Elderly Care Across Borders: Insights from Southeastern European Workers in Germany
Is elderly care in Germany as bleak as it seems? Interviews with care workers from Southeastern Europe reveal surprising insights, challenging media narratives about stress, low pay, and staff shortages.
Activities for Older Adults in a Care Home
Copyright: Centre for Ageing Better
In Germany, the nursing profession is often associated with a high workload, unfavourable working hours, and insufficient pay. This combination has led to its reputation as an unattractive career choice, particularly among members of the younger generations. The fact that care workers enjoy generally great respect and are held in high regard by public opinion does little to change this prevailing perception.[1] Media reports frequently reinforce this image, focusing on staff shortages, burnout among care workers, and systemic challenges. Hardly a week goes by without headlines in German newspapers like the following:
But is this the full story? In November 2024, my colleague Gresa Morina and I spoke with care workers from Southeastern Europe who had come to Regensburg to work in a nursing home for older adults. We discovered perspectives that diverge significantly from the dominant media narratives. Their experiences and insights shed light on the realities of the profession, offering a more complex and at times surprisingly positive view.
The following essay is predominantly based on four semi-structured interviews conducted with female care workers, all employed at the same nursing home for older adults in Regensburg. They come from North Macedonia, Albania, and Romania. Two have been living here only for a few years, while the other two have been in Regensburg for more than twenty-five years. The latter two have had completed training as nurses already in their home countries (Romania and North Macedonia), while the former had gained only some initial experience in elderly care in Albania and currently pursue further qualifications in this field in Regensburg.
The essay offers initial insights into ongoing research, reflecting preliminary observations and hypotheses. It highlights the perceptions of people from Southeastern Europe of their work in elderly care, as well as the similarities and differences between Germany and their home countries. This aims to address common issues and juxtapose media representations with the statements of the four interviewed women.
Elderly Care in Crisis: A Historical Perspective
Even though the fear of a “care crisis” became most apparent in Germany – and other countries as well – only during the COVID-19 pandemic, the term itself is significantly older:
What is a "Care Crisis" ("Pflegenotstand")?
“The term ‘Pflegenotstand’ (care crisis) first appeared in the Federal Republic of Germany in the 1960s. At that time, fewer and fewer women were willing to work as nuns providing elderly and nursing care as acts of ‘charity’ under the umbrella of church welfare organizations in the name of Christian compassion. Since then, the term has referred to a shortage of qualified care workers.”[5]
The 1960s and 1970s were also a time when hospitals and elderly care services were expanded in Germany, resulting in a massive shortage of personnel. Therefore, foreign care workers were frequently employed to counteract the crisis.[6] The first recruitment efforts took place in the 1960s and 1970s from South Korea and the Philippines. In the 1990s, initiatives followed to attract skilled workers from the countries of the former Soviet Union and the former Yugoslavia.[7] However, care service providers have always had problems finding enough qualified staff, primarily due to the difficult working conditions and low salaries.[8]
Personal Narratives: Stories from Southeastern Europe
One of our interviewees, a woman from North Macedonia, also came to Germany through a specialized recruitment program in the early 1990s:
“I trained as a nurse in Macedonia. Then I started studying social pedagogy. […] And then we were contacted by the employment office [in North Macedonia – K.B.) about the care crisis in Germany, informing us that we could apply there.” [9]
She also mentioned that the German employer quickly offered her a contract and accommodation for the beginning, that her Macedonian qualifications were recognized, and that she completed a language course in Germany alongside her job.
Despite often good conditions like job offers and the provision of accommodation, settling in a foreign country is far from easy. Care workers from abroad must adapt to local culture while missing their homes, families, and friends. Additionally, they must master the German language, which often proves to be the greatest hurdle. As if that were not challenging enough, many older residents of the nursing homes speak in a German dialect, which further complicates communication between them and foreign caregivers. Around thirty years ago, migrant care workers were far less common in Germany, and the woman shared in our interview that she faced significant rejection from some of the care-home residents due to her foreign background.
