CareLend ensures that the employer’s integration management concept for the international nurse is provided in a translated version together with the job offer.

The concept in the native language is given to the nurse before she enters Germany.

The respective locations in the home countries are responsible for this, of course in cooperation with CareLend Germany.

Integration management concept of:

CareLend GmbH and CareLend Bildungsgesellschaft mbH

for new nurses from abroad

Welcome

On behalf of all our colleagues, we would like to warmly welcome you to CareLend GmbH and CareLend Bildungsgesellschaft mbH in Germany! The welcome folder provides you with important information about living and integration management in Germany. It is designed to help you quickly feel comfortable with us and get off to a good start. There is some general content, e.g. on finding accommodation, learning German or the German insurance system. In addition, your (future) employer can add specific information about the company and the region. You can use this folder while you are still abroad to prepare for your first steps. At the end, you will find a checklist with important information about your arrival and the documents you will need. If you would like to learn more about working and living in Germany or are looking for an advice center in your region, visit the support portal of www.carelend.de

Have fun reading and a good start!

Managing Director: Mohammed Behairy

Assistant to the Managing Director: Marion Zimmermann and Melanie Fichtler

and all our lecturers and employees

Download Welcome Folder

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PERSONAL AND SOCIAL INTEGRATION OF INTERNATIONAL NURSING PROFESSIONALS
1. Who are we?
In this section, we introduce the company to provide a deeper insight into the respective activities of the company and to show how we counteract the shortage of skilled workers. CareLend GmbH is a care and placement agency for non-academic health professionals. Our team organizes a modern recruitment program for nursing professionals from different countries. Since the founding year of the main company (meieagentur24) in 2004, we have been striving to establish an effective connection between employers and employees by accompanying nurses throughout their entire journey, while also contributing to improving the German healthcare system. In addition, we also provide effective problem solving for any bureaucratic matters before and after the placement. Thus, the State Medical Association of Saxony recommends meineagentur24 (parent company. Since 2004) to medical professionals abroad regarding relocation and learning the technical language. For the time being, we are conducting a global selection process for nursing professionals with a particular focus on a wide range of specializations. This includes, in particular, but not exclusively, professionals from the EU and third countries. These come from areas such as the Middle East, North Africa (MENA countries), Southeast Asia and South America.
Together with CareLend Bildungsgesellschaft mbH, CareLend GmbH organizes the further training of foreign nursing professionals within an adaptation measure. The teaching focuses on technical language and medical-nursing expertise. The aim is for the nurses to receive their professional license and be integrated into the German healthcare system within 10 months of starting the adaptation measure. Thanks to the competent team at CareLend GmbH, the pass rate for the required exam is 100%. In cooperation with CareLend Bildungsgesellschaft mbH, CareLend GmbH also organizes language courses that participants attend as part of the qualification program. Our company provides medical professionals with adapted language courses and comprehensive preparation for the specialist language test, even long before they arrive in Germany. We have a specialized team of experienced teachers who are well prepared to support the nursing staff in terms of education. With a view to their subsequent integration into the German healthcare system, this training is important to enable them to integrate into existing teams of medical professionals without any hurdles and to ensure optimal communication with patients and colleagues.
Our company places a great deal of importance on finding suitable positions for the nurses in medical facilities. CareLend GmbH is responsible for supporting the professionals in all matters for a further two years after they have received their license to practice in Germany. This ensures a stable relationship for both parties – employees and employers – during these two years.
Our competent support provides the qualified nursing staff with extensive security. Even before they enter Germany, we ensure that they receive the employment contract. In addition, we take over the organization of the visa with the purpose of the recognition procedure and the start of work. After entry, our company organizes the residence permit, work permit and, at the end of the adaptation period, the professional permit. The nursing professionals receive their monthly salary from the first month of their adaptation period in Germany. If the original medical facility that agreed the employment contract with the foreign nursing professional before entry no longer requires their services, we undertake to find employment for the professional at a different medical facility. This way, we ensure additional security for the nurse to carry out long-term employment in a suitable medical facility in Germany.
One advantage for the medical facilities is that the facilities we support have the assurance of being able to draw on a pool of nurses and geriatric nurses to cover their need for nursing staff. Likewise, the medical facilities do not have any additional expenses for social security, pensions or long-term obligations related to the employees. If, for whatever reason, the nurse does not fit into the team of the respective medical facility, the relationship can be terminated immediately and CareLend GmbH will immediately take care of a replacement that matches the requirements of the facility. Thus, we bear the risk and relieve the potential employers.
Civil society also benefits from our work in numerous ways. We help to alleviate the acute shortage of skilled workers by training foreign nursing professionals. Managing Director Mohammed Behairy, with his experience in the field of integrating nursing professionals from the EU and third countries, can ensure that cultural differences between nurses and patients, or between employers and colleagues, do not lead to misunderstandings. In this way, we aim to improve the image of medical professionals from abroad in general. This can help to dispel the fear of possibly “wrong” foreign nurses, which is largely unfounded.

2. Project definition: The professional, personal and societal integration of international nurses – Introduction

In recent years, the international recruitment of nurses has increasingly proven to be a relevant strategy for alleviating the shortage of skilled nursing staff, which is expected to increase significantly in the future. At the same time, the conditions for the international migration of nursing professionals have changed significantly, whether due to the increasing “competition” of the global North for these workers or to changes in the legal framework in the nation states that are increasingly relying on labor market-oriented immigration policies. Furthermore, the increasingly professionalized “recruitment management”, which involves labor market intermediaries to an ever greater extent, plays an important role in the changing strategies of migrants.

This means that larger employers in the health and care sector – hospitals and inpatient care facilities for the elderly – are facing new challenges: the care professionals from abroad have undergone a different professional and technical socialization than is usual in Germany and have different qualifications, work experiences and expectations regarding their professional activity and development. This raises the question of what problems arise in the process of workplace integration and how workplace integration can succeed in the face of the globalizing care labor markets, so that the newly immigrated nursing professionals remain in Germany as workers over the longer term.

The research project “Integration in the workplace in globalized labor markets” of a renowned foundation (BIGA, cf. www.boeckler.de/11145.htm?projekt=2014-789-4) is addressing this question. Accordingly, the challenges of globalized care labor markets were identified and dimensions of corporate integration were reconstructed from the perspective of newly migrated nursing professionals and those already established, i.e. nursing professionals and supervisors who have been professionally socialized in Germany. In addition, starting points for successful corporate “integration management” were developed in collaboration with various stakeholders. CareLend GmbH is implementing precisely this in the project of integrating foreign nursing professionals into companies.

The central research results are summarized in the study “Betriebliche Integration von Pflegefachkräften aus dem Ausland” (in German only). After an explanation of the study’s problem and research questions, as well as an explanation of the research design, CareLend GmbH also deals with the changing conditions of the nursing labor market in Germany. The following chapters deal with the questions of how liberalization and labor market orientation of national immigration policy, in conjunction with increased recruitment activities by companies, have already led to an increase in the migration of skilled workers, how this process is controlled by labor market intermediaries like us, and to what extent international nursing professionals can integrate into the German healthcare system.

