the questions of the Green Paper, in the hope that better conditions will exist to safeguard the interests of the health sector, where the responsibilities of the competent authorities (hereinafter referred to as CA) are an essential pillar in the framework of quality assurance and safety of care provided for citizens in Portugal. This Green Paper is based on the premise that the restrictive regulation of professional qualifications has the same stifling effect on mobility as discrimination on the grounds of nationality and that the burdensome and unclear procedures for the recognition of professional qualifications were identified in the EU Citizenship Report 2010. Its introduction contains the projections of the European Centre for the Development of Vocational Training (Cedefop) and the projected shortage of one million health professionals. Although they are articulated, we do not feel that to better manage mobility of health professionals, can be done by further strengthening their general workforce policies and by the possibility of obtaining the recognition of their qualifications in another Member State. Hence the Directive cannot, as intended in the introduction, simply set out clear and simple rules for the recognition of professional qualifications. At the same time, the rules must ensure high quality of services without themselves becoming an obstacle to mobility. Regardless of the choices made in the processes of recognition, it is essential to ensure that there will be no restrictions to the powers of the competent authorities of the host States from exercising their responsibility for verification and the validation of processes. It adds that the modernisation of the Directive may bring new functions to the CA that must be wholly evaluated to understand its impact on these structures, including the financial impact. The EU s structural funds can and may be used to support this investment. If created the professional card should only be a tool for mobility within the EU and not an identification of the professional before patients or employers. Partial access cannot be considered in the case of health professions as it can compromise the safety and integrity of patient care. Ordem dos Enfermeiros Page 1 of 12

Question 1: Do you have any comments on the respective roles of the competent authorities in the Member State of departure and the host Member State? With the institutionalisation of the professional card, the power to verify and recognise the professional qualifications required for the exercise of the profession in the territory is no longer centralised on the competent authority of the host Member State. The responsibilities will be split between the departure Member State and the host Member State, and the latter will be bound to the information contained in the card, issued by the departure Member State, who will be responsible for verifying the qualifications. This change has implications in the recognition procedure and requires a considerable amount of trust between the competent authorities. In this context, and of the choices made in the processes of recognition, it is essential to ensure that there will be no restrictions to the powers of the competent authorities of the host States from exercising their responsibility for verification and the validation of processes. We base these reservations on the fact that the CA in the various MS of the Union are not of the same nature and do not have the same powers. Most of them have different missions, tasks and objectives, and the resources they allocate to the process of recognition of professional qualifications are not the same. Similarly, the criteria guiding the choice of CA differ from State to State. It is with this reality and within this context that different approaches may result in the recognition process, especially in 3 points: 1 st Approach of the recognition procedure recognition procedure focused on professional competences vs. approach based on the administrative component; The difference between the two approaches relates to the specific knowledge that each CA has of the professions it integrates. For example, a CA in charge of all the health professionals will find it more difficult to apply competent technical accuracy to each specific profession. 2 nd Presence or absence of disciplinary power by the CA; Not all CAs have disciplinary power over professionals. In the absence of this assignment, it is important to ensure the articulation between the CA and the bodies of the country responsible for this field. 3 rd Different human, material and financial resources allocated to the recognition process; The introduction of the professional card, as defined in the Green Paper, will mean increased costs and work for the CAs of the departure countries. In this sense, some competent authorities of the departure State will cope better than others with this increase. If the CAs have fewer resources, it is expected that the verification of the recognition terms will be performed with a different accuracy and precision (less thorough). In practice, the philosophy expressed is contrary to the current practice. The accuracy applied in the process of recognition of qualifications will not depend on the host country, but on the accuracy of the different departure countries of professionals. This can result in discrepancies in the recognition procedure within the same CA of the host country, which will deal with different working methods of CAs of the various departure countries. However, it should be noted that this change of roles may enhance greater accountability of CAs regarding the migration process, including the sharing of responsibilities, thus supporting the migrating professional, and force a greater contact between CAs, fostering greater trust and facilitating the institutional relationships between the various EU states. Ordem dos Enfermeiros Page 2 of 12

