Global labour market

Global labour market

The development of a globalised labour market in nursing in Germany

Migration and the development of a globalised nursing labour market

To date the nursing labour market in Germany has had a comparatively low level of immigration by international and European standards: While the share of qualified nurses trained abroad in 2013 was 24.5 % (New Zealand), 16.5 % (Australia) and 7.5 % (Canada), and Switzerland and Great Britain led in this respect in European comparison (Switzerland in 2012 with 18.7 % and Great Britain in 2014 with 12.7 %), in 2010 only 5.8 % of qualified nurses in Germany had completed training abroad (OECD 2015: 118). This is connected in part with the fact that from 2004, after each round of EU enlargement, Germany initially made use of the option to suspend freedom of movement for workers and for longer refrained from state-coordinated and supported recruitment activities in nursing. At present, however, the nursing sector is increasingly under pressure to act to supplement previous strategies for securing skilled workers with recruitment from abroad.

In the scholarly debate, increasing migration of qualified nurses is explained by the fact that:

• neoliberal economic reforms have led to structural changes in the health systems of destination and origin countries and to a globalisation of nursing labour markets, and that qualified nurses moreover locate their own professional and specialist development increasingly in a global context,
• a redesign of the political-legal steering of migration and thus a change in labour migration regimes in the destination countries has taken place, and
• international labour placement is more frequently shaped by professional service providers, labour market intermediaries.

Globalisation of labour markets in nursing

Worldwide migration of nurses has a long history, but has been fundamentally expanded by ongoing primary changes in both destination and origin countries. Particularly in the USA, Canada and Great Britain, recruitment of nursing staff from abroad has for some time been a means of offsetting the shortage of skilled workers (Prescott/Nichter 2014, Britain/Henry 2013). These can recur over a certain period, as interest in talented nurses increases, which at present cannot be controlled through expanded training or other political placements – or they can have deeper causes. The latter option can be expressed for some countries of the global North.

They initially began by raising the productivity of offices, but frequently had the consequence that working conditions and pay for nursing staff crumbled and employer stability declined. As a result nursing professions lost attractiveness, and because numerous Western nations had long underfunded their nursing training (Wrede 2012, Taylor et al. 2012, Yeates 2010), no replacement could be found for some who left. The underlying irregularities still exist today, and in the countries affected there are ever more efforts to offset them through recruitment from abroad.

In many countries of origin of nursing staff as well, the framework conditions of healthcare have since the 1980s and 1990s been changed in several waves along neoliberal models. Triggers for the changes were frequently political and financial emergencies or a possible need to modernise the health system. The changes were frequently supported or driven by global organisations such as the World Bank or the World Health Organization (Chorev 2013, Naval force et al. 2001).

Privatisation of medical care and replacement of comprehensive health techniques by specific and reliable interventions in order to increase the benefit of the health economy (Abramovitz/Zelnick 2010). Although the changes had different types and extents depending on the country (e.g. Fleet et al. 2001, Huber/Solt 2004 for South America), there were general patterns towards wage cuts, hiring freezes and dismissals in healthcare. These increasingly contributed to emigration and are broadly held responsible for the intensified emigration of nursing staff (Aiken et al. 2004, Abramovitz/Zelnick 2010). These advances are not limited only to the countries of the global South or the European margins in the East, but also include other countries.

It is expressed that the geological direction of migration of qualified nurses frequently relates to generally developed connections between nations. The roots frequently go back to the hour of colonialism and imperialism (Choy 2003, Wrede 2012, Ball 2004, Yeates 2009, Bludau 2011, Britain/Henry 2013, Britain 2015, Reddy 201,5, Lutz/Palenga-Möllenbeck 2012) – Germany is a special case that also makes the later start of immigration make sense. In certain countries of origin, actual “production industries for nurses” have emerged (Prescott/Nichter 2014, for India and the Philippines see Yeates 2009, Choy 2003, Reddy 2015), particularly in the Anglo-Saxon countries USA, Canada, New Zealand, Australia and Great Britain (OECD 215). Such generally developed connections and shared conditions are frequently entirely stable and of long duration (Yeates 2010). Incidentally the situation with the country of origin or destination can change at short notice (Wrede 2012, Aiken et al. 2004), e.g. when financial cuts due to financial emergencies lead to cuts in the health framework (Dussault/Buchan 2014: 49).

