HealthManagement, Volume 19 - Issue 2, 2019

Nursing on the move: cross border hiring

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Addressing obstacles for successful hiring


How to navigate the multiple challenges involved in making a cross-border nursing hire a success.


People have always moved from their home countries to other countries in order to settle there permanently or for a certain period to work. The reasons for this are manifold.


The main stakeholders are the migrants themselves, the host employers, coordinating agencies as mediators for both sides, but also country initiatives (political objectives and cooperation within framework conditions).


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On the one side, very significant differences in living standards and professional conditions promote migration as well as the ever-increasing shortage of skilled workers and increasing demands in the healthcare sector on the other side.


The European picture

The European Union (EU) currently consists of 28 countries and sees its main task as cooperation in foreign and security policy as well as cultural, environmental and educational policy and a common monetary policy. The values on which the EU is founded, along with respect for human dignity, freedom, democracy, equality and the rule of law, is respect for human rights and binding standards. All these factors play a role in addressing the issue of "Cross Border Hiring of Nurses" in Europe.


Increased labour mobility is explicitly promoted and desired by the EU in order to promote, in addition to a balanced and sustainable economic social and balanced development, the competitive global economy and promote EU political integration. Thus, all EU citizens have the right to work and live in every Member State (European Union 2012). 


Meanwhile, recruitment and mobility within and outside the EU is often the cause of blatant shortages of skilled staff. However, the greater the need, the more important it is to find out in advance about differences and the comparability of "practiced" professional care in the individual European countries, to develop appropriate assessment tools and to develop a suitable integration strategy.


Main considerations

In the following, some preliminary considerations are formulated for the main stakeholders.


  • Which country is suitable and how is the selection process carried out? 
  • Who is the responsible contact on site?
  • How are the transition periods financed and what preparations must be made (language)?


  • From what country and at what intervals do I want to recruit?
  • Maintaining contact and building trust before arrival (Skype, Social Media)
  • What additional service providers (agencies, language schools, etc.) do I need?
  • Contract design, particularly repayment obligations in case of difficulties)
  • How and by whom should the project be carried out (Integration officer, time and cost)?

Future colleagues on the ward:

  • How would the colleagues on the ward be prepared and involved (formation of intercultural competence)?
  • How to design the onboarding (plan, patient safety, reflection, coaching for all sides)

Recruiting agencies:

  • Agencies specialise according to country and field of nursing and have corresponding references
  • What are the fees of the agencies composed of (recruitment, language training in advance, ethical recruitment and commitment agreements with the migrants)?
  • What kind of support for employers and the recruited persons are there after arrival (housing, mentoring, all-inclusive package)?
  • How flexible are the agencies in the event of problems (time shift, language level not reached, below the agreed number of migrants)?

Language schools:

  • Are the specific language schools experienced with training for the healthcare sector?
  • How regular is the feedback on the language development of the participants and the reliability of the completion test?

All in all, it is important to build a mutual relationship of trust between the migrants on the one hand, and those who will be working with them. Often, one's own employees get the impression that there is much support offered for the persons being recruited, but the long-standing employees themselves, in addition to the considerable workload, are now also responsible for the additional training of these employees without themselves having any advantages.


When selecting recruiting agencies and language schools, it is important for the outcome to build a mutual relationship of trust in order to be able to respond quickly, reliably and individually when difficulties arise. Since the placement of personnel for the agencies is highly attractive, there are also many substandard providers. Just because an agency has a lot of experience in supplying medical staff does not mean that they also have expertise in recruiting nursing staff. The market, the environment and approach are completely different.


Regulated professions meet special social requirements. They are bound by legal regulations and entry requirements and specific qualifications. The professional title is protected by law. Nursing is one of the regulated professions, so both the recognition and the management of the professional title is a basic condition for the permission to practice the profession within the EU. Besides the protection vis-à-vis patients and the nursing profession, the regulations also guarantee the quality and transparency for the healthcare providers (Prölss et al 2019).


Recognition procedures

As a common standard, EU Member and Contractual States have agreed on certain minimum requirements. These are set out in Directive 2005/36/EG and in its revision 2013/55/EU. In contrast to other countries (third countries), the professional qualifications acquired in the EU can be automatically recognised within the EU on application, without examining the individual training contents. In addition, a certain language level (usually B2) for the host country must be proven. It should be noted that the professional qualifications in the respective countries are only recognised if the country was already a member of the EU at that time. Further details on professional recognition, in particular, on the effects of Brexit, are currently available on the EU websites (Europa 2019).


