Xenophobia levels among nurses and associated factors in Türkiye: a cross-sectional study

Abstract

Background

Xenophobia refers to negative attitudes and prejudices directed toward individuals perceived as foreigners. In countries hosting large migrant populations, such attitudes among healthcare professionals may affect communication, trust, and healthcare delivery for migrant patients.

Aim

This study aimed to determine the level of xenophobia among a web-based sample of self-identified nurses from Türkiye and to examine differences in xenophobia scale scores according to selected sociodemographic and professional characteristics.

Methods

This descriptive, cross-sectional, web-based survey study was conducted between January 13 and February 5, 2022, with 761 self-identified nurses employed in healthcare institutions in Türkiye. Participants were recruited through non-probability snowball sampling via social media platforms (Instagram, Facebook, Telegram, X/Twitter, and WhatsApp). Eligibility was based entirely on self-report and could not be independently verified. Data were collected anonymously using Google Forms. Descriptive statistics, independent samples t-tests, one-way ANOVA, effect size calculations, and hierarchical multiple linear regression analyses were performed.

Results

The mean Xenophobia Scale score was 51.42 ± 12.93 (possible range: 11–66). Female nurses had significantly higher xenophobia scores than male nurses (p = .013), whereas nurses who identified as belonging to an ethnic minority group had significantly lower scores (p = .002). Nurses with medium religiosity levels had significantly higher xenophobia scores than those with high religiosity levels (p = .003). Nurses who believed that foreign patients brought new diseases, reported difficulty providing care to foreign patients, and preferred not to provide care to foreign patients had significantly higher xenophobia scores (p < .05). In the regression analysis, ethnic minority status, absence of foreign social contact, belief that foreign patients bring new diseases, and perceived difficulty in providing care to foreign patients remained independently associated with xenophobia scores.

Conclusion

Xenophobia scale scores differed according to several sociodemographic characteristics and migration-related care experiences. However, due to substantial methodological limitations, including non-probability sampling and self-reported online participation, findings should be interpreted cautiously and cannot be considered nationally representative.

Introduction

Migration has been a persistent global phenomenon throughout human history and has intensified in recent decades due to political conflicts, economic instability, and environmental crises [1, 2]. As a result, many countries are hosting increasing numbers of refugees, asylum seekers, and migrants [3]. According to the United Nations High Commissioner for Refugees (UNHCR), Türkiye hosts one of the largest refugee populations in the world, with millions of displaced individuals residing in the country [4, 5]. The increasing presence of migrants in host societies has important social, cultural, and healthcare implications [6].

Xenophobia is generally defined as negative attitudes, prejudice, fear, or hostility directed toward individuals perceived as foreign or outside the national in-group [7]. Xenophobia-related attitudes are closely associated with stereotypes, discrimination, ethnocentrism, and social exclusion [8, 9]. Such attitudes may emerge due to perceived cultural, social, or economic threats and can be influenced by various sociodemographic factors such as gender, education level, socioeconomic status, and political views [10–12].

The growing number of migrants worldwide has also created new challenges for healthcare systems [13]. Migrants and refugees often experience multiple health problems related to difficult living conditions, limited healthcare access, and language barriers. As a result, they frequently seek healthcare services in host countries and interact with healthcare professionals during the diagnosis, treatment, and care processes [14–17]. Among healthcare professionals, nurses play a particularly critical role in the delivery of care to migrant and refugee populations because they are the primary providers of direct patient care and maintain continuous communication with patients and their families [18, 19]. Nurses are often responsible for assessing patient needs, coordinating care, providing health education, and ensuring continuity of treatment across clinical settings. Consequently, nurses’ attitudes toward foreign patients may directly affect communication quality, trust, patient satisfaction, adherence to treatment, and equitable access to healthcare services. In culturally diverse healthcare environments, xenophobia-related attitudes among nurses may therefore have important implications for patient safety, quality of care, and health equity [18, 19].

Providing effective healthcare services to culturally diverse populations requires healthcare professionals to demonstrate cultural sensitivity, empathy, and effective communication skills [20]. Nurses are expected to provide holistic care that respects patients’ cultural backgrounds, beliefs, and values [21, 22]. However, prejudices or negative attitudes toward migrants may negatively influence nurse–patient communication and the quality of healthcare services [23]. If xenophobia-related attitudes are reflected in healthcare interactions, they may create barriers to healthcare access and compromise the quality of care delivered to migrant patients [24–26].