2.1. Problem

The demand for nursing staff will increase significantly in the coming years, which is mainly due to the increase in the number of people in need of care, which is expected to reach around 3.4 million in 2030 (Prognos 2012: 1). If today’s level of care is extrapolated into the future, there will be a shortage of approximately 517,000 nursing professionals (ibid.: 14). This figure takes into account two effects of demographic change: the increasing demand for care services from ever larger cohorts of old and very old people will create a significant need for expansion in the care professions; at the same time, age-related withdrawals from the care professions will lead to an increased need for replacement in the future.

According to the Federal Employment Agency (BA), key indicators show that nursing professions are already among the “bottleneck occupations”: In 2016, unemployment in the nursing and healthcare professions fell by 9.6%, and the number of jobs reported to the BA increased by 19.9% compared to the previous year (the corresponding figures for all occupational groups were 9% and 18.6%). A job vacancy registered with the BA for occupations in health and nursing care remained vacant for an average of 124 days (average for all occupations: 90) and there were 71 unemployed people for every 100 jobs (average for all occupations: 399). The figures are even more pronounced for geriatric care specialists: there were only 38 unemployed people for every 100 registered positions, and these remained unfilled for an average of 153 days (Federal Employment Agency 2016: 27).

Regional industry monitoring shows that the shortage of skilled workers in the health and care industry, which includes hospitals, rehabilitation clinics, nursing and retirement homes, and outpatient care services, varies greatly from region to region (Bieräugel et al. 2012, Lauxen/Bieräugel 2013, Lauxen/Castello 2016). The most urgent shortage of skilled workers currently exists in urban areas of western Germany and in rural areas of eastern Germany.

In order to reduce the shortage of skilled workers in nursing, various labor market policy approaches have been developed and tested in recent years (Federal Ministry for Family Affairs, Senior Citizens, Women and Youth 2012, resolution of the Conference of Health Ministers/Conference of Education Ministers 2015, cf. also Weimann-Sandig et al. 2016). These include, on the one hand, the attempt to attract more employees to work in nursing by expanding training opportunities. This includes, for example, measures to improve the image of nursing professions in the public eye in order to find more trainees among school leavers (Rodewald et al. 2006, Deutsches Institut für angewandte Pflegeforschung 2014: 34). This also includes measures for second-chance qualification (Bonin et al. 2015), for which individual federal states have opened up training to those with lower school qualifications. This enables people with a lower secondary school leaving certificate to gain (staggered) access to a skilled occupation by allowing them to complete a shortened training course to become a specialist after completing a one-year helper course (e.g. in Hesse and Rhineland-Palatinate). Furthermore, more and more nursing degree programs are being developed to attract high school graduates to nursing.

On the other hand, the aim is to bring the skilled workers in the so-called “hidden reserve” into employment (especially women during or after their family phase, see, for example, the recommendations of the German Association for Public and Private Welfare 2012).

The fields of action for companies in the field of securing skilled workers include company health management, which aims to strengthen the ability of nursing staff to work and their motivation (Schmidt et al. 2015, Dietrich et al. 2015, Benedix/Medjedović 2014). At the same time, those parts of the workforce that work part-time can be persuaded to increase their working hours

(Prognos 2012). The many initiatives for the qualification of executives, which influence the retention of nursing professionals through targeted organizational and personnel development, should also be mentioned (Larsen 2016, Joost 2015). Nevertheless, these measures are only partially effective, as they can only mitigate the existing shortage of skilled workers, but not avert it altogether. In view of the above-mentioned problems, the active recruitment of nursing professionals from abroad has been increasingly mentioned for several years as a short- and medium-term solution to the shortage of skilled workers in nursing (Prognos 2012, Braeseke et al. 2013). According to a study by the Bertelsmann Foundation, one in six companies in the care sector surveyed had actively recruited care professionals from abroad in the last three years – but only half of them were successful (Bonin et al. 2015: 63).

Since 2004, our company has received more than 41,000 applications from nursing professionals from abroad and has already established a stable relationship with more than 2,000 potential employers. We have also placed more than 4,000 nursing professionals and doctors from third countries.

Since recruitment requires a considerable amount of effort on the part of the HR managers and, in addition, a high degree of professionalism and quality of personnel management, this strategy for securing skilled workers is primarily a strategy for hospitals and large providers of inpatient geriatric care facilities (ibid.). CareLend GmbH has set itself the task of actively addressing the shortage of skilled workers in rural areas, too, as exemplified by its cooperation with the Sana Klinikum in Borna.

The migration of nursing professionals to Germany is not a new phenomenon: as early as the 1960s and 1970s, there were targeted recruitment initiatives for Korean nursing professionals (Yang 2014, Hartmann 2016). In the 1990s, a large number of nurses came to Germany from the former Yugoslavia as a result of the Balkan wars, and since the 1990s, the countries of the former Soviet Union in Central and Eastern Europe have also been important countries of origin for nurses (Bonin et al. 2015). However, the more recent migration movements of nursing professionals differ from their predecessors in a number of important ways:

• The pressure to act in the care sector has increased significantly due to the shortage of skilled workers.
• Immigration policy in Germany and the EU has fundamentally changed from one of repression and defense to one that is based on fluid spaces of graduated rights and ideas of labor market “management” (Hess/Kasparek 2010; on the conceptual framework of border regime research, cf. also Heimeshoff et al. 2014 and Hess et al. 2017), selectively regulates different forms of migration and thereby seeks to actively shape labour demand and demographics (Ratfisch 2015: 7, Georgi 2007: 5).
• This “migration management” increasingly integrates (civil society) actors, whereby labor market intermediaries, in particular, are involved in the process of acquiring nursing professionals from abroad (cf. Schwiter et al. 2014).

In addition, a globalized labor market for nursing professionals has emerged in recent years: Many countries in the “global North” are characterized by a similar shortage of skilled workers in the care professions and are in increasing competition for skilled nursing staff, who are recruited in more and more countries around the world. Another feature of globalized nursing labor markets is that labor migration in nursing is less and less permanent, with migrants responding flexibly to constantly changing conditions. This makes it necessary to successfully integrate them into the workplace and thus guarantee a long-term supply of skilled workers. In turn, employers in the destination countries adapt their recruitment activities to these developments and try to use various mechanisms to retain nursing professionals in their facilities for longer periods.

So far, little is known about how the integration processes of migrant nursing professionals in Germany proceed. Various studies by institutions with a name show that the course of integration into the workplace is significantly shaped by framework conditions that are already at work in the run-up to the actual migration and are partly inscribed in the professional biographies of the migrants. These include nationally codified requirements for professional qualifications and language skills, as well as the work of labor market intermediaries, who, through their “preparatory” services, have a significant influence on the subsequent (collaborative) work in the company. On the other hand, the results demonstrate the extent to which newly immigrated nursing professionals have to adapt and transfer their knowledge in their new work context.

