Nursing Profession In Germany: Challenges And Strategies

The German healthcare system

Around 83.1 million people live in Germany, making it by some distance the most populated country in the European Union (Federal Statistical Office (Destatis), 2019). Currently, the German population is predominantly older, aged between 50 and 70, which is shown in figure one. The forecast identifies a significant population decline, but the number of older people will not decrease in the following years, prompting the healthcare system to find innovative solutions (Federal Statistical Office (Destatis), 2019). In 2012, the German Federal Ministry of Health released a national health target, called ‘Gesund älter werden’ (‘Healthy ageing’[1]). It comprises 13 single targets, which can be found in appendix one.

Figure 1 – Population Projection Germany

The German health system is currently one of the best health systems in the world (The Red Relocators, 2021). The health status of the population is very good by global standards, which is reflected in general health data, such as the high life expectancy in Germany, which is currently 84.1 years or the low mortality rate for children under 5, which was 3.8 per 1,000 children in 2019 and has been steadily decreasing for about half a century (The World Bank, 2021).

Germany has a statutory health insurance system that was invented in the late 19th century by the German Otto von Bismarck (Busse et al., 2017). This system has been constantly developed and today Germany offers very comprehensive insurance coverage. 90% of the population is insured under this social statutory health insurance scheme. The premium to be paid depends on income (The Red Relocators, 2021). This premium covers a package of services that the insured person can claim from a healthcare provider of their choice, for example hospitals or private providers (The Red Relocators, 2021). The underlying principles of today’s health care system are equal opportunities and adequate accessibility to the health sector for all population strata and groups (Federal Ministry of Health, 2021c).

Germany is a high-income country. In 2012, the country had a gross domestic product (GDP) of €32,554 per capita, which is among the highest in Europe (WHO, 2014). According to the Federal Statistical Office, Germany has one of the highest expenditures on healthcare worldwide. For example, in 2012, the total healthcare expenditure was €300.437 billion, which equals approximately 11.4% of the GDP (WHO, 2014). Healthcare is an important employment sector in Germany. Over 11% of the population is working in healthcare, which is approximately 4.9 million people (WHO, 2014).

To understand how priority setting and decision making occurs in Germany, a Hofstede country analysis was used to compare Germany with the United Kingdom (Hofstede Insights, 2021). As one can see in figure two, the two points which differ most from each other are uncertainty avoidance and long-term orientation.

Figure 2 – Hofstede Comparison Germany and UK

In this figure, it is particularly noticeable that Germans prefer to avoid uncertainties. This is also reflected in the health sector. Germans like to compensate for high uncertainty by relying heavily on professional expertise (Hofstede Insights, 2021). New options are often viewed critically and, if insufficiently tested, recognised as not valid. The healthcare system must be structured and to a certain extend cost-effective (Busse et al., 2017). In Germany, the principle of self-administration applies, a form of principle priority-setting. Thus, it develops principles and guidelines to guide healthcare and insurance organisations (Federal Ministry of Health, 2020b). This brings us to the second big difference in figure two, the long-term orientation. For Germans, it is important to see long-term value behind innovations and inventions. If solutions do not fit into the planned system in the long term or do not bring benefits in terms of the common good, they also drop out (Federal Ministry of Health, 2020).

Hofstede country analysis

There are currently about 350,000 doctors practising in Germany. This results in a ratio of about 3.4 per 1,000 inhabitants. However, this ratio differs considerably between rural and urban areas (The Red Relocators, 2021). Approximately 77% of the German population lives in urban areas (statista, 2020). Medical staff in Germany is limited and highly specialised. Also, there is currently a significant shortage of staff across the hospitals (Schermuly et al., 2015). German care organisations rely increasingly on the migration of health workers as a source of labour (Cooke & Bartram, 2015).

Additionally, there is a “brain drain” in Central and Eastern Europe, geographical migration to better working conditions. Germany is also currently recruiting many care workers from the East (Deutsche Welle, 2021b). To counter this systemic problem, the German government launched ‘Konterzierte Action Pflege’ (‘Concerted Action Care’), in attempt to recruit more people for care professions. The measures started in January 2020 and aimed to create 10% more trainees by 2023 (Deutsche Welle, 2021). However, according to Germany’s leading association of charities, the “Paritätische Wohlfahrtsverband”, Germany needs an additional 100,000 care workers to cover its current needs adequately (Deutsche Welle, 2021a), which cannot be achieved with the current governmental programme.

Furthermore, the attractiveness of the nursing profession has declined in recent years. Particularly prospective trainees often do not choose this profession because of physically hard working conditions, inadequate pay schemes and the regrettably little-recognised image of this job (Deutsche Welle, 2021). Yet, also trained workers leave this job after some years because they are burnt out (Deutsche Welle, 2021).