Nursing experts in the countries of origin likewise react quickly to the changed framework conditions for labour migration in the destination countries, e.g. state recruitment agreements or new open doors for the recognition of expert skills (Yeates 2010). This should for example be possible for the Philippines. When it became more difficult at short notice for Filipino nurses to obtain a work visa due to changed immigration policy in the USA, they set out under the same conditions for Singapore and Saudi Arabia (Arends-Kuenning et al. 2015).

On the other hand this means that countries in which there is a shortage of skilled workers regard qualified nurses in other countries as an advantage for recruiting their skilled workers, which they can use for themselves by changing the legal system of labour migration (Glinos 2015).

The “global care chains” (Ates 2009) have recently become markedly more heterogeneous and have expanded (Yeates 2005, 2010). The consequences of emigration for one’s own health framework conditions and the pattern of offsetting this through migration from other nations are frequently lamented (e.g. Jamaica compensates for the emigration of domestic nurses by recruiting further ones from nations such as Burma, Cuba, Ghana, India and the Russian League (Yeates 2010). Recently there have been political efforts to contain these negative consequences, particularly in the poorest countries (al. 2014), which among other things exclude certain countries from recruitment programmes.

The way in which nurses offer their labour on globalised labour markets is not attributable only to the immediate need to find employment. A trigger for migration can also be the longing for professional advancement, further training opportunities and a better working and everyday environment (Yeates 2010, Kingma 2007, Aiken et al. 2004, Glinos et al. 2015). Mirelle Kingma (2007) reports that nurses use professional stations in various countries to acquire skills or qualifications. Moreover, in most cases migration is not a permanent decision for nurses, but represents a further professional station in global career planning (Glinos et al. 2015).

Changes in the political and legitimate control of migration

Migration of qualified nurses takes place within a general migration regime. In most nation states, residence rights and access to the national labour market are handled very restrictively. More recently, in many countries of the global North a change in political steering can moreover be observed, whereby migration is increasingly regulated according to the principle of economic benefit. Accordingly these states change their legal framework conditions in order – with overall increasing closure – to facilitate entry into the labour market for “desired” target groups (e.g. Bach 2007 for the change in the statutory framework conditions for migration of qualified nurses to Great Britain). In principle two models exist for such regulation of labour migration (Kolb 2014):

• supply-oriented steering of migration via instruments with which destination countries set general criteria for access to their labour market (cf. Hinte et al. 2015 for the points systems in Canada and Australia),
• labour-demand-driven shaping of (also temporary) migration via indicators intended to reflect labour needs on the labour market (cf. Groutsis et al. 2015).

While points systems rather aim at general “potentials” of immigrants (e.g. age, qualification level), labour-demand-oriented shaping tries to steer immigration in a fine-grained way along the needs of the economy (van den Broek et al. 2016) and thereby to increase the efficiency of one’s own labour markets (Overbeek 2002, Castles 2011). This is intended to offset labour shortages in various sectors and at different qualification levels and to ensure that companies can respond flexibly to fluctuations in labour demand (Sporton 2013, Batnitzky/McDowell 2013).

This allows countries that stand further up in the care-chain hierarchy to define qualified nurses in various countries of origin as a labour resource and to try to use them for their own securing of skilled workers.

In Germany the liberalisation of labour markets took place later than in other countries of the global North (Coe et al. 2007); many elements of labour market or migration policy that enable connection to globalised labour markets were introduced late compared with other countries. Nevertheless the verdict of various observers is that since about 2000 – parallel to a general shift from problem-oriented to potential-oriented integration policy (Pütz/Rodatz 2013) – Germany has been undergoing a shift towards labour-market-oriented migration policy (Kannankulam 2013, Buckel 2012). Thus the closure-oriented orientation that dominated in the 1990s was gradually supplemented by the paradigm of “migration management” (Ratfisch 2015: 7, Georgi 2007: 5).

This includes comprehensive and differentiated steering 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 educational and professional qualification were gradually introduced into the regulation of migration and immigration opportunities for the highly qualified were expanded (Ette et al. 2012).

