rela-tionship with other functions, and the level of responsibility; and on a classification of nursing personnel within a limited number of categories determined by reference to education and training, level of functions and authorization to practise.
Income
ILO Recommendation 157 contains an entire chapter devoted to remu-neration (4). Nearly 20 years after its adoption, these provisions are still the benchmarks to assess individual countries' performance. It contains the following provisions.
1. Nurses' pay should be fixed at levels commensurate with their socio-economic needs, qualifications, responsibilities, duties and experi-ence, taking account of the constraints and hazards inherent in the profession.
2. Levels of remuneration should be such as to attract people to the pro-fession and retain them, and should also bear comparison with those of other professions requiring similar or equivalent qualifications and carrying similar or equivalent responsibilities.
3. Levels of remuneration for nursing personnel having similar or equiv-alent duties and working in similar conditions should be comparable, whatever the establishments, areas, or sectors in which they work.
4. Remuneration should be adjusted from time to time to take into ac-count variations in the cost of living and rises in the national standard of living.
5. Nursing personnel who work in particularly arduous or unpleasant conditions should receive financial compensation.
6. Finally, work clothing, medical kits, transport facilities and other sup-plies required by the employer or necessary for the performance of the work should be provided by the employer and maintained free of charge.
None of the CCEE or NIS complies with the ILO Recommendation.
In all CCEE, nurses' wages are reported to be inadequate or poor in ab-solute terms. For example, the wages of nurses in Hungary (equivalent to US $1500 -1600 a year in 1994) and Romania (equivalent to US
$300 -400 a year in 1994) are just above the poverty line. Nurses' wages usually compare very poorly with national averages. For example, a Slovene nurse earns the equivalent of US $5500 a year, while GDP per head was US $8000 in 1995. Rapid inflation in many countries has fur-ther eroded the real value of salaries, and many nurses cannot make ends meet on salaries alone. This forces them to do overtime, take an ad-ditional job or search for informal ways of earning money. Some coun-tries, however, report improvements. For example, nurses in the Czech Republic won higher salaries, moving from the 3 -5 tariff range to the 6 -8 tariff range in the new wage system (which has 12 tariff points) ini-tiated by the 1992 law on wages. Different rates of pay take account of nurses' postgraduate achievements.
The picture in the NIS is similar and often worse. In all countries, nurses' income is low or very low (Table 5). Pay in the health sector is usually 50 -75% of the national average, and nurses earn relatively little compared to other health care professionals. In some countries, staff may be paid nothing at all for months on end. Nurses' low income is af-fecting morale and productivity; in the Russian Federation it generated unprecedented strike action. Government moves to allow local hospitals to establish their own pay scales, sparking fears of a downward wage
spiral, provoked mass protests in Estonia in 1995.
Table 5. Nurses' income in selected CCEE and NIS, 1991 -1994
Country Monthly income (US $)
Tajikistan 3
Republic of Moldova 10 -22
Russian Federation 15
Lithuania 15 -20
Estonia 42 -51
In most western European countries, nursing personnel employed
by the public sector are paid according to regulations or collective
labour agreements between employers and trade unions. With a few ex-ceptions, such as Spain, nurses working in the private sector are better paid than their public- sector colleagues, although that is more likely to be the case in an acute hospital than in a nursing home for the elderly, and data not only vary widely but are difficult to collect. Nurses' wages are usually somewhat lower than those of other professions requiring similar education levels. In Denmark, for example, a nurse's salary is comparable to that of a skilled craftsman. Nurse managers and teachers have higher salaries, as do those in specialist fields such as infection control, psychiatry and health visiting. Nursing auxiliaries and assis-tants are often among the lowest paid workers in society.Wages in most countries are about the national average or somewhat below, except in Austria, Belgium, Greece, Italy and Turkey, where they are much lower. In Spain, for example, the general nurse's average 1992 salary of nearly 2.4 million pesetas (equivalent to US $15 000) is
simi-lar to those of other workers of the same level. Sasimi-lary levels differ
between nurses in specialized care and those in PHC, in favour of the latter. In the United Kingdom, a ward sister with a starting salary of US $20 500 (1992) earned 87% of the average national wage, while in Ireland the starting salary of a qualified nurse compares quite favourably with those of other health professionals; on the other hand, nurses are not paid according to their responsibilities and differentials are very poor. In Italy, nurses receive a basic salary that is regarded as inade-quate, even though numerous supplements are paid (for particular duty hours, overtime, rotation, hazardous work, etc.). There is little differ-ence between the salaries of auxiliaries and registered nurses, and little career development. The annual salary is the equivalent of US $12 800, about the same as an average office worker. In the Netherlands, the starting salary of a general nurse is equivalent to some US $18 000 a year (2584 guilders per month in 1994) and is significantly lower than that of comparable professions. A specialist nurse may expect at least US $6000 more a year.Nurses' salaries in some countries, such as Belgium, France, Ger-many, Greece, Italy and the United Kingdom have, however, risen or been adjusted during the 1990s to improve recruitment. In a few coun-tries remuneration increased considerably; for example, some specialist nurses in Germany received an increase of 30 %.
In general, women's average salaries are lower than those of men in similar jobs, although the picture varies between countries and
accord-ing to salary and career structures, differentials between grades and qualifications, and other factors. For example, the average differential between men's and women's pay in Sweden is 1.6% in favour of men.
The average pay of female nursing assistants and auxiliaries employed by county councils, however, is slightly higher than that of men. In con-trast, male nurses in the United Kingdom earn 21% more than female nurses, and nursing auxiliaries show an even greater differential: wom-en earn only 55% of mwom-en's salaries. Although there is equal pay legisla-tion, disproportionately more male nurses hold better paid jobs, and many more women work part time to combine a job and child care.
A study conducted by ILO in 1994 (19) reported that pay is per-ceived as unsatisfactory worldwide. This is felt all the more keenly as the constraints and demands of the work are heavy and made even heavier by staff shortages. Nurses' demands for better pay relate first to basic salary, which is manifestly inadequate in relation to those of comparable professionals such as teachers, and to continuing efforts to upgrade nurs-ing's social and professional status. The demands also address special al-lowances, particularly for working overtime and stressful or unusual hours, which considerably increases the arduousness of the work, and for shift work, with its special constraints. Nurses also insistently demand a guaranteed level of purchasing power or its maintenance, particularly in countries where inflation is high. In a number of countries, nurses and trade unions are highlighting problems arising from excessive pay dif-ferentials within the profession, which not only cause discontent but also aggravate staff shortages in the worst paid sectors.
Nurses' growing demands have been marked in recent years and have featured in well publicized pay campaigns in many countries. Sometimes these have included strikes or other forms of withdrawal of labour, at odds with the traditional image of nurses and therefore all the more noticeable.
In 1995 alone, lengthy pay disputes in Denmark, Sweden, the United Kingdom and elsewhere caught the mass media's attention.