Emigration challenges for Iranian nurses: A qualitative content analysis study

Abstract

Background

The immigration of educated professionals, including nurses, presents a significant challenge, particularly for developing countries. There has been a lack of research in the Iranian context aimed at thoroughly exploring the motivations and difficulties experienced by nurses seeking to emigrate. This qualitative study was conducted to explore the challenges Iranian nurses encounter when emigrating.

Method

This qualitative study employed a conventional content analysis approach. The participants included 12 Iranian nurses with either experience or an intention to emigrate, selected in 2024 through purposeful and snowball sampling. They provided their written informed consent to participate. Data were collected and simultaneously analyzed through semi-structured individual interviews until theoretical saturation. MAXQDA software version 2020 was utilized to manage and analyze the textual data.

Results

Inductive data analysis revealed 22 sub-categories and three main categories, namely “Repulsions inside the country,” “Allures abroad,” and “Emigration challenges and obstacles”.

Conclusion

Numerous professional, economic, social, and political challenges within and outside the country and the aspiration for a better life and experience in a new setting, have resulted in a strong inclination among Iranian nurses to emigrate. Nonetheless, obstacles, including language acquisition, admission complexity, homesickness after immigration, and cultural disparities, represent significant hurdles requiring further investigation.

Introduction

The emigration rate has increased 1.5 times in the last 20 years, posing a challenge for developing countries [1–2]. The emigration of educated healthcare providers, particularly nurses, is a primary concern as it burdens the healthcare system of the country of origin and reduces the quality of health services. Nurses are the foundation of a health system. Now, the world is facing a health crisis [3]. It is predicted that by 2030, the world will suffer from a shortage of about 15 million healthcare providers, including doctors and nurses [4], exacerbating the current shortage of approximately 9 million nurses worldwide and shifting the public health burden to non-communicable diseases [5]. This issue will intensify as the growing elderly population places greater demands on healthcare providers [6].

In the 1970s, only 5% of nurses worked outside their hometowns. Today, the proportion of immigrant nurses has risen to 37% in Australia, 25% in New Zealand and Switzerland, and 15% in the United States of America, Canada, and England [7]. Numerous factors influence nurses’ migration patterns. Research findings suggest that nurse migration stems from complex economic, social, political, and cultural issues [8]. Nurse migration is not a recent trend. Nursing allows nurses to work in foreign settings and seek employment abroad [9–10]. Over the past few decades, migration waves have led many skilled professionals and educated individuals to depart for Western European and North American nations [11]. Nearly 100,000 nurses trained outside of the United States are now working in the country. Foreign-educated immigrants significantly contribute to the healthcare system in the United States [12]. The most qualified nurses from abroad are employed in the United Kingdom, Ireland, Norway, the United States of America, New Zealand, and Australia [13–14].

Both official and unofficial statistics on the emigration of highly educated individuals from Iran highlight a concerning trend. Skilled professionals such as university professors, doctors, nurses, researchers, engineers, and students leave the country, creating significant political, economic, and social challenges and raising numerous concerns [15]. According to the International Monetary Fund report, Iran ranks first among 91 developing or developed countries in elite emigration [16]. Approximately 180 thousand educated Iranians depart the country annually for better opportunities, resulting in an annual loss of 50 billion dollars from the country’s economy [17]. Additionally, the United Nations’ latest official statistics rank Iran third among 18 developing countries regarding the emigration of specialized professionals [18]. Notably, the emigration of nurses is a particularly prominent issue, stemming from both push and pull factors within and outside the country [19].

Unfortunately, there is a lack of comprehensive data on the emigration of professionals across different fields, including the healthcare sector, in Iran. In certain instances, there is a lack of evidence regarding the number of graduates entering the workforce. The absence of accurate information and statistics in these fields is apparent [20]. The vice president of development and resource management of the Iranian Nursing Organization (INO) stated that in 2021, over a thousand nurses emigrated from the country [21], which increased to over 2000 individuals in 2022 [22], indicating a rising trend [23]. Furthermore, apart from the shortage of precise migration statistics, there is a dearth of in-depth studies examining the causes and factors of Iranian nurses’ emigration. Accordingly, conducting a comprehensive study to elucidate the challenges and factors of the emigration of Iranian nurses seems essential to propose strategies to aid policymakers and nursing managers in decision-making by thoroughly investigating the causes and factors of nurse emigration, thus averting potential harm from care quality and public health. This study explored the causes, factors, and challenges underlying the emigration of Iranian nurses.