Despite the common guiding principles and standards that accompanied the emergence of the nursing profession across national borders, major differences have emerged in the development of the profession in different countries, depending on varying

gender relations, social orders and structures of health systems (Wrede 2012, Choy 2003, Reddy 2015). Furthermore, the largely nationally framed professional norms and identities have developed in interaction with nationally specific regulations and determine the responsibilities and activities as well as the relationships with other professional groups (cf. Kuhlmann et al. 2012, Theobald et al. 2013). In this context, newly immigrated nursing professionals face the challenge of applying their expertise and previous professional experience in the new context of differently defined professionalism and different work organization when entering the German labor market. It is not uncommon for the migrant nursing professionals to be expected to adopt the prevailing “hegemonic [professional] identities” (Batnitzky/ McDowell 2011: 186) in Germany without question. Accordingly, the existence of possibly different expectations and ideas of the newly migrated nursing professionals, which are based on the differently defined professionalism and professional identity, is initially ignored in the company.

At the same time, however, the question arises for employers and colleagues as to how the newly migrated nursing professionals could be integrated into the daily work routine as quickly as possible under the given conditions. However, since integration in the company not only affects the newly migrated nursing professionals, but also requires active participation on the part of the established nursing professionals and superiors, the question arises as to how this can be achieved and what problems may arise in the process.

Despite the common guiding principles and standards that accompanied the emergence of the nursing profession across national borders, major differences have emerged in the development of the profession in different countries, depending on varying

gender relations, social orders and structures of health systems (Wrede 2012, Choy 2003, Reddy 2015). Furthermore, the largely nationally framed professional norms and identities have developed in interaction with nationally specific regulations and determine the responsibilities and activities as well as the relationships with other professional groups (cf. Kuhlmann et al. 2012, Theobald et al. 2013). In this context, newly immigrated nursing professionals face the challenge of applying their expertise and previous professional experience in the new context of differently defined professionalism and different work organization when entering the German labor market. It is not uncommon for the migrant nursing professionals to be expected to adopt the prevailing “hegemonic [professional] identities” (Batnitzky/ McDowell 2011: 186) in Germany without question. Accordingly, the existence of possibly different expectations and ideas of the newly migrated nursing professionals, which are based on the differently defined professionalism and professional identity, is initially ignored in the company.

At the same time, however, the question arises for employers and colleagues as to how the newly migrated nursing professionals could be integrated into everyday work as quickly as possible under the given conditions. However, since integration in the company not only affects the newly migrated nursing professionals, but also requires active participation on the part of the established nursing professionals and superiors, the question arises as to how this can be achieved and what problems may arise in the process.

We at CareLend GmbH are particularly committed to the integration of our international fellow citizens, providing them with active support in entering the German labor market, helping them with all bureaucratic matters and promoting the learning of the language and primary cultural and political aspects. Respect and tolerance are our top priorities. Mohammed Behairy, managing director of CareLend GmbH, and his team ensure that international nursing professionals always feel comfortable here, and it is very important to us to carefully avoid any misunderstandings. Through the required internship, which mainly takes place in medical facilities such as hospitals and nursing homes, international professionals are always in contact with their German colleagues and patients. Mr. Behairy is always keen to share his extensive experience and knowledge in intercultural links between German and Arab society with the staff.

2.2. Study on the shortage of nursing staff in Saxony
The focus of the pilot project of our company CareLend GmbH is on the region of Saxony, but we are also looking at the national picture.
Along with Rhineland-Palatinate, Saxony is one of the federal states with the greatest shortage of skilled workers in both geriatric and nursing care. According to the DNN (Dresdener Neueste Nachrichten), there are just 13 job seekers for every 100 vacancies in geriatric care in Saxony. Nationwide, there are 21 specialists. In nursing, there are 36 unemployed people for every 100 vacancies; nationwide, there are 41.
According to the federal government, more than 25,000 specialist positions are vacant in geriatric and nursing care throughout Germany. Added to this, there is a shortage of around 10,000 auxiliary staff. In 2017, an average of 14,785 vacancies were reported for specialists in geriatric care, and 10,814 in nursing care.
The DNN reports that the coalition agreement between the CDU and SPD included, among other things, an “immediate care program” with 8,000 new specialist positions and better pay. In addition, a “concerted care campaign” has been announced to improve the staffing ratio and a training offensive for male and female nurses.
Statistics from the Federal Employment Agency show that the majority of employees in the care sector are female. In addition, part-time employment is widespread. The Federal Employment Agency describes the shortage situation in Saxony as one in which the indicators point to bottlenecks.
Due to demographic change, a steady increase in the number of people in need of care is to be expected. According to the Federal Ministry of Health, there are around 2.86 million people in need of care in Germany (as of 2015). According to the Statistical Office of the Free State of Saxony, Department of Care Statistics, the total number of people in need of care is 204,797 (as of 2017).

This acute shortage of nursing professionals in the Federal Republic of Germany has existed for several years, particularly in the new federal states. Rural areas, especially in eastern Germany, are particularly affected. This demand for qualified nursing staff will continue to increase in the future.
How high is the actual demand? According to aarpinternational.org, Germany is one of the five “super-aged” countries in the world, and the population of over 65-year-olds will continue to grow and will soon make up a third of the population in 2050. Instead of the current 17 million, there will be around 22 million people over the age of 65 living in Germany in 2030.
This figure shows the number of senior citizens in Saxony on December 31, 1990, through 2030, according to selected age groups:

With the growing proportion of senior citizens in society, the demand for nursing staff is also increasing. Various studies predict a shortage of between 193,000 and 480,000 nursing professionals by 2030.

Germany is unable to cover this shortage with the number of graduates it produces each year in its own country. This is especially true given that nursing is not sufficiently attractive as a specialization for German medical professionals.

3. The emergence of a globalized labor market for nursing care in Germany

3.1 Migration and the emergence of globalized labor markets for nursing care

To date, the labor market for nursing care in Germany has a comparatively low level of immigration by international and European standards: while the proportion of nursing professionals trained abroad in 2013 was 24.5 % (New Zealand), 16.5% (Australia) and 7.5% (Canada), and Switzerland and the United Kingdom were the European leaders in this respect (Switzerland in 2012 with 18.7% and the United Kingdom in 2014 with 12.7%), in 2010, only 5.8% of nursing professionals in Germany had completed training abroad (OECD 2015: 118). This is partly due to the fact that Germany initially made use of the option to suspend the free movement of workers after each round of EU enlargement from 2004 onwards and did not have state-coordinated and supported recruitment activities in the care sector for quite some time. However, the care sector is now increasingly under pressure to take action to supplement existing strategies for securing skilled workers by recruiting from abroad.

In the scientific debate, an increasing migration of nursing professionals is justified by the fact that:

• neoliberal economic reforms have led to structural changes in the health systems of the destination and origin countries and to a globalization of the nursing labor markets; in addition, nursing professionals increasingly see their own professional and academic development in a global context;
• a transformation of the political and legal control of migration and thus a change in the labor migration regime has taken place in the destination countries; and
• international labor recruitment is increasingly being handled by professional service providers, labor market intermediaries.

