Abstract
BACKGROUND:
This study compares Canadian and German healthcare workers employment status and wages based on age, gender, and educational training. The German and Canadian healthcare systems are rarely compared, that if such a comparison between the two countries is available, can provide an insight of health workers employment status and how that might affect the wellbeing of elderly.
OBJECTIVES:
The study investigates the relation of age, gender and post-basic training with annual employment and income of health care workers in Canada and Germany.
METHODS:
Secondary data on age, gender, post-basic education training, employment status and average monthly wages/salary was obtained from the German Socioeconomic Panel and the Canadian Survey of Labor and Income Dynamics data. The German dataset comprised 571 healthcare workers, including 219 nurses, 231 elder carers and 121 care assistants. The Canadian dataset comprised 2,580 healthcare workers, including 947 nurses, 493 elder carers and 1,140 care assistants.
RESULTS:
Primarily, there was a strong relationship between post-basic training and wages for both the Canadian and German samples among elder carers and care assistants. Older healthcare workers (46 years old and above) were generally employed, and age had no predictive power on annual labor earnings. This difference in age was significant among the Canadian than the German nurses. Post-basic training had a significant relation with annual earnings and monthly wages in both the Canadian and German samples.
CONCLUSIONS:
This study suggests that the socio-demographics of healthcare workers as age, gender and advanced training are associated with their employment opportunities, financial rewards, and better career opportunities. The relationship between demographic variables helps understand the relation of healthcare workers employment dispositions and how it might improve the quality of life of older people in nursing homes, hospitals and elderly private homes in Canada and Germany.
Keywords
Introduction
A healthcare worker is a broad term referring to an individual who provides paid care to other individuals. The dictionary defines carer as an unpaid or paid person who helps a patient with daily living activities [1]. The term carer is used in Europe and Australia, and caregiver is used in North America and China. Burau, Theobald and Blank [2] explained that care workers have an occupational status they are also known as personal and home care aides, companion, and caregivers. The carers work for family, children, young people, adults, and elderly in various care situations. The unpaid carers or caregivers are relatives, friends, or neighbors and seek no professional training or educational qualifications. In other contexts, paid care workers are called care assistant, personal care attendant and carer; they are also informally referred to as contracted carers. The paid carer would have four to five clients at a time, which requires that they carefully block their time between clients.
The paid carers or personal care attendants help clients with disabilities, chronically ill or cognitively challenged people. Some healthcare workers simply assist recently discharged patients with short-term needs. In many cases, these care workers care for their clients in their homes, or in home-like settings [3]. Healthcare workers are generally employed in different sectors of the healthcare system, such as hospitals, home-based care, or residential care.
Healthcare workers are the backbone of the healthcare system. They play a key role in providing health and social care services in hospitals, home healthcare, or nursing home environments. As worldwide population ages, healthcare workers increasingly deal with elderly patients’ psychological and social needs [4]. More likely the healthcare systems in countries like Canada and Germany, will face significant challenges in meeting the demands of their aging population.
Canada and Germany are two interesting countries in the way they provide healthcare. Both have a socialized healthcare system, both have an aging population, and both face a crisis in human resources needs to support their aging population. Also, both countries lack the trained healthcare workers needed to meet the growing demand for health clients, minifying the quality of care especially among the elderly [5].
Need for skilled care workers
The understaffed healthcare systems in Canada and Germany may have an impact on the quality of healthcare services. According to the Canadian Nurses Association [6, 7], Canada will experience an extreme shortage of nurses by 2022. Likewise, Germany shortage of nursing staff is expected to grow substantially in the coming years [8]. In addition to the shortage of trained healthcare workers, and other factors, all impact the human resource needs of the healthcare systems. For instance, the mobility of healthcare workers, lack of professional healthcare training, an aging workforce, and job overload have directly or indirectly impacted the quality of elderly care services. The short supply of professional healthcare workers will generally impact the quality of care and consequently the quality of life, especially among those elderly who need medical and social support [9].