Previous studies have examined xenophobia among healthcare professionals, healthcare students, and the general population [15, 17, 27, 28]. Existing evidence suggests that negative attitudes toward migrants may be associated with communication difficulties, reduced intercultural sensitivity, and barriers to healthcare access. However, research specifically focusing on actively working nurses remains limited, particularly in countries hosting large refugee populations such as Türkiye. This gap is important because nurses are among the healthcare professionals who interact most frequently and continuously with patients during care delivery. Xenophobia-related attitudes in nursing care settings may negatively affect therapeutic communication, patient trust, quality of care, patient safety, and equitable healthcare access for migrant populations. Understanding xenophobia-related attitudes among nurses may therefore contribute to the development of culturally sensitive nursing practices, workforce training strategies, and more inclusive healthcare environments. Although data collection for the present study was completed in 2022, the literature review was updated during the manuscript revision process to incorporate recent evidence relevant to migration, xenophobia, and healthcare delivery. These more recent sources were used to contextualize and interpret the findings and did not inform the original study design, data collection procedures, or analysis plan. Given the limited evidence regarding xenophobia among actively working nurses in countries hosting large refugee populations, this study sought to address this gap by examining xenophobia levels among nurses in Türkiye and identifying the sociodemographic and migration-related factors associated with these attitudes. In the context of increasing global migration, understanding healthcare professionals’ attitudes toward migrant populations has become an important component of culturally safe and equitable healthcare delivery.

Research questions

1. What is the level of xenophobia among nurses working in healthcare institutions in Türkiye?

2. Do nurses’ xenophobia levels differ according to their sociodemographic characteristics (such as gender, education level, professional experience, and religiosity)?

3. Is there a relationship between nurses’ experiences and views regarding foreign patients and their xenophobia levels?

4. Which factors are associated with higher xenophobia levels among nurses?

Materials and methods

Study design

This study was designed as a descriptive, cross-sectional web-based survey. This survey conducted among self-identified nurses working in healthcare institutions in Türkiye.

Participants and sampling

The study was conducted between January 13 and February 5, 2022, with nurses working in healthcare institutions in Türkiye. According to national statistics, there were 198,465 nurses working in Türkiye as of January 1, 2020. The minimum required sample size was calculated as 622 using the Raosoft sample size calculator with a 99% confidence level and a 5% margin of error. Considering possible data loss, the sample size was increased by approximately 10%, and the study was completed with 761 nurses. In addition to the population-based sample size estimation, a post hoc power analysis was conducted using G*Power 3.1 to evaluate the adequacy of the achieved sample size for subgroup comparisons. Assuming a medium effect size (f = 0.25), an alpha level of 0.05, and a statistical power of 0.80, the required minimum sample size was substantially lower than the achieved sample of 761 participants, indicating that the study had sufficient statistical power for exploratory group comparisons.

Participants were recruited using non-probability snowball sampling through social media platforms such as Instagram, Facebook, Telegram, X/Twitter, and WhatsApp. Nurses who were between 18 and 60 years of age, actively working in healthcare institutions in Türkiye, and who voluntarily agreed to participate were included in the study. Because the survey was distributed openly through social media platforms, professional status could not be independently verified through institutional registration systems or professional licensing databases. Eligibility was based entirely on self-report. Therefore, although the survey specifically targeted actively working nurses and clearly stated the inclusion criteria, the possible inclusion of individuals outside the intended target population cannot be completely excluded. The 2020 workforce statistic was used because it represented the most recent official national nursing workforce estimate available during the study planning phase.

Data collection tools

The research data were collected by using the Personal Information Form and the Xenophobia Scale.

Personal information form

This form was developed by the researchers based on the relevant literature and included 15 questions. The Personal Information Form included questions regarding sociodemographic and professional characteristics, including age, gender, education level, institution type, region of residence, ethnic minority status, and religiosity. Ethnic minority status was assessed through self-identification (yes/no). Religiosity was assessed using a single self-reported item in which participants evaluated their own level of religiosity as low, moderate, or high. In this study, the term “foreign patients” was used broadly to refer to non-Turkish nationals receiving healthcare services in Türkiye, including migrants, refugees, asylum seekers, and other foreign-born individuals.

Xenophobia scale

The Xenophobia Scale was originally developed by Veer et al. (2011) and later adapted into Turkish by Özmete, Yıldırım, and Duru (2018) [29]. The Xenophobia Scale consists of 11 items rated on a six-point Likert scale ranging from 1 (“strongly disagree”) to 6 (“strongly agree”). Item 8 was reverse-coded prior to analysis. Total scores range from 11 to 66. The Cronbach’s alpha coefficient of the Turkish version was reported as 0.87 [29]. In the present study, the Cronbach’s alpha coefficient was calculated as 0.89. Permission to use the Turkish adaptation of the Xenophobia Scale was obtained from the authors who conducted the Turkish validity and reliability study prior to data collection.