In the tradition of the Green Card, which was designed for IT skilled workers and is regarded as the beginning of the fundamental change in German labour migration policy, the stronger opening of the German labour market through the immigration and residence laws of 2005 created opportunities above all for the highly qualified (Ette et al. 2012, Kolb 2014). Only later did vocational training occupations, to which the nursing professions belong, also come into the focus of public shortage-of-skilled-workers discourses. Thus in 2011 the Federal Government’s concept for securing skilled workers recorded that in bottleneck occupations qualified immigration is to be regarded as an important strategy for securing skilled workers (Bundesministerium für Arbeit und Soziales 2011). The “Act to Improve the Assessment and Recognition of Professional Qualifications Acquired Abroad” (Recognition Act) applicable from 1 April 2012 moreover enabled a legal entitlement to the assessment of professional qualifications acquired in third countries and introduced the possibility of making use of compensatory measures where equivalence is lacking. It applies to the approximately 600 occupations regulated under federal law, including those of health and nursing care worker, health and paediatric nursing care worker and geriatric nurse.

Change in transnational migration arrangements through labour market intermediaries

Although the legal framework determines who has access to the destination country’s labour market under which conditions, the application of these foundations in practice is very complex (Weiß 2010: 123) and there are hurdles whose overcoming requires both material (e.g. financial means) and immaterial resources (e.g. contacts, knowledge), on the part of both migrants and employers interested in immigration (Bludau 2011: 99, Csedő 2008). Employers in particular therefore increasingly frequently delegate the more complex global search for skilled workers to mostly private service providers, so-called labour market intermediaries (Benner 2002, 2003, Schwiter et al. 2014). These try, with the help of various mechanisms, to “dock” workers ready to migrate onto the qualification and labour market regimes of the arrival countries (Groutsis et al. 2015, van den Broek et al. 2016) and thereby decisively shape the processes on globalised labour markets.

Labour market intermediaries are first of all organisations that have the matching of labour demand and supply as a business model (Katzis 1998, Benner 2002, Autor 2009). Classically these are for example temporary employment agencies and labour placement agencies (Bonet et al. 2013), here a named example our company CareLend GmbH.

Research that deals with the role of labour market intermediaries in migration processes points to the diversity of their forms of appearance and activities (Sporton 2013, Findlay et al. 2013, Beaverstock et al. 2010, Faulconbridge et al. 2008). Because of the ever more complex legal regulation of migration (with numerous special provisions by sector or country of origin) they have succeeded in establishing themselves as a fixed component of migration arrangements (Bludau 2010): They can connect the labour markets in origin and destination countries with one another by equipping migrants with required qualifications and competences and supplying them with information about the labour market and the living environment in the host country (Groutsis et al. 2015, Coe et al. 2010, Sporton 2013). At the same time they build relationships with employers in order to understand their wishes regarding workers and to be able to take them into account in the placement process (Bludau 2010).

The described processes of a stronger economic-policy orientation of migration policy and shifting the shaping of migration movements to private intermediaries can from a sociological perspective and drawing on marketization studies be regarded as an example of “marketisation” of essential social fields, in this case the field of placement of qualified nurses. Labour market intermediaries occupy a key position therein, since they – in the terminology of Çalışkan/Callon (2010: 8) (cf. also Callon/Muniesa 2005, Ouma 2015) – are decisively involved in the construction of workers as products as well as in determining their market value and thereby contribute to establishing a market for the placement of qualified nurses. “Marketisation” in this connection also means that qualified nurses are “prepared” along the requirements for labour market and professional access and according to the needs of employers so that they can be placed as “finished” workers on the labour market. For this purpose not only the “objectification” of qualified nurses in the sense of the production of marketable workers (cf. Callon/Muniesa 2005) takes place, but also “subjectification” as the process of becoming a migrant in the context of the global labour market, which is accompanied by the emergence of a specific consciousness on the part of potential migrants. Thus Heidi Bludau (2010, 2011) describes how qualified nurses are already encouraged in the countries of origin to imagine themselves in the new living and working context and to adopt the attitude expected by the employer.