In some countries, aging as a proportion of the population posits new population patterns never seen throughout history; older people are living longer and comprising a larger proportion of the population [10]. The longevity of older people requires increased personal care in daily activities and health support to function independently [11]. Since the 1970s, Germany experienced a decline in birth rate and an increase in average life expectancy shifting the demographics toward a growing proportion of the elderly [12]. A 2017 report by AARP International (the American Association of Retired Persons, now called the National Institutes of Health) [13] indicated that the German population of people aged 65 and above will continue to grow, reaching nearly 24 million, or 41% of the population by 2050. The German population has a healthy life expectancy, with three-quarters of elderly aged 65 and above still feeling fit. In addition, the prevalence and increase of chronic and psychological conditions such as dementia of the elderly population has heightened demand for long-term care. Likewise, Canada has seen a decline in birth rate and an increase in age longevity, with the population of the elderly steadily growing and expected to comprise 25% of the population by 2036 [14–16].
It is general knowledge that elderly patients with health problems have difficulty performing basic daily living activities, such as dressing, eating, getting around, toilet hygiene, and drug intake, subsequently elderly clients need trained professional help in homes or long-term custodial homes for the elderly. Policy makers, government agencies and healthcare institutions ensure that all patients or care service users in home care settings receive proper care, and those who deliver direct or indirect healthcare services ensure their care knowledge and skills are legitimate, certified, and current.
Healthcare workers and their training in Germany and Canada
Nursing training in germany and canada (Nursing training program prior to 1 January 2020)
Germany and Canada are developed economies with two different training systems for healthcare workers. The differences in the length of training for healthcare workers (nurses, elder carers, and care assistants) are shown in Table 1. Both system’s basic education, i.e., tertiary education, leads to a “first-level” tertiary qualification and ensures that healthcare workers can provide care for elderly patients and other health clients. One contrasting difference between the two countries, is that the German elder carers take 3-years to complete their qualification, whereas Canadian training programs have up to 1-year requirement to be able to practice in the field.
Comparison of Healthcare Workers’ qualification between Germany and Canada
Comparison of Healthcare Workers’ qualification between Germany and Canada
Sources: Theobald [17], Federal Government Germany [18] and CNA [7].
Basic educational training leading to a tertiary qualification provides healthcare workers the opportunity to practice as professionals in the healthcare system. In Germany, there is a requirement of a minimum of 10 years in secondary school to meet the admission requirements to a tertiary nursing program in a health science or nursing program [19]. Cassier-Woidasky [19] further explain that a nursing license may require three years of educational training, while general and pediatric nurses receive the same three-year long education and training as a geriatric nurse (elder carers). The German qualification framework require that healthcare candidates who wish to become nursing professionals choose among three different professional training programs. If candidates choose to undergo an academic program to become general nurse, geriatric nurse, or pediatric nurse, candidates must undertake a three-year program in a professional nursing school affiliated with a hospital. From 2020, all various nursing and care professions, such as general, geriatric nursing and pediatric care, are streamlined together for the first two years; in the third year, they are tracked based on the specialization [20].
Additional (Further) training in Germany
The additional training of nurses, elder carers and care assistants is training they receive beyond their basic tertiary/occupational one. In Germany, additional or further training is offered in the form of specialty courses. Additional nurse training leads in the form of specialty courses, ranging in length from a few days in nursing practice to two-year additional theoretical and practical work. Training could happen offsite or onsite in healthcare and long-term care settings, leading to a certification or graduate degrees or postgraduate qualifications [19].
Basic occupational nursing training in Canada
Completion of 12 years of high school or secondary education with a focus on the sciences, such as chemistry, physics, or biology as a requirement to be admitted to a nursing program in a Canadian professional college or nursing school [21]. Not until 1995 did the nursing profession require a three-year qualification which allowed healthcare workers to work as paid elder carers. Once the candidates receive their qualification, they could advance to certification (commonly known as registered nurses). However, after 1995, this requirement changed, and all provinces were encouraged to begin a four-year bachelor’s degree in nursing science [6]. All ten provinces and three territories, except Quebec, currently require a four-year bachelor’s degree in nursing to qualify and register as a nurse. In addition to registered nurse (RN), there are licensed practical nurse (LPN) and registered psychiatric nurse (RPN), the qualification requirements are somewhat different for the nursing specializations, but all are mainly streamed in the same program of study in the first two years and then tracked according to specialization.
