Cease of minimum nurse staffing levels in intensive care
The Ministry of Health’s temporary suspension of the minimum nurse staffing levels in intensive care and in geriatric care will cease on August 1. The requirements were suspended on March 16 to help hospitals be more agile with staffing in the wake of the COVID-19 outbreak. The requirements state that one nurse in intensive care be available for every 2.5 patients during the day and 3.5 patients at night, while in geriatrics one nurse be available for ten patients during the day and for 20 patients at night. Minimum nurse staffing levels for high-maintenance areas of trauma surgery, cardiology, heart surgery, neurology, stroke units and early neurological rehabilitation will remain suspended until December 31.
Additional staff for the public health service
On September 5, the Federal Health Minister and the Chairperson of the State Health Ministers announced the intention to create at least 5,000 new and permanent full-time positions in the Public Health Service (ÖGD) by the end of 2022, with at least 1,500 jobs for doctors, specialists and administrative staff being filled by the December 31, 2021. Most of the positions (up to 90%) are meant to be at the local level. At the federal level, 40 new positions will be created for implementation and evaluation related to the program by the end of 2021. The funding will come from a total EUR 4 billion fund that the federal government will make available until 2026 as part of its "Pact for the Public Health Service" programme (see also Section 2.1 Physical Infrastructure). Digitization is also a major part of the program, and the communication platform DEMIS (German Electronic Reporting and Information System for Infection Protection) will be made available for health authorities at all levels for reporting and notifying by the end of 2022. The five categories for evaluating the digital maturity of a public health office’s digital maturity will be: IT infrastructure, hardware, software, information security and process support.
The German Armed Forces (Bundeswehr) have deployed nearly 1,400 soldiers to support municipalities and districts across the country in fighting COVID-19 until early October. 730 soldiers are currently supporting health authorities with tasks like contact tracing, while 350 more soldiers are deployed at COVID-19 testing stations. While in 2019 there were only 249 requests for administrative assistance from the German Armed Forces, that number in 2020 is already at 981 and rising. 15,000 soldiers in total are potentially available for a COVID-19 emergency contingent, to be deployed at different levels of need.
Extension of bonus payments to hospital workforce
On September 18, the federal government announced to expand the bonus payments given to nurses and care professionals in hospitals fighting COVID-19 to all hospital staff during the pandemic. This regulation was based on a proposal from the German Hospital Association (DKG) and passed in a bill in German Parliament on September 18. According to the overall bill, the Krankenhauszukunftsgesetz (KHZG), hospitals that were particularly burdened by the treatment of COVID-19 patients between January 1 and May 31, 2020, will receive a total of EUR 100 million for employees who were exposed to an increased workload. Hospitals with less than 500 beds with at least 20 COVID-19 patients treated as full or partial inpatients and hospitals with 500 beds or more with at least 50 COVID-19 patients treated as full or partial inpatients are considered particularly burdened. Each hospital’s total amount of remuneration is calculated by the Institute for the Hospital Remuneration System (InEK).
Several measures have been put in place in Germany aiming to expand the workforce in the treatment of COVID-19 patients. In practice, these happened often at the initiative of individual hospitals, cities or regions, with limited overall coordination and planning at the federal level. The measures are taking place with a view to rapidly expand the workforce, provide training and upskilling and assign new roles and responsibilities to allow for flexible reactions to surges in demand against the backdrop of a clinical workforce facing already high workloads in ICU and other wards and a severe nursing shortage pre-existing the pandemic. Although Germany has had an above-average density of physicians and nurses per 1,000 inhabitants compared to other European countries, the rates are much lower per hospital bed, particularly for nurses. In 2017, there were 34,703 nurses with a specialisation in ICU care for an estimated 28,031 intensive care bed.
1) Additional measures to expand workforce capacity
The focus of additional measures to expand the current workforce has been fourfold: asking part-time working health professionals to work full time, calling upon medical, nursing and allied health students to work in clinical practice, attracting retired health professionals to return to clinical practice, as well as easing mutual recognition procedures of foreign-trained health professionals. Germany is currently in the preparatory phase to expand workforce capacity in case of a rapid surge of COVID-19 patients. Several hospitals or cities have used social media or other channels to ask retirees and (primarily) medical students to work in clinical practice, often offering additional, short-term trainings varying in length. One call by a university hospital in Mainz resulted in over 1000 medical students showing interest. Initiatives are usually not coordinated across settings, professions or cities and have therefore been subject to criticism. One exception is Bavaria, where the regional Minister of Health has put in place a system to estimate workforce supply and demand and called upon medical students or retirees to register. At the same time, it has requested hospitals, outpatient clinics and practices to register shortages to distribute the additional capacity. At the initiative of the federal medical student association, a facebook group on social media “medics-vs-COVID19” was created where over 20,000 medical students have registered as of 26 March and efforts are underway to organize the deployment of these medical students in hospitals and other practices. The president of the German Federal Medical Chamber suggested retirees and medical students consider working for hotlines, public health agencies, ambulatory practices or exceptionally also in hospitals, and to ensure personal safety and liability issues . While the respective regional associations of SHI physicians are responsible to coordinate placements, not all offer services online.
