Integration of qualified nurses!
In recent years, the international recruitment of qualified nurses has increasingly proved to be a relevant strategy for mitigating the shortage of skilled workers in nursing, which according to all forecasts will increase sharply in the future. At the same time, the framework conditions of the international migration of qualified nurses have changed substantially, whether through growing “competition” among the Global North for these workers or through altered legal frameworks in nation states that are increasingly pursuing labour-market-oriented immigration policy. Furthermore, increasingly professionalised “recruitment management”, which to a growing extent involves labour-market intermediaries, plays an important role in migrants’ changed courses of action.
For larger employers in the healthcare and nursing sector – hospitals and inpatient care facilities for older people – this creates new requirements: qualified nurses from abroad have undergone a professional and specialist socialisation different from that usual in Germany and come with different qualifications, work experience and expectations of their professional activity and development. From this arises the question of which problems of organisational integration emerge and how organisational integration can succeed in the face of globally constituted nursing labour markets, so that newly migrated qualified nurses remain as workers in Germany over the longer term.
The research project “Organisational Integration in Globalised Labour Markets” of a renowned foundation (BIGA, cf. www.boeckler.de/11145.htm?projekt=2014-789-4) addresses this question. Accordingly, the challenges of globalised nursing labour markets were recorded, and dimensions of organisational integration from the perspective of newly migrated qualified nurses as well as of those already established, i.e. qualified nurses and supervisors professionally socialised in Germany, were reconstructed. In addition, in collaboration with various actors, starting points for successful organisational “integration management” were developed. Precisely this is what CareLend GmbH implements in the project of organisational integration of foreign qualified nurses.
In the study “Organisational Integration of Qualified Nurses from Abroad”, the central research findings are summarised. After presenting the problem and research question of the study and explaining the research design, CareLend GmbH also addresses the changed framework conditions of the nursing labour market in Germany. The following chapters deal with the questions of how liberalisations and the labour-market orientation of national immigration policy, in conjunction with increased recruitment activities by employers, have already led to growing migration of skilled workers, how this process is steered by labour-market intermediaries such as us, and to what extent international qualified nurses can integrate into the German healthcare system.
Problem statement
Demand for nurses will rise markedly in the coming years, attributable above all to the increase in people in need of care, according to forecasts to around 3.4 million in 2030 (Prognos 2012: 1). If today’s level of provision is projected into the future, around 517,000 qualified nurses will then be lacking (ibid.: 14). Two effects of demographic change feed into this figure: through the rising demand of ever larger cohorts of older and very old people for nursing services, clear expansion needs arise in the nursing professions; at the same time, age-related exits from the nursing professions will in future lead to increased replacement need.
According to the Bundesagentur für Arbeit (BA) (Federal Employment Agency), key indicators show that nursing professions already count among the “shortage occupations”: in 2016, unemployment in the occupations of health and general nursing fell by 9.6%, and the number of vacancies notified to the BA rose by 19.9% compared with the previous year (the corresponding figures for all occupational groups are 9% and 18.6%). A vacancy notified to the BA for occupations in health and general nursing remained vacant for an average of 124 days (average for all occupations: 90), and for every 100 vacancies there were 71 unemployed persons (average for all occupations: 399).
For qualified nurses in care for older people the figures are even clearer: for every 100 notified vacancies there were only 38 unemployed persons, and they remained unfilled for an average of 153 days (Bundesagentur für Arbeit 2016: 27).
Regional sector monitorings show that the shortage of skilled workers in the healthcare and nursing sector, which includes the hospitals, rehabilitation clinics, residential homes for older people and nursing homes, and outpatient nursing services, varies greatly by region (Bieräugel et al. 2012, Lauxen/Bieräugel 2013, Lauxen/Castello 2016). The most urgent shortage of skilled workers currently exists in urban areas of western Germany and in rural regions of eastern Germany.
In order to reduce the shortage of skilled workers in nursing, various labour-market policy approaches have been developed and trialled in recent years (Bundesministerium für Familie, Senioren, Frauen und Jugend 2012, resolution of the Conference of Health Ministers/Conference of Education Ministers 2015, cf. also Weimann-Sandig et al. 2016). These include, on the one hand, the attempt to attract more employees into nursing work by expanding training potential. This covers, for example, measures to improve the image of the nursing professions in public perception in order to find more trainees among school leavers (Rodewald et al. 2006, Deutsches Institut für angewandte Pflegeforschung 2014: 34).
This also includes measures of subsequent qualification (Bonin et al. 2015), for which individual federal states have opened up training to those with lower school qualifications. Persons with a Hauptschulabschluss can thus be given (staged) access to the skilled profession by allowing a shortened training pathway to qualified nurse status after the one-year assistant qualification (e.g. Hessen and Rheinland-Pfalz). In addition, ever more degree programmes are being developed in nursing in order to attract pupils with a higher education entrance qualification into nursing as well.
On the other hand, skilled workers in the so-called “silent reserve” are to be brought into employment (above all women in or after the family phase; see e.g. the recommendations of the Deutscher Verein für öffentliche und private Fürsorge 2012).
