The Nordic welfare sector is facing significant challenges when it comes to providing effective social care services. While the demand for services for a rapidly growing elderly population is constantly increasing, the workforce delivering social care services is shrinking, with many workers reaching retirement age. Tackling the challenges related to recruitment and retention of qualified staff – and developing innovative approaches to the delivery of social care services – is becoming increasingly urgent, particularly in rural and sparsely populated areas (SPAs).
This policy brief gives an overview of examples across the Nordic Region aimed at tackling these resource challenges and exploring innovative ways of organising and delivering social care services in rural areas and SPAs. It is based on a desk study funded by Nordic Welfare Centre (see more about this on the last page).
Vård och omsorgssektorn i de nordiska länderna har utmaningar när det kommer till att tillhandahålla likvärdiga välfärdstjänster i hela landet. Medan efterfrågan på tjänster för en snabbt växande äldre befolkning ökar kontinuerligt, så minskar påfyllnaden av lämplig arbetskraft. Detta samtidigt som en växande andel av arbetskraften når pensionsålder. Att rekrytera, behålla och vidareutbilda arbetskraft inom välfärdssektorn är ett uppdrag som samtliga kommuner och regioner tampas med, men kanske mest utmanande är situationen för glest befolkade regioner och kommuner. Att utveckla innovativa tillvägagångssätt för att tillhandahålla dessa tjänster blir allt viktigare i denna kontext och den här denna policy brief presenterar några goda exempel på hur man med skräddarsydda lösningar valt att hantera problemen lokalt. PBn ger även en nordisk översikt över den nuvarande situationen i fråga om ovannämnda utmaningar, tillika ett antal punkter som beslutsfattare kan ta hänsyn till när de ska bemöta dessa. Projektet och PBn är finansierad av Nordens välfärdscenter och är baserat på dokumentstudier och på ett webbinarium arrangerat av Nordens välfärdscenter i december 2020.
The capacity to deliver social care services, and meeting the changing needs of different populations, depends strongly upon the availability of a suitable workforce. Social care professions are at the top of the list of jobs with the highest recruitment needs in many municipalities across the Nordic Region (e.g. TEM, 2019; Tillväxtverket, 2020). This situation has been triggered by demographic changes and by the retirement of large numbers of people. Many workers are approaching pension age in the Nordic Region. This will threaten municipalities' ability to provide services. In Finland, for instance, approximately 12,500 (25%) of nurses are expected to retire over the next ten years within the municipal sector (KEVA, 2020). In Sweden, the total number of retirees in the welfare sector is expected to reach 340,000 people during the same time period (SKR, 2020), with retirement numbers higher than the national average in remote and very remote regions (Tillväxtverket, 2020).
An ageing population also means greater constraints in the health care system as a result of increasing care needs. The old-age dependency ratio is a common demographic indicator used to monitor ageing and the effects it might have on publicly funded welfare provision. This ratio is arrived at by quantitatively relating the population aged 65 years or over with the working-age population. The map in Figure 1 shows the situation in 2020. It reveals the uneven geographic pattern that these processes have produced across the span of Nordic municipalities. Among the 831 municipalities that have a ratio higher than the Nordic average of 31, about one third are located in Finland.
Definition of social care services
The analysis in this policy brief deals with the provision of workforces for social care services i.e. services relating to care of the elderly, and/or people with disabilities and/or care after hospitalisation, as well as the provision of health care that is limited to general practice. The social care sector includes a wide range of professions, such as nurses, assistant nurses, personal assistants and occupational therapists, among others.
Figure 1. The old-age dependency ratio in Nordic municipalities, 2020 (large map); and municipality groups according to the European LAU2 typology for 'degree of urbanisation', DEGURBA (small map).
Figure 2. Average old-age dependency in urban and rural municipalities across the Nordic region. Municipality groups according to the European LAU2 typology for 'degree of urbanisation', DEGURBA.
Figure 3. Average old-age dependency in rural municipalities, by countries and territories. Rural classification according to the European LAU2 typology for 'degree of urbanisation', DEGURBA.
Figures 2 and 3 show these demographic processes over the past ten years. The lines represent averages for municipalities of different types. This shows that the pace of this process is more pronounced in rural areas, with Finland seeing the most rapid changes.
Many rural areas facing challenging demographic developments also have difficulties when it comes to recruitment into the social and health care sectors. This may typically include advertised positions that left unfilled, or filled only temporarily by staff with inappropriate qualifications. This has a negative impact on the quality of care. In Denmark, for instance, almost three in four municipalities have experienced a shortage of skilled workers in the elderly care sector (Ministry of Health, 2018). In Finland and Norway, nurses (and associated professionals) were at the top of the list of occupations facing the largest recruitment challenges in many municipalities (KS, 2019; Occupational barometer, 2020). Three out of four municipalities in Norway say that it is very challenging, or quite challenging, to recruit nurses. Six out of ten say that it is challenging to recruit doctors (KS, 2019).
The overall supply of human resources in a country, in this case nurses and health care personnel, is one of several potential driving factors in the undersupply seen at local and regional levels. National comparisons indicate that the supply of required skills differs substantially across the Nordic countries. See Figures 4 and 5 for details. Although a steady increase in personnel supply can be seen for all countries over the past ten years, Denmark has the lowest levels – both when it comes to the overall supply of nurses, and to the rate of production of new graduates. It should be noted that the organisation of the health sector varies between the different Nordic countries, and the replenishment of available supply of nurses can be related to the supply of auxiliary nurses or health care assistants.
Figure 4. This graph shows the change, between 2004 and 2019, in the number of nurses per 1,000 inhabitants across the Nordic countries (with Finland being up to 2014). The highest numbers are currently to be found in Norway. Norway has also seen the steepest increase during the past ten-year period (OECD health statistics).
Figure 5. For the Nordic countries (except Sweden) the OECD provides a time series from 1996 for the number of nursing graduates. Denmark had the lowest number of graduates in the entire time series. Finland has seen a steady increase since 2005, following an eight-year decline.
In addition to recruitment, the retention of personnel in rural areas and SPAs is also a major issue, due to increasing outward migration. Moreover, there are high attrition rates in social care jobs, due to career reorientation, plus a high degree of sick leave relative to other sectors across all of the Nordic countries. Many experienced nurses are considering leaving the care sector due to various workplace-related factors – such as difficult working conditions, temporary contracts and/or the lack of opportunities for professional development. In Finland, for instance, surveys by the Finnish Nurses' Association (in 2017 and 2018) showed that more than one-third of nurses have considered leaving the profession.
As regards to education-related challenges, the quality of training for nurses has been frequently criticised as insufficient (e.g. Kommunal, 2018; Tehylehti, 2017). Nine out of ten nurses in Norway have experienced the need to increase their competencies in one or more diagnostic areas in which they work (Menon Economics, 2018). Other challenges include low and decreasing numbers of applicants for educational programmes relevant to meeting the current and future demands of a qualified workforce. These programmes also have relatively high drop-out rates. In broad terms, all the factors described above, which influence the resilience of the workforce providing social care services, are illustrated in Figure 6.
It requires a diverse set of measures to address multidimensional challenges related to the recruitment and retention of a workforce providing social care services. The Nordic countries have developed various responses to recruitment and retention problems in the field of social services and care, at national, regional and local levels.
The most common intervention measures are aimed at increasing the quality of initial education, continuous education and training, improving working conditions, increasing the attractiveness of the workplace, and enhancing the general prestige of social care jobs (see Table 1). In recent years, Denmark, for example, has placed emphasis on reducing the drop-out rates from education by improving internships and ensuring a smooth transition between theory and practice. In elderly care, Sweden has prioritised digitalisation, promoting full-time work, and raising skills levels. In Finland, the focus has been on attracting more students to education and promoting the recruitment of labour from abroad. Norway and Iceland have worked at modernising their study plans for health and social care education, with much more emphasis on improving clinical practice and enhancing internship models.
|Educational measures||Workplace measures||Other|
|Increasing the number of available educational places; increasing the quality of education; reducing the duration of training; improving internships and reducing drop-out rates; distance learning; subsidising initial education and continuous training.||Improving working conditions; flexibility in the distribution of nursing tasks, plus task-shifting; professional development; full-time and permanent employment; reducing sick leave; digital technologies to improve efficiency and workplace satisfaction.||Regulatory changes (e.g. a 0.7 per patient minimum staffing requirement at nursing homes in Finland, in order to improve the quality of care); recruitment of permanent staff from abroad.|
Table 1. Examples of the recruitment and retention measures employed across the Nordic countries.