Methods

Design, participants, and data collection

This qualitative study is part of a larger mixed methods study titled “Investigation of the intention to emigrate among nursing students and staffs and related factors,” conducted from October 2023 to July 2024 in Isfahan using a conventional content analysis approach. The participants included 12 nurses with experience in or intending to emigrate, selected through purposive and snowball sampling. The results of the initial phase (quantitative part) were useful in identifying participants with significant emigration experiences (Table 1). Inclusion criteria for participants included Iranian nationality, proficiency in the Persian language, and at least a bachelor’s degree in nursing. The participant selection process continued until theoretical data saturation was reached by the 10th interview and continued until the 12th interview to ensure reliability.

Table 1 Demographic characteristics of study participants

The data was collected through individual semi-structured interviews. Each interview began with a brief overview of the study’s objectives. It was followed by encouraging participants to share their insights and experiences related to emigration and its underlying causes and influencing factors. The interview guide included key questions such as: “Could you describe your immigration experience?“, “What made you decide to immigrate?” “What challenges did you encounter before, during, and after emigration?” “What obstacles did you face during the emigration process?” “What factors facilitated your emigration?” and “Please share your experiences in the destination country.” The phrasing of the questions was tailored based on whether the participant had previously emigrated or intended to do so, with follow-up questions aiming to delve deeper into their responses by asking “Why?” and “How? and requesting further explanation.

The researcher and the participant agreed upon the location of face-to-face interviews, often in one of the rooms at the participants’ workplace in Isfahan hospitals. The interviews were conducted in the presence of the interviewer and the participant only while ensuring the individuals’ privacy. Virtual interviews were conducted via Skype for emigrated individuals who were unreachable in person. The interviews were recorded with the participant’s permission, and their confidentiality was emphasized. The interviews lasted 30 to 60 min, with an average of 45 min, depending on the participants’ situations and conditions.

Data analysis

This qualitative study conducted from October 2023 to July 2024 in Isfahan using a conventional content analysis approach. Throughout the data collection process, coding and analysis were conducted simultaneously. Audio files were transcribed verbatim after each interview. Each interview was thoroughly reviewed multiple times to gain a comprehensive understanding of the data. The meaning units were identified, and the participants’ statements were coded. Subsequently, conceptually similar codes were grouped into categories. As the analysis progressed, the similarities and differences between codes and categories were carefully examined to distinguish their unique features and dimensions. Through continuous comparison, categories were merged, and main themes were derived. MAXQDA software version 2020 was utilized for data analysis management.

Rigor and trustworthiness

To ensure the accuracy and reliability of the data, four criteria proposed by Lincoln and Guba—credibility, dependability, transferability, and confirmability— were considered [24]. Researchers enhanced the accuracy and reliability of their findings by acknowledging their preconceptions, selecting specialists with diverse backgrounds, reaching consensus on the draft, obtaining external validation, meticulously documenting actions and decisions, and providing a detailed description of the research process. Additionally by conducting in-depth interviews with participants in various sessions and settings, employing a combination of data collection methods (such as interviews, observations, and field notes), validating extracted codes with participants to ensure data accuracy, and having experts review the data separately to confirm that the derived categories align with participants’ statements.

Ethical considerations

This study was approved by the Ethics Committee of Isfahan University of Medical Sciences, with the code IR.MUI.NUREMA.REC.1402.172. All interviews were conducted while adhering to ethical guidelines and respecting the participants’ privacy. Before recording any conversations, informed consent was obtained and documented from participants. Furthermore, all information, including participants’ identities and interview materials, was kept confidential.

Results

During the inductive data analysis, 257 open codes were extracted and summarized in 22 sub-categories and three main categories (Table 2). The main categories included “Repulsions inside the country,” “Allures abroad,” and “Emigration challenges and obstacles.” These categories, relevant sub-categories, and transcripts are described thoroughly in the text.

