Mastering minimum nurse staffing levels with digital Workforce Management
With digital staff scheduling, you can reliably comply with minimum nurse staffing levels and design planning efficiently. We provide valuable insights.
The Challenge of Minimum Nurse Staffing Levels
Germany is a good example of a complex regulatory environment in the healthcare sector. The introduction of minimum nurse staffing levels in German hospitals has sparked nationwide debate. First implemented in 2019 and tightened in 2020, the regulation was introduced in response to years of understaffing in hospitals.
Supporters like health economist Jürgen Wasem1 argue the law was necessary to prevent dangerous levels of care. Critics, including the German Nurses Association (DBfK), contend the metrics are flawed and based on already low staffing baselines, offering little actual improvement in care quality. Moreover, the regulation applies only to selected hospital departments, which is another point of criticism.
Despite differing views, the regulation is now binding for most hospitals. Implementing it effectively is essential. This white paper shows how digital workforce management can help hospitals align patient care, staff needs, and operational efficiency while complying with minimum nurse staffing levels and related reporting requirements.
1 www.saarbruecker-zeitung.de/nachrichten/politik/inland/gesundheitsoekonom-juergen-wasem-fordert-mehr-pfleger-in-kliniken_aid-45771031
Legal Requirements Pose Major Challenges
Hospitals face significant legal, organizational, and staffing challenges. Digital workforce management solutions create the necessary transparency, planning reliability, and flexibility to ensure high-quality care despite a shortage of skilled nurses.
Nursing in Germany
Since January 1, 2019, German hospitals have been subject to mandatory minimum nurse staffing levels, regulated by a federal ordinance from the Ministry of Health. This was enacted after hospitals and insurers failed to agree on a standard. Health Minister Jens Spahn stated that self-regulation had failed and minimum staffing rules were needed to ensure safe patient care, particularly in intensive care units.2
To enforce compliance, hospitals must document and report their staffing levels to the Institute for the Hospital Remuneration System (InEK). The regulation defines nursing staff as both registered and assistant nurses, with specific training and licensing requirements.
In 2018, approximately 1.6 million nurses were employed in Germany, yet the need continues to grow. According to the Federal Employment Agency, reported vacancies in elder and hospital care have steadily increased.
2 www.bundesgesundheitsministerium.de/personaluntergrenzen.html
International Approaches to Nurse-to-Patient Ratios
Minimum nurse staffing regulations and nurse-to-patient ratios are not exclusive to Germany. Across the globe, governments and healthcare systems are adopting standards - through legislation, professional frameworks, or data-driven methodologies- to ensure safe and sufficient nurse staffing. Despite differing approaches, these efforts share a common goal: to enhance patient outcomes, improve working conditions, and support the long-term sustainability of healthcare delivery.
One of the most established examples comes from the United States. In California, a nurse-to-patient ratio3 of 1:2 for intensive care units was introduced as early as 1975. In 2004, the state expanded its Nurse Staffing Standards to cover a wide range of hospital departments, setting ratios such as 1:2 in intensive care and 1:5 in medical-surgical units. Compliance is monitored by state authorities, with violations subject to penalties.
At the federal level, the Centers for Medicare & Medicaid Services (CMS) introduced binding staffing minimums for nursing homes in 2024. These standards require 3.48 hours of care per resident per day (HPRD), including 0.55 hours from registered nurses and 2.45 hours from nurse aides. The new regulations are closely linked to quality-of-care indicators and influence federal funding.
Efforts to define safe staffing standards are also gaining traction in Europe. A notable example is Ireland. As part of the broader Sláintecare reform, Ireland’s Safe Staffing Framework was expanded in 2023–2024. It mandates the use of acuity-based nurse-to-patient ratios across inpatient settings, based on data from the Irish National Acuity and Dependency Tool. The framework integrates workforce planning with care quality monitoring. Initial evaluations point to increased nurse retention and improved patient satisfaction.
Other countries, including Australia, Japan, and South Korea, follow similar models that adjust nurse-to-patient ratios based on both patient volume and individual care needs. In Victoria, Australia, hospitals are categorized by care level (Level 1 to Level 4). In Level 1 hospitals-the highest tier-a ratio of 1:4 is required for morning and evening shifts, and 1:8 at night.
3 www.boeckler.de/pdf/p_fofoe_WP_027_2017.pdf
Overview of Minimum Nurse Staffing Levels in Germany
As of January 1, 2019, the minimum nurse staffing regulation (PpUGV) applied to intensive care, geriatrics, cardiology, and trauma surgery. These departments must meet minimum staffing levels, distinguishing between registered nurses and nursing assistants. A further requirement defines the ratio between these two roles per shift.
