Shortage of nursing staff – cause, outlook and solutions

Shortage of nursing staff – cause, outlook and solutions


Share this Post

The nursing crisis is one of the greatest challenges of our generation. The demand for nursing services and therefore for nursing staff is increasing steadily, while the supply of nursing staff is only slowly growing. As a result, the already existing supply gap is getting bigger and bigger. Expressed in figures – from 2030 onwards, there will be one unfilled nursing position for every active nurse. With the current training rates in the nursing sector, Germany will have to find alternative ways and strategies to solve the dramatic nursing shortage.  In the following article, the causes, the current figures and possible solutions are discussed in more detail.

Definition – What does the nursing crisis mean?

The term “nursing emergency” is omnipresent in the media and has also been known to people outside the sector particularly since the corona pandemic. Nursing crisis describes the supply bottleneck in the care of the elderly and sick, which is characterized in particular by a shortage of nursing staff.

The question often discussed is how to the nursing crisis came about and what factors are exacerbating the current situation. In the following, we will get to the bottom of this question.

Causes and drivers

The drivers of the nursing crisis, which are leading to an aggravation of the current situation in the nursing sector, are as follows:

Demographic change and an ageing society have a threefold negative impact on the nursing care crisis

In general, the Germans are getting older and older. This means that people in need of care have to be cared for a longer period of time. The situation is worsened by the fact that more and more Germans are reaching the age at which the probable need of nursing care increases. Finally, the generation of baby boomers will retire by 2030 and thus no longer be available to the market as nursing staff and furthermore may even require nursing themselves. The age structure among the nursing staff currently employed is a particular cause for concern, as only about 25% of the nursing staff are under 35 years of age. The largest share (around 40%) of nursing staff is 50 years old or older. Statistics of the Chamber of Nursing Professions show that only very few nurses remain active in their profession after the age of 60. The Nursing Professional Chamber concludes that about 40% of the nursing staff will retire in the next 10-12 years. All nursing profession groups are equally exposed to this trend, though the intensive care units (ICU) show to be the most affected. Here, the German Institute for Applied Nursing Research (dip) found out that the majority of intensive care nurses stop working in the intensive care units at the latest at the age of 50 due to the high physical and psychological strain or at least change departments.

Poor working conditions – not very attractive for young trainees and a reason for the migration of highly qualified nursing staff to other sectors 

Poor working conditions are often equated with a shortage of care workers. Due to the shortage of nurses in Germany, many nursing homes and clinics are confronted with the situation that if a nurse leaves the team, this vacancy remains unfilled for more than 6 months. The work that arises is now distributed on fewer shoulders and the available personnel must work at the maximum limit / utilization – and this often over several months time. This exceptional situation which can last for several months leaves its mark on the nursing staff, and the sickness rate in the sector is correspondingly high. The sickness rate caused by increased workloads has an aggravating effect on the current crisis, like in a vicious circle.

Another factor is that working conditions are often poor. The stress levels are high, the psychological and physical demands of working with patients and constantly changing shift work are enormous. There is often a lack of appreciation from patients, colleagues, relatives, the institution and society, which is a central concern of many nursing staff and also a core requirement for the time after Corona in Germany. Given the current problems in the industry, maintaining the motivation of nursing staff is difficult to almost impossible and often leads to nursing staff looking for work in other sectors and changing careers after only a few years. This migration of well-trained and experienced nursing staff also has a catastrophic effect on the nursing shortage.

For example, the Institute for Employment Research (IAB) found that only 37 per cent of nursing staff for the elderly are still in their original jobs after ten years. Many quit voluntarily and look for other employment in other sectors.


Remuneration is known as one of the factors that is used in other industries to compensate for harsh working conditions, f.e. as seen with air traffic controllers. The current salaries in the care industry are often not good enough despite the hard and demanding work conditions and therefore have a lot of potential for improvement.

On average, trained full-time geriatric nurses receive € 2,621 gross per month and € 31,450 gross per year. Trained nurses, on the other hand, earn on average about 3,180 euros gross per month.

The nursing staff used the Corona crisis to draw attention to the desolate working and remuneration conditions and their systemic relevance and launched an initiative in which they demanded a salary of €4,000 gross per month. Here the link to the nationwide initiative: {Link}

Health policymakers are also calling for the profession to be upgraded and, in particular, for better pay. A collective agreement for the care sector has been under discussion for a long time and is now finally due to come into force in May – June 2020, as promised by Family Minister Giffey in April 2020.

