The shortage of skilled professionals undermines the German economy. According to the KOFA (Kompetenzzentrum Fachkräftesicherung) state profile of Baden-Württemberg¹⁾, there was a shortage of over 51,000 skilled workers in 2021. This means that an average of 39.3 percent of vacancies were not filled by a suitably qualified professional. The occupational groups with the biggest shortage of qualified professionals in 2021 were healthcare and nursing as well as electricians in the construction sector. This has inevitably become a political issue. Manne Lucha, Minister for Health and Chairman of the Conference of Health Ministers, speaking in Friedrichshafen in June 2023, said, "All those involved – the federal government, the state governments and employers – must work hard to ensure that there is more recruitment and, above all, retention of staff in the healthcare sector."

The health ministers of the German federal states agreed that the recognition of foreign professional qualifications in the healthcare sector, which is regulated by federal law, should be legally simplified and accelerated, that Germany should be made more attractive to foreign professionals and that visa procedures should be made less lengthy. But what do companies in the healthcare sector have to consider when they want to hire foreign professionals from third countries, i.e. countries that are not part of the European Economic Area (exceptions apply to Iceland, Norway, Switzerland and Liechtenstein)?

The so-called EU Blue Card is a temporary residence permit for university graduates that is intended to facilitate and promote the permanent immigration of highly qualified people from non-EU countries to Germany. From November 2023, the Skilled Immigration Act will make it easier to recruit highly qualified people from abroad. Among other things, the new EU Blue Card has been extended to include so-called bottleneck professions. Academics and nursing and midwifery professionals in the healthcare sector will benefit from the scheme.

Furthermore, the Act on the Further Development of Skilled Labour Migration was passed in July 2023. The law is expected to come into force in March 2024 and includes the possibility for nursing assistants to obtain a residence permit for gainful employment. Important information on the current legal situation is provided on the federal government's web portal for skilled workers from abroad "Make it in Germany", by KOFA (Kompetenzzentrum Fachkräftesicherung), a project funded by the Federal Ministry of Economics and Climate Protection (BMWK).

In Baden-Württemberg, companies and international professionals in the fields of nursing, healthcare and education can contact the Welcome Center Sozialwirtschaft Baden-Württemberg, which has offices in Stuttgart, Karlsruhe, Mannheim and Freiburg. The Welcome Centre receives funding from the Ministry of Economic Affairs, Labour and Tourism Baden-Württemberg, sponsorship from Diakonische Werke Baden and Württemberg and also collaborates with other institutions that are part of the League of Independent Welfare Organisations (AWO, Caritas, DRK, Parität, IRG) to help players in the healthcare and social sector recruit skilled international workers.

"Basically, we advise companies on all aspects of hiring skilled workers from abroad, starting with recruitment, i.e. where and how to find international skilled workers, through to language acquisition, the recognition of qualifications, residence permits and integration. We cover the whole spectrum," says Olivia Brohl-Schaffron, an experienced counsellor who heads up the Welcome Centre. She also points to the various specialised advice centres in Baden-Württemberg. For example, there are recognition and migration advice centres both in Germany and abroad that are specifically aimed at skilled workers. One example is the ProRecognition project, which provides advice to skilled workers in ten countries (Algeria, Egypt, Bosnia and Herzegovina (Western Balkans), Brazil, India, Iran, Italy, Colombia, Poland and Vietnam) on how to their get qualifications recognised. One thing you do have to bring with you is time. "It doesn't happen overnight," says Brohl-Schaffron.

If you are a health professional and want to work in Germany, your qualification must first be recognised, as most health professions are regulated. The best possible outcome is full equivalence (certificate of recognition), which means that there are no differences between the educational qualifications in the home country and Germany. The Federal Ministry of Education and Research portal for the recognition of foreign professional qualifications is useful here and refers users directly to the correct recognition office in Germany through the professional filter. For example, the recognition procedure for a nursing specialist is done through the Stuttgart Regional Council - State Examination Office and Recognition Office for Health Professions.

As a rule, skilled workers from third countries do not obtain full recognition of their qualifications directly. They are issued with a deficit notice (also known as "certificate of partial equivalence") and can either participate in an adaptation course or undergo a knowledge test to obtain full recognition of their qualification," says Brohl-Schaffron. This qualification can usually be completed within three to twelve months. Preparatory courses are offered for those who take the knowledge test. "For skilled workers, however, participating in adaptation courses is often the easier option," she stresses. The framework for this is set out in the deficit notice. It lists which hospital wards need to be joined and how long the applicant has to stay there. "This can vary greatly from person to person, because work experience also plays an important role."

For employment in Germany, the foreign skilled worker must also obtain residence status, which requires the worker to provide proof of a so-called employment relationship such as a contract and proof of qualifications in order to obtain approval from the Federal Employment Agency (BA). Approval depends, among other things, on whether the working conditions are comparable with those of domestic employees. The assessment is carried out on the basis of the "Declaration of Employment", which the employer has to fill out.

"However, a company must first consider what resources are available, both in terms of personnel and finances, as this can affect which routes can be taken," says Brohl-Schaffron. Hospitals, nursing homes, day care centres and other institutions can contact the Welcome Centre directly with their questions; this service is free of charge. Questions might cover how to interview a skilled worker from abroad, help with the fast-track skilled worker procedure or questions about the various recruitment projects.