3.1.1 Globalization of the care labor markets

The global migration of nursing professionals has a long history, but it has been significantly expanded by recent structural changes in both destination and origin countries. In particular, the United States, Canada and the United Kingdom have long seen the recruitment of nursing professionals from abroad as a way to counteract shortages of skilled workers (Prescott/Nichter 2014, England/Henry 2013). These shortages can be cyclical in nature – in a given period, demand for nursing professionals increases and cannot be counteracted in the short term by increased training or other policy interventions – or they can have structural causes. The latter can be observed in many countries of the Global North. On the one hand, there is the increased demand for care due to demographic processes; on the other hand, neoliberal reforms of the health care systems were partly responsible for the shortage of skilled workers in many countries (Wrede 2012; for the guiding principles of the reforms, see McGregor 2001).

Although originally introduced with the aim of improving efficiency in the institutions, they often resulted in a deterioration of the working conditions and pay of nursing professionals, as well as a decline in job security. As a result, nursing careers became less attractive, and since a number of Western countries had underfunded their nursing training for years (Wrede 2012, Taylor et al. 2012, Yeates 2010), no replacement could be found for many career changers. The structural imbalances still exist today, and attempts are increasing in the affected countries to compensate for them by recruiting from abroad.

In many of the countries from which the nursing professionals originate, the health systems have also been reformed in several waves since the 1980s and 1990s according to neoliberal models. The reforms were often triggered by political and/or economic crises or a general need for modernization in the health systems. The reforms were often advocated or driven by international organizations such as the World Bank or the World Health Organization (Chorev 2013, Armada et al. 2001) and pursued the goal of

privatize health care and replace comprehensive health strategies with selective and piecemeal interventions in order to make the health industry more cost-effective (Abramovitz and Zelnick 2010). Although the reforms varied in scope and form from country to country (e.g. Armada et al. 2001, Huber/Solt 2004 for South America), there was a general trend towards wage cuts, hiring freezes or layoffs in the health sector. These contributed to increased emigration and are generally held responsible for the increased migration of nursing professionals (Aiken et al. 2004, Abramovitz/ Zelnick 2010). These developments are not limited to the countries of the global South or the European periphery in the East, but also include countries that were hit particularly hard by the effects of the global economic crisis of 2008 (e.g. Greece or Spain, see OECD 2015).

It should be noted that the geographical direction of nursing migration often correlates with historically established relationships between states. The roots often go back to the days of colonialism and imperialism (Choy 2003, Wrede 2012, Ball 2004, Yeates 2009, Bludau 2011, England/Henry 2013, England 2015, Reddy 2015, Lutz/ Palenga-Möllenbeck 2012) – Germany is an exception here, which also explains the later onset of immigration. In some countries of origin, veritable “nurse production industries” have emerged (Prescott/Nichter 2014, for India and the Philippines cf. Yeates 2009, Choy 2003, Reddy 2015), and especially for the Anglo-Saxon countries USA, Canada, New Zealand, Australia and Great Britain (OECD 2015). Such historically grown relationships and mutual

dependencies often prove to be very stable and lasting (Yeates 2010). Nevertheless, a country’s status as a country of origin or destination can change at short notice (Wrede 2012, Aiken et al. 2004), for example, when budget cuts due to socio-economic crises lead to layoffs in the health care system (Dussault/Buchan 2014: 49).

Similarly, nursing professionals in the countries of origin react very quickly to changes in the conditions for labor migration in the destination countries, e.g. government recruitment agreements or new possibilities for the recognition of professional qualifications (Yeates 2010). This can be demonstrated for the Philippines, for example: when it became temporarily more difficult for Filipino nursing professionals to obtain work visas due to a change in US immigration policy, they instead headed for Singapore and Saudi Arabia (Arends-Kuenning et al. 2015).

This means, conversely, that countries experiencing a shortage of skilled workers can identify other countries where nursing professionals are available as a resource for their own workforce development, which they can tap into by making changes to the legal framework for labor migration (Glinos 2015).

The “global nursing care chains” (Yeates 2009) have become much more heterogeneous in recent years and have expanded (Yeates 2005, 2010). The consequences of emigration for the home country’s own health system are often criticized, as is the trend to compensate for this through immigration from other countries (e.g. Jamaica compensates for the emigration of its own nursing staff by recruiting more from countries such as Burma, Cuba, Ghana, India and the Russian Federation (Yeates 2010). More recently, there have been political attempts to curb these negative effects, especially in the poorest countries. In 2010, for example, the WHO Code of Practice on the International Recruitment of Health Personnel was adopted (WHO 2010, Angengendt et al. 2014), which, among other things, excludes certain countries from recruitment programs. This has been quite successful, for example, in significantly influencing the activities of professional labor market intermediaries in Germany.

The fact that nursing professionals offer their labor in globalized labor markets is not only due to the immediate necessity of securing their livelihoods. The desire for professional advancement, further training opportunities and better working and living conditions can also trigger migration (Yeates 2010, Kingma 2007, Aiken et al. 2004, Glinos et al. 2015). Mirelle Kingma (2007), for example, reports that nurses use their professional placements in different countries to acquire skills or qualifications. Furthermore, migration is often not a permanent decision for nurses, but rather represents a further professional step in global career planning (Glinos et al. 2015). Recognizing this is particularly important for the design of company integration processes and for successfully securing skilled workers (cf. Jürgens et al. 2017: 176 ff.).

3.1.2 Changes in the political and legal control of migration

The migration of nursing professionals takes place within the framework of a general migration regime. In most nation states, residence rights and access to the national labor market are handled very restrictively. More recently, a change in political control can be observed in many countries of the global North, whereby migration is increasingly regulated according to the principle of economic benefit. Accordingly, these states are changing their legal frameworks in order to make it easier for “desired” target groups to enter the labor market (e.g. Bach 2007 for the change in the legal framework for the migration of nursing professionals to the UK), while at the same time sealing themselves off more and more. In principle, there are two models for such a regulation of labor migration (Kolb 2014):

• supply-side management of migration through instruments that allow destination countries to set general criteria for access to their labor markets (see Hinte et al. 2015 for the points systems in Canada and Australia),
• managing (temporary) migration based on labour demand using indicators that are supposed to reflect labour demand on the labour market (see Groutsis et al. 2015).

While points systems tend to target the general “potential” of immigrants (e.g. age, level of qualification), labor demand-oriented immigration policies attempt to steer immigration in a more targeted manner along the needs of the economy (van den Broek et al. 2016) and thus increase the efficiency of their own labor markets (Overbeek 2002, Castles 2011). This is intended to compensate for labor shortages in various sectors and at different skill levels and to ensure that companies can react flexibly to fluctuations in labor demand (Sporton 2013, Batnitzky/McDowell 2013).

This allows countries higher up the care chain hierarchy to define care professionals in different countries of origin as a labor resource and to try to use them to secure their own skilled workers.

In Germany, the liberalization of labor markets took place later than in other countries of the Global North (Coe et al. 2007), and many elements of labor market and migration policy that enable the connection to globalized labor markets were introduced late compared to other countries. Nevertheless, various observers have concluded that Germany has been moving towards a labor market-oriented migration policy since around 2000, in parallel to a general shift from a problem-oriented to a potential-oriented integration policy (Pütz/Rodatz 2013; Kannankulam 2013; Buckel 2012). Thus, the isolationist orientation that dominated in the 1990s was gradually replaced by the paradigm of “migration management” (Ratfisch 2015: 7, Georgi 2007: 5).