Lease workers are reinforcing the negative trend – this is the opinion of hospitals, nursing homes, care services and politicians

One of the issues on which the various parties in the care and health industry agree is that leasing workers (also known as temporary or contract workers) are one of the drivers of the care crisis. The various parties all conclude that leasing staff should only be used to compensate for peak capacity utilization. However, voices are also repeatedly being raised calling for a ban on this form of employment in the health and nursing care sector, supported and approved by the political world.

The problems caused to the industry by leasing workers are as follows: 

On the one hand, the high costs of temporary work agencies are putting pressure on the low margins of care services and nursing facilities. Much worse, however, are the consequences for the permanently employed doctors and nurses. On the one hand, leased workers are often not trained in the internal processes, earn several times as much than what the permanent nursing staff earn and have better working hours with the option of excluding shift work. On the other hand, the advantages of leasing lead to a high level of frustration among the permanent nursing staff, who on the one hand receive the lower salaries, work in shifts, have to familiarize the leasing staff with the specific processes in addition to the work they have to do anyway, and have to compensate for the undone work by the leasing staff. A feeling of “unfairness” and imbalance is spreading, driving many nursing staff into the market for temporary workers themselves or out of the industry altogether.

Relatives terminate care activities

185,000 of the 1.7 million relatives are on the verge of completely ceasing their nursing activities due to the overwhelming physical and mental strain. There are also fewer and fewer people who can take over the care of their relatives. Often the children live far away and are professionally very involved, so that caring for their parents / relatives is not feasible without professional help. Even if the number of people in need of care were to remain the same, the need for outpatient and inpatient care would automatically grow with the decreasing number of relatives providing care – and with it the need for skilled workers.

Trend towards inpatient nursing care

Furthermore, a trend away from outpatient care towards inpatient care can currently be observed. In outpatient care, there is one nurse for every 2.06 people in need of care. In inpatient care, the ratio is almost 1 to 1, and this trend will mean that even more skilled nursing staff will be needed in the near future.

Current situation

We currently have 1.4 million nursing staff who care for about 3.7 million people in need of nursing care (source). The personnel gap amounts to about 120,000 nursing staff in 2020 (source). At present, the majority of clinics in Germany do not meet the staffing level required by the nursing staff regulation (PPR). Of these, only 40,000 vacancies are reported to the Employment Agency (source). The low number is explained by the high bureaucratic effort involved in cooperating with the Employment Agency and the low chances of success in finding nursing staff through the Employment Agency. For example, studies analyzing actual personnel requirements came up with a figure of at least 120,000 open nursing staff positions. The basis for measuring the shortage of 120,000 nursing staff takes into account current personnel assessment regulations (PPR) and lower personnel limits. From 2021 onwards, the introduction of the nursing staff regulation 2.0 or the “Soll-ist-Voll-Rechner”, which was developed by Verdi, is planned in order to determine actually reliable figures. It is assumed that with these personnel assessment instruments, the current requirement will already be higher, i.e. 40,000 – 80,000 nursing jobs.            


By 2030, the number of employed nursing staff will not be able to absorb the number of nursing staff leaving the clinics, despite the increased number of training courses that have been offered so far. A decline of about 40,000 nursing staff is expected. In contrast, however, the number of people in need of nursing care will increase due to demographic change, with about 4,000,000 people expected to require nursing care in 2030. The outlook for 2050 is even more dark and extreme. By that time, the number of people in need of nursing care will have doubled, and the demand for nursing care will have tripled.

This situation will cause a shortage of 350,000 to 500,000 nurses in 2030. This figure was determined unanimously by the DIW and the Bertelsmann Foundation study. This means that there are currently around five nursing staff to fill a nursing position that cannot be filled. In 2030, a single nurse would then have to absorb the additional work of an unfilled position.

The figures also show, however, that the financing of such health care system will be spread over fewer and fewer shoulders. In order to avoid a financial collapse of the health care system, proposals must be worked out in the future that are both financially viable and sustainable, so that not only the current but also future generations can benefit.

