You want to hire a qualified nurse from Tunisia or the Western Balkans, and her recognition decision comes with a condition. Before she may use the protected title Pflegefachfrau (registered nurse) in Germany, she has to pass a Kenntnisprüfung (knowledge test) or complete an Anpassungslehrgang (adaptation course). Which route she takes is her own decision. As a recruitment agency for skilled workers from abroad, we see the time until the licence as a phase in which your rota helps decide how well your future nurse progresses.
Nurses from third countries choose their own route
In practice people speak of a qualified nurse. The Pflegeberufegesetz (Nursing Professions Act, PflBG) uses the titles Pflegefachfrau and Pflegefachmann, and anyone who wants to use them needs a licence (Section 1 PflBG). On the way there, the competent authority compares the qualification the candidate obtained in her home country with German training and takes her professional experience into account. What is recognised is the qualification, not the person.
If her training differs substantially from German training in its subjects or practical areas, the authority requires a compensation measure (Section 40 (2) and (3) PflBG). This only applies if she cannot make up the difference through professional experience or through further training formally recognised in the respective country. The compensation measure is the proof that she has the level of knowledge that German nursing training provides.
Official statistics show how often a decision carries such a condition. In the 2025 reporting year, the authorities issued 32,016 positive decisions for Pflegefachfrauen and Pflegefachmänner, including the predecessor professions; 20,142 of them came with the condition of a compensation measure (Federal Statistical Office, Statistical Report 21231). The Federal Statistical Office records full equivalence in 11,877 cases and 390 rejected applications. Around three in five positive decisions in this profession therefore carry a condition, although the figures also include qualifications from the EU.
We have analysed these figures in detail in a separate article on recognition with conditions.
For qualifications from third countries such as Tunisia or the Western Balkan states, meaning countries outside the EU, the European Economic Area and Switzerland, the law provides two forms of proof: the knowledge test and the adaptation course. Section 40 (3) PflBG gives the applicant the right to choose between them.
With that choice, the candidate decides whether she prepares for an examination or completes a course. Your organisation can advise her and commit to study time. For that commitment to hold, it is worth settling four questions early:
- Who in your organisation can instruct her, and with how many hours in the rota?
- Can your team cope better with concentrated release before an examination date or with release spread over many months?
- Are all documents from the home country available, or does the timetable depend on an authority abroad?
- Who talks to the candidate about her choice, and when?
Missing documents or a waiver can lead straight to the compensation measure
The authority must decide no later than four months after the complete documents have been submitted. In the fast-track procedure for skilled workers under Section 81a of the Aufenthaltsgesetz (Residence Act), it is supposed to decide within two months (Section 43 (3) PflAPrV). Both periods only start once all documents are available.
For missing evidence, Section 40 (3) PflBG contains a rule of its own. If the candidate cannot submit documents for reasons beyond her control, and equivalence could therefore only be established with unreasonable effort, she proves her level of knowledge directly through a compensation measure. Here, too, she chooses the route herself.
Your organisation helps most in this phase if someone reviews the documents early. Gaps are then noticed before months have passed. An overview of the documents the procedure requires is in our article on professional recognition.
Independently of missing documents, the law provides for a waiver (Section 40 (3a) PflBG). The candidate can finally waive the authority’s examination of whether her training is equivalent and then proves her knowledge through the knowledge test or the adaptation course. Subsection 3a requires that she be informed about the legal consequences of the waiver and about her options. We regard the waiver as a decision that belongs to the candidate alone and needs careful preparation.
Before the knowledge test, the candidate needs fixed study time
By law, the knowledge test covers the content of the state final examination. The training and examination regulation for the nursing professions, PflAPrV for short, divides it into an oral and a practical part, taken before a state examination board (Section 45 PflAPrV).
In the oral part, the candidate works through a case scenario in front of two examiners that combines requirements from at least three areas of competence. The regulation allows 45 to 60 minutes for it. In the practical part she takes on, in two to four care situations, the tasks the law reserves for qualified nurses and shows that she plans and manages the nursing process responsibly. Each situation is allowed a maximum of 120 minutes, usually with real patients, and the authority determines the setting.
She has to pass both parts. A failed oral part or a failed care situation may be repeated once. The test is to be offered at least twice a year. If the federal states use the regular dates of the final examination, they must make it possible for the candidate to sit the test within six months of the decision (Section 45 (7) and (8) PflAPrV).
For your organisation, this route means study time. An examination measured against the German final examination requires preparation. If she is already working for you as an employee during this time, the study hours belong in your rota, in our view. We advise organisations to fix these hours as early as any other shift and to name an experienced colleague for professional questions.
The knowledge test does not require instruction over many months. The candidate should nonetheless know what support your organisation can provide before she chooses.
The adaptation course can turn your organisation into a place of learning
The competent authority sets the length and content of the course so that its goal can be reached (Section 44 (1) PflAPrV). The legal maximum is three years (Section 40 (3) PflBG). The authority can also set a time frame in the decision (Section 44 (1a) PflAPrV). The course ends with a final interview, conducted by an examiner together with the teacher or practice instructor who supervised the candidate during the course.
The course takes place at nursing schools, at facilities where practical nursing training is provided, or at facilities the authority recognises as comparable. The place of deployment must have patients with the relevant care needs.
In our view, more depends on the organisation with the course than with the test. If your facility takes on the practical part, it becomes a place of learning, and that changes daily life on the ward or on the home-care round. Under the regulation, qualified practice instructors are to be involved to an appropriate extent in theoretical instruction. We therefore recommend showing the instructors’ supervision time in the rota.
The facility offering the course can have a say in its length. It may apply to the authority to shorten or extend it within the scope of the decision, as long as the goal of the course is not put at risk. The application must be justified by a suitable person, for example the practice instructor who supervised the candidate. If the authority does not reject a complete and justified application within two weeks, it is deemed approved (Section 44 (1a) PflAPrV).
If the final interview shows that the candidate has not completed the course successfully, the examiner decides on a reasonable extension. It is permitted only once. Another interview follows. If that one fails too, the candidate may repeat the course once (Section 44 (4) PflAPrV). If your organisation is the place of learning, each of these rounds ties up supervision time there.
The residence permit determines how much your nurse may work for you before the licence
If your new employee holds a residence permit under Section 16d of the Aufenthaltsgesetz, that section governs how much she may work for you until she has her licence. The residence permit for a qualification measure allows, alongside it, employment unrelated to the measure of up to 20 hours a week. Employment that is professionally related to her future occupation is possible without a time limit if the Federal Employment Agency (Bundesagentur für Arbeit) has approved it or the Beschäftigungsverordnung (Employment Ordinance) does not require approval.
Whether your employee counts towards a skilled-staff ratio during this time is not governed by Section 16d. Ask your supervisory authority about this.
Subsection 3 is a case of its own: the recognition procedure combined with qualified employment, often called a recognition partnership (Anerkennungspartnerschaft). Here, employer and future employee conclude an agreement in which the employer undertakes to enable the required qualification measures within the employment relationship. The employer must also be suitable for training or further qualification. In addition, there must be a concrete job offer and further conditions, such as language skills. If all of this is in place, the authority generally grants the residence permit. Before you sign this agreement, you should know how the test or the course fits into your rota.
For the licence itself, Section 2 PflBG requires, besides reliability and health suitability, that the applicant has the German language skills needed to practise the profession. If this proof is not yet available, the language course belongs in the same months as the test preparation or the adaptation course.
Information for orientation only, not legal advice.
Structure beats chance. In our process we accompany the collection and legalisation of documents and the official procedures, and we discuss with you who can instruct in your organisation and how your team copes with release from duty before candidates are presented. How this phase fits into the overall timetable of a hire from abroad is set out in our article on the duration of international recruitment.
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Sources
- Federal Ministry of Justice: Pflegeberufegesetz, Sections 1, 2 and 40. 2026. https://www.gesetze-im-internet.de/pflbg/__1.html, https://www.gesetze-im-internet.de/pflbg/__2.html and https://www.gesetze-im-internet.de/pflbg/__40.html (retrieved 04.10.2026).
- Federal Ministry of Justice: Ausbildungs- und Prüfungsverordnung für die Pflegeberufe, Sections 43, 44 and 45. 2026. https://www.gesetze-im-internet.de/pflaprv/__43.html, https://www.gesetze-im-internet.de/pflaprv/__44.html and https://www.gesetze-im-internet.de/pflaprv/__45.html (retrieved 04.10.2026).
- Federal Ministry of Justice: Aufenthaltsgesetz, Section 16d. 2026. https://www.gesetze-im-internet.de/aufenthg_2004/__16d.html (retrieved 04.10.2026).
- Federal Statistical Office: Statistical Report. Recognition of foreign professional qualifications 2025, Table 21231-03, values rounded to multiples of three for confidentiality. 2026. https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Bildung-Forschung-Kultur/Berufliche-Bildung/Publikationen/Downloads-Berufliche-Bildung/statistischer-bericht-auslaendische-berufsqualifikation-5212301257005.html (retrieved 04.10.2026).