Data collection procedure

The survey was conducted anonymously using Google Forms and distributed through social media platforms, including Instagram, Facebook, Telegram, X/Twitter, and WhatsApp. Before accessing the questionnaire, participants were asked to confirm that they were actively working nurses and voluntarily agreed to participate in the study. No identifying information, such as names, contact information, or IP addresses, was collected. To reduce duplicate participation, the “Limit to 1 response” setting available in Google Forms was activated. However, because no advanced verification procedures (e.g., IP-based tracking or duplicate detection algorithms) were implemented, duplicate responses could not be completely excluded. All questionnaire items were mandatory; therefore, there were no missing data. No centralized registry or database of nurses’ contact information was used in this study. Participation was entirely voluntary, and the survey link was openly distributed in online environments where nurses were likely to be present. To enhance the relevance of the sample, the study invitation clearly specified the inclusion criteria (e.g., being an actively working nurse).

Data analysis

Data were analyzed using the Statistical Package for the Social Sciences (SPSS, version 22.0). Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize participant characteristics. Prior to inferential analyses, the assumptions of parametric tests were evaluated. Normality assumptions were assessed using Shapiro–Wilk tests together with skewness and kurtosis values. Although the Shapiro–Wilk test was statistically significant because of the large sample size (n = 761), skewness and kurtosis values for the Xenophobia Scale total score remained within acceptable limits (skewness = -0.64, kurtosis = 0.71), thereby supporting the use of parametric analyses. Homogeneity of variances was examined using Levene’s test. For comparisons between two groups, independent samples t-tests were used. For comparisons involving more than two groups, one-way analysis of variance (ANOVA) was performed. When ANOVA results were statistically significant, Tukey’s HSD post hoc test was conducted to determine pairwise group differences. Effect sizes were calculated to evaluate the practical significance of group differences. Cohen’s d values were reported for independent samples t-tests, and eta-squared (η²) values were reported for ANOVA analyses. Cohen’s d values of 0.20, 0.50, and 0.80 were interpreted as small, medium, and large effect sizes, respectively. Eta-squared (η²) values of 0.01, 0.06, and 0.14 were interpreted as small, medium, and large effect sizes, respectively. To identify variables independently associated with Xenophobia Scale scores, a hierarchical multiple linear regression analysis was additionally conducted. Variables found to be statistically significant in univariate analyses were entered into hierarchical regression models according to conceptual relevance. Assumptions of linear regression, including multicollinearity, independence of errors, and normality of residuals, were evaluated before model construction. Variance inflation factor (VIF) and tolerance values indicated no evidence of problematic multicollinearity. The level of statistical significance was set at p < .05.

Ethical considerations

Ethical approval for the study was obtained from the İstanbul Gedik University Scientific Research Ethics Committee (Date: January 12, 2022; Approval No: 274). Participants were informed about the purpose of the study, and participation was voluntary. Informed consent was obtained electronically before participants completed the survey. Permission was obtained for the use of the Xenophobia Scale. The study was conducted in accordance with the principles of the Declaration of Helsinki. As data were collected via an online survey, the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) guidelines were followed.

Results

The mean age of the nurses participating in the study was 33.68 ± 7.87 years (min: 18, max: 60). Of the participants, 87.5% were female, 55.1% had a bachelor’s degree, and 34.8% had a master’s degree or higher. In terms of professional experience, 42.3% had been working as nurses for 11 years or more. The majority of participants worked in public hospitals (81.5%), and 38.4% worked in special service units such as emergency departments, intensive care units, and operating rooms. Additionally, 66.5% of the nurses reported that they had lived the longest in western Türkiye. While 84.8% stated that they did not belong to an ethnic minority group, 81.2% reported that their families hadn’t migrated to Türkiye. Most participants (84.8%) evaluated their level of religiosity as moderate (Table 1).

Table 1.

The breakdown of nurses by personal characteristic (n = 761)

Variables		n	%
Mean age of nurses 33.68 ± 7.87 years (min:18, max:60)
Gender	Female	666	87.5
	Male	95	12.5
Education level	Health vocational high school- Associate degree program	77	10.1
	Bachelor’s degree program	419	55.1
	Master’s degree program or above	265	34.8
Years of work experience in the nursing profession	Below 1 year	54	7.1
	1–5 years	214	28.1
	6–10 years	171	22.5
	11 years or above	322	42.3
Institution	Private hospital	141	18.5
	Public hospital	620	81.5
Service unit	Inpatient service	233	30.6
	Outpatient service	117	15.4
	Special service unit*	292	38.4
	Others**	119	15.6
The region where the nurse lived for the longest in Türkiye	Western Türkiye	506	66.5
	Central Türkiye	145	19.0
	Eastern Türkiye	110	14.5
Being a member of an ethnic minority group in Türkiye	Yes	116	15.2
	No	645	84.8
Being from a family that immigrated to Türkiye	Yes	143	18.8
	No	618	81.2
The self-evaluation of the religiosity level	High	72	9.5
	Medium	646	84.8
	Low	43	5.7
	Total	761	100.0

* Emergency service, intensive care unit, surgical operation room, and so on

** Administrative units, administration, and so on

Regarding nurses’ views about foreign patients, 72.5% believed that foreign patients brought new diseases, and 57.3% reported having difficulty providing care to foreign patients. In addition, 71.4% stated that they would prefer to provide care to foreign patients if they had the option. While 56.9% reported not having foreign individuals in their social circles, 41.5% indicated that they would not like to work or live as migrants in another country (Table 2).