Additional nurse training in Canada
Continuing or further training in nursing in Canada comes in the form of specialty courses in nursing. Registered nurses RNs and RPNs can undergo additional training to further their career. These include standalone professional development courses or short-course certification programs. Nurses with a bachelor’s degree can go through additional academic training to achieve a terminal degree such as a master’s degree or a doctorate in nursing [6].
Training of care workers for elderly patients in Germany and Canada
Elder carers training in Germany
In Germany, education and educational training for geriatric nurses is a three-year long degree. Caregivers for elderly patients, person-to-person care and home support workers known as care assistants, are paraprofessionals and work under the supervision of nurses and elder carers in long-term care or residential facilities and home-care settings. The programs for care assistants require one year—“care assistance” training, to work as carers for elderly, and in some cases, a few months of training which sufficiently prepares them to practice in the field. Likewise, for unskilled or low-skilled care workers, on-the-job training is provided by the health care provider allowing healthcare candidates become paraprofessionals in care [22]. Keeping in mind that elder carers occupational role is primary “social” and principally does not fall under the umbrella of the health-science field [22].
Elder care training in Canada
For health workers to obtain qualifications as healthcare paraprofessionals in Canadian provinces, colleges and universities and professional organizations offer various occupational training programs, ranging from 6 to 12 months of training in elder care [23]. The training qualifies candidates as paraprofessional healthcare assistants, senior caregivers, and personal and home support workers for elderly patients.
This study compares Canadian and German healthcare workers on sociodemographic and educational training in relation to their employment and income. The results of this study should provide understanding of some of the implications of healthcare workers status on the wellbeing of elderly. In this study, we consider healthcare workers to be nurses, elder carers and care assistants who work in hospitals, nursing homes and home-care settings in Canada and Germany.
Methods and data
Data was drawn from the German Socioeconomic Panel [24] and the Canadian Survey of Labor and Income Dynamics [25]. The German Socioeconomic Panel is a wide-ranging longitudinal survey of private households. Since 1984 the Panel’s data have been collected annually through interviews of the same respondents [26]. The German Socioeconomic Panel uses a systematic sampling technique and has accrued 24,481 data responses from year 1998 using a computer-assisted interview questionnaire. Responses were obtained from the three healthcare workers: nurses, elder carers and care assistants. The total number of healthcare workers from the German Socioeconomic Panel dataset came to 571 healthcare workers, including 219 nurses, 231 elder carers and 121 care assistants.
For comparative purposes, we used similar data from the Canadian Survey of Labor and Income Dynamics. However, unlike the German Socioeconomic Panel, the Canadian national survey sample was cross-sectional, and accrued data based on a stratified sample and a multistage design that uses probability sampling [27]. The sample from the Canadian Survey of Labor and Income Dynamics data was collected based on a questionnaire designed for computer-assisted telephone interviews [27]. The Canadian Survey of Labor and Income Dynamics accrued a total of 49,787 responses from “Care Workers” those being: “1” = Nurses, “2” = Elder Carers and “3” = Care Assistants. The Canadian dataset comprised 2,580 healthcare workers from the original 49,787, including 947 nurses, 493 elder carers and 1,140 care assistants.
Results
The sociodemographic data of healthcare workers include age, gender, employment status, salary, employment status, salary earnings, education, and training. The independent variables of age, gender, and basic educational training as the independent variables. A logistic regression was performed using employment status and earnings as the dependent variables.
Sociodemographics
Age
The information contained in Table 2 presents the age of healthcare workers in Germany and Canada. The analysis of the data showed German nurses (51.1%) were relatively older than Canadian nurses (45.5%). On the other hand, elder carers in Germany are younger (63.6%) than those in Canada (45.2%). While care assistants were relatively older in Germany than in Canada, and lastly, elder carers in Germany are younger (63.6%) than those in Canada (45.2%).
Demographic Characteristics of Healthcare Workers in Germany and Canada
Demographic Characteristics of Healthcare Workers in Germany and Canada
Source: Computed from German Socioeconomic Panel (Germany) [24] and Canadian Survey of Labor and Income Dynamics (Canada) 2010 datasets [25].