Table 2 Main categories and related sub-categories

Repulsions inside the country

The factors causing repulsion decreased nurses’ motivation, job satisfaction, and intention to work in their country. This concept was obtained from six sub-categories:

Disproportionate workload and salary

The participants believed that low salaries, the high income of individuals with low education, the double financial pressure on educated individuals, and the allocation of more privileges for male nurses increased their desire to emigrate. In this regard, one of the participants stated:

“I’m a specialized nurse with good skills and postgraduate education, but I’m feeling unsatisfied at work; I’m often in a bad mood. Our workload is extremely high, and we don’t receive much recognition.” (PN 4).

Nurses’ low dignity in society

Despite improved nurse dignity in recent years, according to some participants, doctors’ disrespect to nurses, patients and companions’ insults to nurses during care, and conflict with the patient and their companion during work caused their dignity not to be preserved:

“When I was in Iran, I was disrespected by patients and their companions; it would happen either to me or to my colleague, which discouraged me. I was also disrespected by doctors and hospital officials, which was unbearable.” (PN 3).

Economic and social challenges

Some participants believed unstable living costs and the lack of recreational and welfare amenities motivated them to emigrate.

“… inflation, which makes us poorer gradually, made me decide to leave; now it doesn’t matter where it is, I go to a place where I feel safe.” (PN 11).

Incentivize emigration

The participants stated that the encouragement from those around them, including colleagues and relatives, the desire and support from their spouses and family members to emigrate, and their interest in gaining new experiences motivated them to emigrate.

“… my wife’s accompanying me to emigrate was very effective. I mean, this was a kind of encouragement. The more the problems increased, the more I was encouraged to leave that environment.” (PN 9).

Restrictions of professional promotion

The discrimination in the work environment, neglect of individuals’ human rights, rigid employment criteria, mismatch between the job position and the level of education and ability, injustice in nursing, and assigning management positions to specific individuals without noticing the challenges faced by nurses were identified as obstacles to competent nurses’ career promotion, decreasing their motivation to work in their home country.

“… I’ve worked where someone became the hospital manager with no related knowledge; they got the position only through connections, creating thousands of problems; well, there are such discriminations.” (PN 1).

High workload

The heavy workload, mandatory overtime, stress, and mental pressure make it challenging for nurses to sustain their work and provide quality care.

“… Colleagues are forced to work overtime, which is illegal in European and American countries, and no one can assign you forced work; this isn’t tolerable in the long term.” (PN 10).

Allures abroad

Allures abroad represent the factors, particularly in developed countries, that motivate nurses to emigrate and achieve those ideals. This concept was obtained from eight sub-categories:

A better future for offspring

The participants emphasized securing better opportunities for their children’s development, ensuring access to quality education, safeguarding their future, and guaranteeing job prospects as factors influencing their intention to emigrate.

“… a very good point is knowing that your child will have a good future, be independent, and manage themselves; they won’t expect support from you.” (PN 11).

The attractiveness of foreign countries

A new life in an unexplored environment, the attractiveness of the living environment, and interest in working in a different setting were among the factors motivating participants to emigrate:

“… In the first days when we came here, we encountered a new environment and new people. Finally, it has its charm; you don’t think much about the problems, but about the fact that you finally came, about the charm of this country and its sights and people: well, it’s delightful.” (PN 3).

Proportionality of salary and expenses

The participants stated that proportionate salaries, justice in nurses’ and doctors’ salaries, and the possibility of living a comfortable and worry-free life due to high salaries encouraged them to emigrate:

“… a nurse’s salary is excellent here. You can live, travel, and spend money easily, which makes you do the most difficult work.” (PN 2).

Patient-centeredness

Comprehensive patient care, according to the standard nurse-to-patient ratio, without gender restrictions, provides patient-centered and high-quality care abroad.

“In America, there’s a patient orientation; patients define many things; for example, they can reject a specific doctor or a nurse; there’s patient orientation. To treat your patient, you have to consider all of your patient’s needs.” (PN 9).

Straightforward recruitment of nurses

Recruiting nurses based on merit and work history, the advantage of requiring work experience, the promise of a secure future, and the flexibility to work at various life stages make nursing an attractive opportunity for emigration.