Overcoming Challenges: Support Systems in Germany
Not everyone has such a strong will to persevere like the four women we interviewed. Statistically, one in ten foreign skilled workers who come to Germany leave the country within the same year. Homesickness, lack of appreciation, and workplace discrimination often drive them to try their luck elsewhere.[10]
Although none of the four women we interviewed spoke German before their arrival in Regensburg, all of them received good support from their employer and colleagues. They learned the language either through language courses, self-study and/or daily communication with colleagues and residents in the care home. As they said during the interviews, the support from their colleagues and the care home manager is very strong, which helps them a lot. Their employer also provides training programs for those who have only gained initial experience in elderly care in their home countries and do not hold a nursing qualification recognized in Germany. The fact that the nursing home management is evidently capable of creating a pleasant working atmosphere is also reflected in the fact that the already mentioned woman from North Macedonia has been working here for thirty years and a woman from Romania for twenty-three years. Their example challenges the prevalent notion of high job turnover in the care sector.
The Importance of Work Environment in Caregiving
During the interviews, we gained the impression that it is not so much the salary that determines whether someone stays in elderly care, but rather the work environment and working conditions. An article on the image of care work in a magazine targeting hospitals and rehabilitation clinics concludes that the salaries for nursing professionals often even exceed those of bank clerks and mechatronics technicians.[11]
Two of our interviewees hold recognized qualifications as nurses and could therefore work in hospitals, where salaries are generally higher than in care homes for older adults. However, as one of them explains, she has adapted to the field of elderly care and appreciates certain advantages compared to working in a hospital:
“In the hospital, people come in with an illness that is treated quickly, and then they go back home. There are constantly new patients. But [in a care home for older adults – K.B.] it’s more or less ‘relationship care.’ You get to know the people and build a connection with them. And this is nice.”[12]
Thus, what matters more to her are the working conditions and the pleasant, family-like work atmosphere. Another notable aspect is the low staff turnover that contributes to colleagues knowing each other well, trusting one another, and providing mutual support. At the same time, this situation is also beneficial for the relationship with the older residents, as it fosters much closer and stronger bonds.
According to the accounts of two women, they no longer must work night shifts, partly due to their age (they are over fifty years old) and the accompanying physical discomfort that comes with many years of working in care. And their employer, a care home under Catholic sponsorship, has found ways to provide relief in other areas as well. For instance, the woman from North Macedonia is currently only working three days a week in direct care; the other two days she is engaged in social support. This means she organizes activity programs like singing, crafting or playing bingo. These activities bring enjoyable results:
“You are perceived very differently by the residents. They approach you in a completely different way. If they have concerns or something, they’re more likely to talk to you than if you’re just part of the care staff. It’s really remarkable.”[13]
Not a Job but a Calling
The importance of the interpersonal factor, especially the close relationships with the residents, was what all our interviewees highlighted. It is also the main reason why they enjoy their job a lot, even though it is physically and mentally demanding.
Shortly before our conversation, one of the women we interviewed had received recognition for the political science degree she earned in Albania. However, she still wants to complete training as a professional caregiver and remains dedicated to the profession:
“[In Albania – K.B.] I took care of my grandmother during her final phase of life, the last six months before her death. And that’s when I realized that I’m good at working with older people. In the beginning, I had difficulties with the language here, but I have grown and improved, I think. I didn’t know before how patient I was. And I wasn’t aware of my humanity either.”[14]
Even though working with elderly people is physically and mentally demanding, especially with those suffering from dementia, all our interviewees agree that this work gives a great deal back in return. They also emphasize how much fun this work can be and how much joy they derive from communicating with the older residents. They identified patience and empathy as essential qualities one must have to succeed in this job.