Workplace integration is thereby pre-structured to a considerable degree. For objectification and subjectification in the recruitment process are often taken on by various labour market intermediaries who act as “culture brokers” (Bludau 2015: 96 f., Moroşanu 2016: 359 ff.). In this role they are positioned during the migration process (and in some cases also afterwards) between the workers and the employer and take on the communication of values or ideas between the two (Bludau 2015). They thereby influence both preparations for migration processes and social and workplace integration after migration.

Career opportunities for nurses

The findings of previous research show that nursing labour markets are increasingly globalising. Employers define qualified nurses in other countries as a resource for their own securing of skilled workers, and qualified nurses locate their career opportunities increasingly internationally. This development is supported in the destination countries by labour-market-oriented legal regulation that, with increased demand, tries to open access to the domestic nursing labour market for ever new target groups from abroad. Through the requirements for the professional qualifications of qualified nurses in the destination countries, however, their migration remains conditional. As a result complex migration arrangements arise in which the qualified nurses are prepared for their deployment in the destination country and are held in the recruitment process through various mechanisms.

For their workplace integration in Germany the following framework conditions arise from this:

• Increasing mobility of workforces: The global labour markets offer qualified nurses diverse opportunities to earn their living in another country and to shape their professional development. Because destination countries stand in global competition with one another for qualified nurses, retention of skilled workers takes on particular importance.
• Increasing complexity of migration arrangements: Despite the globalisation of nursing labour markets, considerable hurdles remain for qualified nurses (depending on their country of origin) in accessing the labour market in the destination country, and the transferability of their qualifications and competences also remains conditional. Preparing qualified nurses for their deployment in Germany remains left in the recruitment process to various labour market intermediaries who shape the expectations of employers and qualified nurses and who later form the background for workplace integration.
• Increasing heterogeneity of workforces: There are considerable differences in the training of qualified nurses, which is aligned with the occupational profile in the respective national health and social system. In addition qualified nurses bring experience with different organisational and professional hierarchies in their countries of origin. This means that in the facilities
• different professional self-understandings meet that can become the subject of conflicts.

Recruiting skilled workers on globalised labour markets in nursing, e.g. in Germany

As emerges from internationally comparative statistics, Germany is still far from counting as an established destination country of globalised qualified nurse migration. Nevertheless there has in recent years been a clear increase in the migration of qualified nurses to Germany. Below it is shown how labour market access at the level of immigration and recognition of qualifications acquired abroad is regulated for the health and nursing sector and what differences exist between the origin categories “EU member state” and “third country”.

Immigration of nurses from the EU

The rethink regarding qualified immigration as a strategy for securing skilled workers also with regard to the nursing sector fell into the period in which the economic crisis in Southern Europe unfolded its full effect. This triggered considerable cuts in the health systems of Spain, Portugal and Greece and led to wage cuts, dismissals or hiring freezes (Glinos et al. 2015, OECD 2015).

The cuts hit young qualified nurses particularly hard who had just completed their studies or had not yet sufficiently established themselves professionally. They were thus more ready to orient themselves professionally abroad and thereby stood in the focus of the recruitment activities of German organisations.

The recruitment of Southern Europeans for the nursing labour market in Germany took place via state programmes (e.g. MobiPro-EU of the Zentrale Auslands- und Fachvermittlung (ZAV) of the Bundesagentur für Arbeit (Federal Employment Agency)) or through commercial providers (Zentrale Arbeitsvermittlungsstelle 2014, Bundesagentur für Arbeit 2013). Entry into the labour market of the qualified nurses in Germany was facilitated by the legal framework conditions intended to support labour mobility in the EU: As EU citizens they had residence rights in Germany and according to the EU Free Movement Directive received free access to the German labour market. In addition the EU Professional Qualifications Directive (The European Parliament and the Council of the European Union 2005), which entered into force on 20 October 2005, secured the equivalence of training content in the regulated professions such as doctor, dentist and qualified nurse. Thus recognition of the qualifications of all EU citizens as well as for nationals of the European Economic Area and Switzerland took place already several years before the adoption of the Recognition Act. In addition to recognition of professional qualifications, for admission to practise as a qualified nurse knowledge of the German language at B1 or B2 level of the Common European Framework of Reference must be demonstrated.