In addition, there is a potential pool of qualified physicians, as an estimated 14,000 foreign-trained physicians in Germany are waiting for the recognition of diplomas; the waits have been lengthy in some regions. Easing procedures while not compromising quality standards has been suggested, but to date only Bavaria has identified concrete steps forward. In Bavaria, it is planned that foreign-trained doctors meeting the requirements would get a time-limited license to work for one year, other regions are considering a similar way forward.
Some cities or hospitals have also opened calls for volunteers with no or very limited experience in healthcare (e.g. hospital in Giessen and Kiel, city of Koblenz offers basic training in which 60 volunteers participated, the city of Wolfsburg is looking for volunteers with informal caregiver experience). The aim for the volunteers is to support primarily nurses and nursing assistants with basic support tasks and thereby reduce their workload. However, there is very limited documentation of what tasks these are, how this plays out in practice, and how the quality and supervision is ensured.
From the policy side at the federal level, the Minister of Health has announced that the pre-existing directive on minimum nurse staffing levels in hospitals and the professional nurse/nursing assistant ratios in nursing homes and ambulatory nursing practices will be suspended, so that managers can be more flexible with personnel planning and staffing in light of the anticipated shortage if the epidemic rapidly unfolds and/or if high rates of nurses are being infected . There has been criticism of the suspension of the law, e.g. by the Nursing Chamber of Lower Saxony, as this would put patients at risk as well as nurses who may face excess workloads with risks to their physical and mental health.
In sum, while several initiatives are ongoing to expand the workforce, there are no reliable data available on the scale of additional health workers this may generate. There is very limited action at the federal level and – with the exception of Bavaria – at the regional level. Efforts show that individual hospitals and cities are handling the situation ad-hoc and with very limited coordination. There is no supply and demand monitoring or planning in place nationwide or across regions, which may be important in case of regional and local surges of patients or capacity losses in case of infected health workers.
2) Role flexibility and task shifting
The federal Minister of Health has sent an urgent request to German hospitals to provide training and instruction for health professionals to strengthen the manpower capacity in ICUs. In Berlin this request was implemented by an ordinance and hospitals are required to immediately train their medical and nursing staff in the field of intensive care, ventilation and in the treatment of patients with COVID-19 . In general, in Germany the training is organised on a decentralised level by hospitals or the federal states e.g. in Rhineland-Palatinate the coordination is handled by the nursing association, costs are to be reimbursed by the state. The training encompasses 16-hour short qualification on basic knowledge of ventilation and symptom control in COVID-19-patients or a 16-hour refresher course for former intensive care nurses. The DIVI, the German Interdisciplinary Federation of Intensive and Emergency Medicine provides guidance to step-up the qualification of nursing staff including the organization, implementation of the training and qualifications required. It also provides suggestions of specific contents, e.g. for support to ICU staff by professional nurses (but with no qualification in critical care) where the training content should focus on essential tasks and include hands-on training. Hence, there are examples of short trainings to allow task shifting of certain specific tasks and roles to less qualified nurses as a measure to prepare nurses for more task flexibility and ease workloads for ICU nurses so they can concentrate on specialised tasks for complex patients. Online platforms by professional associations and specialist publishers provide currently free access for nurses and physicians (sometimes registration needed) to the latest instructions, news, webinars, scientific articles regarding treatment and care of COVID-19-patients.
On March 21, the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) released recommendations for action to control psychosocial emergency care for healthcare workers. The concept is based on three pillars:
1. Establishment of an area of clinical psychosocial emergency care
2. Creation of a clinical psychosocial emergency care concept and implementation to clinical pandemic and emergency plans
3. The short-term establishment of clinical psychosocial emergency care by a professional team
The recommendations are further based on international quality guidelines for psychosocial emergency care (PSNV) provided by the IASC (2007) and NATO (2008).
On March 28 the “Act for Protecting the Public in an Epidemic Situation of National Importance” was passed. It provides among others that nurses and other health care professionals may carry out curative activities under certain conditions until March 31, 2021. Accordingly, long-term care nurses, health care and nursing professions such as emergency paramedics may engage in curative activities, provided they have the necessary skills and experience for the respective tasks and that the patient's state of health, according to its nature and gravity, does not necessarily require medical treatment, in the exceptional case of an epidemic situation of national importance. The curative activities performed by nurses and nurse professionals must be documented in an appropriate manner. It should be reported immediately to the responsible doctor or other doctor treating the patients.
On March 30, the Ministry of Health announced that the existing regulations regarding state examination of medical students will be adapted. The ‘Ordinance regarding the deviation from the licensing regulations in the context of an epidemic situation of national importance’ foresees among others to postpone the second medical state examination and to reduce the duration of the third medical state examination. Federal states may deviate from this ordinance. The questions of the state examinations will consider the experiences and symptoms of COVID-19. Those medical students with postponed state exams will start their practical year already in April with reduced duration (45 weeks instead of 48). This measure aims to increase workforce in hospitals while ensuring that medical students can pursue their studies.