“… The main strength that made me leave was my major, nursing; I didn’t need to emigrate as a refugee with all the misery and shame; I could have a job for myself from the moment I arrived there.” (PN 5).

A sense of dignity and value abroad

The participants believed that patients overseas highly value the services provided and have a deeper understanding. In addition, nurses hold significant power, respect, and esteem among the healthcare team and members of society. There is improved collaboration and a culture of mutual respect between doctors and nurses.

“… Here, the patients are extremely grateful; if you do something for them, they’ll thank you repeatedly; they like the nurse to be beside them and talk to them, which creates a good feeling” (PN 7).

Safer work environment

Factors such as consistent application of rules, addressing mistakes without bias, taking a systemic approach to errors, ensuring legally-obtained management positions, providing legal protections for nurses, and prohibiting overtime create a better and safer work environment. One of the participants stated:

“… for example, since I’m in Canada, no one has recruited through connections; progress is step by step and has specific rules; it’s not like an elevator letting someone grow.” (PN 4).

Desirable lifestyle abroad

The interview participants emphasized that despite the high costs and tax burden, nurses experience satisfactory well-being abroad. They have access to comfortable amenities and recreational facilities, which contribute to their overall physical, mental, and psychological well-being as citizens.

“… a nurse in Canada gets 5,000 dollars at the lowest level; to have an ideal life there, you need almost 2,500 dollars; you can advance 3,000 dollars a month; you can travel and save money.” (PN 8).

Emigration challenges and obstacles

Obstacles to emigration are elements that impact immigrants and complicate their journey through the emigration process.

Language learning problems

Some of the major challenges hindering emigration included the arduous process of mastering a new language, the time-consuming nature of learning, the cost of participating in language courses, the complexity of achieving proficiency in the destination country’s language, and the reliance on others due to insufficient language skills. In this regard, one participant remarked:

“… I’ve entered the emigration process myself; I know how hard it is to learn another language and be able to communicate, how time-consuming it is; with the shifts that nursing and medical staff have, they need to learn a language. It’s so difficult to learn it completely.” (PN 6).

The hardships of the admission process

The challenges of obtaining a visa and residency, as well as preparing the necessary emigration documents, the high costs associated with legal matters, including hiring attorneys for emigration, the unavailability of international language tests such as the TOEFL in Iran, and the complexities of leaving behind a male child due to the lack of a legal guardian, all pose significant obstacles.

“… to get my certificate, I struggled hard; hiring a lawyer and high fees! Every day a new problem came up, which made these few years pass very hard.” (PN 1).

Homesickness after immigration

The feeling of loneliness in the foreign country, longing for the family and country, emigrating despite the love for the country and compatriots, and the difficulty of commuting due to a busy work schedule were among the experiences of immigrant participants in the destination country. Here is an excerpt from one participant’s experience:

“… After a month, you feel a sense of emptiness; you wonder what that emptiness is. It’s for your family. Although the video and voice call have solved this problem, longing for my family bothers me.” (PN 4).

Housing-related problems

The participants highlighted the challenges of high rental costs, living with immigrants due to financial constraints, living in shared houses, and waiting for housing.

“… If you want to buy a house here, you have to wait a long time and register for it, or you have to live in shared houses because the population is too high, there’re too many immigrants, and the number of houses is small. The housing problem is critical for immigrants.” (PN 8).

Cultural challenges

Basic cultural differences, a different lifestyle, racial discrimination, and misconceptions about Iranians based on the media, followed by inappropriate treatment, were among immigrant nurses’ challenges. In this regard, one of the participants stated:

“…When I came here, I realized that it wasn’t what I thought; I was religious for a while; I couldn’t cope with the culture here; everything went hand in hand to make me return.” (PN 2).

Imposing double mental and emotional pressures

In their interviews, the participants mentioned the fragility of their mental state due to bearing the burden of responsibility, the insipidity of managing life without family support, depression due to the lack of a fellow countryman, and the stressfulness of the nursing profession worldwide.

“… it’s tough for a person to manage all these alone; I got really nervous because there were problems with my child, like his teacher, his food that I had to manage; in my opinion, it’s challenging to emigrate alone and carry the burden of life.” (PN 11).

