Nursing in Germany Introduction Types of Nurse Regulation of Nursing – Basic Level Titles Rules for take-up and pursuit of nursing activities Training Scope of Activity Other titles in the profession of care C. Regulation of Nursing – Post basic level Legal regulation of post-basic training by the German States Individual Länder and the DKG EC Law Deutschland – General (All States) Appendix 1A Training outline for the pediatric nurse Appendix 2 POST-BASIC/POST-REGISTRATION NURSE TRAINING WITHIN THE EU Deutschland – Berlin Deutschland – Bremen Deutschland – Hamburg Deutschland – Hessen Deutschland – Mecklenburg Vorpommern Deutschland – Niedersachsen Deutschland – Nordrhein-Westfalen Deutschland – Rheinland Pfaltz Deutschland – Saarland Deutschland – Sachsen Deutschland – Schleswig-Holstein Introduction The Federal Republic of Germany is a Federal state. The Länder are responsible for general hospital care, general medical care outside hospital, care of elderly or chronically sick patients, health education and public health.1 Germany formally implemented the EEC sectoral nursing directives of 1977 by the Nursing Act of 4 June 1985 (the Krankenpflegegesetz).2 The federal structure accounts for a system of divided responsibilty. The system of Rahmengesetzgebung applies in this legislative area according to Art. 74, no. 19 of the Basic Law3. Federal law regulates the basic training for nurses and sets out the framework for the training of nurses in general, but it is for the Länder to implement it within the guidelines of the Nursing Act and the rules and regulations for the training and general provisions of exams4. Post basic nurse education is left to the Länder. This has resulted in different Länder recognising different types of speciality. In the post basic sector various, mostly indepent, organisations and institutions are involved in providing the training. The DKG (Deutsche Krankenhausgesellschaft) has produced a series of recommendations that are generally used by the Länder which have not in fact legislated post basic nurse training.5 1 Wein, R., “The Federal Republic of Germany” in Quinn and Russell Nursing the European Dimension (Scutari Press, 1993 at p. 86). 2 Krankenpflegegesetz (KrPflG) 4 Juni 1985 (BGBl. I. S 893). 3 Gerd Dielmann, letter, 8 September 1999 4 This was passed on 16 October 1985. 5 See below at page Error! Bookmark not defined. Types of Nurse At the basic level there are the general care nurses, and direct entry paediatric nurses. At the post basic level there are a range of specialist titles which vary from Land to Land. They are detailed in Appendix 2. Regulation of Nursing – Basic Level Titles The Nursing Act (Krankenpflegegesetz) protects three titles. - Krankenschwester/Krankenpfleger (general female/male nurse) - Kinderkrankenschwester/Kinderkrankenpfleger (pediatric female/male nurse) - Krankenpflegehelfer/Krankenpflegehelferin (assistant male/female nurse).6 Persons wishing to bear one of these titles must have a licence to do so according to §1 (1) Krankenpflegegesetz7. The titles are protected; bearing them without a licence according to § 1 (1) KrPflG is deemed an administrative offence; this behaviour carries a fine of a maximum of 5,000 Deutschmark8. The sectoral nursing directives are given effect by §2(3). The permission is revocable if the conditions are not met.9 The law treats nurses and pediatric nurses in a similar way. The same period of time is spent on the training of nurses and pediatric nurses (3 years), the 6 §1 (1) Krankenpflegegesetz 7 An exception is made for EEA origin general care nurses who are providing a temporary service, §1(2) KrPflG. 8 § 25 KrPflG 9 Krankenpflegegesetz §3. aims of training and entry requirements are the same, and both nurses and pediatric nurses are equally admitted to most courses of post basic training. The pediatric nurse is a direct entry branch nurse. The nursing assistant (Krankenpflegehelferin / Krankenpflegehelfer) on the other hand follows a different route of training (1 year10) and the entry requirements are not as demanding 11; nursing assistants are not admitted to courses of post basic training. Rules for take-up and pursuit of nursing activities The minimum age for persons wishing to be admitted to basic training is 17 years; their state of health must be suited to the exercise of the profession. Permission to bear one of the protected titles presupposes, in addition to successful completion of the training, the fulfilment of certain other requirements: the applicant must not be guilty of any conduct indicating that he or she is unreliable in the exercise of the profession12 and the applicant must not be incapable or unsuited to exercising this profession (physical and mental reasons are mentioned in the Act)13. The law sets out further requirements referring to the previous training expected by applicants for basic training leading to the titles of nurses / pediatric nurses14, namely: 1. Completion of an intermediate school education (Realschulabschluß) or equivalent, or completion of another ten-year school education or 10 §10 (1) KrPflG 11 §10 (3) KrPflG 12 § 2 (1) Nr. 1 KrPflG 13 § 2 (1) Nr. 2 KrPflG 14 § 6 Nr. 1 / Nr. 2 KrPflG 2. Completion of a secondary general school education (Hauptschulabschluß) or equivalent schooling provided that the applicant a) has successfully attended a preparatory nursing school for at least two years or b) has completed vocational training with a required training period of at least two years There is also a provision enabling existing nurse assistants to start their training towards the titles of nurses / pediatric nurses; their licence automatically qualifies them15. Training Training for the basic nurse is in principle set out in the Federal Law, but implemented in each Land. The tables in Appendix 1 show the training for the Basic branch nurses in the various Länder. Appendix 1a sets out the training details for the pediatric nurse. Nurse and pediatric nurse have to pass State exams which are taken after three years of training; training involves theoretical and practical tuition as well as a ‘practical training’16 Once passed the diploma is issued by the health authority of the relevant Länder. The permission to practice operates throughout Germany. The Krankenpflegehelfer / Krankenpflegehelferin (assistant nurse) has to pass State examination after one year of training (§ 10 (1) KrPflG). Details on training and examination are set out in the Ausbildungs- und Prüfungsverordnung für die Berufe in der Krankenpflege (KrPflAPrV), a 15 § 6 Nr. 3 KrPflG 16 § 5 (1) KrPflG federal law passed on 16 October 198517. Its annex 1 deals with the training of nurses (a total of 1,600 tuition hours and 3,000 hours of practical training), annex 2 with the training of pediatric nurses (again 1,600 tuition hours and 3,000 hours of practical training) and annex 3 with the training of nurse assistants (500 tuition hours and 1,100 practical hours). Scope of Activity § 4 KrPflG sets out, in very general terms, the aims that shall guide the training of nurses and pediatric nurses and nurse assistants. § 4 KrPflG (1) The training of nurses and of pediatric nurses shall impart the requisite knowledge, capabilities and skills to enable the student to provide assistance in the prevention, detection and curing of diseases (training objective). In particular, training shall be geared to: 1. informed and proficient, comprehensive, systematic nursing care of the patient, 2. conscientious preparation, assistance and follow-up of diagnosis and therapy measures 3. encouragement and instruction of patients in health-promoting behaviour 4. observation of the physical and mental condition of the patient and the circumstances influencing his / her health as well as notifying those participating in diagnosis, therapy and care of these observations 5. initiation of life-saving emergency measures until the arrival of the physician 6. execution of administrative functions where they are closely connected with the nursing measures (2) The training of nursing assistants (second level nursing) shall impart the knowledge, capabilities and skills required for the care of patients as well as the related domestic and other auxiliary 17 Ausbildungs- und prüfungsverordnung für die Berufe in der Krankenpflege (KrPfAPrV) vom functions in wards, functional units and other areas of the health services (training objective). However, there is no legally defined scope of activity for nurses in Germany. 18 Whilst the Krankenpflegegesetz protects titles, it does not protect the functions and activities of the nurse. The first national regulation on health care in 1938 envisaged the requirement of a licence for the exercise of care.19 The relevant provision however, was suspended and never entered into force. When, in 1968 the regulation of care was subject of parliamentary debate, the question occurred if legal protection should be granted not only to nurse titles, but also to the exercise of care. This however was denied; partly, because non-professional employees in health care were still needed, partly, because it seemed hardly possible to distinguish activities of care from other hospital-related activities.20 Other titles in the profession of care As we have seen, the training for the basic nurse is in principle set out in the Federal Law, but implemented in each Länder. The tables in Appendix 1 show the training for the Basic branch nurses in the various Länder. Members of other professions are also active in the realm of care. The Hebamme / Entbindungshelfer is a midwife. The Altenpflegerin / Altenpfleger (elderly care nurse) is styled as a branch nurse in Germany, but their primary function is as a “social” rather than a nursing profession. The precise nature of this profession – social or medical – is a subject of current discussion in 16 Oktober 1985 (BGBI.IS.1973) 18 Christa Nowakiewitsch, Secretary General, CARITAS Gemeinschaft für Pflege-und Sozialberufe e.V., letter 24 April 1999. 19 Krankenpflegeverordnung vom 28. September 1938 (RGBl. I., S. 1310) 20 Hermann Kurtenbach et al., Krankenpflegegesetz mit Ausbildungs- und Prüfungsverordnung fÜr die Berufe der Krankenpflege, Kommentar, Stuttgart, Berlin, Köln 1998 Germany.