In early April, the labour union ver.di and the Federal Association of Employers in the Care Industry (BVAP) agreed to pay a special bonus of EUR 1,500 to long-term care professionals (in ambulatory and residential care) in recognition of their work and efforts during the COVID-19 crisis. The bonus is exempt from tax and social security and will be paid to care workers, care assistants and managers as well as everyday companions, supervisors and assistants. Part-time employees will receive a bonus corresponding to the working hours. Apprentices will receive a bonus of EUR 900.
Financial recognition of health professionals has been discussed throughout the country when Bavaria announced to reward all nursing and care staff in health care, long-term care, rehabilitation, emergency services, institutions for disabled people with a EUR 500 bonus on April 5.
On April 22, Hambourg’s Senator for Health announced that up to 52 soldiers from the Bundeswehr can be deployed to assist in nursing homes in response to the spread of COVID-19 cases in 32 out of 150 facilities. The soldiers will receive a special medical training and will be in place to relieve the burden on the nursing staff, which has been reduced due to quarantine and sick leave needs.
On April 28, the Minister of Health and Minister of Labour agreed on the financing of the bonus of EUR 1,500 which is tax- and social security contribution-free. Two third of the bonus will be financed by the long-term care funds (Pflegekassen) and one third by the federal states and employers. The Federal Ministry of Health and the Federal Ministry of Finance will determine in the second half of the year whether and to what extent the Federal Government will refinance the payment of the one-off bonus.
On May 14, the federal parliament (‘Bundestag’) passed the ‘Second Act for protecting the Population in the Event of an Epidemic Situation of National Importance’. It defines and regulates the payment of the one-time bonus for professionals and all persons working in long-term care settings (including volunteers in social service, contingent workers and service companies’ workers in residential and ambulatory care) for at least three months within 2020. Full-time nurses and care professionals working in direct care are set to receive a one-time bonus of EUR 1,000, with state governments and employers encouraged to increase this sum to EUR 1,500. This individual tax- and social security-free, non-attachable bonus payments are to be paid out in the period from July 15 to December 15, 2020.
The one-time bonuses are graduated according to the extent of direct contact with persons in need of nursing care. Those who work primarily in direct care and support on a full-time basis are to receive EUR 1,000, those “engaged in” a care facility, e.g. in the kitchen or in providing security services, are to receive EUR 667, trainees in nursing professions are to receive EUR 600, and all other employees EUR 334. The bonuses are paid in recognition of the especial physical and psychological strain on staff during the corona pandemic and the increased risk of contracting COVID-19.
The Act also provides the Ministry of Health the possibility to enhance temporary flexibility for trainees, medical and dental students during the epidemic in regard to duration of training and use of online classes and examinations. The Ministry of Health will also be in position to adapt licensing regulations for dentists and pharmacists during the epidemic.
Until May 18, in total 11,800 healthcare workers have been infected with COVID-19 which represents about 7% of the total number of infections in Germany at this time (175,000). 541 of infected health professionals needed inpatient treatment, and 19 died, according to the RKI. Sufficient PPE supply remain a concern in hospitals and medical practices and pose a risk for healthcare workers: 38% of the doctors surveyed by the Marburger Bund (physician’s trade union) claimed to not be adequately supplied with PPE, especially concerning FFP-2 and -3 masks. Supply levels of FFP-2 and -3 masks also remain a concern in long-term care facilities. With high infection rates, nursing homes are among the most affected institutions (see also Section 1.4 COVID-19 in long-term care facilities). According to the RKI, also the number of persons working in residential facilities (including facilities for care of older, disabled, or other persons in need of care, homeless shelters, community facilities for asylum-seekers, repatriates and refugees as well as other mass accommodation and prisons) infected with COVID-19 is high with 8,566 until May 18. 354 of them needed inpatient treatment, and 42 died.
On June 3, the federal government announced the agreement on a stimulus package of EUR 130 billion which also sets out to strengthen the health care system and improve pandemic preparedness (see also Sections 2.1 and 6.1). Included in the package is a new ‘Pact for the Public Health Service’ (ÖGD) which will define minimum staffing levels for public health offices. The federal government intends to provide the federal states with the financial means in the form of fixed VAT amounts to finance the additionally required positions in the local health offices for the next five years - provided that the employment is completed by the end of 2021. To facilitate recruiting in public health offices, wages are to be adjusted to levels in other health care sectors, e.g. by paying functional allowances. The possibility of accomplishing clinical traineeship or practical year in public health offices should be implemented in the regulations for medical licensing and public health subjects must be more firmly anchored in medical education.
On August 5, the German District Association and the German Association of Cities carried out a joint survey on staffing levels at the Public Health Service (ÖGD). There are currently around 13,900 doctors and non-medical staff working in 356 public health offices. In the current corona pandemic, around 5,900 additional employees were deployed in these health authorities, primarily to follow up contacts, for corona tests and to control quarantine.
Sources (among others):