Our desk study identified relatively few recruitment and retention measures targeted at particular geographical areas in recent years, since many of these initiatives appear to have a broader geographical focus. In Norway, however, a number of positive experiences were generated in the late 1990s, when internships focusing on a primary care and in-service training model were introduced as tools for retaining physicians and their families in remote areas. Among the key lessons learned from these measures was that the postgraduate internships in remote areas make it possible for trainees to develop roots in a rural community. Moreover, measures to improve social networking, along with opportunities for professional growth, are among the most important success factors for recruitment, resulting in improved health workforce retention in rural settings (Straume and Shaw, 2010).
As digitalisation becomes intertwined with every element of our lives, the promotion of distance-spanning solutions for healthcare and social care in rural areas has been high on the agenda for all Nordic countries in recent years. Among the benefits of digitally-based health and social care are improved quality, efficiency, inclusion in health and social care provision, and improved access to specialised competencies – especially in rural areas (Lundgren et al., 2020). Digital solutions also have the potential to tackle recruitment challenges. Solutions such as digital consultations and meetings may compensate for the absence of full-time healthcare specialists in a particular community, for instance, making them among the most effective complementary measures in encouraging active recruitment. In addition, digital tools play an important role in creating a good working environment – for instance by providing an opportunity to work in new and more efficient ways, and also to reduce commuting times for health and social care workers.
- Niclas Forsling, Centre for Rural Medicine.
|Monitoring the needs of the workforce||Recruitment and retention within education||The transition from education to work||Worker mobility (to rural areas)||Continuous education and re-training||Workplace measures|
|Skills matching Indicators (SE)||Menn i helse (NO)||Internship supervisors in the Region of Southern Denmark||ALIS vest and nord (NO)||A refresher course for nurses (FI)||Quality agenda in Esbjerg Municipality (DK)|
|Regional STAR offices (DK)||Distance learning programme in nursing at the University of Akureyri (IS)||Simulation centres (IS)||Recruit and retain (NO/SE)||Nursing as a second university education (IS)||Skills-based recruitment in Region Zealand (DK)|
|Reduced training duration (FI)||Common housing for healthcare professionals (NO)||Äldreom|sorgslyft (SE)||Heltidsresa (SE)|
|Rotational agreements (GL)||Yrkesresan (SE)||Senior Policy (DK)|
|Foreign labour mobility (FI)|
|Flexible work arrangement enabled by telemedical and digital tools (IS)|
Table 2. Examples of projects aimed at different stages of the skills supply cycle.
Monitoring the needs of the workforce
Skills-matching indicators in Sweden: The Swedish Agency for Economic and Regional Growth, together with RegLab, has developed an indicator framework which is aimed at exposing the real supply and demand of trained staff in different sectors. Data is from the regional level.
Assessment of the recruitment situation by regional STAR offices in Denmark: Regional STAR offices prepare semi-annual assessments of the recruitment situation for different work categories (including social and health workers, social and health assistants, and nurses) in eight RAR areas. This has been done since 2007.
Recruitment and retention within education
The 'Menn i helse' campaign in Norway promotes gender equality and provides an apprenticeship certificate for men, enabling them to work in the health care and social care. It has produced more than 418 successful graduates since 2010. The project is part of a national programme known as Kompetanseløft 2020, which was the government's plan for recruitment, skills development and professional development within municipal health and care services in2020.
The distance learning programme in nursing provided by the University of Akureyri has contributed to the increasing attractiveness of nursing degrees by making it possible for students to stay close to home during their studies – and potentially to continue working in small and rural communities after graduation.
In Finland, a shorter education programme for assistant practical nurses was introduced as part of the National Development Programme for Social Welfare and Health Care 2012–2015.
The transition from education to work
Internship supervisors in the Region of Southern Denmark have strengthened internship guidance, including the competency development of supervisors, and other initiatives that help improve the quality of the internship programmes and promote an attractive educational environment.
Simulation training in Iceland prepares newly graduated nurses for practical work experience by creating real-life conditions in a controlled environment. Simulation centres have been important in easing the challenge arising from a lack of clinical personnel to supervise internships in Iceland.
Worker mobility (to rural areas)
Shared housing for healthcare professionals during their practical training in rural areas in Norway aimed at strengthening networking opportunities and exchanging of professional knowledge.
'ALIS-Vest' and 'ALIS-Nord' are state-funded pilot projects aimed at tackling the challenge of making municipalities more attractive as employers, for example, by offering combined specialist training/work positions. These projects are implemented in the western and northern parts of Norway.
'Recruit & Retain – Making it Work' is an EU project aimed at creating a framework for rural and remote workforce stability. Among the important outputs of this project is a catalogue of activities which can be used to improve the recruitment and retention of professional workers in rural areas.