This includes comprehensive and differentiated control of migration processes according to the principle of the usefulness of migrants for the receiving society (Kolb 2014, Georgi 2007: 99 f., Menz 2008). Accordingly, criteria of education and professional qualifications were gradually introduced into the regulation of migration and the immigration opportunities for highly qualified workers were expanded (Ette et al. 2012).

In the tradition of the Green Card, which was designed for IT specialists and is considered the beginning of the fundamental change in German labor migration policy, the greater opening of the German labor market through the immigration and residence laws of 2005 created opportunities for highly skilled workers in particular (Ette et al. 2012, Kolb 2014). It was only later that the skilled occupations, which include the nursing professions, came into the focus of the public discourse on the shortage of skilled workers. In 2011, the Federal Government’s concept for securing skilled workers stated that qualified immigration should be seen as an important strategy for securing skilled workers in bottleneck occupations (Federal Ministry of Labor and Social Affairs 2011). The “Act to Improve the Assessment and Recognition of Professional Qualifications Acquired Abroad” (Recognition Act), which came into force on April 1, 2012, also enabled the legal right to examine professional qualifications acquired in third countries and introduced the possibility of taking compensatory measures in the event of non-equivalence. It applies to the approximately 600 professions regulated under federal law, including those of nurse, paediatric nurse and geriatric nurse.

3.1.3. Changes in transnational migration arrangements through labor market intermediaries
Although the legal framework determines who has access to the labor market of the destination country and under what conditions, the application of these principles in practice is very complex (Weiß 2010: 123), and there are hurdles that require both material (e.g. financial resources) and immaterial resources (e.g. contacts, knowledge), both on the part of the migrants and on the part of the employers interested in immigration (Bludau 2011: 99, Csedő 2008). In particular, employers are increasingly delegating the increasingly complex global search for skilled workers to mostly private service providers, so-called labor market intermediaries (Benner 2002, 2003, Schwiter et al. 2014). These intermediaries use various mechanisms to try to “dock” the workers willing to migrate to the qualification and labor market regimes of the destination countries (Groutsis et al. 2015, van den Broek et al. 2016), thereby significantly shaping the processes in globalized labor markets.
Labor market intermediaries are organizations that have the matching of labor supply and demand as their business model (Katzis 1998, Benner 2002, Autor 2009). Typically, these are, for example, temporary employment agencies and employment services (Bonet et al. 2013), here is an example of our company CareLend GmbH.
Research on the role of labor market intermediaries in migration processes points to the diversity of their forms and activities (Sporton 2013, Findlay et al. 2013, Beaverstock et al. 2010, Faulconbridge et al. 2008). Due to the increasingly complex legal regulation of migration (with numerous special provisions by industry or
country of origin), they have become an integral part of migration arrangements (Bludau 2010): They can link labor markets in sending and receiving countries by equipping migrants with the necessary skills and competencies and by providing them with information about the labor market and living environment in the receiving country (Groutsis et al. 2015, Coe et al. 2010, Sporton 2013). At the same time, they build relationships with employers to understand their preferences in terms of employees and to take these into account in the placement process (Bludau 2010).
From a sociological perspective and in line with marketization studies, the processes described of a stronger economic policy orientation of migration policy and the shifting of the design of migration movements to private intermediaries can be regarded as an example of the “marketization” of essential social fields, in this case the field of the placement of nursing professionals. Labor market intermediaries occupy a key position in this process, as they are significantly involved in the construction of workers as products and in determining their market value (in the terminology of Çalışkan/Callon 2010: 8; see also Callon/Muniesa 2005, Ouma 2015), and thus contribute to the establishment of a market for the placement of nursing professionals. In this context, “marketization” also means that nursing professionals are “prepared” according to the requirements for labor market and professional access and the needs of employers, so that they can be placed on the labor market as “finished” workers. To this end, not only the “objectification” of nursing professionals in the sense of producing marketable labor (see Callon/Muniesa 2005) takes place, but also the “subjectivization” as the process of becoming a migrant in the context of the global labor market, which goes hand in hand with the development of a specific consciousness on the part of potential migrants. Heidi Bludau (2010, 2011), for example, describes how nursing professionals are encouraged in their countries of origin to imagine themselves in the new living and working context and to adopt the attitude expected by the employer.
This means that integration within the company is largely predetermined. This is because objectification and subjectivization are often carried out by different labor market intermediaries, who act as “culture brokers” during the recruitment process (Bludau 2015: 96 f., Moroşanu 2016: 359 ff.). In this role, they are positioned between the employees and the employer during the migration process (and in some cases also after) and communicate values and ideas between the two (Bludau 2015). In doing so, they influence both the preparations for migration processes and social and occupational integration after migration.

3.1.4 Career opportunities for nursing professionals

The findings of previous research show that nursing labor markets are becoming increasingly globalized. Employers define nursing professionals in other countries as a resource for securing their own workforce, and nursing professionals increasingly locate their career opportunities internationally. This development is supported in the destination countries by labor market-oriented legal regulation, which, in the face of increased demand, attempts to open up access to the domestic nursing labor market to new target groups from abroad. However, the requirements for the professional qualifications of nursing professionals in the destination countries mean that their migration remains challenging. As a result, complex migration arrangements arise in which the nursing professionals are prepared for their deployment in the destination country and are retained through various mechanisms in the recruitment process.

The following framework conditions arise for their operational integration in Germany:

• Increasing mobility of the workforce: The global labor markets offer nursing professionals a variety of opportunities to earn a living in another country and to shape their professional development. Since destination countries compete globally for nursing professionals, the retention of skilled workers is of particular importance.
• Increasing complexity of migration arrangements: Despite the globalization of nursing labor markets, there are still significant barriers to labor market access in the destination country for nursing professionals (depending on their country of origin), and the transferability of their qualifications and skills remains challenging. Preparation of nursing professionals for their work in Germany is left to various labor market intermediaries in the recruitment process, who shape the expectations of employers and nursing professionals and who later provide the background for integration into the workplace.
• Increasing heterogeneity of the workforce: There are significant differences in the training of nursing professionals, which is aligned with the job description in the respective national health and social system. In addition, nursing professionals bring with them experience of different organizational and professional hierarchies in their countries of origin. This means that
• different professional self-conceptions collide in the institutions, which can become the subject of disputes.

3.2 Securing a supply of skilled workers in globalized nursing labor markets: the example of Germany

As comparative international statistics show, Germany is still far from being considered an established destination country for globalized migration of nursing professionals. Nevertheless, there has been a significant increase in the migration of nursing professionals to Germany in recent years. The following shows how labor market access is regulated at the level of immigration and recognition of qualifications acquired abroad for the health and care sector, and what differences there are between the origin categories “EU member state” and “third country”.