Workplace fields of action in securing skilled workers include workplace health management, which aims to strengthen the work capacity and motivation of nurses (Schmidt et al. 2015, Dietrich et al. 2015, Benedix/Medjedović 2014). At the same time, those parts of the workforce who work part-time can be won over to extending their working hours
(Prognos 2012). Mention should also be made of the many initiatives to qualify managers who, through targeted organisational and personnel development, influence the retention of qualified nurses (Larsen 2016, Joost 2015). Nevertheless, these measures are only of limited effectiveness, because they merely attenuate the existing shortage of skilled workers but cannot avert it entirely.
Out of the problem situations outlined above, the active recruitment of qualified nurses from abroad has for some years increasingly been named as a short- and medium-term solution to the shortage of skilled workers in nursing (Prognos 2012, Braeseke et al. 2013). According to a study by the Bertelsmann Stiftung, every sixth surveyed enterprise in the nursing sector has in the last three years attempted to recruit qualified nurses actively from abroad – but only half were successful in doing so (Bonin et al. 2015: 63).
Since 2004 our company has received more than 41,000 applications from qualified nurses from abroad and has already built a stable relationship with more than 2,000 potential employers. Likewise, we have already placed over 4,000 qualified nurses and doctors from third countries.
Because recruitment involves considerable effort for those responsible for personnel and, in addition, a high degree of professionalism and quality in personnel management is necessary, this securing of skilled workers is above all a strategy for hospitals and large providers of inpatient care facilities for older people (ibid.). CareLend GmbH has set itself the task of actively placing the covering of the enormous shortage of skilled workers at the centre of attention also for rural areas, a noteworthy example being the cooperation with the Sana Klinikum in Borna.
In this regard, the migration of qualified nurses to Germany is not a new phenomenon: already in the 1960s and 1970s there were, for example, targeted recruitment initiatives for Korean qualified nurses (Yang 2014, Hartmann 2016). In the 1990s, through the Balkan wars, a large number of qualified nurses from the former Yugoslavia came to Germany, and the countries of the former Soviet Union of Central and Eastern Europe have since the 1990s also been important countries of origin for qualified nurses (Bonin et al. 2015). More recent migration movements of qualified nurses differ from these precursors, however, in essential framework conditions:
- Pressure to act in the nursing sector has risen sharply because of the shortage of skilled workers.
- Immigration policy in Germany and the EU has fundamentally changed from repression and deterrence to a policy that rests on fluid spaces of graduated rights and ideas of labour-market-policy “management” (Hess/Kasparek 2010; on the conceptual framework of border-regime research cf. also Heimeshoff et al. 2014 and Hess et al. 2017), thereby selectively regulating different forms of migration and seeking actively to shape labour-force needs and demography (Ratfisch 2015: 7, Georgi 2007: 5).
- This “migration management” increasingly integrates (civil-society) actors, whereby labour-market intermediaries in particular are involved in the process of acquiring qualified nurses from abroad (cf. Schwiter et al. 2014).
In addition, a globalised labour market for qualified nurses has become established in recent years: many countries of the “Global North” are characterised by a similar shortage of skilled workers in the nursing professions and stand in growing competition for qualified nurses who are recruited in ever more countries of the world. A further hallmark of globalised nursing labour markets is that labour migration into nursing is ever less frequently intended to be permanent; rather, migrants respond flexibly to permanently changing framework conditions. From this arises the necessity of shaping organisational integration successfully and thus guaranteeing lasting securing of skilled workers. In return, employers in the destination countries adapt their recruitment activities to developments and seek, through various mechanisms, to bind qualified nurses to their facilities over the longer term.
Little is so far known about how the organisational integration processes of migrated qualified nurses in Germany proceed. Various studies by named institutions show that the course of organisational integration is shaped to a considerable extent by framework conditions that are already at work in advance of the actual migration and are in part inscribed in the occupational biographies of the migrants. These include nationally prescribed requirements for specialist qualifications and language skills as well as the activity of labour-market intermediaries who, through their “preparatory” services, substantially shape later (collaborative) work in the organisation. On the other hand, the findings demonstrate the extent to which newly migrated qualified nurses must perform practice-related adaptation and transfer work in their new work context.
Despite the shared guiding principles and standards that accompanied the emergence of the nursing profession across national borders, great differences have developed in various states in the evolution of the profession depending on varying
gender relations, social orders and structures of healthcare systems (Wrede 2012, Choy 2003, Reddy 2015). The largely nationally framed occupational norms and identities have furthermore emerged in interaction with nation-specific regulations and determine the contours of responsibilities and tasks as well as relations to other occupational groups (cf. Kuhlmann et al. 2012, Theobald et al. 2013).
Against this background, newly migrated qualified nurses, on entering the German nursing labour market, are challenged to bring their specialist knowledge and previous professional experience into the new context of differently defined professionalism and different work organisation. It is not uncommon for migrated qualified nurses to be expected to adopt without question the prevailing “hegemonic [professional] identities” in Germany (Batnitzky/ McDowell 2011: 186). Accordingly, the existence of any differing expectations and conceptions among newly migrated qualified nurses, which rest on differently defined professionalism and professional identity, is initially disregarded in the workplace.