A look abroad

If you look at the rest of Europe, you quickly notice that similar dramatic conditions prevail in our neighboring countries. The following table gives a rough picture of the situation abroad:


In relation to the number of inhabitants to the shortage of nursing staff, the Netherlands are facing a similar shortage of nursing staff to Germany – 37,000 open nursing positions – but is still considered a role model in the nursing sector. Here, there are particularly positive examples of how neighborhood assistance can be used to ensure high-quality home care and broad social commitment or to provide follow-up care for hospital patients in so-called “care hotels” (“Zorghotels”).


Here, too, an enormous shortage of nursing staff can be administered, with around 153,000 nursing positions to be filled at present. In contrast to Germany, however, a comparable deterioration in the shortage of nursing staff is not expected over the next 10-15 years, as the situation in France is much more relaxed from a demographic point of view. The birth rate our our French neighbors is 1.9 children per woman compared to only 1.5 children per woman in Germany.


In England, Scotland, Wales and Northern Ireland there is a shortage of around 44,000 carers according to official sources. However, this figure was determined before Brexit. The withdrawal from the European Union and, in addition, the fact that the future partnership with the EU and in this context the free movement of workers is still being negotiated, leads to a great amount of uncertainty. It is unclear for European carers whether they will be allowed to continue to practice their caring professions in the UK in the near future. As a result, there is a lack of planning security for inpatient follow-up facilities and clinics, so that alternative ways of recruiting nursing staff from third countries must be pursued quickly in order to keep the ailing NHS health system alive. It is therefore currently not possible to determine reliable figures for the shortage of nursing staff in the UK, although it can be assumed that these will probably exceed the official 44,000 vacancies.


Switzerland is facing a similar demographic change to Germany. Nursing is the number one of the most needed professions. The rapid development in recent years is dramatic: The demand for nursing staff has doubled in the last four years and the trend is expected to intensify in the coming years, not least because of  the particularly high number (around 45%) of drop-outs in Switzerland. Almost every second nurse changes profession or industry within 10 years. This is also due to the migration of foreign nurses to Switzerland. Most of them come from Germany (34.7%) and France (36.9%), it is virtually impossible to stop the impending nursing shortage.


Apart from the financing of nursing care, the shortage of nursing staff will be the biggest problem in Austria in the coming decades. Like Germany, Austria is convinced that the attractiveness of nursing professions must be increased. In addition to increasing salaries, psychological support and assistance for the workforce, in-service training and higher qualifications are seen as the main factors that will help to solve the shortage of personnel.

Attempts to find solutions or measures against the nursing emergency

The figures and trends of the nursing shortage are alarming. In order to counteract the nursing shortage, committed action by decision-makers and suitable strategies by politicians are now required.

In 2019, the German government has defined five fields of action in collaboration with interest representatives, associations and decision-makers from the health and nursing care industry to combat the nursing care crisis:

  1. Improve employment opportunities by enabling re-training.
  2. Increase labour force participation by improving work-life balance & training.
  3. Extending working hours by converting part-time to full-time jobs.
  4. Investment and training in the education system to increase the number of apprenticeships.
  5. Targeted immigration of care workers from abroad, especially from countries that have a surplus of care workers (exclusively third countries, i.e. non-EU countries) or have a governmental cooperation agreement.

All the above-mentioned fields of action aim to increase the number of people working in the nursing sector and thus to improve the situation in general, the nursing shortage and, more specifically, the working conditions of health and nursing staff.

Through the Concerted Action on Nursing (KAP), the Federal Government, together with a consortium consisting of employers, health insurance companies, employee representatives, experts and associations from the health care and nursing sector, presented a concept for combating the abuses in nursing and the nursing crisis in June 2019. The results are to be understood as proposals for solutions by the following three federal ministries or ministers of state: Federal Ministry of Health under the leadership of Jens Spahn, Federal Ministry of Labour under the leadership of Hubertus Heil and Federal Ministry of Family Affairs under the leadership of Dr. Franziska Giffey.

The concept is divided into three direct and two indirect categories of measures. Direct solutions to the nursing care crisis are the areas of personnel, money and training. More staff are to be employed in nursing care. This is to be achieved by facilitating the recruitment and integration of nursing staff from abroad, improving working conditions and binding rules for staffing nursing facilities and hospitals. More money is also to be invested in nursing staff. This is to be achieved by improving salaries in the nursing sector and introducing a minimum wage and collective agreement. The financial resources of the nursing care insurance system are also to be improved. The number of apprentices is also to be increased. Investments in education are to increase the number of apprentices by at least 10% by 2023.