We consider relevant the proposal to exclude commercial entities from the potential issuers of the professional card. In view of the interests involved, it is important to safeguard the interests related to the recognition of professional qualifications for the practice of the profession in another Member State, when confronted with those of entities whose social purpose is to obtain profits. Question 2: Do you agree that a professional card could have the following effects, depending on the car holder s objectives? Before further analysis, it should be noted that the non-binding nature of the ownership of a professional card raises the issue of the need to predict several regimes depending on whether or not the holder chooses to obtain the card. This can raise difficulties to the legislator and to the CAs when dealing with two different regimes. Moreover, the uncertainty of the Green Paper as regards both the content of the professional card and the eventual necessary checks are listed as a subsidiary and residual mechanism. This, it is important to question the changes deriving from the introduction of the card, in terms of reporting the information to the recipients of the services secured by the providers. Depending on the information included in the professional card and the professional security and reliability of the card, it will be possible to discuss those effects. The document does not specify how or which competent authority will check the validity of the card shown by a professional, hence we have to conclude that this check must be performed by a competent authority in the Member State service provider. a) The card holder moves on a temporary basis (temporary mobility): Option 1: the card would make any declaration which Member States can currently require under Article 7 of the redundant Directive. The absence of a prior declaration is supported on the principle that the possession of the professional card issued by the departure Member State is an identity document that replaces the national register. This option makes it impossible for the CAs and regulators to fulfil the legal duty (at least in some countries, including Portugal) to register all professionals working in the country. This is especially important considering the protection of the citizen, by controlling the quality of the practice, as well as the ethical aspects of professional practice, which in this model would be impossible. Furthermore, the use of the professional card as an identity document originates different professional identification cards, making it difficult to be identified by the citizen and national employers which is the organisation with powers to recognize the professional titles. In some countries, such as Portugal, the professionals (in this case, the nurses and midwives) are identified by their professional card (Cédula Profissional) issued by their national regulator and professional association. The emergence of another instrument that differentiates this procedure in the same territory, in addition to not being useful, in our opinion, does not benefit the safety and credibility of the process. - Option 2: the declaration regime is maintained, but the card could be presented in place of any accompanying documents. Opting for the centralisation of powers within the departure Member State to verify necessary requirements for the recognition of qualifications, either automatic or case-by-case, should provide the host Member State the corresponding safety and, in our opinion, should not restrict the powers of the competent authority from exercising its powers under the penalty of being bound to a decision to which they are committed. Ordem dos Enfermeiros Page 3 of 12

Therefore, access to the full documentation of the professional should be given to the host CA for this, we suggest the use of computing platforms, such as the IMI system (already in use by the European Commission and CAs), and instruments that allow automatic translation. These assumptions having been met, we believe the second option is more feasible, since it solves most problems identified in the previous option. b) The card holder seeks recognition of his qualifications: presentation of the card would accelerate the recognition procedure (host Member State should take a decision within two weeks instead of three months). Once again we say that opting for the centralisation of powers within the departure Member State to verify necessary requirements for the recognition of qualifications, either automatic or case-by-case, should provide the host Member State the corresponding safety and, in our opinion, should not restrict the powers of the competent authority from exercising its competences under the penalty of being bound to a decision to which they are committed. While, on the one hand, this system already raises some concerns regarding the temporary exercise, the systems that aim to ensure the possibility of establishing that exercise should deserve special consideration, given the restriction of powers resulting from the shift of responsibility from the authorities concerned. Depending on the clarification of these issues, we believe it is possible to achieve a more or less significant reduction of the decision deadlines. Consequently, we feel that to reduce the decision deadline from 3 months to 2 weeks is far too drastic, especially if some information needs to be further verified. The card may speed up the recognition procedure, giving more credibility