Table 2.

The breakdown of nurses’ views about foreign patients and the mean Xenophobia Scale score (n = 761)

Variables					n		%
Thinking that foreign patients bring new diseases		Yes			552		72.5
		No			209		27.5
Being in contact with a foreign individual in the inner circle		Yes			328		43.1
		No			433		56.9
Having difficulty in providing foreign patients with care		Never provided a foreigner with care before			92		12.1
		Yes			436		57.3
		No			233		30.6
Preferring not to give care to the foreign patient if that option is available		Yes			218		28.6
		No			543		71.4
Wanting to live/work as a migrant in another country		Yes			270		35.5
		No			316		41.5
		N/A			175		23.0
		Total			761		100.0
Scale	Mean		Sd.	Min.		Max.
Xenophobia Scale	51.42		12.93	11		66

Note: Min.: minimum, Max.: maximum

The mean score obtained from the Xenophobia Scale was 51.42 ± 12.93 (min: 11, max: 66), indicating that the mean score was located in the upper range of the scale (Table 2).

When xenophobia levels were examined according to sociodemographic characteristics, statistically significant differences were found according to gender, ethnic minority status, and self-reported religiosity level (p < .05). Female nurses had significantly higher xenophobia scores than male nurses (t = 2.501, p = .013, Cohen’s d = 0.28), indicating a small effect size. In addition, nurses who reported belonging to an ethnic minority group had significantly lower xenophobia scores compared with those who did not belong to an ethnic minority group (t = -3.142, p = .002, Cohen’s d = 0.31), reflecting a small effect size. A statistically significant difference was also found according to self-reported religiosity level (F = 5.889, p = .003, η² = 0.015), indicating a small effect size. Post hoc analysis (Tukey’s HSD) demonstrated that nurses with medium religiosity levels had significantly higher xenophobia scores than those with high religiosity levels (High < Medium). No statistically significant differences were observed between the low religiosity group and the other religiosity groups. No statistically significant differences were found according to age (η² = 0.002), education level (η² = 0.004), years of professional experience (η² = 0.005), institution type (Cohen’s d = 0.16), service unit (η² = 0.007), region lived in the longest (η² = 0.005), or family migration history (Cohen’s d = 0.02) (p > .05). Overall, although some group differences reached statistical significance, the observed effect sizes were generally small (Table 3).

Table 3.

The comparison of nurses’ mean Xenophobia Scale scores as per their demographic characteristics (n = 761)

Variables		Xenophobia Scale		Effect size
		Mean ± Sd	Test, p
Age	18–26 years	50.50 ± 12.88	F: 0.680 p: 0.507	η² = 0.002
	27–34 years	50.93 ± 12.89
	35 years or above	51.83 ± 13.29
Gender	Female	51.86 ± 12.56	t: 2.501 p: 0.013	Cohen’s d = 0.28
	Male	48.31 ± 14.95
Education level	Health vocational high school- Associate degree program	51.09 ± 12.33	F: 1.628 p: 0.197	η² = 0.004
	Bachelor’s degree program	49.51 ± 14.62
	Master’s degree program or above	51.97 ± 12.97
Years of work experience in the nursing profession	Below 1 year	48.33 ± 14.00	F: 1.232 p: 0.297	η² = 0.005
	1–5 years	51.43 ± 12.32
	6–10 years	51.58 ± 12.93
	11 years or above	51.84 ± 13.13
Institution	Private hospital	49.70 ± 13.63	t: -1.752 p: 0.080	Cohen’s d = 0.16
	Public hospital	51.80 ± 12.75
Service unit	Inpatient service	51.11 ± 12.57	F: 1.689 p: 0.168	η² = 0.007
	Outpatient service	53.37 ± 11.92
	Special service unit*	50.95 ± 13.22
	Others**	49.64 ± 14.36
The region where the nurse lived for the longest in Türkiye	Western Türkiye	51.77 ± 12.32	F: 1.767 p: 0.172	η² = 0.005
	Central Türkiye	51.79 ± 13.31
	Eastern Türkiye	49.26 ± 14.94
Being a member of an ethnic minority group in Türkiye	Yes	48.03 ± 15.72	t: -3.142 p: 0.002	Cohen’s d = 0.31
	No	52.02 ± 12.28
Being from a family that immigrated to Türkiye	Yes	51.67 ± 12.07	t: 0.138 p: 0.890	Cohen’s d = 0.02
	No	51.36 ± 13.13
The self-evaluation of the religiosity level	High (1)	47.24 ± 16.10	F: 5.889 p: 0.003 1 < 2*	η² = 0.015
	Medium (2)	52.08 ± 12.26
	Low (3)	48.37 ± 15.23