The only problem the interviewed care workers mentioned that is also frequently addressed in the press is staff shortages. However, they did not describe it as particularly severe, as the home where they work is usually adequately staffed during shifts. Nonetheless, they expressed a desire for more personnel, primarily to have more time for the older residents, as interpersonal interaction is often wanting.
One woman expressed concern about the (lack of a) next generation of care workers, as young people seem increasingly less inclined to pursuing this profession.[15] She also noted that fewer people from Eastern and Southeastern Europe are coming to Germany to work in this field or are returning to their home countries. She explains this by noting that the economic situation has significantly improved elsewhere, particularly in EU countries like Romania. There are more qualified jobs, including in the care sector, with higher salaries. She added that the cost of living in Germany, especially for housing, has made the country less attractive for many people.[16]
A surprising observation was that none of the interviewees complained about salaries or working conditions, unlike media portrayals. Quite the opposite was true: They could not understand why the job has such a poor image.
Changing Attitudes: A Comparative View of Elderly Care
Of course, we also wanted to know from our interviewees what similarities and differences they noticed in elderly care between Germany and their home countries, and how they generally assessed the quality care services. The first observation was that they only trained in elderly care after arriving in Germany, even those with prior nursing qualifications, as care homes for older people were either nonexistent or very rare in their home countries at the time when they left.
They noted that in their native countries, older family members would not have been placed in care homes in the past. In general, care homes had a poor reputation and, in many families, placing elderly people in a nursing home was considered taboo. However, our interviewees also acknowledged that social relations were different back then. Families were larger and lived closer together, allowing several people to share the care of an older family member.
In countries like Romania much has changed over the past three decades, as one interviewee told us. Elderly care and nursing homes now exist there as well. With the emigration of many young people, it is likely that more older individuals will be placed in nursing homes in the future, as many of their children live abroad and are unable to care for their parents. Along with this, the taboo of placing older family members in a care home will dissolve more and more.
Furthermore, three of four interviewees had no problem with placing older people in a care home in general. On the contrary, they believed it could even be beneficial for many who either have no relatives or whose children live far away, as living in a care home ensures they are not alone. A woman from Albania, though, mentioned that she would not place her father, who is currently in need of care, in a nursing home. Later, we learned that other family members in Albania care for him. It can therefore be assumed that such attitudes may change when circumstances require different solutions.
When asked whether they would consider moving into a nursing home when they are old, our interviewees generally answered yes. Of course, everyone wants to stay fit for as long as possible and grow old at home if they can. However, the woman from Albania, who had cared for her grandmother, emphasized that she does not want to become a burden to her son or be dependent on him in the future. Instead, she wishes for him to live his life independently.
Conclusion
The nursing home where our four interviewees work serves as a positive example of good working conditions and atmosphere. While our conclusions are preliminary and due to the small sample specific, they provide a foundation for further research and allow to formulate hypotheses.
Firstly, effective nursing home management is crucial for fostering good working conditions and a positive work atmosphere. This role requires empathy and humanity, which significantly influence whether care workers stay or leave. Small, immediate adjustments by management can greatly improve employee satisfaction, often without waiting for broader reforms or union agreements.
Secondly, none of our interviewees could understand why the job has such a poor image. All of them emphasized how much they enjoy their work and how enriching they find it – regardless of the physical and mental challenges that this job entails.
Thirdly and finally, we could initially discern only a few differences in the perspectives on caring for older people between Germany and Southeastern European countries. This is likely because two of the interviewees have been working in Germany for a very long time and have largely adopted the local attitudes. At the same time, it can be assumed that younger people from and in Southeastern Europe are gradually developing different views from those of their parents. Conditioned in part by significant emigration, which reduces the importance of traditional family caregiving roles or makes them unsustainable, younger people find it less problematic to place older relatives in a care home. This last point, i.e., the question of how caregivers from Southeastern Europe in Germany may hold different views and attitudes towards elderly care and ageing compared to their colleagues working in their home countries, will be a focus of our further research.
