Resolutions

Primary qualifying academic degree programmes in nursing, therapeutic and midwifery sciences

Resolution by the 23rd General Meeting of the HRK, 14.11.2017

Summary
•    Far-reaching changes in society and healthcare create increasingly higher requirements for qualifications in the healthcare system. This makes higher education training in primary qualifying academic degree programmes necessary for a portion of workers in paramedical professions that is significant to the healthcare system.
•    To date, academic degree programmes at higher education institutions have predominantly been set up in cooperation with vocational schools. However, academic degree programmes accompanying training or incorporating training in cooperation with vocational schools often do not meet higher education standards for the academic qualification of staff, academic foundations or the structure of the training.
•    The HRK therefore emphasises that for primary qualifying academic degree programmes, the responsibility for the design, implementation, evaluation and accreditation of academic degree programmes – including for practice-based training – must lie with the higher education institution awarding the final degree.
•    A particular problem for all primary qualifying academic degree programmes is the conflicts that arise between the academic self-image of the higher education institutions and narrowly defined regulations governing professions. The HRK therefore calls upon the legislature to introduce the overdue amendment of relevant provisions in legislation governing the professions.
•    In relation to higher education institutions, the establishment of primary qualifying academic degree programmes requires the development and establishment of the corresponding academic disciplines on the part of the higher education institutions. These disciplines are to be characterised by the development of theory and methods as well as genuine, long-term research. Systematic and ongoing research funding is also necessary within the framework of existing programmes and those to be newly established.
•    Clinically-based academic degree programmes require a cooperation agreement with university hospitals and/or the academic teaching hospitals.
•    The establishment of primary qualifying academic degree programmes will involve a partial shifting of the costs of training from the health sector to the federal states, which are responsible for providing higher education. Students in the relevant academic degree programmes must also be entitled to training funding as a matter of course. 


I. Introduction
The far-reaching changes taking place within the healthcare sector are associated with increasingly high requirements for the qualifications of workers in the healthcare professions[1]. Scientific and technical progress in all areas of healthcare is giving rise to new options for diagnosis and therapy. The rapid pace of digitalisation is opening up further possibilities for the capture, storage and evaluation of data and information that support diagnostic and therapeutic decisions. Teleservices in the healthcare sector, eHealth and Medicine 4.0 describe new forms of healthcare that not only alter interaction with patients, but also interaction within healthcare professions.

These developments are associated with a changed division of labour in the healthcare sector. Complex care processes and elaborate measures in the areas of health promotion, prevention, cure, rehabilitation, palliative care and nursing demand increasingly the multi-professional and cross-sectoral cooperation of a variety of specialised personnel. Willingness and competence to cooperate and to think and act in cross-functional and cross-sectoral ways are therefore required alongside specialised expertise.

Further challenges for healthcare arise from social developments such as demographic change, increasing diversification of social structures and ways of life and the growing number of people from migrant backgrounds. The diversification of healthcare needs is associated, in particular, with higher demands on the social and intercultural competencies of those working in the healthcare professions.

The healthcare sector, making up 12 per cent of employees and 11 per cent of the gross domestic product, is of great significance to the national economy. In view of existing problems such as cost trends, shortage of specialised staff and undersupply in rural regions, it is absolutely imperative that the qualification and employment structure be optimised so that it meets the needs created by scientific and social developments and is well positioned to deal with future innovations. In particular, the shortage of specialised staff must be addressed through attractive career prospects and professional profiles that develop dynamically.

The Advisory Council on the Assessment of Developments in the Health Care System opened up debate about cooperation and the distribution of tasks in the healthcare sector with a review in 2007[2], and the Robert Bosch Foundation further extended this debate with a memorandum in 2011[3]. The German Council of Science and Humanities addressed these developments from a scientific perspective, and stated in its 2012 “Recommendations on higher education qualifications for the healthcare system” that “critical importance attaches [...] to multisectoral and interdisciplinary care at the interfaces between the various health professions”[4]. In its view, this has implications for future qualification requirements and qualification paths. The Council said that, in view of these challenges, the members of the paramedical professions charged with particularly complex tasks must be equipped to reflect on their own actions in healthcare provision on the basis of scientific knowledge. Training at vocational schools is not sufficient for this purpose, it said – for complex tasks in nursing, therapy and obstetrics, primary qualifying training must take place at a higher education institution.[5]

