Impact of hopelessness on migration intentions of nursing students: a path analysis

The term “brain drain” refers to the migration of highly skilled individuals from developing countries to developed countries in search of better pay and working conditions, professional development and higher living standards, thereby contributing socially, culturally, and economically in the destination country [1, 2]. Currently, brain drain is rapidly increasing, and the nursing profession is significantly affected by this trend [3, 4].

The phenomenon of nurse migration actually emerged in the 1940s and showed a steady increase over time. Globally, the percentage of nurses working away from their country of birth increased from 5% in the 1970s to 13–37% in recent years [5, 6]. This means that approximately one in every eight qualified nurses practices in a country other than the one they were trained [7]. Factors pushing nurses towards moving abroad include increasing incidents of violence in healthcare settings, stressful working conditions, poor healthcare management, low wages, long working hours, and inadequate staffing levels. Additionally, poor living conditions, political instability and oppression, dangerous working conditions, economic hardships, war, lack of freedom of expression, feelings of insecurity and uncertainty about the future, and hopelessness related to not seeing any improvement in current conditions also accelerate nurse migration. Conversely, improved working conditions, access to advanced technology and education, career opportunities, new experiences, and the desire to be part of a medical team that offers greater autonomy and is highly respected are the pull factors that motivate nurse migration [6, 8].

Nurse migration can be associated with a number of benefits, such as aiding in the development of transnational connections and partnerships, gaining experience, knowledge and new skills, and sending remittances to their families, thereby driving economic growth in their home countries [9].

Brain drain, which implies a loss to the source country of vital skills and professional knowledge, is only relevant as a concept if linked with permanent migration. If the migrant nurses return to their home country, they will once again be a national resource [10]. However, when nurses settle in developed countries, it results in a free export of skilled human resources, representing the most significant cost of international migration [11]. Furthermore, the migration of qualified workforce increases the burden on remaining healthcare workers. This negatively affects the quality of patient care, limiting access to quality healthcare services for the community, and results in unequal distribution of the global health workforce. The WHO reported a global shortage of 9 million nurses and midwives, and projections for 2030 suggest that the situation will become even more concerning [11]. In OECD countries, there are 3.6 physicians, 8.8 nurses, and 4.4 beds per 1000 people. In Turkey, however, there are 2 physicians, 2.4 nurses, and 2.9 beds per 1000 people, placing Turkey just above Colombia and second to last among OECD countries [12]. The economic crisis ongoing since 2008, political instability following the 2016 coup attempt, and particularly the COVID-19 pandemic have influenced young nurses’ decisions to leave Turkey, raising concerns about potential future nurse shortages in the country. Accurate planning of healthcare services and a thorough understanding of the factors influencing the future size of the healthcare workforce are essential to mitigate nurse shortages in the future [6].

Previous studies involving nursing students in Turkey have mainly focused on the development of a scale to determine the viewpoints of nursing students about brain drain [13] and assessment of their attitudes towards migration [2, 6, 14, 15]. However, to the best of our knowledge, there are no studies examining the drivers of migration, with a specific focus on the association between feelings of hopelessness about the future and the tendency to migrate among nursing students in Turkey.

This study aimed to investigate the levels of hopelessness about the future among nursing students in relation to their intentions to migrate in a province of Turkey. By including students from two public universities, representing an integral part of the future healthcare workforce, this study sought to provide valuable insights for policymakers and nursing educators. The anticipated outcomes of this study are intended to extend beyond academic contributions. They are expected to inform strategic interventions aimed at reducing brain drain among nursing students. By exploring the association between hopelessness and the tendency to migrate, this research aimed to catalyze the development of targeted initiatives to retain talent within the local healthcare sector. This effort was undertaken not only to enhance nursing education but also to improve healthcare service planning, with the aim to contribute to the existing body of knowledge on this alarming issue.

The sociodemographic characteristics of the nursing students and their perspectives on migration are presented in Table 1. 57% of the students indicated that they are considering moving abroad. Among the reasons cited for this decision, the most common were economic problems (12.9%) and poor living conditions (11.1%), while educational challenges (5.3%) and disbelief in any improvement in the future (5.5%) were less frequently mentioned.

The mean score for the subscale of feelings about the future was significantly higher among the students of Turkish nationality, those with lower income, those considering moving abroad, and citing reasons such as poor living conditions, unfavorable work environment, and economic factors for their migration intentions (p < 0.05) (Table 2).

The mean score for the subscale of loss of motivation was significantly higher among female participants, students from the northern parts of Turkey, the first-year students, those with lower income, those considering moving abroad, and those who expressed disinterest in exploring new places and meeting individuals from different cultures (p < 0.05) (Table 2).

The mean score for the subscale of future expectations was significantly higher among female participants, students from the northern parts of Turkey, Turkish citizens, the third-year students, those with lower income, those considering moving abroad, and those who were motivated to move abroad due to poor living conditions and economic factors (p < 0.05) (Table 2).