In addition, the nursing profession has some significant disadvantages. On the one hand, it is physically demanding, which means that you can only do it if you are fit. The shift work also makes the job unattractive (Deutsche Welle, 2021d). On the other hand, it is also mentally exhausting. Geriatric nurses must cope with a lot, you are often confronted with suffering, pain, and death during working hours.

Although German hospitals usually are modern and use the latest technology (The Red Relocators, 2021), it is unlikely that nursing will develop into something purely machine based. Therefore, this report analyses how the nursing profession can be made attractive again. Within this, the report looks specifically at the workforce planning and development in the specific area of elderly care.

Many people feel morally obliged to care for their elderly family members at home, even though 42.1% of women and 60.3% of men in Germany work full time and therefore have little capacity or are unable to care for their elderly family members (European Institute for Gender Equality, 2021). In addition, there is a work-related migration of labour in some parts of Germany, as working conditions and pay are unevenly distributed. As a result, families are separated, i.e., the option for families to take care of their elderly family members becomes an impossible task (Moral-Fernández et al., 2018). This makes it necessary for the German healthcare system to take actions to address the concerns of their population that there is a smooth-running system for the elderly. Currently, this is addressed by the national health goal, which aims to strengthen the elderly mentally and physically, while the interests of relatives and informal helpers of older people are considered (GVG, 2021).

Shortage of medical staff

The problem that the healthcare personnel is overstretched throughout the country, could be addressed by with several different strategies. This section will provide an options appraisal of three different options.

Option 1: Implementing a process of officially recruiting foreign care staff that households can hire using a demand model, based on the population needs.

The most obvious option is to hire more staff, which could free up resources in the health sector. The Federal Minister of Health in Germany, Jens Spahn, emphasised multiple times, that 13,000 additional nursing jobs have been created and financed through the social health insurance, as well as 20,000 jobs for nursing assistants. However, they have not yet been filled (Federal Ministry of Health, 2021b). The government wants to tackle this problem through migrant workers (Deutsche Welle, 2021c). However, recently, the standard for a migration German language test approval rose and immigrant nurses often do not have sufficient training to maintain the standards (Johannes Gutenberg University, 2019).

Nevertheless, migrant workers seem to be the solution to this problem at the moment. There are multiple platforms, offering overstretched families help with their elderly. According to a leading German consumer safety group, “Stiftung Warentest”, more than 250 placement agencies offer 24-hour care for private households, mainly by Polish, Romanian and Slovakian care workers (Stiftung Warentest, 2017). They live in the same house as the family and take care of the household while looking after the person in need of care (Johannes Gutenberg University, 2019).

In a 3-year research project, the Johannes Gutenberg University analysed this circumstance and claimed that this working arrangement is not well regulated. They stated: “This is presumably because these arrangements appear to be in the interests of all parties involved: The families have found a solution, the immigrant workers are receiving better pay than they could expect in their home countries, and the state can retain the current care system instead of implementing reforms that would be unpopular because they would be expensive” (Johannes Gutenberg University, 2019).

Option 2: Implement a process that provides better working conditions for existing staff, enabling them to retain workers in all areas of elderly care in all parts of Germany, including a better payment scheme and the opportunity to expand the workforce’s knowledge and capabilities.

To keep the workforce in all parts of Germany, one possible solution would be to develop a nationwide equal pay system. Currently, especially for geriatric nurses, there is no equal pay system as care work often is in the hand of private operators, which are not tied to certain tariffs (Deutsche Welle, 2021). In addition, to create further benefits for employees, there must be the opportunity to expand and develop their skills, separated from the amount of work that the employees are currently facing. For example, in 2019, the German Federal Employment Agency, launched the “Qualifizierungschancengesetz” (“Qualification Opportunities Act”), the possibility of promoting further vocational training for employees was expanded and there was a drastic increase. A total of 9,700 participants began retraining in the field of geriatric care (Federal Employment Agency, 2020).

Purpose and Strategic Priorities

Geriatric Care

Nursing Care

Figure 3 – Measure entries for the promotion of further vocational training for geriatric and nursing care in Germany, annual totals (Federal Employment Agency, 2020)

This has the advantage that training and further education can be adapted to the current needs of the population. If staff at a site specialise in different areas of expertise, there can be an agile deployment of staff that exploits the full potential and leads to more efficient work (Chas Health Organisation, 2017). In this way, the geriatric nurses are always up to date with the latest nursing care and know how to properly use new technologies, for example a multitasking care robot (Van Aerschot & Parviainen, 2020). This method simply makes the work easier, which leads to more effective worktime usage, increased motivation of the staff and, in the long run, to the fulfilment of the national health goals (Chas Health Organisation, 2017).