3.2.1 Migration of nursing professionals from the EU

The change in thinking about skilled immigration as a strategy for securing skilled workers in the care sector occurred at the same time as the economic crisis in southern Europe was unfolding. This triggered significant cuts in the healthcare systems of Spain, Portugal and Greece, and led to wage cuts, layoffs and hiring freezes (Glinos et al. 2015, OECD 2015). The cuts hit young nursing professionals particularly hard, as they had just graduated or had not yet established themselves professionally. This made them more willing to seek professional opportunities abroad, and they became the focus of recruitment activities by German organizations.

The recruitment of southern Europeans for the care labor market in Germany took place through state programs (e.g. MobiPro-EU from the International Placement Services (ZAV) of the German Federal Employment Agency) or commercial providers (Zentrale Arbeitsvermittlungsstelle 2014, Bundesagentur für Arbeit 2013). The entry of the nursing professionals into the German labor market was facilitated by the legal framework designed to support labor mobility in the EU: as EU citizens, they had a right of residence in Germany and, according to the EU Free Movement Directive, were granted free access to the German labor market. In addition, the EU Professional Qualifications Directive (Directive 2005/36/EC of the European Parliament and of the Council of 20 October 2005 on the recognition of professional qualifications), which came into force on October 20, 2005, ensured the equivalence of training content in regulated professions such as doctor, dentist and nurse. Thus, the recognition of the qualifications of all EU citizens as well as for nationals of the European Economic Area and Switzerland took place several years before the adoption of the Recognition Act. In addition to the recognition of professional qualifications, knowledge of the German language at B1 or B2 level of the Common European Framework of Reference must be demonstrated for admission to the profession of nursing.

Since the principle of freedom of movement applies to EU citizens, no data is available for migration from EU countries to Germany. The recognition statistics are the only way to estimate approximately how many people have come to Germany from their home countries in the south of the EU as a result of the economic crisis (see Figure 4).

The statistics show an increase in the number of recognition procedures initiated for educational certificates from all four southern European countries between 2012 and 2015, with by far the largest number of applications being submitted by nursing professionals who had completed their training in Spain. Spain is a Western European country whose health system was severely affected by the financial crisis (OECD 2015), and the number of recognition procedures for qualifications from Spain increased by a factor of 4.5 between 2012 and 2014.

Number of recognition procedures by country of training for nurses from southern Europe, 2012–2017

However, in 2015, the number of nurses seeking to have their Spanish-acquired qualifications recognized fell by two-thirds, and in 2016, only 105 Spanish nurses applied for professional recognition. In 2017, the number was only 72.
Number of work permits issued by Germany to Romanian and Bulgarian citizens in the nursing and geriatric care professions, 2011–2013

In addition to migration from the countries of Southern Europe affected by the economic crisis, many nursing professionals have come to Germany from the countries of Eastern Central Europe and Southeastern Europe since the 1990s. These migratory movements were driven by the political and economic developments resulting from the transformation. For the more recent migration from the new EU accession countries Romania, Bulgaria (2012) and Croatia (2013), statistics are only available for the transitional period during which Germany had not yet opened its labor market to these countries.
Figure 5 shows that the EU accession of Bulgaria and Romania on January 1, 2012 was accompanied by a doubling of work permits for their citizens in the nursing and geriatric care professions, with immigration from Romania at a significantly higher level. Migration of nursing professionals from Croatia has been comparatively high since their accession to the EU on July 1, 2013: in the first half of their EU membership, Croatian citizens received 333 work permits in the nursing and geriatric care professions. In 2014, 690 nursing professionals were already able to access the German labor market.
The five most common countries of training for the profession of nurse in all recognition procedures in Germany, 2012–2017

With regard to recognitions from the newer EU accession countries, it must be noted that the principle of automatic recognition of professional qualifications according to the EU Professional Qualifications Directive applies to professional qualifications acquired since EU accession.This means that the requirements for the recognition of professional qualifications from abroad may be somewhat higher for nationals of the new member states because they may be subject to compensatory measures such as aptitude tests or adaptation periods.

The ranking of the most common training countries is now dominated by third countries (see Figure 6), more specifically by Bosnia-Herzegovina, Serbia, the Philippines and Albania. Romania is the only EU member state among the five most common training countries.

The number of recognition procedures sought for nurses indicates that labor migration of nursing professionals from EU countries to Germany has increased significantly in recent years.

The sharp increase in the number of applications from Bosnia and Herzegovina in 2014 can be explained by the recruitment agreement concluded that year. Since then, there has been a significant increase in the number of applications each year. While Bosnia-Herzegovina was the only third country among the five most common training countries until 2014, Serbia joined this group in 2015, followed by the Philippines in 2016 and Albania in 2017. The next section takes a closer look at the migration of nursing professionals from third countries.

3.2.2 Migration of nursing professionals from third countries

The migration of nursing professionals from third countries is much more strictly regulated than that of EU citizens – it is subject to restrictions at the level of entry and residence. At the same time, there are facilitations that have been introduced due to the shortage of skilled workers in the care sector. According to § 18 of the Employment Ordinance of July 1, 2013, nursing professionals from third countries have simplified access to the German labor market if:

• they can demonstrate at least two years of vocational training equivalent to a German vocational qualification,
• their employment conditions correspond to those of domestic nursing professionals,
• the vacancy has been posted on the job exchange of the Federal Employment Agency (BA) or the person concerned has been placed by the BA for work on the basis of an agreement with the employment service in the country of origin.

The latter agreements have existed since 2013 with Bosnia-Herzegovina, Serbia and the Philippines. In addition, according to § 6 para. 2 sentence 1 no. 2 of the Employment Ordinance, the occupation must be on the BA’s positive list. This is compiled every six months on the basis of the shortage of skilled labor analysis and lists occupations in which there is a shortage of skilled labor and thus the filling of vacancies with foreign applicants is considered “justifiable in terms of labor market and integration policy” (Bundesagentur für Arbeit 2016: 19).

Approval ratings for third-country nationals by selected occupations (KldB 2010) in Germany, 2011–2014

The control of labor migration via the BA’s positive list reflects the high priority given to matching in German labor market policy – the effort to optimally align labor supply and demand. The current BA list includes occupations in geriatric care, health care and nursing, as well as specialized nursing.

A further restriction on labor market access is imposed on third-country nationals whose country of origin is on the list of WHO countries from which no nursing professionals are to be recruited. In this case, only the BA is allowed to recruit or place the professionals (Angenendt et al. 2014).

Figure 7 shows that the influx of nursing professionals from third countries has increased due to the successive introduction of facilitations. It also shows that there are significantly more workers who receive approval in the nursing and healthcare professions than in the geriatric care professions; nevertheless, the number of approvals for third-country nationals is also increasing in these professions.

Furthermore, the percentage of nursing professionals among all approvals granted to third-country nationals is continuously increasing. While in 2011, only 0.4% of all approvals for third-country nationals were granted for nursing and healthcare professions, this figure had already increased to 2.7% in 2014.A similar trend can be seen for geriatric care professions, albeit at a lower level (0.2% of all approvals in 2011 and 1.5% in 2014) (special evaluation by the BA).