The total BHS score was significantly higher among female participants, students from the northern parts of Turkey, the third-year students, those with lower income, those considering moving abroad, those motivated to move abroad due to poor living conditions, those not citing economic factors as a reason to move abroad, and those who were disinterested in exploring new places and meeting people from different cultures (p < 0.05) (Table 2).

The total score and the score for Pull Factors subscale of the ABDS were significantly higher among female participants, the students with lower income, those considering moving abroad, those with a desire to move abroad due to poor living and working conditions, educational and economic issues, those who believed that nothing will get any better even if conditions improve in Turkey, and those interested in moving abroad to explore new places and meet people from different cultures (p < 0.05) (Table 2).

The Push Factors subscale score was significantly higher among female participants, those with lower income, the students who did not consider moving abroad permanently, those with a desire to move abroad due to poor living and working conditions, and economic issues, those who believed that nothing will get any better even if conditions improve in Turkey, and those interested in moving abroad to explore new places and meet people from different cultures (p < 0.05) (Table 2).

The mean total and subscale scores were as follows: Beck Hopelessness Scale (BHS) total score ranged from 0 to 20, with a mean of 8.2 ± 5.0. The subscales of BHS were as follows: Feelings about the future (range: 0–5) with a mean score of 1.90 ± 1.76; Loss of motivation (range: 0–7) with a mean score of 2.9 ± 2.2; and Future expectations (range: 0–5) with a mean score of 2.5 ± 1.6.

For the Attitudes Towards Brain Drain Scale (ABDS), the total score ranged from 16 to 80, with a mean of 59.9 ± 12.8. The subscale scores were as follows: Pull Factors (range: 12–60) with a mean of 43.6 ± 9.6; and Push Factors (range: 4–20) with a mean of 16.2 ± 3.7 (Table 2).

In this study, the relationship between hopelessness and migration intentions (brain drain) among nursing students was investigated using path analysis. The analysis revealed a significant direct association between hopelessness, measured by the Beck Hopelessness Scale (BHS), and migration intentions, measured by the Attitudes Towards Brain Drain Scale (ABDS) (r = 0.246, p < 0.05) (Table 3). The regression equation derived from the model is as follows:

Brain Drain = 54.86 + 0.621 * Hopelessness.

In this study investigating the level of hopelessness among nursing students from two public universities in Gaziantep, Turkey and its impact on their intentions to migrate, it was found that a significant portion of the students were considering moving abroad, with a notable preference for Germany. Economic factors, poor working conditions, and educational challenges were identified as the main reasons for the desire to move abroad. Furthermore, the students showed low levels of hopelessness and a high tendency for migration.

Healthcare professionals are among the occupational groups that are most affected by brain drain. The international migration of nurses from developing countries to developed countries has accelerated (International Organization for Migration, 2021). The increase in nurse migration can be attributed to various factors, including globalization, the removal of borders between countries, advancements in transportation and communication, and technological developments, as well as migration-promoting policies of developed countries driven by changing economic and political structures [13]. Although there is evidence indicating an increase in nurse migration in Turkey in recent years, few studies are available [2, 6, 13‐15, 18]. Given the significant shortage of qualified healthcare workers in Turkey, it is essential to gather evidence-based data and develop future human resource strategies.

A noteworthy finding of the present study was that, although the female nursing students had higher expectations for the future compared to their male counterparts, they also exhibited higher levels of motivation loss and hopelessness. This suggests that female students are more likely to be affected by the push factors in Turkey and the pull factors in other countries which may be influential in the decision to migrate. This observation is in line with previous research indicating that female nursing students tend to experience higher levels of hopelessness [19] and a stronger inclination to move abroad [20]. In contrast, some studies have reported higher levels of hopelessness among male students [2, 21], while others found no gender-based difference in the decision to migrate [22, 23]. Although nursing has traditionally been perceived as a female-dominated profession in Turkey, it is increasingly being chosen by men, albeit in smaller numbers [24]. In Turkey, with its patriarchal social structures and male dominance, women often find themselves in secondary positions across various domains including education, the workplace, politics, household roles, interpersonal relationships, and public sphere [25]. Therefore, we think that female nursing students in Turkey may be negatively affected by gender inequality, leading to feelings of hopelessness about the future and a greater inclination to migrate due to not having equal opportunities as their male counterparts.

In the present study, the nursing students of Turkish nationality reported negative feelings and pessimism about the future. Interestingly, the students coming from the northern regions of Turkey had higher expectations for the future but showed higher levels of motivation loss and hopelessness compared to those from other regions of the country. Similarly, in a study, Turkish students were found to have higher levels of hopelessness compared to German students [26]. These results suggest that economic conditions, development levels, and cultural factors in different regions and countries may affect young people’s future prospects. We think that social, economic, educational challenges, as well as unemployment may diminish the hopes of young people and drive them toward migration in search of better opportunities.