to the documents required by the Directive, because these are checked by the competent authority of the departure Member State, and may contribute to a reduction from 3 to 1 month. In light of what we have said, in our opinion with the electronic instruments available to us it makes no sense to create a physical professional card. The need for printing and updating would represent an unnecessary cost and its validity would be too limited. The IMI platform can be used to support this card. That is, it should be an electronic certificate issued by the CA of the departing country, which immediately sends the request and information to the host country. The speed of the entire procedure with an electronic card of this type is significantly higher since it reduces the decision time of the CA of the host country, and reduces the time it takes for the documents to reach its destination. c) The card holder seeks recognition of his qualifications which are not subject to automatic recognition (the general system): presentation of the card would accelerate the recognition procedure (host Member State would have to take the decision within one month instead of four months). This procedure should be considered. In the general regime, the professional may have the need for compensatory measures and the evaluation of the procedure is done case-by-case, which is more time consuming. In this sense, we suggest that the application to the general regime of the professional card should be in a second phase after an extended discussion of its effects and consequences. So the first phase should work only for the regime of temporary mobility and automatic recognition. Ordem dos Enfermeiros Page 4 of 12

Question 3: Do you agree that there would be important advantages to inserting the principle of partial access and specific criteria for its application into the Directive? (Please provide specific reasons for any derogation from the principle.) Taking into consideration the various professions included in the Directive, and having analysed only the principle, we agree with the partial access. However, its application to health care and to the professionals in the practice, can lead to a corseted vision of the person/patient or service user. So, mindful of the explanation, we disagree with partial access in nursing and midwifery. In Portugal, there aren t various levels of nurse/midwife nor the possibility, professionally speaking, to segment the practice. The lack of vision of the individual s unity has originated equally corseted interventions causing waste of resources and producing results below expectations. In our opinion, partial access should not be applied to health professionals. The integration of the principle in the Directive, as well as the application criteria and exceptions, must be done very carefully because of the implications stemming from them. Question 4: Do you support lowering the current threshold of two-thirds of the Member States to one-third (i.e. nine out of the twenty seven Member States) as a condition for the creation of a common platform? Given the purpose of common platforms, the waiver of compensation measures (test or adaptation period) for recognition of qualifications in professions that do not benefit from automatic recognition raises no special caution as to the recognition of qualifications for the exercise of the nursing or midwifery profession. However, we still need to address and pinpoint the cautions needed in the recognition of qualifications for the exercise of the profession as listed in Annex II of the Directive, incorrectly identified as Nurse. when in fact these are technicians with training limited to specific areas that do not fit into a broader vision of what is implied in nursing care. This is an historical process in which the modernisation of this directive should find the tie limits of its application within the recognition of qualifications context. The information obtained from contacts with other CAs is that the training level of these programmes is usually quite low, seen in the light of the Bologna process. The creation of common platforms with this type of training will result in difficulties in the recognition of qualifications in countries that have not adhered to the platform, since most of these courses have no structure to be recognised. The accession of new countries to the EU, with less developed levels of nursing and/or midwifery education, will make it possible to meet the requirement of having nine countries for the creation of platforms in these areas (according to the proposal of the European Commission), which will create two different regimes in Europe as far as Nursing and Midwifery are concerned, and is not justified. Do you agree on the need for an internal market test (based on the proportionality principle) to ensure a common platform does not constitute a barrier for service providers from non-participating Member States? (Please give specific arguments for or against this approach). No informed opinion. Ordem dos Enfermeiros Page 5 of 12

Question 5: Do you know any regulated professions where EU citizens might effectively face such situations? Please explain the profession, the qualifications and for which reasons these situations would not be justifiable. This question is based on the assumption, expressed in the Green Paper, that if a professional already works in a given country where that profession is not regulated nor has lower training levels, his professional recognition should be made easier, circumventing the minimum conditions laid down in the Directive. In the provision of health care, the safeguard of quality and safety of care, must be above any other objective, be it mobility or another. This attempt to circumvent the rules violates the principle of subsidiarity by assuming that one can harmonise the eligibility requirements for access to a profession at the lowest common denominator in the EU. In this sense, considering that the Directive addresses the minimum training requirements, it cannot limit the Member States which believe should go beyond the minimum in order to guarantee the best responses to the citizens. Question 6: Would you support an obligation for Member States to ensure that information on the competent authorities and the required documents for the recognition of professional qualifications is available through a central online access point in each Member State? The measures taken in respect of access to information and e-government cannot be such that they impair or affect the exercise of the powers reserved to the competent authorities, as is the case of Ordem dos Enfermeiros. The central national contact points of certain activities should follow certain logic to ensure access to information as instrumental to the exercise of other rights by professionals near the legally competent bodies, under penalty of dispersion of responsibilities and the exercise of powers under less legal safety. Therefore, safeguarding the lack of confusion between functions, powers and duties of the competent authorities and of the national contact points, this sharing of information can be useful for professionals, and may become an instrument in the transparency of processes and access to information, regarding which we can do no other than agree. Would you support an obligation to enable online completion of recognition procedures for all professionals? (Please give specific arguments for or against this approach). We agree with the principle, however, that the online completion of the procedures should be complemented by a documentary check. Even if uploading documents is possible, they should be checked. On the other hand, the creation of e-government functionalities for the purposes listed above should take into account the financial costs and the assuming of responsibilities resulting thereof for the various authorities involved, namely the competent authorities. The competent authorities should also have time to adapt to this process, if it becomes mandatory. Question 7: Do you agree that the requirement of two years professional experience in the case of a professional coming from a non-regulating Member State should be lifted, when a professional accompanies a client? Considering the area of health care and the importance of ensuring professional competences and protecting the citizen and the professional who are outside their country, we do not agree that the two-year requirement be lifted. In fact, we consider that it should eventually be three years, with regard to nurses and midwives, based on Benner s theory that supports the stages in the evolution of professional maturity and safety. Ordem dos Enfermeiros Page 6 of 12

Should the host Member State still be entitled to require a prior declaration in this case? (Please give specific arguments for or against this approach). Considering the disagreement with the previous question, this context should not apply. Question 8: Do you agree that the notion of regulated education and training could encompass all training recognised by a Member State which is relevant to a profession and not only the training which is explicitly geared towards a specific profession? (Please give arguments for or against this approach). Regulated training should be geared towards a specific profession. To broadband it, in disciplines or related areas, may weaken the necessary preparation for a profession. Question 9: Would you support the deletion of the classification outlined in Article 11 (including Annex II)? (Please give specific arguments for or against this approach). The question is not really the classification into five or eight levels, but the coherence of processes and principles. This matter requires further analysis given that the Union has a European Qualifications Framework which provides 8 levels. The existing diversity calls for dimensions to be taken into account that do not compromise the transparency and coherence of the system. Question 10: If Article 11 of the Directive is deleted, should the four steps outlined above be implemented in a modernized Directive? If you do not support the implementation of all four steps, would any of them be acceptable to you? (Please give specific arguments for or against this approach.) Step 1 Article 14 (1) of the Directive defines the conditions according to which the host Member State can impose compensation measures. The Commission s proposal: deletion of the condition: difference in the duration of training of at least one year in itself is currently a justification for the compensation measures. Advantages and disadvantages: The duration of training in itself should not be an exclusive criteria, but it is an objective indicator and easy to measure on the type of training. It may not be the case that, in itself, requires compensation measures, but along with another condition, it may happen. For example, one year less of training and x hours less (4 600 hours for Nursing, for example). To delete this condition alone can cause major discrepancies in training in Europe. If it were to be done, it should be complemented by another evaluation system number of ECTS. Step 2 Deletion of the following condition: professionals are required to have at least two years of professional experience if their profession is not regulated in their home Member State. If they do not fulfil this requirement, they cannot currently benefit from the general system. Advantages and disadvantages: It is true that there is no reason why professionals with less professional experience should be excluded, but in the absence of regulation in the home country, evaluation conditions and quality assurance must be created. Professional experience may not be a mandatory condition, but is an indicator that, if it were deleted, should be replaced with one that meets the objective of safeguarding quality. Once again, the analysis of competences and the number of ECTS, if they were defined, should be the solution to which we should be heading. Ordem dos Enfermeiros Page 7 of 12