F: One-Way Analysis of Variance, t: t-test, *Post hoc (Tukey HSD): Nurses reporting high religiosity had significantly lower xenophobia scores than those reporting moderate religiosity

** Emergency service, intensive care unit, surgical operation room, and so on

*** Administrative units, administration, and so on

When xenophobia levels were analyzed according to nurses’ views and experiences regarding foreign patients, significant differences were observed in several variables (p < .05). Nurses who believed that foreign patients brought new diseases had significantly higher xenophobia scores than those who did not hold this belief. A statistically significant difference was found in xenophobia scores according to difficulty in providing care to foreign patients (F = 20.806, p = .001). Post hoc analysis (Tukey’s HSD) suggested that participants who reported difficulty had significantly higher xenophobia scores than those who had never cared for foreign patients, while those who did not report difficulty had the lowest scores (Yes > Never > No) (Table 4).

Table 4.

The comparison of nurses’ mean Xenophobia scale scores as per their views about foreign patients (n = 761)

Variables		Xenophobia Scale		Effect size
		Mean ± Sd	Test, p
Thinking that foreign patients bring new diseases	Yes	53.41 ± 12.10	t: 8.010 p: 0.001	Cohen’s d = 0.65
	No	45.25 ± 13.59
Being in contact with a foreign individual in the inner circle	Yes	48.89 ± 14.48	t: -4.247 p: 0.001	Cohen’s d = 0.31
	No	52.90 ± 11.55
Having difficulty in providing foreign patients with care	Never provided a foreigner with care before (1)	50.63 ± 13.38	F: 20.806 p: 0.001 2 > 1>3*	η² = 0.052
	Yes (2)	53.55 ± 12.11
	No (3)	46.91 ± 13.52
Preferring not to give care to the foreign patient if that option is available	Yes	54.17 ± 12.69	t: 4.064 p: 0.001	Cohen’s d = 0.33
	No	49.96 ± 12.99
Wanting to live/work as a migrant in another country	Yes	51.01 ± 12.87	F: 1.031 p: 0.357	η² = 0.003
	No	52.18 ± 12.61
	N/A	50.66 ± 13.59

F: One-Way Analysis of Variance, t: t-test *Tukey’s HSD

Note: Cohen’s d values of 0.20, 0.50, and 0.80 were interpreted as small, medium, and large effect sizes, respectively. Eta-squared (η²) values of 0.01, 0.06, and 0.14 were interpreted as small, medium, and large effect sizes, respectively

A hierarchical multiple linear regression analysis was conducted to examine variables independently associated with Xenophobia Scale scores (Table 5). Sociodemographic variables (age, gender, education level, religiosity, and ethnic minority status) were entered in the first block, intercultural contact variables (contact with foreign individuals and family migration history) in the second block, and migration-related care perception variables (belief that foreign patients bring new diseases and difficulty providing care to foreign patients) in the third block. Before conducting the regression analysis, assumptions were evaluated. Correlation coefficients among predictors were examined and no correlation exceeded r = .70, indicating no evidence of problematic multicollinearity. Variance Inflation Factor (VIF) values ranged between 1.01 and 1.08, and tolerance values ranged between 0.93 and 0.99, further supporting the absence of multicollinearity. Durbin–Watson statistics (1.994) indicated no substantial autocorrelation of residuals.

Table 5.

Hierarchical multiple linear regression analysis of variables associated with Xenophobia Scale scores