At the same time, however, the question arises for employers and colleagues of how newly migrated qualified nurses can be integrated as quickly as possible into everyday work under the given conditions. Because integration into the organisation does not concern only newly migrated qualified nurses but also requires active participation on the part of established qualified nurses and supervisors, the question arises of how this can succeed and which problems may arise here.
Despite the shared guiding principles and standards that accompanied the emergence of the nursing profession across national borders, great differences have developed in various states in the evolution of the profession depending on varying
gender relations, social orders and structures of healthcare systems (Wrede 2012, Choy 2003, Reddy 2015). The largely nationally framed occupational norms and identities have furthermore emerged in interaction with nation-specific regulations and determine the contours of responsibilities and tasks as well as relations to other occupational groups (cf. Kuhlmann et al. 2012, Theobald et al. 2013).
Against this background, newly migrated qualified nurses, on entering the German nursing labour market, are challenged to bring their specialist knowledge and previous professional experience into the new context of differently defined professionalism and different work organisation. It is not uncommon for migrated qualified nurses to be expected to adopt without question the prevailing “hegemonic [professional] identities” in Germany (Batnitzky/ McDowell 2011: 186). Accordingly, the existence of any differing expectations and conceptions among newly migrated qualified nurses, which rest on differently defined professionalism and professional identity, is initially disregarded in the workplace.
At the same time, however, the question arises for employers and colleagues of how newly migrated qualified nurses can be integrated as quickly as possible into everyday work under the given conditions. Because integration into the organisation does not concern only newly migrated qualified nurses but also requires active participation on the part of established qualified nurses and supervisors, the question arises of how this can succeed and which problems may arise here.
We at CareLend GmbH are particularly committed to the integration of our international fellow citizens, with our energetic support in integrating them into German working life, assisting them with all bureaucratic matters and promoting the learning of language and primary cultural and political aspects.
Respect and tolerance stand at the top of our priorities. Mohammed Behairy, Managing Director of CareLend GmbH, together with his team ensures that international qualified nurses always feel at ease here, and it is a great concern of ours to clear away any misunderstandings with care. Through the required internship, which takes place above all in medical facilities such as hospitals and nursing homes, international skilled workers always come into contact with their German colleagues as well as with patients. Mr Behairy is always keen to pass on his extensive experience and knowledge of intercultural links between German and Arab society to the staff.
Investigation of the shortage of qualified nurses in Saxony
The focus of the pilot project of our company CareLend GmbH relates to the region of Saxony; however, we also cast our gaze nationwide.
Alongside Rheinland-Pfalz, the Free State of Saxony is one of the federal states with the greatest shortage of skilled workers both in care for older people and in general nursing. According to the DNN (Dresdener Neueste Nachrichten), in care for older people in Saxony there are barely 13 jobseekers for every 100 vacancies. Nationwide the figure is said to be 21 skilled workers. In general nursing there are 36 unemployed persons for every 100 vacancies; nationwide we stand at 41.
According to the Federal Government, more than 25,000 skilled-worker posts in care for older people and general nursing are unfilled across Germany. In addition, around 10,000 assistants are lacking. In 2017 an average of 14,785 vacancies for skilled workers in care for older people were notified; in general nursing the figure was 10,814.
The DNN reports that the CDU/CSU and SPD promised in the coalition agreement, among other things, an “Immediate Programme for Nursing” with 8,000 new skilled-worker posts and better pay. In addition, a “Concerted Action on Nursing” for a better staffing ratio and a training offensive for nurses has been announced.
A statistic of the Bundesagentur für Arbeit states that the majority of those employed in nursing are female. In addition, part-time employment is widespread. The shortage situation in Saxony is described by the Federal Employment Agency as indicating bottlenecks on the basis of the indicators.
Because of demographic change, a steady increase in people in need of care is to be expected. According to the Bundesministerium für Gesundheit (Federal Ministry of Health), around 2.86 million people in need of care live in Germany (as at: 2015). According to the Statistical Office of the Free State of Saxony, Nursing Statistics Department, the number of people in need of care totals 204,797 (as at: 2017).
This acute shortage of qualified nurses in the Federal Republic of Germany has already existed for a number of years, particularly in the new federal states. Predominantly rural areas, especially in eastern Germany, are affected. Looking ahead, this need for qualified nursing staff will continue to increase.
How high is the actual need? According to aarpinternational.org, Germany is one of the five “super-aged” countries in the world, and the population aged over 65 will continue to grow and by 2050 will soon make up one third of the population. In 2030 there will be around 22 million inhabitants aged over 65 living in Germany instead of the current 17 million.
With the growing share of older people in society, the need for nursing staff rises at the same time. Various studies assume a shortage of between 193,000 and 480,000 qualified nurses for the year 2030.
Germany cannot cover this shortage with the annual graduates in its own country. Not least because nursing is not a sufficiently attractive specialisation for German skilled workers in the medical field.