Step 3 Deletion of the classification (Article 11) and the explicit definition of the reasons that the CA should give when imposing compensation measures (see text) Advantages and disadvantages As regards the deletion of the classification (Article 11), please see the answer to question 9. For the remaining parts, we have no objections to the definition of measures that increase transparency. Step 4 Obligation of the essential provisions of the Code of Conduct for national administrative practices falling under the Directive (such as the requirement for competent authorities to offer aptitude tests twice a year). Advantages and disadvantages The Code addresses issues of transparency, administrative agility and respect for the rights of migrating professionals. The design of mechanisms that facilitate mobility are welcome, however it is advisable to consult the CA for the integration of contributions, considering that the CAs were not consulted in the construction of this Code. Question 11: Would you support extending the benefits of the Directive to graduates from academic training who wish to complete a period of remunerated supervised practical experience in the profession abroad? (Please give specific arguments for or against this approach). In the case of regulated professions (listed in Annex V), we see no need to restrict mobility. However, the conditions for the professional practice in the host Member State should be respected, since these are not clinical placements or clinical training integrated in academic curricula, which are the responsibility of higher education institutions, but a situation of professional practice. Question 12: Which of the two options for the introduction of an alert mechanism for health professionals within the IMI system do you prefer? Option 1: Extending the alert mechanism as foreseen under the Services Directive to all professionals, including health professionals? The initiating Member States would decide to which other Member States the alert should be addressed. Option 2: Introducing the wider and more rigorous alert obligation for Member States to immediately alert all other Member States is a health professional is no longer allowed to practice due to a disciplinary sanction? The initiating Member State would be obliged to address each alert to all other Member States. It depends on what is considered a disciplinary action in the Member State and who has the power to assign it. The legal and ethical differences are significant. It would be better to determine the type of disciplinary action and under the responsibility of which authority. The guidelines for professional practice, professional regulation (entity and characteristics) and the national legal frameworks are quite different. Please also note that not all CAs have disciplinary powers, which may delay or frustrate the speedy transmission of information. This sharing of information brings up the issue of protection of personal data, which seems to be safeguarded, as provided for in the Green Paper. Whatever the option you decide to take, the terms of the said sharing of information on each professional for the purpose of issuing alerts to other State-Members must be taken into consideration. A fundamental aspect is to consider sharing the disciplinary information only after a final sentence, and never before, which would violate the principle of presumed innocence. Ordem dos Enfermeiros Page 8 of 12

Question 13: Which of the two options outlined above do you prefer? Option 1: Clarifying the existing rules in the Code of Conduct; Option 2: Amending the Directive itself with regard to health professionals having direct contact with patients and benefiting from automatic recognition. The exercise of health professions, considering their complexity, the severity of the consequences of inadequate or improper practices, and the need to transmit accurate information to professionals to ensure continuity of care requires rigour and knowledge of technical terms in the field of health to ensure the safety and reliability of the information conveyed. In this sense, we disagree that this process may fall under the responsibility of employers (as written in the Green Paper) and that the lack of language skills cannot be a reason for refusing professional recognition (footnote 26 in the Green Paper). With regard to health care professionals, we understand that CAs should be able to assess the language skills of technical professionals who apply for recognition, therefore agreeing with Option 2. We believe, however, that it is up to the European Commission to promote, through structural funds, the funding of technical language courses for health care professionals who support the migrating professionals. The existence of these courses is very scarce in Portugal, for example. Question 14: Would you support a three-phase approach to modernisation of the minimum training requirements under the Directive consisting of the following phases: - the first phase, to review the foundations, notably the minimum training