A similar pattern of male-female ratio was observed in Canada and Germany, near 85% of nurses are female, while the proportion of Canadian male nurses (16.6%) was relatively higher than in Germany (13.2%). However, among elder carers, the male proportion was higher in Germany than in Canada; among care assistants, the ratio pattern was similar.
Average monthly salary
According to German Medicine Net [28] and Pay Scale [29], the monthly salary, before taxes of German nurses with a three-year diploma was between 1,800 and 3,000 euros. Depending on the healthcare worker’s additional qualifications and certification(s), this salary may reach 3,500 euros per month. On the other hand, in Canada, the average monthly salary of registered nurses (with a bachelor’s degree) is approximately 5,000 to 6,000 Canadian dollars, equivalent to about 3,600 euros [30]. The information in Table 2 showed that 95.4% of German and 90% of Canadian nurses were earning 3,500 euros per month or higher in 2010. Lastly, 5% of German and 10% of the Canadian nurses were earning up to 3,400 euros or the equivalent per month.
The income of German elder carers is regulated by the federal government policy or the German Federal States’ minimum wage which is calculated at an hourly rate. The new national minimum wage for elder carers came into force in 2020 [31] under the Posted Workers Act by decree of the Ministry of Labor. According to Posted Workers of 2010, the minimum wage for care assistants in 2013 was between eight to nine euros per hour. In Canada, the average hourly wage depends on the healthcare assistant’s place of work and is between 9.98 and 19.35 Canadian dollars per hour, with annual bonuses of up to $1,021 Canadian dollars [29].
Education and training
As shown in Table 2, 85.4% of nurses in Germany have a 3-year diploma in nursing, and 56% in Canada have a 4-year degree in nursing. Only 14.6% of Germany’s elder carers spent additional years in further training, while in Canada, 44% reported having additional years of further training in nursing. There was no difference in further training of elder carers and care assistants between the two countries.
Basic and further occupational training
There was a difference in basic occupational training between nurses in Germany and Canada. In general, nurses and elder carers in Germany have a similar 3-year occupational training period while nurses in Canada, have a 4-year degree in nursing, allowing them to qualify as registered nurse. There is no advanced tertiary education for care assistants in Canada and Germany, they generally go through professional development in a period less than one year for certification or qualifications to allow them to practice in the field.
Further training and employment
Employment status of healthcare workers (Nurses, Elder Carers and Care Assistants) in Canada
The analysis of the Canadian dataset showed that all nurses, elder carers and care assistants were employed either full time or part time during a period of one year. While the German Socioeconomic Panel dataset reported 6% of nurses being unemployed; no employment statistics of care assistants was available for the Canadian sample and hence, data analyses was performed for the German sample only. Table 3 reports results of the logistic regression of age and additional training on employment.
Employment status of care workers in Germany by their age, and further years in training
Employment status of care workers in Germany by their age, and further years in training
The results of the regression analysis showed the relationship of age and years of additional training as independent variables on employment status. Healthcare workers’ (nurses, elder carers and care assistants) age and additional training (leading to academic degrees or short training courses during their service) was significantly associated with the employment status. The odds ratio for the years of additional training of nurses was 1.96 and for both elder carers and care assistants was 2.487, indicating a strong relation of 96% chance of nurses being employed, and a 50% chance of elder carers and care assistants being also employed. There was a positive association between the age of nurses and their employment status; however, older nurses had a higher probability of being employed than younger nurses. The unemployment rate was higher among elder carers who were 46 years and older, compared to those who were 45 years and younger. The odds ratio for the age of nurses was 4.507; i.e., there is a 51% probability of nurses, 46 years and older of being employed. Similarly, for older elder carers and care assistants, the odds ratio was 2.99 indicating that there was 99% likelihood of being employed.
Further training and earnings
German healthcare workers employment and its relation to additional training
The Canadian Survey of Labor and Income Dynamics data showed all Canadians were employed. Hence, the analysis was only conducted for the German sample using variables relating additional training and employment. The German healthcare workers (nurses, elder carers and care assistants) who have completed some form of additional training during their employment in the healthcare sector were mostly employed compared to those without any additional training, which means that additional training has a positive impact on employment status. The odds ratio of 1.96 suggests that there was 96% chance, at a significant level of p < 0.01, that nurses with additional training stay employed as compared with those nurses who have had no additional training. For elder carers and care assistants, the odds ratio of 2.487 at a significant p-value of p < 0.006, indicates that carers with additional training have a higher probability to remain employed than those with no additional tertiary education beyond their tertiary education.
