Abstract

Background:

The interaction of numerous factors leads to nurse migration. The poor national nurse production rate and the high incidence of migration of Pakistani-Educated nurses are the two main causes of Pakistan’s extremely low nurse-to-patient ratio.

Objective:

This study intends to explore the perceptions of Pakistani nurses about the migration of the nursing workforce

Methods:

This qualitative descriptive exploratory study used purposive sampling to conduct semi-structured interviews with three groups of Pakistani-educated nurses: those who have migrated, those who are working professionally and have established their careers in Pakistan, and those who are student nurses pursuing nursing education in Pakistan from January to April 2019. The interviews explored the nurses’ perceptions of migration as a nursing workforce. Six analytical methodologies were used to analyse the forty-one IDIs that were performed.

Results:

Inductive analysis of qualitative data resulted in three main themes and nine sub-themes i.e. motivation for migration, contextual transition, and adaptation to the new environment. These themes were constructed from the image of nursing, work environment, scope of nursing, quality of life, beginning again, obscured individual identity, contrasting healthcare system, capacity building, acclimatization, and settling.

Conclusion:

We found that Pakistani-educated nurses are highly motivated to migrate. The most frequent causes of nurses’ intention to migrate were wage disparities, political upheaval in Pakistan, working circumstances, lack of opportunities for professional development, active recruitment, and personal safety. The findings can inform the policy of professional organizations and government agencies to decrease the brain drain.

Keywords:

Pakistan, healthcare system, nursing workforce, migration.

INTRODUCTION

In the year 2020-2021, over 1,000 Pakistani-prepared nurses emigrated for better jobs [1]. In Pakistan, the government has paid little attention to the development of a strategy for nursing workforce planning and management. As a result, the nurse-to-patient ratio is quite low. In this context, the migration of Pakistani educated nurses to foreign countries harms an already weak healthcare system. Subsequently, the decision of Pakistani nurses to work abroad constitutes a ‘doubleedged sword’, where personal development abroad conflicts with the collective development of healthcare in the home country [2]. Numerous factors seem to contribute to the regional and national shortage of nurses, such as decreasing trend amongst people to enter nursing programs, the demand and supply gap of nurses as compared to market need, and internal and external migration of nurses from disadvantaged areas within countries or from low and middle-income countries to high-income countries [3].

The actual number of nurses in Pakistan is unknown and the estimated numbers usually differ from reality [2] as many nurses who are working in Pakistan are not registered with Pakistan Nursing Council. As per the Pakistan Bureau of Statistics, Government of Pakistan in 2021 there are 121,245 Registered Nurses, 44,693 Registered Midwives, and 22,408 Registered Lady Health Visitors [4]. As per Express Tribune 2018, a meeting was held at the Ministry of National Health Services Regulations and Coordination (NHSRC) in which NHSRC Federal Minister Aamir Mehmood Kiyani informed only 5,000 of said nurses hold Bachelor’s degrees in Nursing, 190 Master’s degrees, and only 9 PhDs in Nursing [5].

The migration of Pakistani educated nurses to foreign countries has been taking place for decades therefore, it is an established phenomenon. Advertisements regarding job vacancies in Saudi Arabia, Bahrain, Oman, Abu-Dhabi, Kuwait, United Kingdom, and other countries appear in the newspaper on weekly basis. There is no absolute data available that depicts the number of Pakistani educated nurses that migrate annually however, it is estimated that approximately 15% of nurses from developing countries including Pakistan are moving to developed countries every year [6]. Developing countries like Pakistan is the main victim of the loss of trained health professionals because of the increase in globalization which has resulted in a severe shortage of nurses due to internal migration from rural to urban areas, and external migration from developing to developed countries. Significant loss of healthcare human resources due to the increased migration trend has compromised the capacity of health systems to deliver care in areas where it is required the most [6].