In the case of migration from so-called third countries, there is no automatic recognition, but the rule is to check individually per applicant as to the extent qualitatively and quantitatively the qualification fulfils requirements. To the extent that something is missing, the deficit must be made up retrospectively in order to enable an equivalent recognition by the host country. This can extend the recognition procedure due to compulsory assignments and examination requirements.


In the past, the applicant submitted the personal proof of professional qualification obtained in the home country and the language certificate to the respective authority of the "host country" and filed an application for equivalence. Tedious procedures and problems through translations and individual interpretations were the result.


Since June 2015, it has been possible to use a European occupational status card (EBA) to allow a significantly simplified, legally valid and more efficient recognition of professional qualifications. This is achieved through an EU-initiated European Internal Market Information System (IMI). The applicant can now submit his documents online via the home country. There it is checked as to whether they are complete, genuine and valid, since the result is placed in IMI as an individual "account." The host country can now establish equivalence directly via the IMI and issue the occupations permit. In the case of revocation of the occupational permit or other occupationally relevant offenses, this will then become immediately apparent at European level. Employers or any other interested parties, if authorised, can check the validity of the EBA online using its reference number (Bundesministerium für Bildung und Forschung nd).


Entry requirements qualification/level of education

The EU directive distinguishes between two options. These allow access to training for 10-year schooling and access to study for 12-year schooling. The duration of the qualification (training or study) must be at least three years and 4,600 hours (theory and practice). The scope of the theoretical training must be at least one-third and that of the clinical-practical training at least half of the minimum training period.


Regardless of whether the professional qualification is training or study, the minimum competencies set out in Directive 2013/55/EU must be achieved.


The educational level of a vocational qualification is based on the country-specific qualifications framework. The basis for this is the learning outcomes associated with the qualifications. Based on technical (knowledge and skills) as well as personal competencies (social competence and independence) these are then evaluated and assigned in the eight designated levels of the respective NQF (European Commission (2019). 


The eight-level European Qualifications Framework (EQF) serves as a reference framework. It should make it possible to compare educational qualifications and their qualification levels within the European Union. 


It is divided into eight different qualification levels, level eight corresponds to the doctorate, level six a bachelor's degree. 


Specialisations are often done as postgraduate training. However, the formats are very different in terms of fields of study, level of qualification, duration and possibilities of use and are therefore only limited for comparison within Europe (and partly also within one's own country) and are only (differently for each country) recognised for specially designated further education.


Despite their comparability at the European level, the real job profiles and competencies of caregivers in the individual countries are very different and must be considered in advance for assignments.


In many European countries, hardly any nursing basic skills or body proximity care activities are carried out, neither in education nor in later professional practice. These are usually the responsibility of nursing assistants. In the eastern European countries, the nursing staff is traditionally still often subordinate to the medical staff and this thus weakens a real professionalisation and encounter at eye level. The delivery of nursing and physical care activities is often perceived by the nurses trained in Eastern Europe as a higher status than others. 


Way ahead

Despite all European regulations and adjustments, the actual recruiting procedure requires an attentive and clear assessment and accompanying procedure, which suits both the country and their own institution. Best practice examples can help to provide the best and most secure way of integration for all clients. 


Key Points

  • There is an increasing shortage of healthcare personnel
  • Mobility within and outside the EU contributes to this shortfall
  • In cross-border nursing, main points for stakeholders to consider include maintaining trust prior to commencement of employment, on boarding, language skills and cultural differences
  • In the EU, job responsibilities in different countries can differ greatly in spite of having similar titles
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Official Journal of the European Union (2012). Available from 


Prölss J et al (2019). Pflegemanagement. Medizinisch Wissenschaftliche Verlagsgesellschaft. Pflegemanagement. Berlin.


Europa (2019) What is a regulated profession. Available from -qualifications/regulated professions/index_en.htm 


BMBF-Bundesministerium für Bildung und Forschung Europäischer Berufe Ausweis (nd). Available from 

European Commission (2019) Descriptors defining levels in the European Qualification Framework. Available from

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