Annual employment earnings by age, gender and further training in Canada and Germany
For both Canadian and German healthcare workers (nurses, elderly carer and care assistants) the relation between annual employment earnings as the dependent variable and age, gender and additional training (i.e., post-basic training) as the independent variables was analyzed. The annual employment earnings include annual salaries, overtime earnings and annual bonuses. For the German sample, age of nurses was positively associated with the annual employment earnings which suggests that older nurses (46 years and above) were likely to have higher annual earnings than those who are 45 years or younger. Further, healthcare workers (nurses, elder carers and care assistants) gender, uniquely entered for each of the healthcare workers in the regression was not significantly related to annual employment earnings. More so, healthcare workers (nurses, elder carers and care assistants) additional years of post-basic training showed weak association with annual employment earnings. Continued nurse training beyond post-basic and tertiary education was strongly related to an increase in annual earnings compared to nurses with no further training. These results reached near significance and should be approached with caution (See Table 4 for the logistic regression results).
Annual employment earnings by age, gender and additional training in Canada and Germany
Annual employment earnings by age, gender and additional training in Canada and Germany
Source: Computed from The German Socioeconomic Panel [24] and The Canadian Survey of Labor and Income Dynamics 2010 datasets [25].
For the Canadian sample, the age of healthcare workers (nurses, elder carers and care assistants) was not predictive of annual earnings, whereas gender and further training had a positive relation with annual employment earnings. The greater the period of training, the stronger the relation to employment earnings. Female healthcare workers were more prone to stay at the job than males and their earning would increase with greater years of experience. Thus, females will likely receive higher wages than males. Nurses with ten or more years of experience had a higher annual earning than those with less than ten-year experience. For the elder carers and care assistants, years of experience was positively related to their annual earnings. The odds ratio of 1.862 says that 86% of the times the cumulative years of experience among elder carers and care assistants, will more likely have an increase in their annual earnings (see Table 4).
This study explored the relation between sociodemographic variables of age, gender and training (educational and professional) on employment status. Considering the main findings, the results showed that German healthcare workers age and further training was directly related to employment, that with increased years of training i.e., experience, the more likely Germans healthcare workers (nurses, elder carers and care assistants) will be employed. However, when it comes to wages, the German sample of healthcare workers, maybe ambivalent in taking up further training on the job or outside, because many may find out that when their advanced training has been completed, their wages do not significantly improve, which might indicate that annual wage increase may be due to overtime work, thus leaving little time to pursue further professional training. It is well documented that increased post-basic training is concomitant with pay increase leading to positive incentive for healthcare workers [32]. But, when such training comes at the cost of an increased workload, it might have adverse impact on the continuation of work in the healthcare system. In many studies, it is shown that the high turnover rates among healthcare workers have substantive implications for the services provided for the elderly clients, but also for the working conditions of the remaining staff in the same institution. Those remaining staff are shorthanded and overworked, leading to a number of human errors in drug administration, social and physical support for the elderly; thus, diminishing morale in the workplace and subsequently leading many healthcare workers to leaving the profession [33].
Elder carers and care assistants further training results showed the strong relation of annual income, these results may include income due to overtime for both Canadian and German samples. The Canadian sample data analysis showed that with increased years of experience, nurses earnings did not increase over a 10-year period, but did for elderly healthcare workers and nurse assistants. Even with an increase in age, there was no increase in salary, which could be demoralizing for many of the healthcare workers and leave the possibility of quitting the job. However, the German sample results indicate that although training among nurses and elder carers had no impact on monthly wages, a statistically significant relationship with annual wages was shown. This relationship might not exclude such factors as further training and suggests that increased earnings with years of training and further professional development, maybe a moral motivator to impute quality health services with existing prerogatives to retain healthcare workers in the health system.