periods, and preparing the institutional Framework for further adaptations, as part of the modernization of the Directive in 2011-2012; - the second phase (2013-2014) to build on the reviewed foundations, including, where necessary, the revision of training subjects and initial work on adding competences using the new institutional framework; and - in the third phase (post-2014) to address the issue of ECTS using the new institutional framework? Modernisation notes a sense that derives from the most recent changes in the functioning of the bodies of the European Union, with the approval of the Lisbon Treaty. It should be stressed that with the possible establishment of a legal discipline (through the Directive) to appeal to implementing acts or delegated acts with a view to updating training contents and the development of sets of competences, the European Commission will be enabled, in itself, although with the backing of the European Parliament, to regulate these issues, although with the threshold of untouchability of the essential elements in each field, that are reserved for the legislative act of the Parliament. Aware of this legal framework applicable to the terms provided for the modernisation of automatic recognition, our is a reserved stance on the admissibility of such acts by the Commission relating to the matters identified (training contents and sets of competences) to the extent and within the limits in the establishment of the essential elements of these matters in the Directive, such as contents and objectives. In the overall analysis of the framework text in the Green Paper, we agree with these phases. It should, however, be borne in mind that the basic training of some professions, including nursing and midwifery, is not integrated in higher education in all countries, which will limit the use of ECTS. Work should be started as soon as possible to balance the training level in these countries and professions across the EU. Ordem dos Enfermeiros Page 9 of 12

Question 15: Once professions seek establishment in a Member State other than that in which they acquired their qualifications, they should demonstrate to the host Member State that they have the right to exercise their profession in the home Member State. This principle applies in the case of temporary mobility. Should it be extended to cases where a professional wishes to establish himself? (Please give specific arguments for or against this approach). In the interest of equal arguments and balance in the pursuit of the interests in question, it will be adequate to extend the proposed requirement to the system of automatic recognition for the purpose os establishment. The provisions that increase the safety of citizens are welcome. The expansion of this principle will speed up the sharing of information. If the professional card were to be widespread, it could be integrated in the information transmitted, freeing the professional from yet another procedure. Is there a need for the Directive to address the question of continuing professional development more extensively? This is a matter that needs further clarification since it varies widely across the various MS, and its regulation is far too ambiguous, in particular as regards the necessary credibility and safety, which is essential for the training of health professionals. Question 16: Would you support clarifying the minimum training requirements for doctors, nurses and midwives to state that the conditions relating to the minimum years of training and the minimum hours of training apply cumulatively? (Please give specific arguments for or against this approach). In the framework of tertiary education, based on competences and ECTS, it makes no sense to continue to refer to years and hours of training. Competences and a minimum number of training ECTS should be established. Question 17: Do you agree that Member States should make notifications as soon as a new programme of education and training is approved? The OE has been supportive of this obligation, especially considering the cases in which course updates are suggested in Annex II of the Directive. The position of the OE is also to request that the CAs be consulted on the new training programmes and the feasibility of mobility in these programmes. Considering the national context and the accreditation of training by the Agency for the Evaluation and Accreditation of Higher Education, the highest quality requirement would be that accreditation under the responsibility of the Agency would necessarily need the opinion of the professional organisation that regulates the profession. Only then would it make sense to notify and inform on the curricula. Would you support an obligation for Member States to submit a report to the Commission on the compliance of each programme of education and training leading to the acquisition of a title notified to the Commission with the Directive? Compliance with the Directive does not imply that the teaching programme ensures mobility. In the case of Nursing and of some of the titles listed in Annex II, and others proposed (by Austria), they have no framework in some EU countries, which leads to two situations: 1 st The professional has sufficient training to be recognised as a general nurse and enters by means of the automatic system. The specialty training undertaken will be evaluated by the employers only. Ordem dos Enfermeiros Page 10 of 12