Applications for the recognition of professional qualifications from third-country nationals are always subject to a case-by-case examination. The aim is to determine whether the training content corresponds to that of German vocational training. If full equivalence cannot be determined due to deviations, a compensatory measure consisting of an adaptation period or a knowledge test is imposed.The recognition statistics show that most recognition applications are still submitted by EU citizens, but that the proportion of third-country nationals is continuously growing, which indicates an increasing globalization of the care labor market. While applications from third-country nationals still accounted for 30.7% of all applications in 2012, in 2013 it was already 32.3%, in 2014 35.8%, in 2015 43.9%, in 2016 56.3% and in 2017 68.9% (special evaluation of the recognition statistics).

Unlike EU citizens, third-country nationals must complete the compensation measures and achieve the required language level within 18 months in order to remain in Germany.

Even if the demand for skilled workers is by no means covered by nursing staff from abroad, the data analysis provides valuable evidence that Germany has become an increasingly important destination country for global labor migration. The following chapter explains how the migration processes are designed and what role labor market intermediaries play in them.

3.3. Design of globalized care labor markets

As shown, globalized care labor markets are characterized by increased mobility of care workers and an increasing commercialization of recruitment. Migration movements are strongly dependent on the socio-economic, political and legislative conditions in both the countries of origin and destination, and can change over time (Wrede 2012).

In the following, we use the example of Germany to illustrate how new destination countries for labor migration of nursing professionals are established and which migration arrangements arise in the process. It turns out that state initiatives play a central role in the globalization of nursing labor markets that have so far been nationally or regionally oriented, as they pave the way for private-sector initiatives.

It is shown how the recruitment of nursing professionals from abroad was organized by state initiatives in the process of globalization of regional/local nursing labor markets (see Chapter 3.1.), but how a commercialization quickly took place in the placement of workers (see Chapter 3.2.). The conceptual understanding of the preparation of nursing professionals for their future professional activities as the “production of marketable objects and subjects” (see Chapter 3.3.) makes it easier to classify the company integration processes based on this (see the articles by Kontos et al. and Rand et al. in this volume).

3.3.1. State initiation and support of recruitment strategies in the care sector

In the context of a continuous change in migration control (cf. on this in general Hess and Kasparek 2010, Heimeshoff et al. 2014 and Hess et al. 2017), Germany has gradually adapted the regulatory framework for immigration to the labor requirements of the economy, especially since 2005, and has also introduced facilitations for the “bottleneck occupations” in health, In the case of nursing professionals in particular, it can be shown that the role of the state is not limited to creating a regulatory framework, but also includes targeted measures to prepare and support specific recruitment initiatives. Such state-controlled recruitment initiatives were intended to establish Germany as a destination country in globalized labor markets for nursing care. In addition, the aim was to show companies ways of securing their supply of skilled workers through recruitment.

One of the first federal initiatives to support the recruitment of skilled workers was MobiPro-EU (Bundesagentur für Arbeit 2013). Young people aged between 18 and 35 who were registered as unemployed in an EU member state and wanted to take up a qualified job in a shortage occupation in Germany qualified for the program.

The program was open to both state and private-sector project sponsors, and the costs for language courses, removals and recognition procedures in regulated shortage occupations were covered for participants and project sponsors respectively. In 2013, the program helped 282 nurses find employment in Germany; in 2014, that number rose to 436 (information from the ZAV press office on April 30, 2015).

In 2012, the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) launched the TripleWin program for recruiting nursing professionals from third countries. The program focuses exclusively on countries of origin with which Germany has a bilateral recruitment agreement (e.g. the Philippines, Bosnia-Herzegovina and Serbia). This links the recruitment of skilled workers for the German labor market with development policy. Other nationwide initiatives recruit nursing professionals from China for inpatient geriatric care facilities (the German Employers’ Association for Nursing Care in cooperation with the ZAV, since 2013) or train already qualified nursing professionals from Vietnam according to German training standards to become certified geriatric nurses (BMWi together with GIZ, since 2013).

In all these initiatives and pilot projects by state actors, the numbers of nursing professionals recruited for the German labor market are small compared to the labor demand. However, the main achievement of the state programs was to prepare the placement of Germany as a destination country for nursing professionals in the initial phase of recruitment. Countries were selected for recruitment initiatives where youth or nursing unemployment was high (e.g. Greece or Spain, which were particularly hard hit by the socio-economic crisis) or which already had a long history of nursing migration (e.g. the Philippines).

In tapping into the perceived or presumed supply of workers abroad, the main service provided by the government agencies in their recruitment initiatives is that they:

• match the demand for skilled workers in Germany with the supply of skilled workers in other EU countries along the principle of EU labor mobility (e.g. ZAV organizes job fairs in other EU countries together with EURES),
• systematically address the formal and organizational aspects of the recruitment process from third countries, which are often seen as major hurdles by employers, and make them accessible to various stakeholders (e.g. checklists for recruitment, language and technical preparation in the country of origin, applying for a residence permit and labor market admission in Germany, cf. Peters et al. 2016),
• create platforms in the projects on which cross-institutional agreements can be made between institutions.

While the agreements to recruit miners and nurses from the Republic of Korea in the 1960s and 1970s were still aimed at preventing the emergence of private-sector businesses (e.g. offering placement services) in the recruitment process (Hartmann 2016: 129), the current initiatives are characterized by private-sector actors are deliberately involved. To shape and stabilize the recruitment process in a way that allows nursing professionals to prepare for deployment in Germany over a period of several months, transnational alliances are being established or existing networks are being used (cf. Coe et al. 2007, Faulconbridge 2008, Sporton 2013).

Despite the long-term perspective of establishing the recruitment of nursing professionals as a strategy for securing the supply of skilled workers, the state’s participation was not planned on a permanent basis, as was the case in the other pilot projects. The aim of most initiatives was thus not the long-term and large-scale continuation of state efforts to secure the supply of skilled workers, but rather the independent securing of skilled workers’ needs by market players.

3.3.2 Private sector organization of recruitment of care workers through labor market intermediaries

Recruitment, immigration and placement of care workers in Germany is increasingly market-based. This market-orientation is framed by state regulations and initiated by state (pilot) initiatives, in order to be continued and intensified by both care facilities and labor market intermediaries. The care facilities see this as an opportunity to cover their own demand for skilled workers, while the labor market intermediaries, encouraged by the forecasts of the future development of the shortage of skilled workers in care, have the goal of developing and serving a profitable business field in the long term by recruiting care professionals from abroad.

Marketization can be understood as a process of “designing, implementing and reproducing specific socio-technical arrangements that perform a calculated and monetized exchange of goods and services” (Berndt 2015: 4 f.). In the area of the commercialization of the placement of nursing professionals, such recruitment arrangements, consisting of the regulative framework, administrative responsibilities and networks of various actors, have been tested in exemplary fashion in state initiatives. A broader circle of private-sector actors was then able to orient themselves on the experiences gathered here. These include both care institutions – hospitals, nursing homes and outpatient care services – and, in particular, private labor market intermediaries, such as temporary employment and recruitment agencies.

Around 2012, these discovered the recruitment of nursing professionals from abroad as a new and promising business area and expanded their range of services accordingly. This was encouraged by the fact that most employers abandoned their own recruitment activities after the first attempts and outsourced the recruitment to private or quasi-private (e.g. GIZ) actors. In addition, there were cases in which care institutions developed a business model around the recruitment of skilled workers, blurring the lines between the roles of service provider and labor market intermediary.

Geographically, the placement activities of most labor market intermediaries are limited, according to their own statements, to EU member states whose citizens can benefit from the automatic recognition of their nursing training and freedom of movement. There are also fewer bureaucratic hurdles and thus the placement tasks are less complex.

As Benner (2003: 622) shows, labor market intermediaries establish themselves in regional labor markets as actors because they reduce the transaction costs of recruiting skilled workers abroad for employers, manage the risks involved in the recruitment process, and build networks to support recruitment activities. Following on from this finding, it can also be stated for the German labor market for nursing professionals that labor market intermediaries ensure the continuous adaptation of regional labor markets to changing conditions.

As this project shows, the transaction costs arising from low transparency of the framework conditions in the recruitment process are considerable – for both employers and nursing professionals. Since labour market intermediaries mainly work on behalf of employers, their contribution to reducing transaction costs includes, for example, selecting suitable employees, recognizing their qualifications acquired abroad, teaching additional skills (e.g. language skills) and organizing the migration process.

As Coe et al. (2007), Faulconbridge (2008) and Beaverstock et al. (2010) have shown, most recruitment arrangements are stabilized by networks of various actors. In the public recruitment initiatives, the relevant networks are those that include public actors in Germany and their counterparts in the country of origin. By contrast, networks that arise in private sector recruitment models are much more heterogeneous.

Particularly in the country of origin, where the activation, selection and initial preparation of the nursing professionals takes place, actors are involved whose primary role is not in the narrower field of labor recruitment:

• Universities in the country of origin are recruited to design the professional preparation of the nursing professionals with a view to later migration or to identify people who would be willing to migrate to Germany. For example, meineagentur24 has held several meetings with the Ministry of Education and the Cabinet of Ministers in Egypt. The willingness of Egyptian universities to integrate the German nursing curriculum into the Egyptian curriculum together with our company is very strong.
• Our language schools in the countries of origin (Egypt, Tunisia, Morocco, India, Pakistan, Zambia,..) are involved in recruitment activities by participating in the selection of nursing professionals or in the conclusion of contracts. Teachers also act as “culture brokers” (Bludau 2015: 96 f., Moroşanu 2016: 359 ff.) by giving nurses recommendations during language courses on how they should behave in professional contexts and in everyday situations in Germany. At the same time, they take on the function of monitoring learning success on behalf of the labor market intermediaries, depending on the personal situation of the course participants. This strategy is used in particular by meineagentur24, which is on the ground and can build a particularly close relationship of trust with the nursing professionals.
• Future colleagues of the nursing professionals who have a migration background from the same country are tasked with acting as “cultural ambassadors” or “professional ambassadors” for living and working in Germany, participating in the selection and preparation of nursing professionals, or helping them to settle in after their arrival.
• Training providers in Germany work as experts in nursing training or as providers of adaptation courses or post-qualifications in recruitment arrangements that provide for the original (second) training of nursing professionals according to German standards.
• We are a support team for foreign nursing professionals during the adaptation process and after receiving the professional license. In order to not only present cultural aspects, customs and traditions, but also to give the foreign nursing professionals the opportunity to experience them for themselves, we ensure that they can participate in various events, such as weddings, stag and hen nights, funerals, baptisms, birthdays, youth inaugurations and school starts.

In the context of the globalization of labor markets and the associated commercialization of employment services, private labor market intermediaries have been able to position themselves as central actors in recruitment arrangements. Because they shape the preparation of nursing professionals to work in Germany over a longer period of time, their retention strategies have an impact beyond the narrower recruitment process. This has a direct impact on the success or failure of subsequent workplace integration and thus fundamentally shapes immigration as a strategy for securing skilled workers, as the next section will show.

3.3.3. Marketization process as a starting point for workplace integration

As already indicated, the process of in-company integration is framed by the market-based organization of labour supply processes. This chapter therefore turns to a more detailed analysis of this process

and shows what effects this has on in-company operations. In order to classify these processes, theoretical approaches that deal with marketization and subjectivization processes are particularly helpful.

Callon/Muniesa (2005: 1232 ff.) and Çalışkan/Callon (2010: 5) show how marketization, as the “creation of a market” (here, the market stands for the placement of nursing professionals), requires the successful implementation of very specific framing processes. They identify objectification as one of the essential elements of this framing: it is objectification that makes goods comparable and tradable in the first place, and thus suitable for market transactions. Applied to the “good nursing professional” and the market-based organization of the recruitment and placement of nursing professionals from abroad, all measures that prepare nursing professionals for the subsequent German labor market can be understood as objectification, because only they make professionals “tradable” in globalized labor markets.

In globalized labor markets, processes of objectification can be seen in the fact that foreign nursing professionals are prepared for access to state-regulated nursing professions in their country of origin by means of a set of different measures and in line with the legal framework of the destination country. In only the rarest of cases are the specific nursing qualifications of the nursing professionals adapted in the process. Labor market intermediaries primarily focus on language skills, since only these enable admission as a nursing professional in Germany. In particular, nursing professionals from EU countries have their nursing qualifications automatically recognized. Thus, the level of German proficiency achieved and the time required to acquire it ultimately determine the market value of the professionals. Interviews with labor market intermediaries show that future employers, on the other hand, assess the importance of language skills quite differently:

In this respect, German language skills play an ambivalent role in the area of tension between the commodified placement of workers and their integration into companies. On the one hand, they represent an objective criterion in the recruitment process, along which the admission of recruited nursing professionals to the profession is decided – thus, language acquisition decisively shapes the recruitment and placement process. On the other hand, the empirical studies (see the articles by Kontos et al. and Rand et al. in this volume) show that in the work process, the formal criteria for assessing language skills may lose their effect: superiors and colleagues emphasize that the German language skills of newly immigrated nursing professionals are initially insufficient to perform more demanding tasks. With regard to the

framing of the company’s activities through the objectification of the nursing professionals in the sense of making them marketable and preparing them for their future profession, the market-oriented placement process proves to be

crucial to the success or failure of their integration into the company.

Furthermore, objectification involves the nursing professionals disengaging from their social relationships in their country of origin (cf. Çalışkan/Callon 2010: 5 f.). The aim of this is to ensure that the nursing professionals focus on the preparation process.

Even in the case of nursing professionals who do not yet have a family of their own, the function of separating them from the direct influence of their family of origin (e.g. by moving language courses to a distant city) is to bind them to the preparation process. In this way, loyalty to the labor market intermediary and the future employer is to be created among the recruited nursing professionals, which initially increases the calculability of the placement process. This should also be supported by contractual obligations.

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Notes:

For better readability, the masculine form is often used in the text. This always refers to both the feminine and the masculine form.