The German Rectors’ Conference endorses the recommendation of the German Council of Sciences and Humanities that a portion of the personnel working in the paramedical professions significant to the healthcare system should obtain an academic primary qualification at higher education institutions. Academisation in the paramedical professions is the necessary consequence of the need for qualitatively altered, more demanding care and a care structure that is becoming more complex. However, the HRK does not agree that a determination of specific percentages as proposed by the German Council of Science and Humanities would be helpful.[6] In the view of the HRK, the content to be covered and the degree of academisation should be derived from the special demands of the respective professions and the training objectives that the particular academic degree programme is designed to achieve, as well as from the added value to society that is derived from optimised conduct of care and the further development of the healthcare system.[7] The HRK also endorses the recommendations of the German Council of Science and Humanities made in 2012 that primary qualifying higher education training in the paramedical professions should be supplemented by corresponding options for continuing academic education.

The academisation of healthcare professions is currently being implemented by government to a varying extent. While the new Pflegeberufereformgesetz (Nursing Professions Reform Act)[8], which will enter into effect in 2020, for the first time provides fundamental statutory regulation of primary qualifying training in nursing at higher education institutions, in the acts governing the other therapeutic paramedical professions (physiotherapy, occupational therapy, speech therapy) and midwifery, initially only the model clauses were extended for a further four years – without provisions being adopted for primary qualifying academic degree programmes. A prioritised amended law on the midwifery profession is expected due to Union legal provisions, with a second set of comprehensive guidelines until  2020.

In this present resolution, the HRK outlines those key points that it considers imperative for the content design and formal structure of primary qualifying academic degree programmes in the therapeutic, nursing and midwifery sciences.


II. Design of primary qualifying academic degree programmes in the therapeutic, nursing and midwifery sciences

A higher education in the area of the paramedical professions, such as is already standard in almost all European countries, equips graduates of the respective academic degree programmes to reflect critically on their own occupation on the basis of scientific knowledge, to further develop it and to perceive emerging new tasks and requirements and implement them autonomously. For some professions this can involve tasks being carried out with the higher qualification that were not previously taken up by any professional group or that were previously not permitted to be performed as they were reserved for doctors.

1. Content and structure of primary qualifying academic degree programmes – problems and proposed solutions

The development and establishment of primary qualifying academic degree programmes raises the question of what structure these academic degree programmes should have. To date, along with continuing education academic degree programmes, predominantly academic degree programmes accompanying or incorporating training in cooperation with vocational schools have been established at higher education institutions, in which a higher education, a science-based training, a vocational, and practical job training component either accompany each other or are integrated in a variety of study formats in various learning locations. Primary qualifying academic degree programmes that make do without cooperation with vocational schools exist only at comparatively few government higher education institutions.

Difficulties arise from the integrated training approach if courses run by the vocational schools form part of the training. These components do not meet higher educational requirements for the academic qualification of personnel, academic foundations or structure of the courses.

As a rule, when establishing and further developing primary qualifying academic degree programmes, requirements must be satisfied that are derived from legislative and regulatory provisions governing the professions, EU guidelines, the higher education acts, structural guidelines for bachelor's and master's academic degree programmes, and the standards of national and international scientific and professional associations including education organisations. However it is important to note the weighting here. Responsibility for the design, implementation, evaluation and accreditation of academic degree programmes must lie with the higher education institution awarding the final qualification. The training profiles and criteria developed on the basis of the European and German qualification framework must be entrenched in the legislative foundations governing the professions and professional education. Qualification to practice must have an academic foundation and take place in cross-institutional cooperation and as the responsibility of the educational institutions. International mobility of students must also be enabled without disadvantage to later professional recognition.

A particular problem for all primary qualifying academic degree programmes is the conflicts that arise between the academic self-image of the higher education institutions and narrowly defined regulations governing professions. Legislation governing the professions defines the education requirements that must legally be fulfilled in order to be authorised to use the respective professional title.

The HRK therefore calls on the legislature to introduce overdue changes to the pertinent provisions in the acts governing the professions, some of which date from the 1970s and are tailored to vocational school training. In particular, adaptation to the requirements and standards of high-quality higher education training should be ensured in the relevant areas. A curricular integration of practical training is fundamental. The reform of the Nursing Professions Act is just a first step here.