Also, it is also quite possible that the people to be cared for regain a certain degree of independence through the right treatment (van Seben et al., 2019). In this way, work is further facilitated and possible deterioration, for example in old people’s homes, is halted  (Little et al., 2019).

Training in the field of nursing is irrevocably necessary to prevent patient harm (Simone et al., 2016). However, due to the current low staffing levels, a complete replacement of the staff to be trained is hardly possible and will lead to the work being distributed among the remaining, already existing staff. Therefore, overload will not decrease in the short term and may even increase. Also, there is currently only little infrastructure for extended learning, meaning that special training venues for e.g., elderly care technology must be created first.

Option 3: Implementing an award system for new apprentices to recruit more care workers.

Another way to address this problem ethically could be an award system to attract care workers inside the country and to implement a financial bonus if someone chooses to learn a care profession. Although there is already a financial bonus, namely the waiving of school fees in public geriatric nursing schools in most German federal states, a supplementary award system can help to attract more care workers (German Bundestag, 2018). The sheer number of people relieves many caregivers, fewer mistakes are made, and resources are saved because fewer caregivers are absent due to illness (Teng et al., 2010).

However, this requires more financial resources than the other two options. A suitable funding option would be through social security, or more precisely, long-term care insurance. In Germany, long-term care insurance is a supplementary insurance to statutory health insurance and is also paid monthly by employer and employee. It serves to provide financial security for people in need of long-term care and people with disabilities in the health care system. However, there may also be additional costs here, as it can only be estimated how many people will use this option.

There are also ethical considerations, as many people might choose this vocational training mainly for the financial bonus and not because they want the good for the elderly. For a full assessment of the options, including scoring, see appendix two.

Options Appraisal

According to the scoring in the option appraisal, there is a neck-and-neck race between option two and three. However, option three turned out to be the most favourable option, implementing a financial bonus to new trainees. This option also fits the German approach best, as it is long-term oriented and there is only a limited amount of uncertainty.

In addition, there is already an existing one-off bonus for care workers, which was introduced due to the coronavirus pandemic. The bonus for elderly care workers is currently up to €1,500 per head (Federal Ministry of Health, 2020a). Two thirds of this are covered by the statutory long-term care insurance. The other third is paid by the federal states and varies depending on the federal state (Federal Ministry of Health, 2020).

Specific

Within this framework, the aim is to permanently increase the number of nursing staff. In order to achieve this, an entry bonus and a graduate bonus are to be introduced in addition to the school fees paid in state schools in almost all federal states. The financing is to be taken over by the long-term care insurance. Since the low number of nursing staff is mainly due to insufficient pay and the bad job image, it is hoped that this measure will increase the number of nursing staff in the near future.

Measurable and Time-Defined

As already mentioned, about 100,000 additional geriatric nurses are needed (Deutsche Welle, 2021). This target should be reached within the next 10 years. Regular measurements will be taken. The main monitoring will take place after 3, 5 and 10 years to see how the number of new geriatric nurses has changed and how many people have left shortly after starting the apprenticeship or due to retirement. In addition, regular interim measurements will be taken to see how the health status of the elders and the daily care routine of the geriatric nurses has changed. This will be done by surveys and interviews, as well as feedback sessions.

Relevant and Achievable

This goal is very relevant and topical. There is currently a crisis in the nursing workforce in Germany (Federal Employment Agency, 2021). More care workers are desperately needed. In terms of feasibility, this option is realistic. The expected result will be achieved because the insufficient payment is the main factor why people do not enter the profession. At the same time, 100,000 people is a high number (Deutsche Welle, 2021). However, as this number is spread over 10 years, regular interim measurements and possible strategy adjustments can be made, which will have a goal-oriented effect on the number of caregivers. A visual representation of the smart objectives can be found in appendix three.

In Germany, a country that wants to plan effectively with its comparatively large resource potential, a sound economic analysis is crucial. The associated costs are irregularly recurring, as every time someone starts or completes training as a geriatric nurse, the bonus is spent. However, the cost peak per year will be concentrated in August and September, as these are the months when training starts or ends, depending on the federal state.

