Short answer for employers: International nurses can be recruited via the Triple Win program, the Western Balkans scheme or private agencies. Expect total costs of €15,000-30,000 per skilled worker and a lead time of 6-12 months. The accelerated skilled worker procedure (€411 fee) can shorten the visa process to approx. 4 months. Since the PUEG (July 2023), part of the costs can be refinanced via care rate negotiations.
One in five care workers in Germany is a foreign national. According to Integration media service (2025) that was over 306,700 people in 2024. And since 2022, employment growth in the care sector has been IAB Research Report exclusively by international specialists. The number of German nursing staff? Declining.
That is the reality, not the forecast.
Nevertheless, many institutions are hesitant. The costs seem high, the process opaque, and anyone who has experienced a poorly supervised placement is understandably skeptical. But the alternative - temporary work at €5,000 to €7,000 a month, overtime, bed closures - is more expensive. Not on paper, but on the ward.
This guide is for management, nursing service managers and HR departments who want to make an informed decision. It deals with the institutional recruitment of nursing staff from third countries - not 24-hour home care by Eastern European helpers. These are two fundamentally different topics that are unfortunately constantly mixed up in Google searches.
About this guide: Created by TalentOrbit International GmbH - specializes in the placement of international healthcare professionals from the Philippines, India, Kazakhstan and Kyrgyzstan. Our assessments are based on practical support for employers throughout the entire recruitment and integration process.
Demographic trends are further exacerbating the situation. According to Nursing staff forecast by the Federal Statistical Office the demand for nursing staff is expected to rise to 2.15 million by 2049. There could then be a shortage of between 280,000 and 690,000 nursing staff. The range shows that even in the optimistic scenario, there is a shortage of more skilled workers than some federal states employ in total.
| Key figure | Value (source) |
|---|---|
| Employees in care professions (2024) | approx. 1.7 million (BA) |
| Of which foreign nursing staff | 306,700 / 17.8% (BA 2025) |
| Proportion of foreigners in geriatric care | 21.7% (IAB 2024) |
| Percentage of foreigners in nursing care | 16.5% (IAB 2024) |
| Projected shortage until 2049 | 280,000-690,000 (Destatis) |
Sources: Federal Employment Agency, Focus on the Labor Market 2024; IAB Research Report 22/2024; Federal Statistical Office, Press Release No. 033/2024
Who the Shortage of skilled workers in the care sector as a temporary problem should remember this figure: It takes an average of 204 days to fill a vacancy in geriatric care with domestic applicants. Over half a year. During this time, the existing team compensates - with overtime, by taking time off, with gradual exhaustion.
Most of the pro and con lists on the internet are either written by agencies that only see advantages or by commentators who have never been involved in an integration project. Here is a sober assessment - with a clear classification at the end.
Long-term personnel stability. Internationally recruited specialists are looking for a permanent job. They move their lives, not their schedule. Reputable agencies report retention rates of over 85 % after two years - some, like TalentOrange, publish 96 % after five years. You'll never achieve that with temporary work.
High professional competence. In many countries of origin, nursing is a university degree. A specialist from the Philippines has a Bachelor of Science in Nursing, often four years of study plus clinical practice. According to the IAB, two out of three foreign employees in the nursing sector work as specialists - not as assistants.
Economic efficiency. Depending on the region, a temporary worker costs a facility between €4,000 and €7,000 per month - between €48,000 and €84,000 per year. An internationally recruited specialist costs €15,000 to €30,000 plus the regular salary. The calculation is explained in detail below.
Refinanceability. Since the Care Support and Relief Act (PUEG, July 2023), recruitment costs can be claimed on a pro rata basis via the care rate negotiation. At the same time, the legislator has restricted the refinancing of temporary work. This shifts the calculation in favor of sustainable recruitment.
Team rejuvenation. Many care teams are ageing. International professionals not only bring manpower, but also a different perspective on care - and often an appreciation for working conditions that experienced German nursing staff have long taken for granted.
Lead time. 6 to 15 months. This is not a quick fix. If you urgently need staff today, you can bridge the gap with temporary work - but you should start recruiting abroad at the same time. Both at the same time is not a contradiction, but good planning.
Language barrier. Even with a B2 certificate, specialists need three to six months to master dialects, nursing jargon and documentation style. This is normal. A specialist language course after arrival and a mentor on the ward help more than impatience.
Integration effort. The new colleagues need a practical instructor, help in finding accommodation, support in dealing with the authorities. The existing team needs intercultural awareness training - not as a compulsory event, but as a genuine discussion about what is changing and why this is good. Without this investment, the risk of dropping out increases.
Recognition risk. Not every specialist passes the knowledge test at the first attempt. Failure rates vary depending on the federal state and examination center. Good agencies mitigate this with targeted exam preparation - ideally AZAV-certified so that the costs are eligible for funding via education vouchers.
Migration. Those who are well qualified and linguistically fit are also courted by other employers. Loyalty is created through fair conditions, genuine integration and prospects - not through gagging contracts. Institutions that treat their international specialists well rarely lose them.
Our conclusion: The advantages clearly outweigh the disadvantages - but only for organizations that see integration as part of the project rather than a secondary task. Anyone who commissions a placement agency and then hopes that the rest will take care of itself will be disappointed.
The reformed Skilled Immigration Act has gradually come into force since November 2023 and was fully implemented on June 1, 2024. The situation has improved noticeably for employers who want to hire nursing staff from abroad - even if „simply“ is a word that rarely appears in German administrative law.
Pillar 1 - Skilled workers with recognized qualifications: Persons with a professional qualification recognized in Germany can pursue any qualified occupation. For nurses as a regulated profession, the recognition requirement continues to apply.
Pillar 2 - Professional experience: Skilled workers with at least two years of professional experience and a professional qualification recognized by the state in their country of origin can enter the country under simplified conditions - even if recognition in Germany is still pending.
Pillar 3 - Potential (opportunity map): The new opportunity card enables entry to seek work on the basis of a points system. However, this pillar is less relevant for institutional nursing recruitment than the first two.
Recognition partnership: Skilled workers can now enter Germany and start the recognition procedure here. Prerequisite: employment contract, agreement on joint implementation of recognition, German language skills of at least A2. This is a real game changer - previously, recognition had to be completed before a visa was issued. More on our page about the legal framework.
Nursing assistants from third countries: For the first time, a separate residence permit has been created for nursing assistants. People with a nursing qualification below the three-year specialist qualification can now be legally employed in the health and care sector.
Facilitated family reunification: Skilled workers benefit from simplified regulations. Proof of sufficient living space is not required. Sounds like a detail - but for a care worker who is considering moving to Germany, the ability to bring their family home is often the decisive factor.
The nursing profession is regulated in Germany. Anyone wishing to work as an international nurse requires a state license to practice the profession in accordance with the Nursing Professions Act (PflBG). Without ifs and buts.
The four requirements:
Until full recognition is obtained, international specialists work as „recognized nurses“ - with a limited field of activity, but on the way to full professional practice.
| Recruitment route | Costs | Duration | Special feature |
|---|---|---|---|
| Triple Win (ZAV/GIZ) | 5.000-7.000 € | 12-18 Mon. | State, ethical, language course incl. |
| Private agency | 8.000-15.000 € | 6-12 Mon. | Flexible, full service possible |
| Western Balkans regulation | Variable | 3-6 Mon. | 50,000 visas/year, recognition required separately |
| Direct recruitment | 3.000-8.000 € | 6-18 Mon. | High internal costs, expertise required |
⚠️ Important for the Western Balkans regulation: It facilitates entry, but does NOT replace the recognition requirement for regulated professions. It is suitable as a residence bridge during the recognition procedure or for employment as a care assistant.
You can find a detailed comparison of brokerage models - including a quality seal check and selection checklist - in our guide to the Nursing recruitment from abroad.