The causes of migration are numerous and multifaceted and often are influenced by both sender and recipient country. The most frequent causes of nurse migration are wage differences, political unrest, working conditions, lack of opportunities, the possibility for professional development, active recruitment, a better quality of life, and personal safety [7]. One of the significant factor that qualifies nurses to migrate from Pakistan to abroad be their image and status as nurses in society [8]. The prodigious demand for nurses in most developed countries makes the migration process more efficient as thousands of nurses migrate each year to obtain labour abroad. Additionally, the lack of incentives and information about opportunities at home, and the nonprobability of pensions hinder nurses to return to their country of origin. On the contrary, the major reasons for nurses to stay and work in their home country are often based on commitment and morals, culture, linguistics, and good governance [7].

The article aims to explore the perceptions of Pakistani nurses about nursing workforce migration. Also, to identify push and pull factors of brain drain among Pakistani Nurses; explore the perceptions of future nurses regarding nurse migration phenomena; analyze the impact of nursing workforce migration on the Pakistani healthcare system; and proposed findings of the project as a guideline that professional organization and government agencies can incorporate at the policy level for implementation of proposed strategies to decrease brain drain.

MATERIALS AND METHODS

This is the qualitative descriptive-exploratory study conducted from January 2019 to April 2019. The qualitative descriptive study follows the tradition of qualitative research i.e. empirical method of investigation and is used in qualitative descriptive research studies, particularly for examining healthcare and nursing-related phenomena [9]. This type of study design is appropriate for the research questions focused on discovering who, what, and where of events or experiences and gaining insights from informants regarding a poorly understood phenomenon. Three types of nurses with nursing degrees from Pakistan participated in the study i.e. group 1: Pakistani nurses who have migrated, group 2: Pakistani nurses who had already established careers in Pakistan, and group 3: Pakistani nursing students who were pursuing their nursing degrees there. A welldefined inclusion and exclusion criterion was developed for the recruitment of participants in this study based on the study’s objectives (Table 1). A purposive sampling strategy was used and participants were approached using the snowball technique. Sample size determination for qualitative studies is data saturation [9, 10], initially, it was intended to conduct 60 interviews i.e. 20 from each group, however, theoretical saturation was achieved after 41 interviews. This was cross-checked with all the researchers. The final sample consisted of 41 participants i.e. 10, 13, and 18 from groups 1, 2, and 3 respectively. There was no dropout, however, 4 participants that were approached declined to participate in the research due to their busy schedules.

Out of three researchers, the first author was a PhDBioethics and Global Public Health scholar and she obtained training for conducting qualitative in-depth semi-structured interviews, the second author was the supervisor for this research work and the third author had formal training exposure to conducting qualitative research work during Master of Science in Nursing program. Data collection was done by semi-structured in-depth individual interviews along with complementary note-taking to apprehend participants’ verbal and nonverbal responses from Pakistani-educated nurses in a language that participants preferred i.e. English, Urdu or bilingual using video conferencing software such as Skype, WhatsApp, Botim or face to face as per the preference of the participant.

Table 1:

Inclusion and Exclusion Criteria.

Inclusion and Exclusion Criteria
Study Participants	Inclusion Criteria	Exclusion Criteria
Group 1 Pakistani-educated Nurses that have migrated.	Pakistani nurses who obtained their pre-registration nursing education in Pakistan and had worked in Pakistan as a nurse with first-hand experience in the Pakistani health system. Should have working experience as a registered nurse in the country where they have migrated Currently working as nurses in their countries of migration with valid registration/licensure from the national regulatory body for nurses.	Pakistani nurses who have migrated abroad for study purposes and not having license/registration through the national regulatory body of their respective country Pakistani nurses who are working as care assistants without licensure/registration Pakistani nurses whose parents or spouses migrated and had no experience working as registered nurses in Pakistan.
Group 2 Pakistani-educated Nurses that are working at the professional level and have established their careers in Pakistan	Pakistani nurses who obtained their pre-registration nursing education in Pakistan and had worked in Pakistan as a nurse for at least 5 years with first-hand experience of the Pakistani health system. Should have registration from Pakistan Nursing Council (PNC). Should be currently working as a registered nurse in Pakistan.	Pakistani-educated nurses currently working as nursing administrators and educators. Foreign qualified nurses working in Pakistan.
Group 3 Student nurses that are acquiring nursing education in Pakistan	Nursing students enrolled in 3 years Diploma in General Nursing (RN) program or 4 years Generic Bachelors of Science in Nursing (BScN) degree program at Pakistan Nursing Council (PNC) recognized institutes.	Students enrolled in programs other than RN and Generic BScN.