Data from 2019 is used to calculate the costs. As can be seen in figure three, 27,309 people started a career in elderly care in 2019, which is now more than trainees in nursing (Federal Statistical Office (Destatis), 2020)

Figure 4 – New Apprentices in Nursing Care Occupation (Federal Statistical Office (Destatis), 2020)

The annual net financing balance of the social long-term care insurance system was €3.29 billion in 2019 (Federal Ministry of Health, 2021a). Based on these values, it is estimated that sufficient state funds are available to introduce an additional award system, being an entry bonus of €1000 and a graduate bonus of €2000 per person. This results in an additional entry bonus burden of €27.3 million. Since during the training circa 30% of trainees in nursing professions drop out prematurely (Ministry of Economic Affairs, Innovation, Digitalization and Energy of the State of North Rhine-Westfalia, 2021) we must reckon with an additional graduate bonus of circa € 38.2 million. This adds up to € 65.5 million. In addition, there are administrative costs, material costs and marketing costs. The total cost of the project is approximately € 69 million, which is clearly within the budget.

Domain	Projected cost in million € per year
Administrative and material costs	Approx. 1.2[2]
Marketing Costs	Approx. 2
Projected Bonus costs	65.5
Total	68.7

Table 1 – Estimated Budget Listing

The benefits of this project can be divided into three different categories (Harvard Business School, 2019). The first category is the intangible benefits. These include, for example, that the new trainees feel valued and recognised. This leads to increased motivation, which in turn increases the quality of work. This has a positive effect on the work environment, job stability is increased, and the achievement of personal and governmental work goals is promoted. This development would benefit the elderly, which falls into the second category, indirect benefits (Chas Health Organisation, 2017).

The third benefit is competitive advantage. By improving productivity, Germany is improving its statistics in elderly care. This could influence the decision to move to another part of Germany for pensioners and working people, making the geographic-demographic distribution in Germany more harmonious and disadvantaged regions benefit from the development (Arnold, 2012).

The possible risks were assessed using an impact and probability table. The table gives values from 1 to 5, where 1 represents the lowest and 5 the highest probability of occurrence or impact.

Criteria	Risk 1: People just take the bonus and then cancel the apprenticeship, leading to an unexpectedly high dropout rate	Risk 2: People do not pursue their vocation, but only money and change their profession later in life	Risk 3: Many people start this training, and the financial resources and infrastructure needs to be adjusted	Risk 4: Post-pandemic consequences, e.g. a demographic shift and less need for elderly care staff
Impact	3	2	4	4
Probability	2	2	3	5
Plan or Disregard	Plan	Disregard	Plan	Plan

Table 2 – Risk Assessment: Impact and Probability

As a mitigation of risk one, a clause is possible which states that if the financial bonus is claimed, the claimant must participate in the geriatric nurse training for at least one year and must also provide evidence of this. For the third risk, one could introduce a restriction that limits the training bonuses to a certain number in the first years. If there is a high demand, one can upgrade infrastructure with the financial buffer of the long-term care insurance (Federal Ministry of Health, 2021). To address risk four, it is possible to create further training for geriatric nurses that allows staff to retrain in similar nursing professions, such as gerontological nursing, preventative care, rehabilitation, or palliative care (Kelly et al., 2008).

Conclusions

Germany is the most populated country in the European Union (Federal Statistical Office (Destatis), 2019). However, as almost all industrial nations, it has an ageing population and an increasing need for geriatric nurses. Currently, there is too less staff employed in this sector (Johannes Gutenberg University, 2019). Although there is a national strategic goal for the care of elderly, there is no sufficient statement from the government how the staff problem will be managed (Deutsche Welle, 2021). Therefore, the business case proposes multiple options to address this issue.

To summarise this business case, it can be said that of the 3 possible options, the best option in the long term was to introduce a financial bonus for prospective and graduating geriatric nurses. The other two options, hiring foreign care workers and giving elderly care workers the opportunity of additional job advantages like training were excluded through a scoring table. The report includes statements that recruiting foreign care workers cannot maintain the standard of German elder care in the long run due to cultural and language differences, and that creating opportunities for further training will not bring more workers in in the short run (Deutsche Welle, 2021).

The leadership skills required for change are long-term workforce capacity planning, as well as flexibility in implementation and the ability to promote innovation. However, the leadership skill that is needed the most is trust-building. According to the Federal Minister of Health, Jens Spahn, a great deal of trust has been broken in the field of care for the elderly in recent years. This must now be replaced (Federal Ministry of Health, 2021). To achieve this all stakeholders should be included, especially the geriatric nurses, elderly people, and the apprentices. Hereby, it is crucial to encourage people to stay by making them understand the importance of their job and giving them a certain degree of job stability. However, there is also some time pressure behind this project because, as noted in figure one, population change will soon result in a shift in age demographics. Therefore, elderly care training must be a priority, as otherwise the care system will be hopelessly overstretched in less than 20 years.

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