Bibliography
[1] Claudia Bettina Maier u. a., „Das ‚Image‘ der Pflege: das Ansehen des Pflegeberufs in der Öffentlichkeit und bei Pflegefachpersonen“, in Krankenhaus-Report 2023: Schwerpunkt: Personal, hg. von Jürgen Klauber u. a. (Berlin, Heidelberg: Springer, 2023), 52, https://doi.org/10.1007/978-3-662-66881-8_4.
[2] mdr.de, „Altenpflegerin ruft wegen Personalnot Polizei und Feuerwehr | MDR.DE“, 16. April 2024, https://www.mdr.de/nachrichten/deutschland/gesellschaft/pflegeheim-personalmangel-nacht-notruf-polizei-feuerwehr-katastrophenschutz-100.html.
[3] „Ohne ausländische Pflegekräfte geht nichts mehr“, tagesschau.de, 15. Oktober 2024, https://www.tagesschau.de/wirtschaft/arbeitsmarkt/auslaendische-pflegekraefte-studie-100.html.
[4] Lea Hensen, „Sorgenkind Pflege: Warum eine umfassende Reform nötig ist | Vorwärts“, 18. November 2024, https://vorwaerts.de/inland/sorgenkind-pflege-warum-eine-umfassende-reform-noetig-ist.
[5] Diana Auth und Lisa Heinzelbecker, „Pflegenotstand“, Themenblätter im Unterricht (Bonn: Bundeszentrale für politische Bildung, 17. August 2022), p. 3, https://www.bpb.de/shop/materialien/themenblaetter/511983/pflegenotstand/.
[6] Elisabeth Vatareck, „Pflegenotstand: Problem einer alternden Gesellschaft – Pflegebox“, Pflegebox.de, 16. Oktober 2020, https://pflegebox.de/ratgeber/pflege/pflegenotstand-ursache-und-massnahmen/.
[7] Oliver Lauxen, Christa Larsen, und Lukas Slotala, „Pflegefachkräfte aus dem Ausland und ihr Beitrag zur Fachkräftesicherung in Deutschland. Das Fallbeispiel Hessen“, Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz 62, Nr. 6 (1. Juni 2019): 792, https://doi.org/10.1007/s00103-019-02956-4.
[8] Vatareck, „Pflegenotstand“. Interestingly, Medical historians even suggest that Germany experienced a care crisis as early as the 1920s, although at that time, the issue was commonly referred to as a “nursing shortage” (“Schwesternmangel” in German). They even trace the roots of the problem back to the 19th century. See Manuel Opitz, „‚Der Pflegenotstand ist mindestens 100 Jahre alt‘. Über die Folgen einer verpassten Chance“, geo.de, 16. Mai 2024, https://www.geo.de/wissen/weltgeschichte/-der-pflegenotstand-ist-mindestens-100-jahre-alt–34677520.html.
[9] Interview with woman from North Macedonia (IWNM).
[10] Luise Sammann, „Ausländische Pflegekräfte – Zwischen Heimweh und Hoffnung“, Deutschlandfunk Kultur, 24. Januar 2023, https://www.deutschlandfunkkultur.de/auslaendische-pflegekraefte-deutschland-100.html.
[11] Stefan Eschmann und Michael van Loo, „Image der Pflege – Die Realität ist besser als ihr Ruf“, f&w – führen und wirtschaften im Krankenhaus, Nr. 6 (2018): 17.
[12] Interview with woman from Romania (IWR).
[13] Interview with IWNM.
[14] Interview with woman from Albania (IWA1).
[15] Margit Ebbinghaus, „Pflege? Damit kann ich mich (nicht) sehen lassen …“, BIBB Report (Bonn: Bundesinstitut für Berufsbildung (BIBB), Januar 2022), https://www.bibb.de/dienst/publikationen/de/17936.
[16] Interview with IWR.
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