Exploring the different models of the four-day workweek as social innovations in Germany's healthcare system.

BACKGROUND: The German healthcare system faces a persistent shortage of skilled professionals, particularly in nursing, driven by demographic change, high workloads, and challenging working conditions. In response, new working-time models such as the four-day workweek have emerged as potential solutions to improve job attractiveness, employee well-being, and staff retention. This study examines different models of the four-day workweek as social innovations within the healthcare system, focusing on their development, implementation, and implications across institutional levels.

METHODS: A qualitative research design was employed, with 27 semi-structured interviews conducted between August 2024 and February 2025. Participants included nurses, physicians, hospital managers, political stakeholders, and representatives from unions and professional organizations. Data were analyzed using qualitative content analysis following Mayring, supported by MAXQDA software. The analysis was guided by a theoretical framework on the institutionalization of social innovations, examining processes across micro-, meso-, and macro-levels. An iterative approach was used to link empirical findings with theory.

RESULTS: Three main working-time models were identified: part-time work, the compressed four-day workweek (constant weekly hours distributed over fewer days), and the reduced four-day workweek (fewer hours with unchanged pay). Part-time work is widely used as an individual coping strategy but entails financial risks. The compressed model is more easily implemented within existing regulatory and financial structures and is perceived as attractive, yet it does not significantly reduce workload and may intensify daily strain. The reduced model shows greater potential for improving well-being and retention but faces substantial challenges related to staffing, financing, and regulatory constraints. Overall, findings reveal tensions between normative expectations of high-quality care and limited resources, leading to paradoxical outcomes across system levels.

CONCLUSIONS: The compressed four-day workweek represents an adaptive but limited innovation, while the reduced model holds transformative potential but requires systemic change. Effective implementation of new working-time models in healthcare depends on coordinated action across institutional levels, including supportive financial, regulatory, and organizational frameworks.