An interview topic guide for semi-structured interviews for all three groups was developed, the content was reviewed by the experts and it was pilot tested by pilot interviews. The questionnaire was translated from English to Urdu using a standard back translation procedure and repeated checking and reviewing by bilingual nurses and researchers so that respondents can use either language as they prefer. The majority of the interviews took place in Urdu, which is spoken throughout Pakistan. Before starting the interview, the researcher built rapport with the research participant by explaining the study and obtaining consent. The duration of each interview was 45-60 minutes. All interviews were audio-recorded for analysis and were conducted based on the participants’ convenience and comfort. In case of any missed or additional information, the participants were again contacted, and this was conveyed to the participants before taking their consent, to ensure their availability for the interview. The first author conducted all the interviews and did transcription word by word, and Urdu and bilingual interviews were translated into English. The transcription sheet was reviewed by all researchers. The transcripts generated were not sent to the participants for comment and/or correction due to feasibility issues. To obtain transferability, the data was collected from Pakistani-educated nurses from across the globe.

Data analysis was done using six analytical strategies used for qualitative studies data analysis i.e. data coding from notes; recording of insights and reflections on the data; sorting through the data to identify similar phrases, patterns, themes, sequences, and important features; looking for commonalities and differences among the data and extracting them for future analysis; gradually deciding on a small group or generalizations that hold for the data; and examining these generalizations in the light of existing knowledge. The data was coded by the first and third authors and no software was used for managing the data. The themes, sub-themes, and categories were identified using this process. The findings were reported in the data reporting phase.

Rigour in this study was maintained through credibility, transferability, dependability, and conformability. Credibility was maintained by disclosure of the researcher’s own experience and by note keeping a journal of the content and process of interaction. Moreover, all the interactions with participants from recruitment until the interview was recorded and postinterview discussion in field notes was written as well. In this study, transferability was ensured by describing the context of the current study under the result section and by providing a complete description of the context of the study, all the assumptions regarding the study, and an accurate description of the participant’s accounts. In the findings section, the context of the study has been discussed in detail to supplement the data. Dependability for this study was achieved by an iterative review of the study findings among all the researchers. The criteria mentioned above were met to ensure the trustworthiness of the study. Participants’ accounts are described in an accurate manner and study findings are discussed in context. Conformability was assured by ensuring the process of reflexivity and by triangulation in the data analysis process.

RESULTS

A total of forty-one (41) participants, 10, 13, and 18 from groups 1, 2, and 3 respectively were screened and agreed to be interviewed. All participants were enrolled in different private schools in Karachi, Pakistan (Table 2).

All interviews were held online at the chosen time of interviewees using video conferencing software. This was because the participants were from across the globe and online interviews were feasible. The interviews ranged from 45 to 60 minutes with an average of 52 minutes. The age range of participants ranged from 28 to 54 years. Eight, three, and thirteen females and two, ten, and five males were interviewed from groups 1, 2, and 3 respectively. Group 1 had participants three participants from the United States of America, two from Canada, one from the United Kingdom, two from Australia, one from the United Arab Emirates, and one from Saudi Arabia. All the participants of groups 2 and 3 participants were from Karachi, Pakistan. At the time of recruitment groups, 1 and 2 participants were actively working as registered nurses in hospitals. Group 3 participants were enrolled in a generic Bachelor of Science in Nursing (BSN) program.

Table 2:

Demographics of Participants.

Group	Gender		Age range (in years)	Professional Qualification
	Male	Female		RN	BSN	Masters
Group 01 Migrated Pakistani Nurses	02	08	28 to 54	3	4	3
Group 02 Non-migrated Pakistani Nurses	10	03	25 to 35	4	9	0
Group 03 Pakistani student nurses	05	13	19 to 28	2	16	0

The in-depth individual interviews provided an opportunity to research participants to reflect on and share their respective experiences about the working environment, motivation for migration, challenges and stressors, adaptation, and strategies. The content analysis of the interview resulted in the development of several categories. Three major themes and nine subthemes emerged from thematic analysis (Fig. 1). The themes and sub-themes identified from the interviews are discussed below.