For both Canadian and German healthcare workers’ annual income increase may be due to overtime work as a top-up of their monthly salary. While desired by many healthcare workers, studies however have shown that working overtime lowers the probability of remaining employed [34] and thus the healthcare worker leaving work altogether. While the effect of ‘overtime’ confirms previous peer reviewed research on nurses and doctors, that in addition to arduous working hours and commuting time, overtime adds another burden for healthcare workers’ having to extend their work hours leading many healthcare workers (namely, healthcare workers for elderly patients) to discontinue training.
Healthcare organizations might also find it financially difficult to support training for staff. While desiring to maintain the regiment of work for their staff, caring for elderly patients in a custodial setting, healthcare workers are restricted in their movement, they have strict work hours and may have few opportunities for further training (see Table 5 for comparative findings between Canada and Germany of further training on employment status, monthly wages and annually earning). However, those who do enjoy such an opportunity, do so to advance their careers and to gain an occupational advantage and possibly leaving the practice of healthcare into more technical and administrative work [35].
Comparative findings of work situation by further training
Comparative findings of work situation by further training
Registered nurses in Canada and Germany have the privilege to further their educational training toward higher degrees; in particular, those with a bachelor’s degree or the basic educational qualification, could pursue a master’s or doctorate degree in nursing [35]. This opens opportunities for professional growth that leave many practitioner jobs open for novice and new entrants in the profession. When the demand of practitioners is not fulfilled, both countries Canada and Germany open their doors for foreign labor. This issue has made training in healthcare a requirement for the new entrants, especially for those foreign health care workers that may also need language training [36]. While the call to maintain standard practices in professional development to allow healthcare workers remain up to date with current knowledge in the field [37], it appears that Canada and Germany both lack the prerogatives and incentives for further training; stressing on the need for new policies, strategies, and planning in healthcare development to further improve the work conditions and professionalization of healthcare workers meeting the requirements of a new generation of elderly clients.
Overall, the findings in this study confirm the relationship between further training, employment, and increased annual wages. Given the relation between educational training with employment and wage-related variables. There may be other variables at play such as job satisfaction and attrition, all may have an indirect impact on quality care of the elderly. A well-trained and financially rewarded healthcare worker will no doubt offer professional and robust care for the elderly. In this context, health service managers and policy makers are advised to pay more attention to the importance of employees’ professional development and employment benefits as in wages.
Certain limitations of the study must be underlined in the data collected. As in much of the existing literature on the topic. The data obtained for the Canadian sample was cross-sectional and collected on an annual basis rather than being longitudinal. Cross-sectional studies may be biased because they only capture the current measure at the time of healthcare workers’ current service. Longitudinal data and its analysis follow through the healthcare workers overtime and give a fuller picture of healthcare workers characteristics. It is also worth mentioning that such data linked to patient care and sociodemographic information could provide rich and new knowledge on quality healthcare, especially for the care of elderly clients.
Last, an important and significant component of this study was the examination of the differences between the Canadian and German data on further training. Both nations’ healthcare systems face the same extenuating conditions, particularly in terms of further training and in linking that training to promotions and salary increases. Both countries are in front of a crossroads and a critical strategic decision in regard to healthcare policies and strategies. Both countries are in need for trained healthcare workers and demand supersedes that of supply. What strategies both countries may take can affect the quality of life of future elderly generations. Clearly any decisions made relies on the integration of the current research and findings, that elderly care must be professionalized and linked to a qualification system, instituting the highest standards of care through training and retraining and rewarded through salary and other job security incentives. Further, health related colleges and training organizations must strategize to increase or even double the size of students in areas of geriatrics and geriatric care.
Both Canada and Germany have somewhat fluid immigration rules for professionals, especially those in great demand. So, when there is a demand for healthcare workers the immigration doors are open to health professionals from developing nations. But what these policies are doing is depleting health professional and “good” health professionals from source countries other than Canada and Germany and mostly from nations of developing economies, both countries need to find grounded and long-term solutions that enact and effective healthcare services for elderly generations.
As a caveat, the data obtained were at the national level, perceived satisfaction data and quality care information have not been collected. Although such data and its analyses would be significant for policy makers in making better decisions on post-basic education and further training in the healthcare profession. Beyond the scope of this study, further analysis could explore the relationship between working time and wages and between professional development and wage satisfaction.
Conflict of interest
None to report.