In this study, while the first-year nursing students exhibited lower levels of motivation regarding their future, the third-year nursing students showed higher expectations but also higher levels of hopelessness about the future. However, in previous studies, it was found that second-year students [2] and fourth-year students [24] had higher levels of hopelessness. It may be assumed that first-year nursing students, being at the outset of their education with no experience, may not have fully developed prospects for the future compared to other students. The higher levels of expectation and hopelessness observed among the third-year students may reflect their greater awareness of current problems in the healthcare system, as well as their maturation and greater exposure to the challenges and realities of their educational and cultural environment.

In the current study, it was anticipated that the nursing students with lower income would exhibit higher levels of hopelessness and a stronger desire to move abroad. The rapid increase in the number of universities in Turkey, the growing number of graduates, the competitive job market with thousands of young people vying for limited positions, and prevailing unemployment issues suggest that those students facing economic hardships may feel hopeless. Consequently, they might seek opportunities in wealthy countries that offer better prospects and improved conditions.

In this study, 57% of the nursing students considered moving abroad permanently. These students displayed heightened concerns, expectations, loss of motivation, and hopelessness about the future, which triggered a stronger inclination towards migration. Similarly, studies on nursing students reported mild levels of hopelessness [2] and high scores on attitudes towards migration [6, 8, 14, 18]. Consistently, other studies from Turkey found that 66.3% [18] and 73.3% [8] of nursing students expressed a desire to work abroad after graduation. Studies on nursing students in other countries also indicate a similar trend, with 70% [27] and 91.3% [28] of the students intending to migrate. We think that nursing students in Turkey aspire to live in countries that offer better opportunities due to the poor working conditions, low wages, increased incidents of violence in healthcare settings, lack of policies to prevent workplace violence, labor rights violation, mobbing, feelings of devaluation, recurrent economic crises, lack of meritocracy, and political instability in the country. In line with our findings, in a study from Turkey examining the drivers of migration among nurses, the three most important reasons cited by the nurses were poor economic conditions, negative work environment, and low social value and prestige of the profession [29].

Migration results from a complex interplay of various push and pull factors. Push factors are those that influence individuals’ decisions to leave their own country, often related to unfavorable conditions in their current environment. On the other hand, pull factors are those that draw individuals to another country, such as job opportunities, better living and working conditions, opportunities for professional advancement, and a promise of freedom from religious or political persecution. Studies have reported that for nurses, the primary push factors include poor living conditions, economic hardships, security issues, political problems, oppression, wars, limited employment opportunities, insecurity, and weak healthcare management, and major pull factors include a stable life, family security, the need for skilled labor, and education, job, and career opportunities [13, 30, 31]. In this study, the students expressing a desire to move abroad due to concerns about living conditions, financial problems, working conditions, and educational issues showed high scores on the ABDS Pull and Push Factors subscales as well as a strong tendency to migrate. This finding aligns with the data from a previous study which reported that 59.5% of nurses considered migrating for education, 40.5% for better job opportunities, and 21.6% for a higher standard of living [32]. In addition, the desire to migrate even if conditions in Turkey improve, lack of belief that conditions will ever improve, and the desire to migrate to explore new places and meet people from different cultures were the most common reasons for considering migration among the nursing students. More recently, discouraging work conditions such as increased violence against healthcare workers and the excessive workload at the time of the pandemic seem to have reinforced the nursing students’ inclination towards migration.

Among the nursing students participating in this study, 20.2% expressed a preference to move to Germany. In contrast, a study by Nguyen et al. found that 59% of nursing students desired to work in the USA and 49% in the United Kingdom [27]. According to the UNESCO (United Nations Educational, Scientific and Cultural Organization), the top destination countries that receive the most immigrants include the USA, the UK, Germany, France, Australia, Japan, Russia, Spain, Belgium, Canada, and Italy [33]. The preference for Germany among the students may be attributed to several factors. Germany offers more favorable working conditions and wages for nurses compared to Turkey. Also, there is significant promotion of nursing job opportunities in Germany through internet and social media channels. Germany’s population is getting older, and consequently there is a high demand for nurses. Also, Germany is the top destination for migration due to its high-quality universities, advanced research centers, and extensive economic and cultural opportunities. As noted by Karaca and Yurttaş, the preference for Germany among healthcare workers may be influenced by the possibility that they would be subjected to less discrimination because of the large Turkish population living there [34].

More than half of Turkish nursing students consider moving abroad to seek better working conditions, higher living standards, financial gains and educational opportunities, with Germany being their top destination country. In spite of low levels of hopelessness observed among the students, the tendency for migration persisted. These results highlight the need for policymakers and educational institutions to develop strategies and practices aimed at reducing migration tendencies of nursing students by focusing on improving nurses’ living and working conditions in Turkey.

In this context, the following actions are proposed: