Abstract

Background: Ever since mandatory long-term care insurance was introduced in Germany in the 1990s, there has been concern about staffing of nursing homes. By 2017 staffing ratios between federal states differed by more than 15% and perceived understaffing was a major concern for (i) the quality of care and (ii) the undersupply of nurses due to unfavourable working conditions. Against this background the Reform Act from December 2015 commissioned the development of a new instrument to identify necessary staffing ratios. The University of Bremen was mandated to develop this instrument, and presented the final product by September 2020. At the moment this new staffing scheme is subsequently implemented.

Objectives: The contribution will describe the methods applied in developing the instrument as well as the resulting instrument itself. This translates the number of nursing home inhabitants and their case-mix into staffing requirements according to certain degrees of qualification, thus replacing general quotas of registered nurses to auxiliary staff by ratios of nurses per inhabitant. As a consequence, care mix will follow case mix.

Methods used to develop the staffing scheme: In order to develop the staffing scheme an observational study in 62 nursing homes was conducted. This was based on: (i) an individual planning of necessary interventions for each inhabitant, (ii) a description of good practice for each of the 111 interventions forming the intervention catalogue covering all nursing actions, and (iii) an attribution of nurses' qualification levels to any intervention for different types of inhabitants. All nurses where shadowed for about one week by 242 experienced nurses acting as "shadowers".

Findings: Applying the new staffing scheme on all German nursing homes yields an extra demand of about 115,000 nurses (full-time equivalent), which corresponds to an increase of more than one third of the current nursing staff. Interestingly, the additional demand concentrates on nurses with a 1-2 years training, and not on registered (geriatric) nurses with a three-year education. This somewhatsurprising result is due to the fact that qualified nurses spend about half of their time performing tasks that could also be performed by less qualified assistant nurses. The staffing scheme rather assumes a competence-based distribution of tasks to nurses of different qualification levels.

Conclusions: In a first step to implement the new staffing scheme, the Act on the Improvement of Health Care and Long-Term Care ("Gesundheitsversorgungs- und Pflegeverbesserungsgesetz") of 22nd December 2020 made the financing of up to 20,000 additional posts possible. From July 2023 onwards, funds for another 25,000 nursing posts have been made available (Act on the Further Development of Health Care = Gesundheitsversorgungsweiterentwicklungsgesetz of 19th July 2021), and for 2025 a third introduction step is planned. However, maximum positive effects of the additional posts on the quality of care and higher job satisfaction depend on the implementation process, which also requires considerable organisational and staff development as nurses of all qualification level need to live up to new roles.

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