The Accelerated skilled worker procedures according to § 81a AufenthG is not a nice-to-have. It's the difference between „skilled worker arrives in four months“ and „skilled worker waits a year for a visa appointment“.
What it brings:
Costs: 411 € - according to Make it in Germany. These are also incurred in the event of rejection, but in terms of the total cost of a recruitment project, €411 is a bargain for a time saving of six to eight months.
This is where it gets uncomfortable. Because the €15,000 to €30,000 from the glossy brochures is only half the truth - it covers the agency side. What's on your agency's invoice is significantly more.
| Cost item | Lower range | Upper range | Explanation |
|---|---|---|---|
| Agency fee | 5.000 € | 15.000 € | Triple win cheaper, private agency more expensive |
| Language training (B1/B2) | 1.500 € | 5.000 € | In the country of origin + B2 course in Germany if applicable |
| Recognition procedure | 500 € | 1.500 € | Translations, fees, equivalence check |
| Knowledge test or adaptation course | 1.500 € | 10.000 € | Preparation course + exam or 6-12 months training course |
| Accelerated skilled worker procedure | 411 € | 411 € | Fixed administration fee |
| Flight + initial equipment | 1.000 € | 2.000 € | Depending on the country of origin |
| Housing support (3 months) | 1.500 € | 3.000 € | Deposit, furnishings if applicable |
| INTERIM TOTAL (agency/external) | approx. 12,000 € | approx. 30,000 € | This is on the invoice |
If you ask ten nursing service managers about the costs of recruiting abroad, you will get the agency number ten times. The following items will not appear in any recruitment brochure - but they will appear on your cost center.
| Hidden item | Estimated expenditure | Why it arises |
|---|---|---|
| Practical instructor capacity | 80-160 hours | Time off for induction, exam preparation, professional support. Your practical instructors are already overworked - now someone else is joining them. |
| Loss of productivity Training | 6-12 weeks | New specialists do not work at full capacity at the beginning. Nursing processes, IT systems, documentation standards - all this takes time. |
| Intercultural coaching | 500-2.000 € | Workshop for the existing team. This is constantly underestimated, but is critical for acceptance. If the ward perceives the new colleagues as a burden, integration will fail - regardless of qualifications. |
| Internal administrative expenses | 40-80 hours | Administrative procedures, contracts, registrations, social security, bank accounts - even with agency support, there is still work to be done internally. |
| Re-examination in case of failure | 500-1.000 € | Not every knowledge test works the first time. Plan for a buffer. |
| House hunting in metropolitan areas | variable | In Munich, Frankfurt or Hamburg, finding an affordable apartment for a single professional is a challenge. Some facilities provide their own living space - this is a strong retention factor. |
The sum of these hidden items is between €3,000 and €8,000 per specialist. Together with the visible costs, the total costs are realistically 15,000 to 30,000 €. Not 10,000, as some brochures suggest.
But: these are one-off costs. Temporary work is a permanent subscription.
Numbers instead of gut feeling. A nursing home with 120 beds replaces three temporary workers with three internationally recruited nursing staff.
| Position | 3 temporary workers / year | 3 international FK / year 1 |
|---|---|---|
| Placement/recruitment (one-off) | - | 3 × 20.000 = 60.000 € |
| Monthly personnel costs (gross + AG) | 3 × 5.500 × 12 = 198.000 € | 3 × 3.800 × 12 = 136.800 € |
| Total costs year 1 | 198.000 € | 196.800 € |
| Total costs year 2 | 198.000 € | 136.800 € |
| Savings after 2 years | - | approx. 62,400 € |
The calculation is conservative. In metropolitan areas, the cost of temporary work is more likely to be around €6,000 to €7,000 per month. And it doesn't take into account what is difficult to quantify: the stability in the team, the lower fluctuation, the ability to plan duty rosters. No need to fill in from your free time because the temporary employee has canceled again.
Break-Even: With average values, the investment pays for itself after three to five months. Often faster for facilities with high temporary employment rates.