"Companies that want to carry out recruitment projects require personnel, and even more money," explains Brohl-Schaffron. In such a recruitment project, a company might, for example, want to find out whether it already has foreign employees who have been working as assistants in Germany for some time and have a recognisable qualification which has not yet been officially recognised.

The six-step fast-track (or expedited) procedure for qualified professionals²⁾ significantly shortens the administrative procedure between the point when skilled workers apply for work in Germany and when they can start working. To apply for the fast-track procedure for skilled workers, an employer needs a power of attorney from the future employee to submit the application to the local Foreigners Authority in Baden-Württemberg. The Foreigners Authority draws up an agreement with the employer for the fast-track procedure, which is subject to a processing fee of 411 euros to be paid by the employer. The Foreigners Authority forwards all documents to the competent office for recognition. This is also subject to a fee. The competent office makes a decision on recognition within two months of the documents being submitted.

After recognition, the approval procedure carried out by the Federal Employment Agency (BA) is initiated by the Foreigners Authority and takes a week. If all requirements are met, the Foreigners Authority issues a so-called preliminary approval to the visa once it has also checked the applicant’s passport and what is called the guarantee of subsistence, which is covered by the job offer. The foreign professional must submit the preliminary approval to the German mission abroad and will thus receive an earlier appointment to apply for the visa, which must take place within three weeks. Once the visa application (fee: 75 euros) has been completed on the day scheduled, a decision on the application will be made within three weeks. However, there is no guarantee that a visa will be granted by the German mission abroad.

The Triple Win³⁾ programme has been running since 2013 to help companies recruit nursing professionals. It is a partnership between the German Agency for International Coooperation (GIZ) and the Central Placement Office for Foreign and Specialised Personnel (ZAV), which is part of the Federal Employment Agency. Triple Win focuses on nursing professionals from Bosnia-Herzegovina, the Philippines and Tunisia. In addition, young people from Vietnam who already have nursing experience are offered three-year generalist nursing training leading to future employment.

Triple Win comprises four phases: employer counselling (e.g. drawing up service contracts), placement of skilled workers (e.g. placement proposals and individual selection interviews by employers), preparation before entry to Germany (e.g. a language course up to level B 1) and after entry (e.g. accompaniment during the integration process). Based on the service contract, the employer pays a remuneration of 7,900 euros gross (as of September 2021).

The conditions for participation in Triple Win are that the employer provides accommodation and pays a gross monthly salary of at least 2,300 euros before, or 2,800 euros after, professional recognition. The employer pays the travel costs from the country of origin to Germany and supports and finances both the acquisition of the required language skills (B2) and the recognition process in Germany. In 2023, the Ministry for Social Affairs, Health and Integration Baden-Württemberg will make a total of one million euros of additional funding available specifically for language acquisition. Applications for this funding should be made through the Employer Service of the Federal Employment Agency. In addition to these nationwide programmes, there are also numerous regional programmes in Baden-Württemberg. Regional alliances for skilled labour can also provide further assistance.

"When a hospital recruits skilled workers from abroad for the first time, it is also important to involve the permanent staff," says Brohl-Schaffron. This helps avoid potential conflicts. Many hospitals are already well-positioned in this area, for example, by having integration managers who accompany the skilled workers. In addition to integration in the company, social integration is also important. In Stuttgart, for example, welcome mentors help with this.

The Welcome Center also offers free events on a wide range of topics, such as "residence for family reasons". "This is an important topic, because some professionals have partners and/or children that they want to bring over with them," says Brohl-Schaffron. "There are various things to consider: Do they want to bring their family with them right from the outset? Are they earning enough to support them? Is there suitable accommodation available?"

For the nurses themselves, preparing to work in Germany is also another important step. "Nursing in Germany is different from other countries. Both the training and the work are very different, because in Germany, for example, there is a lot more basic care involved in nursing, which is also physically demanding. Language is also incredibly important. You need a really good command of German, because the requirement is an advanced language level, the B2 certificate."

The issue of housing is also a hurdle, irrespective of family reunification: "I know institutions that would like to employ a skilled worker but cannot find anywhere for them to live. And it's no good if all the other requirements are met but the person has no place to live," says Brohl-Schaffron. The extent of the need for housing for foreign nursing professionals is shown by efforts made by some municipalities: in Freiburg, for example, a poster campaign with the slogan "Wir brauchen PFLEGE - PFLEGE braucht Wohnraum" (We need CARE - CARE needs housing) has been running since June 2023. This is intended to encourage private landlords to rent flats to nursing professionals.

"What is actually difficult in Baden-Württemberg is that people need either a confirmed job offer to apply for recognition or counselling certificate from a recognition counselling service of the IQ Network Baden and Württemberg. It’s a chicken-and-egg problem, because a company would naturally prefer to hire a skilled worker who already has a notice of deficit. So the rough order of things from the skilled worker’s point of view is: learn German, start looking for a job, apply for recognition and then for a visa," says Brohl-Schaffron.

In addition to the lack of housing, she believes there are other obstacles to hiring foreign professionals in Baden-Württemberg. "There are two problems: one is the lack of digitalisation, because you cannot apply for recognition and residence online, and we are already noticing that. In a few other federal states, this is already possible in principle. It can take up to four weeks to send and receive a letter, which increases the period of time it takes for obtaining the necessary documents enormously. The second problem is understaffing in the recognition offices and Foreigners Authorities. We see that the number of applications is growing, and if the number of staff in the respective offices is not increased, the required examination of the documents becomes very difficult."