2 nd Training is not sufficient enough to be recognised as a general care nurse. The curriculum is evaluated and compensation measures are defined to allow the limited/partial practice in the specialty area. In the second situation, the lack of communication between the MS and their CAs can give rise to significant discrepancies in training that require long and complex compensation measures. Considering the aim of facilitating mobility, we believe that the report of compliance with the Directive does not bring significant gains. Should Member States designate a national compliance function for this purpose? (Please give specific arguments for or against this approach). For the same reason given in the previous question, we believe that it is not the compliance with the Directive that may cause the problems. At national level, the compliance check makes sense if it matches the evaluation of comparability between training programmes in the case of nursing this issue is essentially about the training contained in Annex II. Question 18: Do you agree that the threshold of the minimum number of Member States where the medical speciality exists should be lowered from two-fifths to one-third? (Please give specific arguments for or against this approach). Not applicable. Question 19: Do you agree that the modernisation of the Directive could be an opportunity for members States for granting partial exemptions if part of the training has already been completed in the context of another specialist training programme? If yes, are there any conditions that should be fulfilled in order to benefit from a partial exemption? (Please give specific arguments for or against this approach). Not applicable. Question 20: Which of the options outlined above do you prefer? Option 1: Maintaining the requirement of ten years of general school education Option 2: Increasing the requirement of ten years to twelve years of general school education The evolution of the nursing and midwifery professions, coupled with the increasing complexity of clinical situations requires professionals to have emotional maturity and professional competences that are difficult to attain with merely 10 years of prior schooling. Furthermore, several studies show that most EU countries have 12 or more years of general education, and that almost 60% of nursing courses are at university level. The harmonization of systems in the EU according to the university level facilitates the implementation of the Bologna process, improving the comparability of training, competences and titles. In this sense, the only option to consider is the second one (minimum 12 years of general education), but should, in our view, not include the number of years, but the general education required to access university education in each Member State. Question 21: Do you agree that the list of pharmacists activities should be expanded? Do you support the suggestion to add the requirement of six months training, as outlined above? Do you support the deletion of Article 21 (4) of the Directive? (Please give specific arguments for or against this approach). Not applicable Ordem dos Enfermeiros Page 11 of 12

Question 22: Which of the two options outlined above do you prefer? Option 1: Maintaining the current requirement of at least four years academic training? Option 2: Complementing the current requirement of a minimum four-year academic training by a requirement of two years of professional practice. As an alternative, architects would also qualify for automatic recognition after completing a five-year academic programme, complemented by at least one year of professional practice. Not applicable. Question 23: Which of the following options do you prefer? Option 1: Immediate modernisation through replacing the ISIC classification of 1958 by the ISIC classification of? Option 2: Immediate modernisation through replacing Annex IV by the common vocabulary used in the area of public procurement? Option 3: Immediate modernisation through replacing Annex IV by the ISCO nomenclature, as last revised in 2008? Option 4: Modernisation in two phases: confirming in a modernised Directive that automatic recognition continues to apply for activities related to crafts, trade and industry activities. The related activities continue to be as set out in Annex IV until 2014, date by which a new list of activities should be established by a delegated act. The list of activities should be based on one of the classifications presented under options 1, 2 and 3. Not applicable. Question 24: Do you consider it necessary to make adjustments to the treatment of Eu citizens holding third country qualifications under the Directive, for example by reducing the three years rule in Article 3 (3)? Would you welcome such adjustment also for third country nationals, including those falling under the European Neighbourhood Policy, who benefit from an equal treatment clause under relevant European legislation? (Please give specific arguments for or against this approach). Analysing the arguments presented the information in current Directive and the reply to question 7 does not seem to justify the reduction in the number of years. As a matter of equality, we recognise the legitimacy and appropriateness of the claim to adjust the legal treatment of such situations; however, based on the same principle of equality, in its material dimension, we pinpoint the potential differences of regime applicable to the attainment of qualifications obtained in third countries, in such terms that are likely to undermine the principles and purposes of this Directive. Seen in a different way, we believe that it would be important to ensure case-by-case evaluation mechanisms and the commitment of the competent authorities in deciding on the recognition of qualifications, as well as the establishment of compensation mechanisms to guarantee the achievement of objectives and purposes in the cases under consideration. Ordem dos Enfermeiros Page 12 of 12