The Ärztliche Approbationsordnung (ÄApprO, Medical Licensing Regulations), which create a balance between academic and practical training, can serve as a model for statutory regulation of the professions. In Section 1 of these regulations, academic and practical training, the capacity to practice in an independent and autonomous fashion and pursue continuing education and ongoing training, and academically based practical and patient-oriented training are defined as central objectives of medical training.[9]

2. Quality standards

The establishment of primary qualifying academic degree programmes requires the development and establishment of the corresponding academic disciplines, which are characterised by genuine, long-term research and the development of theory and methods, incorporating relevant foundation disciplines and related disciplines in the process. It is only upon this foundation that the necessary acquisition of scientific knowledge and competences during a degree can be guaranteed and research-based teaching can occur.

The exclusive responsibility of the higher education institution for the entire academic degree programme including vocational aspects is fundamental to the design and structure of primary qualifying academic degree programmes. The higher education institution is responsible at all times for quality assurance and maintenance of academic standards, particularly those applying to content, the didactic and learning-outcome-based development and delivery of the curriculum and for determining its structure and timing in accordance with the relevant degree and examination regulations. The following key points must be taken into account in this process:

•    Appropriate staffing, equipment and facilities are necessary. In particular, academically qualified teaching personnel must be available in sufficient numbers.
•    Practical professional training at the respective levels must at minimum satisfy the requirements that are to be achieved in outcomes and competences through the degree. The training must be delivered by, and the responsibility of, the higher education institution. On the higher education institutions’ part, full-time higher education teachers must be employed for this purpose, as well as staff at the practical training location who have subject and teaching qualifications.
•    Quality criteria and models need to be developed to implement requirements for comprehensive quality assurance for academic degree programmes, with particular reference in this context to practice-based training.
•    The extent of recognition given to competences acquired outside the higher education institution needs to be reviewed. This recognition is currently frequently performed in an overly broad fashion[10], and without sufficient curricular transparency.  In future, considerations of quality and its assurance need to be taken into account in this process.[11] Recommendations of the German Council of Science and Humanities should be taken into account.[12]
•    The approach taken in the Nursing Professions Reform Act of integrating state professional licensing examinations involving institutional cooperation into the higher education final degree examination appears to be a useful solution. Agreements will need to be reached between higher education institutions and regulatory bodies for this purpose.

3. Location of the primary qualifying academic degree programmes

Depending on the profile, primary qualifying academic degree programmes can be set up both at universities[13] and at universities of applied sciences. Cooperation arrangements between universities and universities of applied sciences are also conceivable. As a general rule, it is desirable to achieve a diversity which is guided by differing training objectives and content profiles in the academic degree programmes and in the structural networking of the academic degree programmes at the respective locations.

In the view of the HRK, cooperation arrangements, in particular with university medicine and/or the academic teaching hospitals, are necessary with the prospect of mutual stimulus and development in teaching and research in the case of clinically based academic degree programmes.

With respect to optimal patient care, high priority should be attached to the capacity to act inter-professionally and communicate across professions, as demanded by the German Council of Science and Humanities in 2012. The developments in the healthcare system that have been outlined will result in members of the paramedical professions performing more complex tasks in future – as matter of a joint responsibility but also with a focus on their own responsibility and autonomy – from which new requirements for inter-professional interaction in the healthcare profession and also altogether new institutional forms will emerge.[14] In establishing and locating the new academic degree programmes, the option of interdisciplinary cooperation should therefore be a significant criterion.

Overall, with respect to the establishment of academic disciplines and their requisite interdisciplinary networking it is necessary that these academic degree programmes should be established more than at present at state higher education institutions and religious higher education institutions acting on the government's behalf, which have an appropriately broad academic environment to offer. 

4. Research and early career researchers

The development and expansion of independent research and long-term research structures, which are associated with the development of the corresponding theory and methodology, are essential for the establishment of the underlying academic disciplines. The need to develop research in the area of nursing, therapeutic and midwifery sciences that was identified by the German Council of Science and Humanities in 2012 remains unchanged. The systematic and ongoing funding of research is needed, not only for the underlying basic research, but also for applied research within the framework of existing funding programmes and those to be newly established.