Fig. (1):

Themes, Subthemes, and categories.

Theme 1: Motivation for Migration

The motivation for migration was examined amongst all three groups of Pakistani educated nurses. The data depicted that Pakistani-educated nurses are highly motivated to migrate to a foreign country for various reasons.

Subtheme 1.1: Image of Nursing

The societal image of nursing was one of the major concerns of the participants. A participant stated that “In Pakistan, nurses are viewed as slaves and there is no respect for nurses. Such behaviors decrease nurses’ respect resulting in de-motivation” (ID# 14). Another participant stated that “People use to say that the image of nursing is not good in our society and people of society will not consider you good if you enter in this profession. They say that it is low category job” (ID# 19). One more participant said that “nurses have to experience degrading behaviors from patients and attendants.” The role of media in creating a false image of nurses in society was also found to be another contributing factor. A participant stated that “media and televisions portray a very false image of nurses as individuals who are supposed to blindly follow doctors’ orders as if they don’t hold brains and education. The image of nursing in the country is usually portrayed as that of doctor’s assistants by the media” (IDI# 14). On the other hand, the prodigious demand for nurses in most developed countries makes the migration process more efficient as thousands of nurses migrate abroad each year. A participant stated that “the image of and appreciation for nurses in developed countries is higher than underdeveloped or developing countries. Obviously, this motivates them to move there” (ID# 15). However, the perception of the profession was found to be positive among the participants themselves. A participant stated that “though the societal perception regarding the image of nursing varies, it cannot be denied that it is a noble profession where we serve humanity” (IDI# 01).

Subtheme 1.2: Work Environment

The work environment was highlighted as a foundational feature for nurses. The participants described an enormous contrast concerning the work environment in Pakistan as opposed to abroad. An emigrant participant stated that “Stature or healthcare organizations in Pakistan are in atrocious position. I realized it upon my migration. The healthcare in Pakistan lacks good infrastructure, a clean environment, and adequate staff… the workload is quite high due to the unsatisfactory nurseto-patient ratio. On the other hand, overseas hospitals have good infrastructure, clean hospital environment, nurse to patient ratio is good, the workload is satisfactory and flexible working hours” (IDI# 03). Another participant stated that “here we (nurses) are sometimes expected to perform the job of clerks and ward aids” (IDI# 13).

According to the participants, the work environment was not limited to the building of the hospital only it also encompassed work culture. One of the major findings that research participants have shared is that in Pakistan they have experienced uncompassionate behavior by authorities. Participants stated that “hospital management does not show any caring behavior towards their employees. Nurses are expected to perform duty even if they are not feeling well, the salary of nurses is deducted in case of any mistake or error” (IDI# 15). A student nurse verbalized that “students usually experience a student-teacher gap which serves as a hindering factor for their learning” (IDI# 34). The participants also reported cases of harassment and intimidation by doctors, colleagues, patients, and attendants. A participant stated that “Doctors think that they are the only knowledgeable beings in the world, and nurses don’t know anything. They become very rude and arrogant if nurses suggest them something out of the existing care plans. Nurses should be heard as they are also educated and sensible bodies” (IDI# 16). Another participant verbalized that “When a nurse provides information to Patients and attendants then they are not trusted, and the same thing is explained by a doctor than patients trust them blindly as they consider that as she is a nurse therefore she doesn’t know anything and doctor has studied more, therefore, we can trust on doctors” (IDI# 12). Student nurses also verbalized the cases horizontal violence that “senior students should guide junior students. Usually, senior students assume junior students are low; and try to get their work done. Junior students are ragged and bullied” (IDI# 30).