In addition, since the PUEG, temporary employment costs can only be included in care rate negotiations up to the amount of the usual collectively agreed wage. The difference between the collectively agreed rate and the actual temporary staff remuneration is borne by the facility alone. This makes sustainable recruitment even more economically attractive.
Three ways you should know:
1. care rate negotiation (SGB XI): Care facilities can claim the verifiable costs of foreign recruitment as material personnel expenses. Working with a quality seal-certified agency makes it much easier to argue your case to the care insurance funds.
2. education vouchers from the Federal Employment Agency: B2 language courses and knowledge test preparation courses can be financed via education vouchers - provided the training provider is AZAV-certified. This can relieve the employer of one of the largest single items.
3. hospital financing (care budget according to PpSG): The outsourced care budget has applied to hospitals since 2020. According to PwC benchmarking, it increased by almost 23 % between 2020 and 2023. Recruitment costs can be taken into account as personnel expenses if the specialist is deployed at the bedside. At the same time, the legislator has capped the use of temporary staff in the care budget.
State subsidies: Baden-Württemberg covers up to €3,000 per skilled worker for language learning abroad. Further programs exist in NRW, Bavaria and Lower Saxony. Enquire at your BA regional office.
Nursing staff from EU/EEA countries generally receive automatic recognition. The most important countries of origin: Poland (approx. 9,700 employees), Croatia (approx. 8,700), Romania (approx. 8,000). According to IAB Study 2024 However, EU recruitment is stagnating - growth is now coming almost exclusively from third countries.
Philippines: Academic 4-year degree (B.Sc. Nursing), good knowledge of English, active recruitment via Triple Win. More: Career opportunities for nursing staff from the Philippines.
India (Kerala, Telangana): Over 8,800 nurses in the German healthcare sector (as of 2024). Fast-growing recruitment country with a strong nursing culture and a high level of English.
Central Asia: Kazakhstan and Kyrgyzstan are moving into focus as regions of origin - well-trained specialists, high motivation and a labor market that is less competitive than the Philippines or India.
Caucasus: Increasingly Nursing staff from Georgia Europe-oriented, culturally open and with an education system that is geared towards EU standards.
Western Balkans: Over 51,000 nursing staff from Albania, Bosnia-Herzegovina, Kosovo, Montenegro, North Macedonia and Serbia are already working in Germany. Bosnia is also part of the Triple Win program.
TalentOrbit places specialists from the Philippines, India, Kazakhstan and Kyrgyzstan - Countries with well-trained nursing staff and high motivation for a career in Germany.
Not every international recruitment is a success. In practice, projects rarely fail due to the professional competence of the caregiver. They fail due to a lack of housing, unaccompanied visits to the authorities, loneliness in the first few months.
The most common reasons:
No welcoming culture in the team. If the existing team perceives the new colleagues as competition or an additional burden, the project is over - regardless of how well trained the specialist is. The solution: provide information at an early stage, talk honestly about changes, offer intercultural workshops that are not a compulsory program but real discussion spaces.
Unrealistic expectations of the language. B2 does not mean C1. Technical terms, dialects, the way people communicate on the ward - it all takes months. Plan for accompanying specialist language courses, appoint mentors and practice patience. The language will come. It just doesn't come on the first day.
Living space as a blind spot. A skilled worker who lives in a hostel for three weeks because no one has looked after an apartment does not feel welcome. Facilities that provide their own accommodation or at least guarantee initial accommodation for three months have a clear advantage when it comes to retention.
Too little time as a practical instructor. International specialists need more support than experienced German colleagues - not because they can do less, but because systems, documentation and processes are different. If the practice supervisor is already looking after three trainees and now also has to train the new international colleagues, this is at the expense of everyone.
Agency without aftercare. The critical phase begins after entry, not before. Agencies that disappear after placement leave a gap. Specify 6 to 12 months of integration support in the contract - with concrete services, not empty words.