The difference in working conditions

The different work styles, the responsibility of meeting the patient’s basic needs, the need to keep up-to-date scientifically, and the strict rules were work-related problems faced by immigrant nurses. In this regard, a participant stated:

“… Here, nurses change the patient’s diaper and bed sheet, but we Iranians work luxuriously and don’t do such tasks; auxiliary nurses do them. If I had no choice, I’d be ready to return to Iran and do the same job again. Nursing in Iran is easier than here.” (PN 2).

Limitations of living outside of Iran

The participants mentioned high taxes, limited income, and the high price of services as limitations.

“… here isn’t a country where you can get rich immediately. The other problem is high tax because the country relies on it; citizens are used to them, and the immigrants are getting used to it.” (PN 5).

Discussion

This study explored the challenges, causes, and influencing factors behind the emigration of Iranian nurses. Key factors driving the desire to emigrate included issues within the country, such as disparities in workload and salary, economic instability, social and political problems, limited opportunities for career advancement, and diminished social status. These challenges dampened nurses’ motivation and enthusiasm, prompting them to seek opportunities abroad. According to Onso (2020), emigration arises when the home country fails to meet its citizens’ socioeconomic and political needs [25]. The pressures leading to nurse emigration encompass poor living conditions, political instability, oppressive governance, economic hardships, conflict, limited freedom of speech, security concerns, restricted job prospects, insecurity, and uncertainty [26]. A study conducted by the International Nurses Association regarding the international emigration of nurses highlights that this trend often reflects significant challenges within their home countries [27]. In Spain, a literature review focusing on the emigration of Spanish nurses from 2009 to 2014 identified unstable and precarious employment and changes in the healthcare system due to austerity measures following the financial crisis as the primary reasons for the emigration [28]. Additionally, Shamsi et al. noted in their study (2020) that in Iran, a country with a limited social support system, work-related injuries were among the main factors driving nurses to emigrate [29].

Other challenges contributing to nurses’ emigration include the appeal of abroad, driven by factors such as better prospects for their children, higher salaries relative to living expenses, patient-centered care, straightforward recruitment processes, recognition and appreciation outside their home country, improved and safer work environments, and a more desirable lifestyle. Furthermore, a study by Hessam al-Mansour in 2023 revealed that individuals who emigrate, seeking a safer and high-quality life, employment, and professional development opportunities for themselves and their families, mainly come from low-income countries [28]. In 2024, Danny noted that countries like Germany, the UAE, the UK, and Singapore have adopted various strategies to attract Internationally Educated Nurses (IENs), including competitive salaries, travel perks, licensure exam incentives, recognition of foreign qualifications, and expedited visa processing [30].

During the study, the challenges and obstacles of emigration for nurses were identified, including difficulties with language learning, complicated admission process, homesickness post-emigration, residence-related challenges, cultural differences, and mental and emotional pressures of the destination country, as well as adjusting to different working conditions from their home country. Smith et al. emphasized in their 2022 study that one of the major challenges for nurses immigrating to Germany, Australia, and the United Kingdom was the lack of language proficiency and the need to improve language learning skills [13]. Additionally, Dahl’s 2022 study highlighted that immigrant nurses encountered communication barriers, discrimination, marginalization, and cultural mismatch [6]. The findings of these studies, as well as the present research, underscore the significance of acknowledging the challenges and obstacles faced by emigrating nurses.

Limitations

This study had some limitations. one of them was the inability to access several participants. We attempted to address this limitation by utilizing virtual communication methods. Some participants may have opted not to share their experiences for personal reasons. Also, The comprehension and experiences of participants regarding migration issues may be shaped by socio-economic factors and the specific time frame of the research, and these perspectives can evolve over time.

Conclusion

The longing for a better life and a new working environment, combined with numerous occupational, economic, social, and political challenges both domestically and internationally, has spurred a strong desire among Iranian nurses to emigrate. However, they encounter obstacles such as language acquisition, hardships in the admission process, homesickness, and cultural disparities. These hurdles require further examination. Given the vital role of nurses in the country’s healthcare sector, policymakers should address the issues outlined in the study. It seems, Improving nurses’ economic conditions and emphasizing their dignity and respect can help reduce nurse’s immigration.