Variables			Model 1 B (SE)	β		p	Model 2 B (SE)		β	p		Model 3 B (SE)		β	p
Constant			53.292 (3.343)	—		< 0.001	50.709 (3.476)		—	< 0.001		50.838 (3.455)		—	< 0.001
Age			-0.004 (0.060)	− 0.003		0.943	-0.002 (0.059)		− 0.001	0.968		-0.027 (0.057)		− 0.017	0.635
Gender			-2.834 (1.426)	− 0.072		0.047	-2.392 (1.421)		− 0.061	0.093		-1.738 (1.361)		− 0.044	0.202
Education level			-0.016 (0.758)	0.001		0.983	0.107 (0.755)		0.005	0.888		0.083 (0.720)		0.004	0.908
Religiosity			-1.500 (0.725)	− 0.075		0.039	-1.404 (0.723)		− 0.070	0.052		-1.297 (0.689)		− 0.065	0.060
Ethnic minority status			3.759 (1.310)	0.105		0.004	3.624 (1.309)		0.101	0.006		2.924 (1.250)		0.081	0.020
Contact with foreign individuals			—	—		—	3.650 (0.935)		0.140	< 0.001		3.236 (0.893)		0.124	< 0.001
Family migration history			—	—		—	-0.396 (1.203)		− 0.012	0.742		-0.605 (1.151)		− 0.018	0.599
Belief that foreign patients bring new diseases			—	—		—	—		—	—		6.628 (1.017)		0.229	< 0.001
Difficulty providing care to foreign patients			—	—		—	—		—	—		1.466 (0.332)		0.156	< 0.001
Model	R	R²			Adjusted R²			ΔR²			ΔF		F
Model 1	0.154	0.024			0.017			0.024			3.666		3.666
Model 2	0.208	0.043			0.034			0.019			7.644		4.849
Model 3	0.366	0.134			0.124			0.091			39.362		12.903

Notes: Higher Xenophobia Scale scores indicate greater xenophobia-related attitudes. Binary categorical variables were dummy coded prior to analysis. ΔR² indicates change in explained variance at each regression step. ΔF indicates F-change associated with each hierarchical regression step. Durbin–Watson = 1.994. VIF values ranged from 1.01 to 1.08, indicating no evidence of problematic multicollinearity. For Model 1, ΔF equals the overall F-statistic because no prior block existed for comparison

In Model 1, sociodemographic variables explained 2.4% of the variance in Xenophobia Scale scores (R² = 0.024, Adjusted R² = 0.017, ΔF = 3.666, p = .003). Gender, religiosity, and ethnic minority status were significantly associated with Xenophobia Scale scores. In Model 2, intercultural contact variables explained an additional 1.9% of the variance (ΔR² = 0.019, ΔF = 7.644, p = .001). Having contact with foreign individuals was significantly associated with Xenophobia Scale scores. In Model 3, migration-related care perception variables explained an additional 9.1% of the variance (ΔR² = 0.091, ΔF = 39.362, p < .001). The final model explained 13.4% of the variance in Xenophobia Scale scores (R² = 0.134, Adjusted R² = 0.124, F = 12.903, p < .001).

In the final model, ethnic minority status (β = 0.081, p = .020), contact with foreign individuals (β = 0.124, p < .001), belief that foreign patients bring new diseases (β = 0.229, p < .001), and difficulty providing care to foreign patients (β = 0.156, p < .001) remained independently associated with Xenophobia Scale scores.

Discussion

The present study aimed to determine the xenophobia levels of nurses working in Türkiye and to identify the factors associated with these attitudes. The findings suggested that participants in this online sample reported relatively high xenophobia scale scores. Additionally, xenophobia levels were associated with several sociodemographic characteristics and experiences related to caring for foreign patients. Although the Xenophobia Scale measures attitudes related to xenophobia, some responses observed in the present study may also reflect perceived communication difficulties, occupational burden, infection risk perception, or structural healthcare challenges encountered during the care of foreign patients.

In the current study, the mean Xenophobia Scale score was 51.42 ± 12.93 out of a possible maximum score of 66. This indicates that the average score of the participants was positioned in the upper range of the scale. In recent years, Türkiye has become one of the countries hosting the largest number of refugees and migrants in the world [4]. Healthcare professionals frequently encounter migrant patients in clinical settings, which may create communication challenges and increase workload due to language barriers, cultural differences, and limited healthcare resources [6, 30, 31]. These challenges may be associated with negative attitudes toward foreign patients. Similar findings have been reported in previous studies conducted among healthcare professionals and physicians [14, 25, 27, 28].

Another important finding of the study was that female nurses had higher xenophobia levels than male nurses. One possible explanation may be differences in clinical exposure and patient interaction; however, the present study did not directly assess these variables. Therefore, this interpretation should be considered speculative. Similar results have been reported in studies examining xenophobia among healthcare professionals and the general population [10, 25, 27, 28, 32, 33]. However, some studies have reported opposite findings or no significant relationship between gender and xenophobia [14, 34, 35], indicating that this relationship may be influenced by contextual factors and sample characteristics rather than representing a universal pattern. In addition, the gender distribution of the sample should be considered when interpreting this finding. Because female nurses represented the vast majority of the sample, the observed gender-related differences may partly reflect sampling imbalance rather than a stable population-level pattern. Similarly, the overrepresentation of participants from western Türkiye and digitally active social media users may have influenced the distribution of xenophobia scores and limited the representativeness of the findings. Alternative explanations, including gender-related response tendencies, social desirability patterns, or sample composition effects, should also be considered.