Because the principle of free movement applies for EU citizens, no data are available for migration from the EU states to Germany. How many persons from the southern EU states came from their home countries to Germany as a result of the economic crisis can only be estimated approximately on the basis of the recognition statistics.

The statistics show an increase in recognition procedures opened for educational certificates from all four Southern European countries between 2012 and 2015, with by far the most applications submitted by qualified nurses who had completed their training in Spain. Spain stands for a Western European country whose health system was severely hit by the financial crisis (OECD 2015) and so the number of recognition procedures sought for qualifications from Spain between 2012–2014 increased 4.5-fold.

Number of recognition procedures by country of training in the occupation of health and nursing care worker from Southern Europe, 2012–2017.

In 2015, however, the number of nursing care workers who wanted to have their qualifications acquired in Spain recognised fell threefold and in 2016 only 105 Spanish qualified nurses applied for recognition of their professional qualifications. In 2017 it was only 72 persons.

Number of work permits for Romanian and Bulgarian nationals in the occupations of health and nursing care as well as geriatric care in Germany, 2011–2013.

Alongside migration from the Southern European countries affected by the economic crisis, since the 1990s many qualified nurses from the countries of East-Central Europe as well as South-Eastern Europe have come to Germany. These migration movements were promoted by the transformation-related political and economic developments. For the more recent migration from the new EU accession countries Romania, Bulgaria (2012) and Croatia (2013) statistics are available only for the transitional period in which Germany had not yet opened its labour market to these countries.

Regarding recognitions from the newer EU accession countries it must be noted that the principle of automatic recognition of professional qualifications under the EU Professional Qualifications Directive applies to professional qualifications acquired since EU accession. Thus the requirements for recognition of professional qualifications from abroad for nationals of the new accession states can turn out somewhat higher because they may be subject to compensatory measures such as aptitude tests or adaptation courses.

The number of recognition procedures sought in the occupation of health and nursing care worker provides first indications that labour migration of qualified nurses from the EU states to Germany has increased considerably in recent years.

The strongly increased number of applications from Bosnia and Herzegovina in 2014 is to be explained by the recruitment agreement concluded that year. Since then a clear increase in applications has been observed every year. Whereas until 2014 Bosnia and Herzegovina was the only third country among the five most frequent countries of training, in 2015 Serbia, in 2016 the Philippines and in 2017 Albania rose into this group.

In the next section the migration of qualified nurses from third countries is examined more closely.

Immigration of nurses from third countries

Migration of qualified nurses from third countries is regulated markedly more strongly than that of EU citizens – it is subject to limitations at the level of entry and residence. At the same time there are facilitations that have been introduced because of the shortage of skilled workers in the nursing sector. Via § 18 of the Employment Ordinance of 1 July 2013, qualified nurses from third countries receive simplified access to the German labour market if:

• they can present at least two years of vocational training that is equivalent to the German professional qualification,
• their employment conditions correspond to those of domestic qualified nurses,
• the vacancy to be filled is published in the job exchange of the Bundesagentur für Arbeit (BA) (Federal Employment Agency) or the person concerned was placed by the BA for Employment on the basis of an arrangement with the labour administration of the country of origin.

The latter arrangements have existed since 2013 with Bosnia and Herzegovina, Serbia and the Philippines. In addition, pursuant to § 6 Abs. 2 Satz 1 Nr. 2 of the Employment Ordinance it is required that the occupation stands on the BA’s positive list. This is drawn up half-yearly on the basis of the skilled worker shortage analysis and lists occupations in which there is a shortage of skilled workers and thus filling the posts with foreign applicants is regarded as “labour-market and integration-policy responsible” (Bundesagentur für Arbeit 2016: 19).

Approvals for third-country nationals by selected occupational activities (KldB 2010) in Germany, 2011–2014

The steering of labour migration via the BA’s positive list reflects the high priority of matching in German labour market policy – the endeavour to align labour supply and demand optimally with one another. In the current BA list, among others the occupations in geriatric care, health and nursing care as well as specialised nursing care are listed.

A further restriction of labour market access is experienced by third-country nationals whose country of origin stands on the list of WHO countries from which no qualified nurses are to be recruited. In this case only the BA may recruit or place the skilled workers (Angenendt et al. 2014).