Our complete Recruitment process We have documented the results on the employer side - from needs analysis to successful integration.
Everything that happens before entry is logistics. Everything that happens afterwards is integration. And integration determines whether the skilled worker is still working for you after two years - or whether they have gone to a competitor who has done a better job.
TalentOrbit offers comprehensive information on the Living in Germany for international specialists.
Realistic information about working conditions, climate, cost of living. Start looking for accommodation - not just when you arrive, but three months beforehand. Appoint a buddy on the ward: an experienced nurse who is the contact person during the first few weeks. Not the practice supervisor - they have a different role.
Structured induction with clear milestones. Support in dealing with authorities (registration, residence permit, social security). Specialist language course - parallel to work, not at some point. And: a sympathetic ear. Anyone starting 8,000 kilometers away from home has other worries than where the printer room is.
Regular feedback meetings. Further training opportunities. Showing career prospects - ward management, wound management, practice guidance. Family-friendly measures. Experience shows that facilities that offer international specialists not just a job, but a perspective, have retention rates of over 90 %.
The total costs are between €15,000 and €30,000 per skilled worker - including placement, language training, recognition, initial accommodation and internal integration costs. The agency bill alone is between €5,000 and €15,000. Since the PUEG (July 2023), some of the costs can be refinanced via care rate negotiations.
It takes 6 to 15 months from the time the order is placed to the first day of work. The biggest variables: the duration of language training and waiting times at visa offices. The accelerated skilled worker procedure (§ 81a AufenthG, €411) can shorten the administrative processes in Germany to around four months.
Long-term staff stability (retention rates above 85 %), high level of expertise (university education in many countries), more economical than temporary work from the third month, and refinancing options via PUEG and education vouchers.
Lead time of at least 6 months, initial language barriers despite B2, integration effort in the team, risk in the knowledge test, and potential emigration in the event of inadequate support. The disadvantages can be significantly reduced through good preparation and structured integration.
With temporary employment costs of €5,500/month and total recruitment costs of €20,000, the investment pays for itself after three to five months. From the second year onwards, a facility saves around € 20,000 per specialist compared to temporary staff.
The most common countries of origin are the Philippines, India, Bosnia, Tunisia, Mexico, Colombia and Brazil. Experts from six partner countries are placed via the Triple Win program (BA/GIZ). The focus is also increasingly shifting to Georgia, Kazakhstan and Kyrgyzstan.
Skilled workers from third countries generally have to take a knowledge test or complete an adaptation course. Until then, they work as „recognized nurses“. A complete guide can be found in our article on Recognition of foreign qualifications.
Yes, recruitment costs can be taken into account as personnel expenses via the care budget (PpSG). Care facilities in accordance with SGB XI can include the costs via care rate negotiations. In addition, training vouchers from the BA can be used for AZAV-certified courses.
Recruiting international nursing staff is no longer an experiment. It is part of everyday life in over 17 % of the German care sector. The legal framework has improved thanks to the Skilled Immigration Act. The refinancing options have become more concrete since the PUEG. And the economic superiority over temporary work is mathematically proven after three to five months.
However, anyone who only sees international nursing staff as a quick solution to staff shortages will be disappointed. Success requires lead time, investment and a real commitment to integration. The costs are real. The hidden costs are more real. But the alternative - a team that has been understaffed for months, a temporary staffing bill that repeats itself every month, wards that are merged - is more expensive.
Hand on heart: Most of the organizations we advise started with temporary work. And they are now doing the math.
Next step: Have your personnel requirements checked. TalentOrbit International GmbH supports you in the recruitment and integration of international nursing professionals - from needs analysis and cost planning to successful integration.
➡️ Contact: www.talentorbit.de/kontakt | +49 (0) 2173 265 3870 | info@talentorbit.de
This guide was updated in February 2026 and takes into account the legal situation of the Skilled Immigration Act (as of June 2024) and the PUEG (as of July 2023). For the latest developments, please visit www.talentorbit.de/blog.