The study also found that nurses who were members of an ethnic minority group had lower xenophobia levels. One possible interpretation is that the possibility that individuals who belong to minority groups may have experienced social exclusion, discrimination, or stigmatization themselves, which may increase their empathy toward migrants and foreigners. Experiencing similar social processes may enable these individuals to develop more tolerant and inclusive attitudes toward culturally different groups [36, 37].

Another notable finding was the significant difference in xenophobia scores according to self-reported religiosity level. Participants reporting high religiosity had lower xenophobia scores than those reporting moderate religiosity, whereas no significant difference was observed for the low religiosity group. Therefore, the observed relationship does not suggest a simple linear association and should be interpreted cautiously. Importantly, religiosity did not remain statistically significant in the multivariable regression model. Therefore, this finding should be regarded as exploratory and interpreted cautiously, as the observed univariate association may have been influenced by other related factors. As religiosity was assessed using a single self-reported item in a web-based survey, the potential influence of social desirability bias cannot be excluded, particularly given the socially sensitive nature of this variable. In addition, the concentration of responses in the “moderate” category may have limited the variability of the measure, thereby reducing its discriminative capacity. Because the “moderate religiosity” category included the vast majority of participants, subgroup comparisons should be interpreted cautiously, as unequal group sizes may have reduced statistical stability and analytical sensitivity. Although religiosity is sometimes discussed in relation to constructs such as tolerance or empathy, the present data did not directly assess these dimensions. Accordingly, possible explanatory mechanisms remain speculative. The relationship between religion and xenophobia has been reported to be complex in the literature [38–42], and future studies using more robust and multidimensional measures of religiosity are warranted to clarify this association.

The results of this study also showed that nurses who believed that foreign patients brought new diseases had significantly higher xenophobia levels. However, this finding may reflect both perceived clinical risk and potentially stigmatizing attitudes toward migrant patients. Such beliefs may also stem from healthcare professionals’ perceptions regarding infection risk, epidemiological differences, and patient safety. Consequently, it is thought that this relationship may reflect both clinical risk perception and potential attitudinal tendencies. Migrants are often perceived as a potential source of health risks due to differences in living conditions, vaccination coverage, and epidemiological profiles [35, 43–46]. Such perceptions may contribute to the development of fear-based attitudes and social distancing behaviors toward migrant patients [47]. Importantly, some variables evaluated in this study may not exclusively reflect xenophobia-related attitudes. For example, concerns regarding infectious diseases, communication difficulties, or reluctance to provide care may also be associated with perceived clinical burden, occupational stress, patient safety concerns, or structural healthcare challenges. Therefore, these findings should not be interpreted solely within a xenophobia framework.

Another important finding was that nurses who had foreign individuals in their social circles had lower xenophobia levels. Consistent with the contact hypothesis, previous literature has suggested that intercultural contact may be associated with lower levels of prejudice and discrimination. Direct interaction with individuals from different cultural backgrounds may help reduce stereotypes, increase empathy, and promote mutual understanding [14, 25, 48]. Therefore, increased intercultural communication and social interaction were associated with lower xenophobia scores in this sample. Accordingly, the observed associations may reflect a combination of attitudinal, professional, and system-level factors rather than purely prejudicial orientations.

Finally, nurses who reported difficulties in providing care to foreign patients and those who stated that they would prefer not to care for foreign patients if given the option had significantly higher xenophobia levels. Communication barriers, language differences, and cultural misunderstandings may increase stress and workload for healthcare professionals, which may coexist with negative attitudes toward migrant patients within clinical practice. Previous studies have similarly reported that nurses and midwives may experience communication difficulties and professional challenges while providing care to migrant and refugee patients [49–51].

The hierarchical regression analysis provided additional insight into variables independently associated with Xenophobia Scale scores within this web-based sample. Sociodemographic variables explained only a limited proportion of variance, whereas migration-related care perception variables contributed more substantially to the model. In the final model, ethnic minority status, absence of foreign social contact, the belief that foreign patients bring new diseases, and perceived difficulty in providing care to foreign patients remained independently associated with Xenophobia Scale scores. Importantly, these findings should not be interpreted as indicating causal relationships because of the cross-sectional design of the study. In addition, some variables included in the regression model may reflect perceived communication difficulties, occupational burden, infection risk perception, or structural healthcare challenges rather than exclusively xenophobia-related attitudes. Therefore, the observed associations should be interpreted cautiously and within the broader context of migration-related healthcare delivery. The relatively modest explained variance of the final model (13.4%) also suggests that xenophobia-related attitudes are likely influenced by additional psychological, institutional, sociopolitical, and contextual factors that were not assessed in the present study. Future studies using more comprehensive theoretical frameworks and longitudinal designs are needed to better understand these complex relationships.