The 2020 expansion of the PpUGV included more departments and specified the following ratios:
The Role of Digital Workforce Management
While countries around the world take different approaches to defining nurse staffing standards, one question remains the same everywhere: how can these regulations be implemented effectively and sustainably in day-to-day operations? The answer lies in leveraging digital Workforce Management.
Effective digital Workforce Management supports strategic personnel planning. It makes processes more transparent and easier for staff. Nursing and ward managers get clear insights into absences and overtime, allowing early intervention.
This transparency improves strategic decision-making at the executive level. Administrative workload is reduced, freeing up time for leadership. Time is money – especially in healthcare.
Hospitals that implemented digital scheduling 15 years ago, like the clinic in Ingolstadt, hired 12 additional nurses with no added personnel costs. Staff workload was reduced and turnover declined. The hospital received a special award from the German Taxpayers Association.
Other success stories include clinics in Leverkusen, Saarbrücken, the Children's Hospital "Auf der Bult," University Medical Center Mainz, and St. Elisabeth Hospital Herne. All use digital Workforce Management to meet the challenge of delivering top-quality care despite ongoing staff shortages.
Forward-Thinking Healthcare: Klinikum Saarbrücken
With 2,000 employees, Klinikum Saarbrücken has long embraced workforce flexibility. It uses ATOSS Medical Solution for digital scheduling and compliance with reporting regulations introduced in January 2019.
All required staffing data is stored in the software and available at the click of a button. This includes reporting per quarter, unit, and shift. The hospital also benefits from skills management and flexible deployment of staff.
Daily planning is based on midnight statistics from the SAP hospital information system, allowing real-time adjustments. A dedicated float pool with 30+ qualified staff helps cover short-term gaps.
The clinic is a pioneer in workforce flexibility, offering lifestyle-based working hours since 2011. Staff can adjust their weekly hours as needed. This flexibility helps meet new minimum staffing standards and retain skilled professionals. The clinic has been recognized by Focus Money for offering top career opportunities in healthcare.
Mr. Hesse, Klinikum Saarbrücken is considered a pioneer in flexible working hours in the healthcare sector. Why is that?
Since 2011, we’ve been offering our employees so-called “choice-based working hours.” In practice, this means that full-time staff can temporarily increase or decrease their weekly hours depending on their personal life situation. This concept - and the new legal requirements for nurse staffing - can be implemented very easily using our software.
We set the course early. With innovative working time concepts, we counter the acute shortage of skilled workers. And we are ready for the new legal requirements.
How do you ensure compliance with the mandated minimum nurse staffing levels?
We already know that, with our current staffing levels, we generally meet the required minimums. For day-to-day planning, we rely on midnight statistics from our SAP-based hospital information system, which feed into the ATOSS Medical Solution. Since January 1, 2019, our planning teams have been able to closely monitor nurse deployment on a daily basis. In the event of short-term shortages, we can rely on our cross-departmental float pool. This additional flexibility tool includes more than 30 qualified staff who are available for selected shifts or designated days. This allows us to maintain a high level of care security for our patients.
How do you efficiently comply with the documentation requirements of the minimum staffing regulation?
The regulation requires hospitals to calculate average staffing levels per month, broken down by ward and shift. We’ve been using system-supported scheduling with integrated working time management for many years. All working hours of our hospital staff are centrally stored in the ATOSS solution. This gives us real-time insights into the daily staffing levels of each shift and department, as well as actual hours worked. The centralized documentation of planned and actual working hours in our software is a tremendous help when generating reports. As a result, the required documentation can be produced at the push of a button-within the legally prescribed deadline of two weeks after the end of each quarter.
Interview with Thomas Hesse, Director of Human Resources and Authorized Signatory, Klinikum Saarbrücken gGmbH
Conclusion
This paper highlights the value of digital Workforce Management. For it to fully realize its benefits, hospitals must commit to investing in digital transformation. A McKinsey study states: "Digitization offers enormous potential for healthcare systems. New technologies allow efficiency gains at equal or even higher quality. Costs can be reduced across the system, and patients benefit from new tools."4
Going paperless alone could save up to €9 billion, according to the study. Yet 58.5% of surveyed providers have no digital strategy, and 83.1% rate their own digital maturity as "low" or "medium."
4 www.mckinsey.de/publikationen/digitalisierung-chance-mit-milliardenpotenzial