Indirect solutions to the nursing shortage and to improve the general situation are the expansion of the nursing staff’s area of responsibility and the digitalisation of processes.

Jens Spahn is sure that the situation in nursing care is improving thanks to the KAP and says: “Nursing care must become more attractive again. This can only be achieved with more staff. Because this not only relieves the burden on the individual nursing staff but also leaves more time to look after those in need of care. The resolutions adopted by the Concerted Action are a mandate to all those involved. And they are a promise to all nursing staff: “We will continue to fight to improve the situation in nursing care.

Criticism of the Concerted Action Nursing

In general, it is a good sign that care is on top of the political agenda. However, the Concerted Action on Care is viewed critically by various stakeholders in the health and care sector because it is a clear compromise between the various stakeholders and is not sufficient in this form. Furthermore, the concept is largely a declaration of intent rather than binding agreements. Fundamental questions such as implementation and financing remain unresolved.

In addition to the public measures against the nursing crisis, there are numerous other private measures. The ecosystem of private measures can be divided into four areas:

  1. Temporary employment agencies – address the nursing emergency with domestic funds, but do not solve the drivers of the problem.
  2. Own initiatives of institutions and foundations include, for example, testing new working models and recruiting or training nursing staff from abroad.
  3. Recruitment agencies recruit nursing staff from abroad.
  4. nnovative organisations such as Buurtzorg, for example, use special approaches to increase employee friendliness and efficiency.

Five further proposals to solve the nursing shortage

The most obvious solution is probably to render caring jobs more attractive through better salaries, working conditions and by a favourable work-life balance.

Nevertheless, alternative solution ideas are being discussed by politicians and various decision-makers in the health and care sector. For the sake of completeness and in order to discuss the topic from the different perspectives, we have selected five alternative ideas aiming to solve the nursing care crisis and present them below. It should be emphasized that these are not solutions proposed by or supported in any way by Careloop.

1. Obtain care services directly abroad

Instead of promoting the recruitment of foreign nursing staff, as the Constituent Action Nursing does, according to Apotheken Umschau, more and more Germans are considering having nursing care provided directly abroad. The reasons are, on the one hand, the lack of nursing staff or the lack of free places in inpatient nursing facilities or outpatient nursing services and the resulting long waiting times for the much required care. On the other hand, the issue of financing plays an important role for a large number of people in need of care. Care facilities and services abroad are often many times cheaper than in Germany.

2. Using Hartz IV recipients for nursing care

This proposal is well known and topical, but also controversial. In the near future, the district of Central Saxony would like to put this approach into practice and employ the long-term unemployed in the care sector. However, this will first require changes to the law before it can be implemented. The proposal from many of the founders is particularly controversial, however, because it involves workers from outside the profession who have not completed the qualifications, further training or retraining and are therefore unable to guarantee the high quality of nursing care required.

3. Academic training

Abroad, there are often academically trained nurses who can take on more tasks in the daily hospital routine. There is now a growing demand that Germany should orient itself and catch up with international standards. The resulting greater range of tasks and responsibilities offers better career opportunities for nursing staff. In addition, it offers a relief for doctors of the burden by taking over medical activities. This renders the nurse’s job with even more responsibility, attractiveness and offers further arguments for better pay. One of the major advocates and supporters of this strategy is the Robert Bosch Stiftung.

4. Use technological progress in care

The issues of digitization and technologization are repeatedly mentioned in discussions on how to solve the nursing shortage and how nursing care in Germany could be raised to the next level of quality. This is not so much about replacing the human being with a robot as a caregiver, but rather about supporting the caregiver with computers and robots so that more time can be invested in the personal care of the patient and in the human exchange with the person in need of care. With the widespread use of care robots, technological innovations and digitalization, a personnel gap of up to 50,000 caregivers could thus be counteracted. The aim is to use the latest technology and digitization to simplify and shorten work processes, right through to the transfer of the simplest tasks to robots that are not performed on but for the patient.   

5. Promote further training opportunities for assistants

In contrast to registered nurses, there are currently a large number of nursing assistants. Here, the state should use the existing potential of nursing assistants and support them in their further training to become nursing specialists. Giving these assistants a career perspective increases the motivation of the assistants themselves and also brings benefits for the existing nursing staff in the team, as the work and responsibility can be distributed on more shoulders. Finally, it also makes it easier for the nursing facilities to reach the minimum nurse-patient-ratio and to guarantee qualitative care for those in need of care.