Moreover the share of qualified nurses among all approvals granted to third-country nationals rises continuously. Whereas in 2011 still 0.4 % of all approvals for third-country nationals were granted for the occupations of health and nursing care, in 2014 it was already 2.7 %. A similar tendency is to be recorded for occupations in geriatric care, albeit at a lower level (0.2 % of all approvals in 2011 and 1.5 % in 2014) (special evaluation by the BA).

In the recognition of professional qualifications, applications by third-country nationals are always subject to an individual case assessment. This is to establish whether the training content corresponds to German skilled worker training. If full equivalence cannot be established because of deviations, a compensatory measure is imposed consisting of an adaptation course or a knowledge examination. The recognition statistics show that most recognition applications are still submitted by EU citizens, but that the share of third-country nationals is growing continuously, which points to increasing globalisation of the nursing labour market. Whereas applications by third-country nationals in 2012 still made up 30.7 % of all applications, in 2013 it was already 32.3 %, 2014 35.8 %, 2015 43.9 %, 2016 56.3 % and 2017 68.9 % (special evaluation of the recognition statistics).

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

Even if skilled worker needs are by no means covered by qualified nurses from abroad, the data analysis provides valuable indications that Germany has gained strongly in importance as a destination country of global labour migration. How the migration processes are designed and what role labour market intermediaries play therein is explained in the following chapter.

State initiation and support of exhibition strategies in the nursing sector

In the course of a continuous change in migration control (cf. generally on this Hess and Kasparek 2010, Heimeshoff et al. 2014 and Hess et al. 2017), Germany has especially since 2005 gradually adapted the regulatory framework for immigration to the labour needs of the economy and in doing so has also introduced facilitations for the “bottleneck occupations” of health, nursing and geriatric care. Precisely using the example of qualified nurses it can be demonstrated that the role of the state is not limited only to creating a regulatory framework, but also includes targeted measures to prepare and support concrete recruitment initiatives. Such state-steered recruitment initiatives were intended to establish Germany as a destination country on globalised nursing labour markets. In addition, pathways for securing skilled workers via recruitment are to be shown and opened to enterprises.

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

The programme was open to both state and private-sector project sponsors and within its framework the costs of language courses, moves and recognition procedures in regulated bottleneck occupations were covered for participants or project sponsors. Whereas the programme in 2013 helped 282 qualified nurses into employment in Germany, in 2014 it was already 436 qualified nurses (information from the ZAV press office on 30 April 2015).

For the recruitment of qualified nurses from third countries the Gesellschaft für Internationale Zusammenarbeit (GIZ) launched the TripleWin programme in 2012, which concentrates exclusively on countries of origin with which Germany has a bilateral recruitment agreement (e.g. Philippines, Bosnia and Herzegovina, Serbia). Recruitment of skilled workers for the German labour market is thus linked with development policy. Further nationwide initiatives recruit qualified nurses from China for inpatient geriatric care facilities (Arbeitgeberverband Pflege in cooperation with the ZAV, since 2013) or train already qualified nurses from Vietnam to German training standards as examined geriatric nurses (BMWi together with the GIZ, since 2013).

In all these exemplarily described initiatives and pilot projects of state actors, the numbers of qualified nurses gained for the German nursing labour market are small compared with labour needs. The essential achievement of the state programmes, however, consisted in preparing in the initial phase of recruitment the placement of Germany as a destination country for qualified nurses. For the recruitment initiatives countries were selected in which unemployment among young people or among qualified nurses was high (e.g. Greece or Spain, which were particularly severely affected by the socio-economic crisis) or which already had a long history of qualified nurse migration (e.g. the Philippines).

In tapping the perceived or presumed labour supplies abroad, the main achievement of the state bodies in the recruitment initiatives consists in that they:

• bring together skilled worker needs in Germany with skilled worker supplies in the EU abroad along the principle of EU labour mobility (e.g. the ZAV organises job fairs abroad in the EU jointly with EURES),
• systematically work through the formal and organisational aspects in the recruitment process from third countries, which employers often regard as major hurdles, and make them accessible to various actors (e.g. checklists for recruitment, linguistic and specialist preparation in the country of origin, applying for the residence permit and labour market admission in Germany, cf. Peters et al. 2016),
• create platforms in the projects on which cross-facility arrangements between facilities are made.

Whereas in the 1960s and 1970s the agreements on recruiting miners and nurses from the Republic of Korea still aimed to prevent the emergence of private-sector business (e.g. offering placement services) in the recruitment process (Hartmann 2016: 129), present initiatives are characterised by private-sector actors being deliberately included. For the arrangements that are to shape and thus stabilise the recruitment process so that qualified nurses prepare over several months for deployment in Germany, transnational alliances are built or already existing networks are used (cf. Coe et al. 2007, Faulconbridge 2008, Sporton 2013).

Despite the long-term perspective of establishing recruitment of qualified nurses as a strategy for securing skilled workers, involvement by the state – similar to the other pilot projects – was not planned permanently. The goal of most initiatives was thus not the long-term and large-scale perpetuation of state efforts in securing skilled workers, but the independent securing of skilled worker needs by market actors.

Recruitment of qualified nurses coordinated by the private sector through labour market intermediaries

Recruitment, immigration and placement of qualified nurses to Germany are increasingly taking place in a market form. This marketisation is framed by state regulations and initiated by state (pilot) initiatives, so that it can then be continued and intensified both by care facilities and by labour market intermediaries. The care facilities see therein the possibility of covering their own skilled worker needs; the labour market intermediaries – stimulated by the forecasts on the future development of the shortage of skilled workers in nursing – have the goal of developing from the placement of qualified nurses from abroad a profitable business field and serving it in the long term.

Marketisation 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 marketisation of labour placement of qualified nurses, such recruitment arrangements, consisting of the regulatory framework, administrative responsibilities and networks of various actors, were tested exemplarily in the state initiatives. A broader circle of private-sector actors could subsequently orient themselves by the experience gathered here. This includes both nursing facilities – hospitals, geriatric care facilities and outpatient care services – and above all private labour market intermediaries, which include temporary employment and labour placement companies.

These around 2012 discovered the recruitment of qualified nurses from abroad as a new and promising business field and expanded their service offering accordingly. This was promoted by the fact that most employers abandoned their own recruitment activities after the first attempts and transferred recruitment to private-sector or quasi-private-sector (e.g. the GIZ) actors. Alongside this there were cases in which care facilities developed an own business field from the recruitment of skilled workers and the roles of service provider and labour market intermediary mixed.

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

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

For as this project shows, in the recruitment process the transaction costs that arise from low transparency of the framework conditions are considerable – both for employers and for qualified nurses. Because the labour market intermediaries mainly act on behalf of employers, their contribution to reducing transaction costs includes e.g. the selection of suitable workers, the recognition of their qualifications acquired abroad, the conveying of additional competences (e.g. language competence) and the organising of the migration process.

As Coe et al. (2007), Faulconbridge (2008) and Beaverstock et al. (2010) have set out, most recruitment arrangements are stabilised through networks of various actors. In the state recruitment initiatives networks are primarily relevant that include state actors in Germany and their counterparts in the country of origin. By contrast, networks that arise in private-sector recruitment models are composed much more heterogeneously.

Especially in the country of origin, where the activation, selection and first preparation of the qualified nurses take place, actors are involved whose primary role does not lie in the narrower field of labour placement:

• Universities in the country of origin are won over to shape the specialist preparation of qualified nurses already with a view to later migration or to identify persons who would be ready to migrate to Germany. For example meineagentur24 has held several meetings in this regard with the Ministry of Education and the Minister Cabinet in Egypt. The readiness of the Egyptian universities is very strong to integrate the German curriculum in nursing into the Egyptian curriculum jointly with our company.
• Our language schools in the country of origin (Egypt, Tunisia, Morocco, India, Pakistan, Zambia, ..)participate in recruitment activities by being involved in the selection of qualified nurses or in concluding the contract. The teachers moreover act as “culture brokers” (Bludau 2015: 96 f., Moroşanu 2016: 359 ff.) by giving the qualified nurses during the language courses recommendations on how they should behave in professional contexts and in everyday situations in Germany. At the same time they take on the function, on behalf of the labour market intermediaries, of monitoring learning success performance depending on the personal situation of the course participants. This strategy is used in particular by meineagentur24, which is itself on site and can build a particularly close relationship of trust with the qualified nurses.
• Future colleagues of the qualified nurses who have a migration background from the same country are commissioned to act as “cultural ambassadors” or as “professional ambassadors” for living and working in Germany, to participate in the selection and preparation of the qualified nurses or to assist them with settling in after arrival.
• Education providers in Germany participate as experts for nursing training or providers of adaptation courses or further qualifications in recruitment arrangements that provide for an original (second) training of qualified nurses to German standards.
• We are a support team for the foreign qualified nurses during the adaptation programme and after receipt of the licence to practise. In order not only to present cultural aspects, customs and practices but moreover to give the foreign qualified nurses the opportunity to experience these themselves, we ensure that they can take part in various events, for example weddings, stag and hen parties, funerals, memorial services, baptisms, birthdays, Jugendweihen as well as school starts.

In the context of the globalisation of labour markets and the accompanying marketisation of labour placement, private labour market intermediaries have been able to place themselves as central actors in recruitment arrangements. Because over a longer period they shape the preparation of qualified nurses for working in Germany, their retention strategies take effect beyond the narrower recruitment process. This has immediate effects on the success or failure of later workplace integration and thereby fundamentally shapes immigration as a strategy for securing skilled workers, as the next section will show.

Promotion of the process as the initial phase of workplace integration

As has already been indicated, the process of workplace integration is framed by the market-form organised labour placement processes. This chapter therefore turns to a more precise analysis of this process and shows what effects on workplace events accompany it. For classifying these processes, theoretical approaches that deal with marketisation and subjectification processes are particularly helpful.

Callon/Muniesa (2005: 1232 ff.) and Çalışkan/Callon (2010: 5) show how marketisation as “creation of a market” (here the market activity stands for the placement of qualified nurses) presupposes the successful implementation of quite specific framing processes. As one of the essential elements of this framing they designate objectification: This first makes goods comparable and tradable and thereby a suitable object for market transactions. Transferred to the “good qualified nurse” and the market-form organisation of recruitment and placement of qualified nurses from abroad, all measures that prepare qualified nurses for the later labour market Germany can be understood as objectification, because only they make the skilled workers “tradable” on globalised labour markets.

Processes of objectification show themselves on globalised labour markets in that foreign qualified nurses are already prepared in the country of origin through a set of different measures and along the specifications of the legal framework of the destination country for access to the state-regulated nursing professions. In the rarest cases are the concrete nursing-specific qualifications of the qualified nurses already adapted thereby. Primarily the labour market intermediaries concentrate on language competences, because only these enable admission as a qualified nurse in Germany. Especially for qualified nurses from EU states, recognition of their nursing qualification takes place automatically. Thus ultimately the level of German language skills achieved as well as the time needed for their acquisition decide the market value of the skilled workers. The interviews with the labour market intermediaries show that future employers by contrast evaluate the importance of language skills quite differently:

In this respect German language skills take on an ambivalent role in the field of tension between marketised labour placement and workplace integration. On the one hand they constitute in the recruitment process an objective criterion along which decisions are made on the professional admission of recruited qualified nurses – thus language acquisition decisively shapes the recruitment and placement process. On the other hand the empirical surveys (cf. the contributions by Kontos et al. and Rand et al. in this volume) show that in the work process the formal criteria for assessing language skills could lose their effect: From the side of superiors and colleagues it is emphasised that the German language skills of newly migrated qualified nurses initially do not suffice to perform more demanding tasks. With regard to the framing of workplace events through processes of objectification of qualified nurses in the sense of making them marketable and preparing them for the later profession, the market-organised placement process proves to be

decisive for the success or failure of workplace integration.

Moreover objectification includes detaching the qualified nurses from their social relationships in the country of origin (cf. Çalışkan/Callon 2010: 5 f.). This has the aim that the qualified nurses focus on the preparation process.

Even for qualified nurses who themselves do not yet have a family, separating them from the direct influence of their family of origin (e.g. by relocating language courses to a distant city) has the function of binding them to the preparation process. In this way loyalty towards the labour market intermediary and the future employer is to arise among the recruited qualified nurses, which initially increases the calculability of the placement process. This is to be additionally supported by contractually recorded obligations.