How Will Germany Respond to the Global Nursing Shortage?

BERLIN — The shortage of nurses around the world is extremely challenging in many ways for healthcare systems. Nurses at the World Health Summit this year discussed how to address this issue as quickly as possible.

In a session entitled “Reconsidering Nursing,” they advocated a new understanding of  the role of nurses, new competency models for nurses, and global standards of care with country-specific adaptations. Extending the sphere of competency for nurses in multidisciplinary teams, particularly in Germany, may help increase the attractiveness of nursing jobs and ensure the delivery of high-quality healthcare for the general population.

New Minimum Requirement?

“We believe that the nursing shortage is a problem that was accelerated by the COVID pandemic and can only be resolved by integrating training, qualification, skills acquisition, and legislation in nursing professions,” said Rebecca Graystone, PhD, senior vice president of the American Nurses Credentialing Center, who facilitated the discussion. Considering the work environment of nurses is equally important.

Nursing training is one of the main topics of the World Health Organization (WHO) publication on Global Strategic Directions for Nursing and Midwifery 2021–2025, as Amelia Latu Afuhaamango Tuipulotu, PhD, the WHO’s chief nursing officer, explained. “It has been shown, for example, how important a bachelor’s degree is for safe and high-quality care.” According to the WHO publication, calls for the standardization of nursing and midwifery training with a bachelor’s degree as a minimum are increasing.

Complexities of Nursing

“Nurses are the backbone of healthcare, and nursing is a highly complex phenomenon,” said Wentao Zhou, PhD, director of education for continuing education and training at the National University of Singapore’s Centre for Nursing Studies. The many challenges faced by nurses include the following:

• The diversity among patients, not only in terms of their medical conditions, but also their backgrounds and social standings

• The shortage of nurses, which results in high workloads

• The complexity of multidisciplinary collaboration and communication

• The speed of technological advances

• Increasing crises in public health and due to natural disasters

• The fast pace of changes in medical and nursing knowledge.

“All of these challenges directly or indirectly impact the well-being of nurses, as they have to be in a position to deal with these challenges,” said Zhou.

The Healthcare Ecosystem

The basis for a functional “healthcare ecosystem” is stability in several aspects of the staffing situation for nurses, she added. “That is why investment in nursing is so important,” Zhou emphasized.

On one hand, the focus should be on the well-being of nurses as individuals, placing importance on their physical and mental health, their clinical and social skills, and the respect shown to them. On the other hand, it is the responsibility of nursing management to reduce hierarchies, to support the professional development of their nursing staff, and to invite them to introduce their own ideas (about organizational processes, for instance).

The German Situation

Carla Eysel, chief human resources and nursing officer at the Charité University Hospital in Berlin, and Helene Maucher, manager of corporate strategy for nursing at German private hospital group Sana Kliniken, illustrated the difficult situation in the field of nursing in Germany while offering potential solutions. The country faces a shortage of more than 35,000 nurses required to maintain the current standard in medical care. Fewer people are starting with basic nursing training, and only 70% of them graduate.

Germany is far from achieving the proposed academization of the nursing profession. According to figures from the Federal Institute for Vocational Education and Training (BIBB), the rate of prospective nurses with a university-based education was less than 2% in 2021. Moreover, academic qualifications are more common in management roles rather than in clinical positions.

The situation abroad is quite different. An international comparison carried out in 2019 showed that the rate of graduates in nursing studies was 45% in the Netherlands and 100% in Sweden and the United Kingdom.

Not Attractive Enough?

“Germany may be a first-world country,” said Eysel, “but we struggle to offer attractive conditions of employment to our nurses.” Even though professional education is rather good in Germany, it does not correspond to international requirements. “Bachelor’s and master’s degrees in nursing are not attractive in this country, because the scope of clinical activities that are permissible afterward does not correspond to the skills acquired.”

By way of example, Eysel cited the lack of permission for academically trained nurses to make diagnoses, prescribe medicines, or administer vaccines due to legal restrictions in Germany. These things, however, are within the scope of activities for nurse practitioners in the United States, for example.

Maucher listed the following possible consequences of failing to address the lack of nursing staff effectively:

• Continually increasing workload for people employed in nursing

• Reduced manpower in nursing

• Longer waiting periods for patients

• Decline in treatment quality

• Entire institutions at risk of closing

• Negative impacts on public confidence in politics.

Autonomy and Responsibilities

What are the suggested solutions for the country’s problematic nursing shortage? “We ought to envision and work toward nursing as a profession with high socioeconomic acceptance and roles with autonomy based on the level of qualification and with proper legislation,” said Eysel. “Bachelor’s and master’s degrees should lead to roles such as nursing practitioners, with responsibilities that are extended accordingly and with adequate remuneration.”

Depending on the sector and the specific job requirements, even more specialized roles (such as community health nurses) would be possible. This system, according to Maucher, would also attract an international workforce if domestic and foreign qualifications were compatible. Moreover, a further digitization of the workplace would help to increase the attractiveness of nursing as a profession.

Both nursing experts view the currently proposed legislation for the Hospital Transparency Act and hospital reform as an opportunity to reach the aforementioned goals. “These initiatives could provide a general framework for more academic qualifications and more autonomous activities in nursing, contributing to the provision of high-quality healthcare in the future,” said Eysel. “The time to act is now.”

Nursing Management

Klara Karlsson, head of learning and development at Karolinska University Hospital in Stockholm, reported on the impact of structural reform in a large Swedish hospital. While executive positions were held exclusively by doctors before 2019, these roles began to be filled increasingly with nursing managers. This change was accompanied by other structural changes with more extensive collaboration between various areas of the hospital.

“The tasks that were entrusted to nursing managers from then on had to do with budget, beds, and operations,” Karlsson explained. “This is because a nurse knows better than a doctor whether a bed is available and whether there are nurses that can be deployed.” The outcome of this reorganization was that the university hospital’s bed capacity increased by around 20% with the same personnel.

Karlsson further pointed out that “our health system was conceived more than 100 years ago. It is our responsibility to modify and transform it according to the challenges that we are facing today and that we can anticipate in the future.”

This article was translated from the Medscape German edition.

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