Promoting foreign labour mobility to address shortages of staff, as in the case of nursing mobility from Estonia to Finland, is also beneficial. In addition to competence assessment and training for acquiring professional qualifications, language lessons are provided in medical Finnish for nurses studying and living in Estonia.
Rotational agreements have been set up in Greenland with a hospital in North Zealand, Denmark. According to this agreement, the hospital in Denmark contributes to the permanent staffing of an intensive care unit in Nuuk. There are six nurses from the hospital in North Zealand who take turns at this, on a two to three-month basis.
Flexible work arrangements can be arrived at through telemedical examinations and consultations. For example, the physician in the East Iceland region is fully employed by the hospital in Neskaupstaður, in East Iceland, although they are physically present in the region for just ten days every month. The doctor's main task is telephone consultations, including the renewal of prescriptions for medicines, and patient examinations using digital equipment.
Continuous education and re-training
A refresher course to return nurses to employment is taught at the Turku University of Applied Sciences in Finland. This is designed for people who already have a degree in nursing but who have not been practising the profession for some reason and would now like to restart their career.
Nursing as a second degree in Iceland targets graduates who have taken relevant courses – for example, in the social sciences, psychology and biology. This nursing programme lasts two years instead of the normal four years.
"Boosting elderly care" (Äldreomsorgslyftet) is a national programme in Sweden running from 2020-21. It aims to enhance competencies and to make it more attractive to work in elderly care.
"The career journey" (Yrkesresan) aims at increasing the knowledge-base and competencies of municipal employees in the social care sector in Sweden. It became a nation-wide initiative in 2020, and it is coordinated by the Swedish Association of Local Authorities and Regions (SALAR).
What is called 'the quality agenda' in Esbjerg Municipality, Denmark, specifies nursing tasks and the requirements for achieving particular competencies. It does this as a means of focusing on the importance of the role of nurses in the local health service provision and in order to ensure a higher quality of care overall. It stipulates which nursing tasks can and cannot be delegated. Anchored in this quality agenda, and through a professional community, the overall image of nursing and its workplace setting has changed to become more positive in Esbjerg municipality as a result.
Skills-based recruitment takes place in hospitals in Region Zealand, Denmark. The project goal here is to help hospitals to achieve better-targeted recruitment. Rather than 'business as usual', namely filling empty positions, the emphasis is on working to fill skills gaps. This means smarter use of human resources through internal reorganisation, and by encouraging employees to focus on the tasks that they are best at, thus giving staff an opportunity to live up to their full potential.
'Full-time journey' (Heltidsresa) is a joint project from SALAR and Kommunal which aims at making full-time employment the norm in the social care sector.
Senior Policy developed by Local Government Denmark (2019) contains 22 concrete recommendations concerned with how the municipalities should work to motivate employees who are close to retirement age to keep working a little longer.
In order to address challenges with regard to the provision of social care services in rural areas and SPAs effectively, a focus on recruitment and retention alone is not enough. There is an accompanying need to re-think the way we organise and deliver social care services. This may be thought of in terms of developing new and improved services, new ways to provide services, and new products or production processes, as well as management and organisational changes. To a large extent, innovative solutions will make use of digital tools and technologies, but they may also involve gradual improvement in everyday practices.
For instance, Öldrunarheimili Akureyrar in Iceland, and Tubberödshus elderly care home in Sweden, are among the examples of alternative management and organisational models that employ alternative care philosophies for running elderly care facilities and strive to provide a higher quality of care and workplace satisfaction overall.
Though the process of developing such innovative approaches can often be slow, the COVID-19 pandemic has demonstrated our ability to adopt digital tools (and to transform the way we provide services) relatively quickly when the need arises. In Finland, in the middle of the lockdown, health care districts and communities organised some of their services into new forms and platforms. Among the concrete examples here are the speeded-up processes of in-work training in many fields. Training of anaesthesia nurses was organised within weeks and was provided at workplaces in collaboration with universities, for example. After closing certain municipal facilities, some communities re-organised staff and established staff resource pools to move staff to where they were needed, instead of instituting lay-offs. Many organised new services, e.g. assistance for the elderly or the delivery of groceries (Mursu, 2020).
- Sanja Mursu, Kommunarbetsgivarna Finland.
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Oskar Penje, Cartographer/GIS Analyst, Nordregio
Anna Berlina, Senior research advisor, Nordregio
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