Overall, the findings suggested that higher xenophobia scores were associated with ethnic minority status, absence of foreign social contact, perceived care difficulties, disease-related beliefs regarding foreign patients, and reluctance to provide care to foreign patients. These findings may have implications for efforts aimed at addressing xenophobia-related attitudes in healthcare settings. Interventions focusing on cultural competence, intercultural communication, and awareness of migrant health may help support more inclusive healthcare environments for culturally diverse patient populations. However, the findings should be interpreted within the methodological and contextual limitations of this exploratory web-based study, including non-probability sampling and self-reported participation.

Strengths of the study

This study has several strengths. First, the study included a relatively large sample size of nurses (n = 761), which increases the reliability of the findings. Second, the participants were recruited from different regions of Türkiye and from various healthcare institutions, allowing for a broader perspective on nurses’ attitudes toward foreign patients. Third, the use of a validated and reliable measurement tool, the Xenophobia Scale, enhances the methodological rigor of the study. Finally, this study contributes to the limited literature examining xenophobia among actively working nurses, particularly in countries hosting large migrant and refugee populations.

Limitations

This study has several limitations that should be considered when interpreting the findings. First, the cross-sectional design does not permit causal or directional inferences between variables, even though multivariable regression analysis was conducted. Second, data were collected through a web-based survey using a non-probability snowball sampling method, which may have introduced selection bias, self-selection bias, and limited the representativeness of the sample. Third, all data were based on self-reported responses and may therefore be subject to response and social desirability biases. In addition, participant eligibility relied entirely on self-report within an openly distributed online survey, and professional identities could not be independently verified through institutional or licensing systems. Participant eligibility was assessed through a single self-reported confirmation that respondents were actively working nurses. Furthermore, although the survey platform was configured to limit participants to a single response, advanced response verification procedures (e.g., IP-based tracking, duplicate-response detection algorithms, or response-time analysis) were not implemented. Therefore, the authenticity and integrity of individual responses could not be fully guaranteed. In addition, no attention-check items or response-time filtering procedures were implemented to identify careless responding. Fourth, the sample size calculation was based on the most recent national nursing workforce statistics available during study planning (2020), which may not have fully reflected the nursing population at the time of data collection in 2022. Finally, the findings reflect data collected in early 2022 and may therefore have been influenced by the sociopolitical and migration-related context of that specific period. In addition, the overrepresentation of female nurses and participants from western Türkiye may have affected subgroup comparisons and further limited the generalizability of the findings to the broader nursing workforce in Türkiye. Accordingly, the findings should not be considered nationally representative and should be interpreted primarily as exploratory results derived from a web-based sample of self-identified nurses.

Conclusion

This study explored xenophobia-related attitudes among a web-based sample of self-identified nurses in Türkiye. The findings suggested possible associations between xenophobia scale scores and certain sociodemographic characteristics and professional experiences related to the care of foreign patients. However, findings should be interpreted cautiously because of the exploratory web-based design and sampling limitations. In addition, some observed associations may reflect professional, structural, or clinical burden-related perceptions rather than exclusively xenophobia-related attitudes. Future research using verified participant recruitment procedures, more rigorous sampling strategies, and contemporary datasets is needed to better understand xenophobia-related attitudes among healthcare professionals.

These findings highlight the importance of addressing xenophobia-related attitudes in healthcare settings. Educational programs focusing on cultural competence, intercultural communication, and migrant health should be incorporated into nursing education and in-service training programs. Such initiatives may support culturally sensitive healthcare practices for migrant patients. Future studies using more recent and nationally representative samples are needed to evaluate whether these attitudes persist under current sociopolitical conditions.

Author contributions

- Conceptualization: KDB, NÇ- Methodology: KDB, NÇ- Validation: KDB, NÇ- Formal Analysis: KDB- Investigation: KDB, NÇ- Resources: KDB, NÇ, BK- Data Curation: KDB, NÇ- Writing-Original Draft Preparation: KDB, NÇ, BK- Writing-Review & Editing: KDB, BK- Visualization: KDB- Supervision: KDB.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

Data is available from the corresponding author upon resonable request.

Declarations

Ethical approval

Ethical approval for the study was obtained from the İstanbul Gedik University Scientific Research Ethics Committee (Date: January 12, 2022; Approval No: 274). Participants were informed about the purpose of the study, and participation was voluntary. Informed consent was obtained electronically before participants completed the survey. Permission was obtained for the use of the Xenophobia Scale. The study was conducted in accordance with the principles of the Declaration of Helsinki. As data were collected via an online survey, the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) guidelines were followed.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.