A few weeks ago, Katri Kukk-Toomsalu, head nurse at the PERH Women's Clinic, defended her master's thesis at the Estonian Academy of Security Sciences. The thesis, based on 22 interviews with employees from various hospitals and professional associations, analyzed the motivation of Estonian healthcare workers to ensure the continuity of healthcare services in the event of an armed conflict.

Loyalty and nationality-based tensions

In the context of a potential armed conflict, questions of national loyalty and trust emerged as a central theme.

"Fourteen interviewees highlighted a trait they see as specific to Estonia — namely, that colleagues' motivation may also depend on their location and ethnicity," Kukk-Toomsalu writes.

Nine interviewees expressed doubts about colleagues who consume Russian media and whose views raise concerns. Two had experienced workplace conflicts with pro-Russian colleagues. "/.../ I've cried, even had verbal fights — right when the war in Ukraine began. I was so shocked that someone I know so well could think that way," said one interviewee, a nurse.

At the same time, Kukk-Toomsalu emphasized that ethnicity should not be used as an automatic criterion for assessing loyalty.

"/.../ they're ready to contribute to the republic regardless of the fact that they speak Russian. It's a huge mistake to equate Russian-speaking with pro-Russian — that's not the case. I'd say, in fact, we often see the opposite," explained another nurse interviewed for the study.

In her thesis, Kukk-Toomsalu found that younger Russian-speaking employees tend to be more supportive of Estonia and better understand how a potential armed conflict could affect their lives and well-being. In contrast, older generations show more pro-Russian attitudes, often shaped by Russian media and Soviet-era worldviews.

A doctor originally from Ida-Viru County noted that differing political views often lead families to avoid such topics altogether. "For example, during the war between Ukraine and Russia, they don't support Ukraine! They don't outright support Russia either, but their position is very hesitant. /.../ We haven't talked about it since Crimea, really. That's when it all ended. After Crimea, we had a falling-out and decided not to speak about it anymore," the interviewee said.

Hospital location a factor

One of the key demotivating factors identified was the potential physical danger associated with working during an armed conflict. According to healthcare workers, the level of risk depends on the size and location of the hospital. For example, North Estonia Medical Center (PERH) and Tartu University Hospital were seen as more likely targets, as they serve as Estonia's primary trauma centers.

Working at smaller county hospitals was viewed as a safer alternative. "If I worked at Saaremaa Hospital, it would be a 10 out of 10 — I would absolutely stay and work there. 100 percent I'd stay. But I'm in Ida-Viru County. It's a bit more complicated. There's really no hope here," said one interviewee, a nurse.

Of the 22 healthcare workers interviewed for the thesis, 15 said they would remain in Estonia and continue working in their profession in the event of an armed conflict.

"The events in Ukraine have shown that the threat landscape in Europe has changed significantly and is continuing to intensify," Kukk-Toomsalu notes, highlighting the relevance of the topic.

In Ukraine, healthcare facilities and workers have been the target of widespread attacks. According to the World Health Organization, there have been 1,940 documented attacks, including strikes against hospitals and pharmacies.

Work organization and critical labor shortage

Kukk-Toomsalu's thesis also highlighted the overlapping employment of healthcare workers as a particular area of concern.

In Estonia, it is common for healthcare professionals to hold multiple jobs, which provides additional income and staffing flexibility. However, in a crisis situation, this practice could threaten the continuity of care. If a significant number of healthcare workers were forced to give up their secondary positions during an emergency, the resulting staff shortages could cause serious disruptions.

Hospitals are already facing a shortage of medical personnel. The absence of even a single doctor can significantly impact hospital operations. "And since both of our hospitals are short-staffed, even without an armed conflict, if one doctor goes on care or sick leave, it really affects both emergency departments. If they work full-time in both places, then their absence becomes a major issue," noted one doctor interviewed for the thesis.

The critical shortage of healthcare professionals and their overlapping roles also contribute to faster burnout among staff. This raises doubts about the system's ability to cope in the event of an armed conflict. "We're already in a damn crisis during peacetime," said one nurse, summing up the situation.

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