Qualification profiles in nursing – the current situation in German speaking countries

Reform of nursing training programmes due to changes to the general conditions

As of the beginning of 2020, trainee nurses in Germany can choose to pursue regular vocational training in the form of a three-year programme leading to the qualification of a nurse or opt to study for a foundation degree in nursing. There is also the opportunity to obtain a separate degree in geriatric nursing or as a qualified children’s nurse (§§ 59–62 PflBG [Nursing Professions Act]).

Nurses operate in high-tech environments such as intensive care units and other acute hospital wards as well as working in rehabilitation and in various types of long-term care (outpatient or inpatient care). These areas of activity are subject to different kinds of logical approach. Acute care nursing very often focuses on curation and aspects of medical care, whereas the emphasis at long-term care institutions and during home-based care is on providing support to help patients cope with the restrictions they face in everyday life (cf. Twenhöfel 2014). Despite these areas of focus, each field also requires the aspects of nursing covered by the other. In home-based care, for example, current social legislation regulations exhibit a clear division between tasks that can be allocated to the care or to the cure aspect respectively. Nurses who have passed the requisite examinations predominantly perform medical nursing tasks, whereas auxiliary staff carry out functions related to the provision of basic care and assistance in the household. These respective task profiles result in different qualification levels (cf. Twenhöfel 2007), thus prompting the call for “coherent and inter-delineated requirements and competence profiles to be defined. These should be integrated into clear, plausible, consecutively staged and a permeable system offering skills profiles that are in line with requirements” (Lehmann et al. 2019, no page reference), it is also suggested internationally within the scope of the ICN Nursing Care Continuum.¹ Further objectives are to ensure vertical permeability whilst also using relevant continuing training programmes to facilitate the increase in horizontal complexity by means of professionalism (cf. Twenhöfel 2014). In the nursing sector there is a wide range of possible qualifications from assistant training courses to doctorate programmes. This diversity has not yet been enshrined in nursing care practice. Nurses with academic qualifications are frequently not involved with direct patient care, nor are clear regulations put in place to govern cooperation between assistants and skilled staff. The nursing training systems in Austria, Switzerland and Germany are presented below in order to map the qualification levels across the three countries in comparative terms and to identify structural needs for Germany.
 

Areas of competence in Switzerland and Austria aligned to qualification profiles

At the beginning of the millennium, Switzerland opted for a system which provides for both graduated vocational training and academic education. Following the reform of the nursing training system and the introduction of the Vocational Training Act in 2012, nursing professions were integrated into the vocational education and training system of the Bundesamt für Berufsbildung und Technologie (BBT) [Swiss Federal Office for Professional Education and Technology], to which new professional qualifications in nursing were created (cf. Ludwig/Steudter/Hulskers 2012). These qualifications range from Federal Diplomas of Vocational Education and Training at upper secondary level (health and social care worker, healthcare assistant) to Advanced Federal Diplomas of Higher Education at Tertiary B Level (registered nurse) and also encompass universities, universities of applied sciences and universities of education programmes at Tertiary A Level (bachelor’s and master’s degrees and doctorates).

At master level, Switzerland also offers Advanced Nurse Practitioner (ANP) programmes, which include special qualification profiles that link scientific knowledge and nursing practice within the context of healthcare provision. Courses at universities of applied science, higher trade and technical schools provide generalist training that allows responsibility for the nursing process to be assumed. A further aim is for nurses to take part in drawing up policy strategies to promote the long-term good health of the population. Healthcare assistants provide care, support and everyday assistance to vulnerable persons who have fallen ill and also seek to bolster the physical, social and mental well-being of such patients. Healthcare assistants perform their duties autonomously whilst acting in accordance with the relevant general legal conditions, operational regulations and within the scope of the employability skills they have acquired (cf. Fent/Jörg 2018). By way of contrast, health and social care workers carry out their tasks on the basis of instruction. Plans are in place in Switzerland to conduct a project to evaluate qualification profiles within the next four years.²