The development of new academic disciplines also involves the creation of academic career paths and the funding of early career researcher through doctoral training programmes as well as independent research in various fields of care. More use should be made of cooperation arrangements between universities of applied sciences of applied sciences and universities and also extra-university research institutions in order to support early career researchers.

5. Practical consequences

The establishment of primary qualifying academic degree programmes in the area of paramedical professions means that the development of theory and methodology as well as research will increasingly become part of the particular disciplines. Graduates will be equipped to meet more complex and challenging professional requirements and will be capable of delivering services autonomously. Their interdisciplinarity, inter-professionalism and opportunities for cooperation will contribute to safeguarding and evidence-based improvement of healthcare and its quality. Higher education training and the new level of training quality achieved are, however, associated with changes in cost structures.

Through the establishment of primary qualifying academic degree programmes, there will be a partial shifting of the costs of training from the health sector to the federal states, which are responsible for providing higher education. In view of the requirements named above in relation to higher education training and the benefits to be expected for healthcare, it is necessary for the federal states to fulfil this financial responsibility and fund the relevant academic degree programmes adequately. The German Council of Science and Humanities pointed out as far back as 2012 that additional funds must be made available for higher education training in the paramedical professions. Likewise, students of the relevant academic degree programmes must be entitled to training funding as a matter of course.

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[1] The concept of healthcare professions is used operationally in the present text as an umbrella term for all professional groups working in the healthcare system, including doctors. The professions involved are healthcare professions, professions under the Berufsbildungsgesetz (Vocational Training Act), trades in the healthcare sector and other professions. A distinction is made between these and the paramedical professions. These constitute a part of the healthcare professions and include roles in the areas of nursing, occupational therapy, speech therapy, physiotherapy and midwifery. Training in these professions is regulated by the state (see glossary for more detailed explanations).
[2] Advisory council on the Assessment of Developments in the Healthcare System: “Kooperation und Verantwortung“ (Cooperation and responsibility) 2007.
[3] Robert Bosch Foundation: “Kooperation der Gesundheitsberufe“ (Cooperation of health professions) 2011
[4] German Council of Science and Humanities: Recommendations on higher education qualifications for the healthcare system (2012), p. 6.
[5] German Council of Science and Humanities, cited above
[6] In its paper (footnote 1), the Council nominated an order of magnitude of 10 to 20 per cent of a training cohort.
[7] Robert Bosch Foundation: Gesundheitsberufe neu denken – Gesundheitsberufe neu regeln (Rethinking Health Care Professions, Reorganizing Health Care Professions), position paper 2013
[8] Act for the Reform of the Nursing Professions (Nursing Professions Reform Act – PflBRefG) dated 17 July 2017. Bundesgesetzblatt (Federal Law Gazette) I No. 49 dated 24/07/2017, p. 2581-2614 (see glossary for details)
[9] See Section 1 ÄApprO.
[10] According to the guidelines of the Standing Conference of the Ministers of Education and Cultural Affairs of the Länder in the Federal Republic of Germany, the recognition of up to 50 per cent of work performed outside higher education institutions is possible. "Anrechnung von außerhalb des Hochschulwesens erworbenen Kenntnissen und Fähigkeiten auf das Hochschulstudium (II)" (Recognition of knowledge and skills acquired outside of the higher education system in higher education degrees (II)) 18/09/2008.
[11] It would also be beneficial to adapt the structure of vocational school training to higher education training by basing it on modularisation, self-study phases, competence-based examinations and an analogous quality assurance system, making training courses transparent.
[12] German Council of Science and Humanities: Bestandsaufnahme und Empfehlungen zu studiengangsbezogenen Kooperationen: Franchise-, Validierungs- und Anrechnungsmodelle. (Current situation and recommendations on degree-programme-based cooperation arrangements: franchise, validation and recognition models.) Drs. 5952-17, Berlin (Self-publishing), esp. p. 65-68.
[13] including the Universities of Education in Baden-Württemberg
[14] German Rectors’ Conference, Project nexus: Interprofessionelles Lehren und Lernen in hochschulisch qualifizierten Gesundheitsfachberufen und der Medizin (Inter-professional teaching and learning in paramedical professions with higher education qualifications and in medicine), 2017