Subtheme 1.3: Scope of Nursing

The scope of nursing was another factor that influenced nurses’ decision to migrate. A participant stated that “The role of nurses in Pakistan is usually limited to medication administration and hygiene care. However, in the foreign world nurses are involved in total patient care plans and activities throughout the patient’s hospital stay” (IDI # 8). Similarly, one more participant stated that “Anybody dressed in a white uniform was providing care there to patient. There was no difference between ward boys or paramedic’s means there was no differentiation” (IDI # 6). The participant verbalized that “We don’t have any specialist nursing role in Pakistan. Even, if we have it at some hospitals, the role is not established properly. However, nurses have emerged in several roles in the western practice and literature” (IDI # 2). One participant shared nursing as a female-oriented profession by stating “When I started nursing at that time there were no male nursing, there were female nurses” (IDI #6).

Subtheme 1.4: Quality of Life

The quality of life was another factor impacting nurses’ migration rates. A participant stated that “Then I guess the salary scale of course because the currency over here is far better than what Pakistani currency is so obviously like how much you earn here is like in a month you can earn what you can earn in Pakistan in probably three or four or five years its one-month salary here” (IDI# 4). Similarly, one more participant stated that “my children are studying in a good foreign school. Education is very developed here in comparison to Pakistan. Hence, it is an added benefit to me” (IDI# 5).

Theme 2: Contextual Transition

This theme discusses the major obstacles that research participants experienced during their transition.

Subthems 2.1. Begin Again

The majority of the Group 1 participant shared their emigration experiences of beginning again. They shared that after migration they had to begin everything from the scratch. A participant stated that “I left Pakistan almost 3 years ago at that time I was working as Assistant Professor and as a Vice Principal…when I migrated, I had to restart things from the level of a bedside nurse” (IDI # 03) the struggle for the license to practice was another contributing factor. A participant verbalized that “I had to work as a nursing assistant in a hospital abroad until I gave my licensure exams and then started as a registered nurse” (IDI# 02). Additionally, Group 2 participants have shared that the major obstacle that they have experienced during the transition from student to staff nurse is low education and competence. A participant stated that “The nursing education system is disorganized in Pakistan. It needs to be upgraded. A very recent example is that post-RNs cannot go for a master’s. This hinders the educational and clinical competence of nurses ultimately influencing the quality of care, scope of nursing, and image of the profession” (IDI# 15). Moreover, Group 3 participants expressed novice student anxiety, theory-practice gap, and increased anxiety due to decreased competence as major challenges that they experienced while working as student nurses during academic clinical rotation. A participant stated that “We have learned lots of things in theory, but the practices are quite different. For example, we were taught about bed baths. There were around 4 towels and 3 mittens which we used during our sign off yet, due to shortage of resources in clinical practice we hardly get one towel on one patient” (IDI# 37). Another participant verbalized that “I was new to the environment and had no work experience. I required a guide during my initial days which was not provided to me... Teachers should have understood that I am new and fresher and it’s a new experience but at that time my teacher was not able to understand this…because of which my start phase clinical was full of difficulties” (IDI# 29).

Subtheme 2.2. Obscured Individual Identity

The contextual transition was not easy for participants, as they had experienced, obscured individual identity by undergoing cultural shock, isolation and racism, and perceived discrimination in a new environment. Group 1 participants shared that during the transition there was a lack of support system because of which they were unable to achieve work-life balance. A participant stated that “It is really hard to survive without family in a completely new culture. You have no friends to talk to, no support system to enjoy. Also, we are paid according to our hours of job (abroad). So it becomes difficult to maintain the work-life balance” (IDI# 09).

Further, they struggled to get oriented and accommodated in the new environment. A participant from the group stated that “The healthcare systems of outside countries are very different from that of Pakistan. It requires a lot of time and effort to get acquainted with the new environment and system” (IDI# 14). A participant from group 3 stated that “when student nurses go on clinical than clinical side is the worst experience because firstly, they are new because of which they are not mentally prepared that what are they supposed to do on clinical means we are just on clinical just after 3 months of commencement of 1st semester and then on clinical we are blank because we don’t know anything even we were not taken for a visit of the hospital before starting clinical” (IDI# 28).

The participants from Group 1 also shared their experiences of isolation and racism based on their identities. A participant verbalized that “No matter how much hard work we do, we are always identified as outsiders” (IDI# 06). One more participant stated that “I am not sure about other hospitals or clinics but as a Christian, I experienced discrimination in my clinic in Saudi Arabia as they used to give priority to Muslims. In Pakistan, I never faced such discrimination although my all colleagues were Muslims” (IDI# 14). The participants from group 3 opened up regarding their struggle against bullying and mobbing behaviors and stated that “senior students should guide junior students. Usually, senior students assume junior students are low and try to get their work done. Junior students are ragged and bullied” (IDI# 37).

Subtheme 2.3. Contrasting Healthcare Systems

The participants from group 1 also highlight the difference in the healthcare system of Pakistan versus abroad, as another challenging factor in their transition. The difference in practice emerged as an important challenge for the participants. A participant stated that “The first couple of months were quite challenging for me as the system is different” (IDI# 10). Further, Group 3 participants reported that even within the country they feel that there is a difference in nursing educational institutes as some institutes are providing quality education whereas, some are making compromises on educational standards. The difference is also quite evident between public and private sector nursing institutes. A participant verbalized that “Here in Pakistan as well, there are differences in the standards of various nursing schools. We cannot compare the school of nursing of the (toprated private nursing school) with the school of nursing of any government university” (IDI# 33).

The Group 2 participants reported that the educational system of Pakistan is substandard as curriculum regulation by the Pakistan Nursing Council (PNC) and Higher Education Commission (HEC) is disorganized and has several disparities. A participant shared that “The standard of nursing education in Pakistan is definitely of no match to the foreign universities. The curriculum regulation by PNC and HEC is quite disorganized and has lots of disparities” (IDI# 15).

Another major obstacle that researches participants experienced during this transition is legislation and meeting the requirement. A participant verbalized that “Initially we gave an exam (nursing licensure) then in our hospital we searched for the job again and applied in the same hospital again and then we got the job of nurses so initially we were appointed as nursing aid as we didn’t give (licensure) exam at that time. After a year I was able to get a job as a nurse” (IDI# 5). Credentials and equivalency issues were also experienced by a few research participants because of the irregularities of PNC and HEC guidelines. A participant said that “I faced degree equivalency issues as I did Post RN BScN and we were not taught 2 courses Islamiat and Pakistan Studies which according to HEC are important. So to obtain equivalency I was expected to do these two courses before proceeding with my application further” (IDI# 15). The majority of the research participants from all three groups shared that the nursing curriculum in Pakistan is disorganized and there is a severe lack of regulation in the nursing profession by PNC. A participant stated that “there is lack or regulation by the national body of nurses I mean PNC as there is no defined scope of practice for nurses” (IDI# 19).

Theme 3: Adaptation to New Environment

This theme discusses the adaptation process and strategies of research participants to overcome the barriers that they have experienced during the transition.

Subtheme 3.1. Capacity Building

The research participants acquired capacity building through empowerment and reconstruction in which they learned new skills, planning strategies to overcome the language barrier, did bridging courses, and worked with self-motivation and accountability. A participant verbalized that “I try to learn every new thing possible. As I have practically learned various skills which were taught during the theory courses. Learning always helps individuals to get adapted to new places” (IDI# 33). Another participant verbalized that “I also took classes for the English language; started speaking in English so that I could learn it” (IDI# 06). One more participant said that “One has to be self-motivated towards change. Until I will not accept and get motivated towards the new environment and its practices, I will not be able to get adapted and adjusted into it” (IDI# 14).

Furthermore, progressive organizational exposure also facilitated their adaptation process as they were able to utilize knowledge learned during previous education and training, and the current organization’s positive learning environment. A participant stated that “I was confident because of my schooling and training in Pakistan” (IDI# 02). Another participant added that “I was fortunate to have a very good organization where they value their employees, provide training to them and the environment is very positive” (IDI# 02).