Having recognised that existing qualifications will no longer be able to take account of future operational requirements in nursing, the Österreichischer Gesundheits- und Krankenpflegeverband (ÖGKV) [Austrian Healthcare and Nursing Association] took the bold decision in 2011 to draw up a national competence model. A graduated qualification system was developed on the basis of the ICN (International Council of Nursing) “Nursing Care Continuum Framework and Competencies” (cf. ÖGKV 2011, pp. 15 ff.). Nursing assistants who have completed one year of training work under instruction and supervision, whereas specialist nursing assistants are permitted to operate autonomously within defined action parameters once they have undergone a qualification period of two years. Generalists in healthcare and nursing complete a three-year programme of training at bachelor level (BSc Health Sciences at a university of applied sciences). They assume responsibility for complex specialist or professional processes and act as technical line managers for nursing assistants and other support staff. Healthcare and nursing specialists are qualified at the master level. They instigate development processes and are in charge of monitoring and evaluations. They apply scientific methods and are responsible for the implementation of research results. The competence model serves as a reference framework for evaluating the reorganisation it sets out (cf. ÖGKV 2011). This evaluation is currently (until 2023) being conducted via a multi-tier project (cf. Pleschberger/Holzweber 2019).
 

Qualification profiles in Germany

Since 2020 there has been a nationally standardised generalist nursing vocational training at secondary level in Germany. The Nursing Professions Reform Act also stipulates a statutory foundation for basic academic training (bachelor). The legal reform at federal level does not include any qualifications at assistant level. Areas of responsibility for assistant training programmes currently rest with the federal states. The qualification profile is defined in Annexes 2 to 5 of the Ausbildungs- und Prüfungsverordnung für die Pflegeberufe (PflAPrV).³ According to Annex 2, registered nurses are responsible for the nursing process, for designing communication in a way that is appropriate to the situation, for inter-professional cooperation on the basis of laws, ordinances and ethical guidelines and for scientific research findings. Pursuant to Annex 5, those who have completed higher education are expected to take charge of the structuring and management of highly complex nursing processes on the basis of scientific decisions, to be involved in the development of guidelines and expert standards, and in professional development. 

Two additional separate qualifications—“geriatric nurse and “registered children’s nurse”—are included at the level of professional training (Annexes 3 and 4). Trainees are able to opt for these when they make the transition to the final stage of training.

In Germany exists a total of 27 different training programmes for specialist nursing assistants. The 16 federal states are responsible for them (cf. Jürgensen 2019). They agreed to adopt “Benchmarks for training programmes in assistant and auxiliary occupations in nursing for which the federal states have responsibility” at the Conference of the Ministers of Labour and Social Affairs (2012) and at the Conference of the Ministers of Health (2013).⁴ In Bavaria, for example, this agreement has been implemented in the form of the “School regulations for full-time vocational schools involved in the training of nurses, nursing assistants, geriatric nursing assistants, midwives and paramedics” (Vocational School Ordinance on Nursing, BFSO Pflege). The objective of training is stipulated to be “Care for persons in need of nursing and implementation of nursing measures in stable care situations, primarily in inpatient and outpatient acute care [...][and] [...] in long-term care” (§ 2 Paragraph 1 No. 2 and No. 3 BFSO Pflege). Specialist nursing assistants work autonomously in stable nursing situations in accordance with their qualification profile.
 

Commonalities and differences in the qualification levels

The qualification profiles in German speaking countries exhibit commonalities in the area of responsibility for the nursing process in that registered nurses have case responsibility for the patient. In Austria and Switzerland, registered nurses also take charge of professional management within the care system. In comparative terms, we can ascertain that Switzerland and Austria are choosing to increase the level of training for registered nurses (generalists in healthcare and nursing, registered nurses with a degree qualification). By way of contrast, Germany is only partially lifting entry prerequisites to tertiary level. Responsibility for the nursing process may be assumed both by persons who have completed training at a vocational school and by those who have obtained a bachelor’s degree.

The German Council of Science and Humanities has recommended that 20 percent of nurses involved in direct patient care should have undergone academic training (cf. Wissenschaftsrat 2012). In Austria and Switzerland, the skilled worker qualification permitting assumption of responsibility for nursing processes is aligned to reference level 6 of the EQF.⁵ In Germany, this is localised at level 4 of the German Qualifications Framework (DQR).⁶ In Switzerland, healthcare assistants who execute nursing tasks independently without assuming responsibility for the process are aligned to this level. No official alignment of assistant occupations to the Austrian National Qualifications Framework has taken place thus far. If we look at the training structure, it would be possible to align these qualifications to EQF reference levels 3 and 4 in the same way as in Switzerland (cf. Table). Specialist nursing assistants in Austria and healthcare assistants in Switzerland act autonomously in conducting tasks in line with their competence profile (after two or three years of training), whereas nursing assistants in Austria and health and social care workers in Switzerland work under instruction and supervision.
 

Commonalities and differences in the qualification levels

The qualification profiles in German speaking countries exhibit commonalities in the area of responsibility for the nursing process in that registered nurses have case responsibility for the patient. In Austria and Switzerland, registered nurses also take charge of professional management within the care system. In comparative terms, we can ascertain that Switzerland and Austria are choosing to increase the level of training for registered nurses (generalists in healthcare and nursing, registered nurses with a degree qualification). By way of contrast, Germany is only partially lifting entry prerequisites to tertiary level. Responsibility for the nursing process may be assumed both by persons who have completed training at a vocational school and by those who have obtained a bachelor’s degree.

The German Council of Science and Humanities has recommended that 20 percent of nurses involved in direct patient care should have undergone academic training (cf. Wissenschaftsrat 2012). In Austria and Switzerland, the skilled worker qualification permitting assumption of responsibility for nursing processes is aligned to reference level 6 of the EQF.⁵ In Germany, this is localised at level 4 of the German Qualifications Framework (DQR).⁶ In Switzerland, healthcare assistants who execute nursing tasks independently without assuming responsibility for the process are aligned to this level. No official alignment of assistant occupations to the Austrian National Qualifications Framework has taken place thus far. If we look at the training structure, it would be possible to align these qualifications to EQF reference levels 3 and 4 in the same way as in Switzerland (cf. Table). Specialist nursing assistants in Austria and healthcare assistants in Switzerland act autonomously in conducting tasks in line with their competence profile (after two or three years of training), whereas nursing assistants in Austria and health and social care workers in Switzerland work under instruction and supervision.

Initial specific initiatives for a revision of assistant occupations are now becoming discernible in Germany (cf. Bavaria). The representative of the Federal Government has announced endeavours to achieve further standardisation of nursing assistant training.⁷ Competence profiles in nursing practice still need to be converted into tasks profiles and specific job descriptions right across the German speaking countries. No nationally uniform regulations relating to competence profiles for special nursing expertise are in place at master level, neither in Austria and Switzerland nor in Germany. The table represents an attempt to present formal qualifications in Switzerland, Austria and Germany in accordance with the EQF. The qualification profiles addressed here concentrate on the vertical differentiation of competencies. Alongside this vertical differentiation, the possibility exists in all three countries to attain more detailed professional expertise via continuing training courses. Comparative analysis in this field represents a separate and urgent research desideratum. This article also constitutes an initial attempt to compare the training programmes in German speaking countries. This makes it clear that the mix of qualifications in nursing currently still displays a high degree of requirement for regulation and that a robust regulatory structure is difficult to discern.

SABINE DAXBERGER
Academic researcher at the University of Osnabrück

MIRIAM PETERS
Academic researcher at BIBB

CLAUDIA HAUCK
Managing Director of the Bavarian Caritas Association for Nursing and Social Care Occupations

Translation from the German original (published in BWP 2/2020): Martin Kelsey, GlobalSprachTeam, Berlin