Subtheme 3.2. Acclimatization and Settling

The participants also highlighted the role of acclimatization and setting as a strong part of their adaptation process. A participant said that “Family is settled here therefore no chance of moving back but yes if I get an opportunity to serve my country to make any difference or if I can be of any help to my country, I would never step back” (IDI# 2). One more participant stated that “Actually I would not like to come back because I have a daughter here and she is settled here. The culture and the things that she had adopted here like multinational things so I want her to grow up in this environment so her base should be strong” (IDI# 06).

Collegiality and support from surrounding people were other important contributing factors to adaptation. A participant verbalized that “Peer support was there we used to have outings together there is no malefemale issue here. You can sit alone on the break with a male colleague that’s not an issue” (IDI# 05).

Some participants shared the fear in the association of beginning everything again, if they returned to their home country, as an important component of adaptation. She stated that “Since I have lived here for so long that now it is like my country to me and I am serving this country because this country has given me too much so I don’t have any reason to come back to Pakistan because if I will return then I will take time to settle back because I have a routine here” (IDI# 06).

Moreover, the participants also shared the reconciliation of different realities as an important part of their adaptation phase, which included learning foreign nursing practices, experiencing, and embracing diversity, and rediscovering self as key factors in their adaptation journey. A participant stated that “I have learned the new nursing practices, if I would have been in Pakistan then I would not have been able to learn these new skills” (IDI# 09). One more participant said that “I enjoy being in a diversified working environment. It had helped me in understanding different people, their culture, and their religion” (IDI# 05). Another participant verbalized that “I have rediscovered myself. Migration in itself is a learning journey where you learn through rediscovering yourself” (IDI# 09).

DISCUSSION

The findings highlighted trends of migration of the nursing workforce, the factor contributing to migration, their transitional challenges, and associated adaptation strategies. The causes of migration are numerous and multifaceted and often are influenced by both the sender and recipient country [11, 12]. The most frequent causes of nurses’ migration highlighted in the study were wage differences, political unrest, working conditions, lack of opportunities, a possibility for professional development, active recruitment, a better quality of life, and personal safety. Additionally, the lack of incentives and opportunities, and the non-probability of pensions hinder nurses to return to their country of origin. On the contrary, major reasons for nurses to stay and work in their home country are often based on commitment and morals, culture, linguistics, and good governance. These findings are congruent with various national and international studies [11-14].

Moreover, societal perceptions regarding nurses in the Pakistani context also serve as a major push factor for nurses to migrate as society perceives nursing as a lowcategory job [12, 13]. Also, nurses had to experience degrading behavior from patients and attendants and there is an unembellished dearth of respect for nurses [13, 14]. Pakistani media also portrays nurses as doctor’s assistants [12-15], and the family members’ perception regarding nursing is not good and most extended family members discourage young people to pursue the field of nursing as a career. In contrast, there is an extremely positive image of nurses in foreign countries which result in nurses’ emigration from Pakistan [12, 16].

Interestingly, despite several unwelcoming societal perceptions, a strong sense of nobility and grace for the nursing profession was viewed among the participants themselves which was a novel finding. The self-perception of research participants regarding the profession of nursing in Pakistan is very positive as they contemplate that it is a noble profession in which they serve humanity. However, at the same time, they expressed that in Pakistan there is decreased self-respect of nurses as they are considered slaves because of which they experience low self-esteem, disappointment, and less motivation.

Further, various challenges were highlighted which not only contributed to migration but were also experienced after migration during their transitional phase. Inadequate resources for patients and staff, poor infrastructure, unclean hospital environment, staff shortage, high nurse-to-patient ratio, increase workload because of the shortage of staff, and unnecessary work expectations as nurses to the job of clerks and ward aids have been voiced by all three groups of Pakistani educated nurses [12-18]. On the other hand, overseas hospitals have good infrastructure, clean hospital environments, nurse to patient ratio is good, and the workload is satisfactory and flexible working hours ultimately resulting in improved quality of life [11-13, 19]. However, the struggle of beginning again from the scratch, obscured sense of identity, and contrasting healthcare systems were identified as other transitional challenges which are congruent to other studies [11-14, 19, 20].

Finally, the participants highlighted various adaptational strategies to overcome the transitional barriers. The research participants acquired capacity building through empowerment and reconstruction in which they learned new skills, planning strategies to overcome the language barrier, did bridging courses, and worked with selfmotivation and accountability. Furthermore, progressive organizational exposure also facilitated their adaptation process as they were able to utilize knowledge learned during previous education and training, and the current organization’s positive learning environment [18, 20].

RECOMMENDATIONS

The study findings possessed various recommendations at the individual, organizational, and administrative levels to give due recognition to the nursing profession in Pakistan, decrease exploitation, and ultimately strengthen the healthcare system of the country. At the individual level, to maintain their profession’s standing in the nation and to enhance their quality of life, nurses should work toward ongoing, high-quality education. At the organizational level, to attract and keep employees, healthcare businesses should enhance their service models, guarantee a safe and clean working environment, and invest in quality infrastructure. Moreover, nursing leadership and administration need to respond to nurses’ real concerns more quickly. Nursing administrators should research to determine the factors causing nurses to leave the profession and to close any gaps so that the healthcare system as a whole may be improved. At the government level spending on the health sector, particularly for nursing development, should be increased. This can be done by raising pay, ensuring job security, and fostering educational possibilities. In addition, to maintain the nation’s people resources and keep the nursing workforce, the law-and-order situation needs to be strengthened. Most importantly, the Higher Education Commission (HEC) and the Pakistan Nursing Council (PNC) should take a leading role in addressing the existing nursing difficulties for the implementation of a standardized curriculum nationally and the equivalency of educational qualifications. Also, to support strategic planning for nurse retention in Pakistan, a national database register for nurses should be established within the PNC to track the annual number of nurses graduating from, working in, and moving from the nation. Lastly, more money should be raised to improve the nursing education system so that nursing schools can accommodate and assist more students, hence increasing the number of nurses.

For migrated nurses the findings of the study recommend that the emphasis should be strong academic and clinical preparation to obtain a nursing license, building their professional network as that will allow them to connect, and enhancing their language skills as it acts as one of the barriers for communication with patients and colleagues, learning about cultural differences to provide culturally competent care, seek mentor-ship, staying up-to-date with current practices and policies, and most importantly take care of themselves.

LIMITATIONS

The results cannot be generalized beyond the study sample, due to the qualitative and subjective nature of the study method

CONCLUSION

This study provides important insights regarding the factors that facilitate or inhibit the migration of Pakistani educated nurses to foreign countries. It also provides a contrast over three generations of nurses and examines that the dynamics have remained the same which depicts the attention and interest of key stakeholders in promoting the retention of nurses in their home country. The results of this study may help in developing methods that will encourage nurses to stay in their positions, strengthening Pakistan’s healthcare system. The findings from this study may provide an understanding to formulate effective strategies to promote nurse retention to strengthen the healthcare system of Pakistan.

DISCLAIMER

This paper has evolved out of Ph.D. research work done by the first author.

ETHICS APPROVAL

The study was conducted after obtaining approval from the Institutional Review Board of the American University of Sovereign Nations with reference # FWA00026409. All procedures in studies involving human participants were carried out by the institutional and/or research committee’s ethical standards, as well as the Helsinki declaration. Data collection was initiated only after approval from the ethics review committee.

CONSENT FOR PUBLICATION

Verbal and written informed consent for data collection and publication was obtained from all participants by sending an informed consent form via email which was signed by the participant and a scanned copy was submitted to the researcher. Participants were explained that their participation in the research will be voluntary and that their decision about whether to participate or not would affect them in any way. Assurance was also provided to them that they are free to withdraw their participation in this study at any time without any harm if they wish to do so.

AVAILABILITY OF DATA

The authors confirm that data supporting the results of this study are available in the article.

FUNDING

None.

ACKNOWLEDGEMENTS

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

AUTHORS’ CONTRIBUTION

SKP: Conceptualized the idea, designed the outline of the manuscript, wrote the first draft, did data collection and analysis, and prepared the final draft. DM: was the supervisor for the project and reviewed all the drafts. NR: Contributed to the data analysis phase and writing results and discussion section of the study, and reviewed the final draft.

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