Determinants and mitigating factors of the brain drain among Egyptian nurses: a mixed-methods study

Abstract

Background

A brain drain is a migration of employees in their quest for an improved level of living conditions, better earnings, access to advanced technology and secure political conditions in diverse places worldwide. The brain drain of nurses is an ongoing phenomenon that impacts the quality and quantity of the nursing workforce and affects the quality of care. The nurses' brain drain is commonly known as a result of the interplay of many factors. So, identification of these factors and how to manage them is a timely topic in nursing research.

Aims

This study aims to investigate determinants of the nurses' brain drain and mitigating factors from nurses' perspectives in Egypt.

Methods

Mixed-methods research was conducted using a concurrent triangulation design. A sample of 325 nurses who were working at an Egyptian university hospital answered a brain drain questionnaire while the qualitative investigation was guided by a semi-structured interview with a purposive sample of 35 nurses to elicit exploratory perspectives on factors causing brain drain and mitigation strategies. Results were analysed using inferential statistics and thematic data analysis.

Results

Both push and pull factors can predict about 99.6% and 97.5% of the nurses’ brain drain, respectively. Seven themes were derived from the qualitative content analysis, and six themes were categorised under ‘push-pull’ factors. In addition, the ‘mitigating factors theme’ was identified with five sub-factors as possible solutions. Economic and work environment reasons were reported as the most influential for nurses’ brain drain.

Conclusions

Policymakers could use the identified factors from quantitative and qualitative data for creating a system that would improve nurses' conditions and policies, and prevent nurses' migration. Nursing leaders have a significant role with non-remuneration strategies in retaining nurses through creating an empowering work environment. In addition, shared governance, a strong nursing syndicate role and professorial marketing would be essential mitigating factors for the nurses' brain drain.

Introduction

Migration of personnel is commonly known as brain drain or the human capital flight (Baral and Sapkota, 2015). The term ‘brain drain’ refers to the migration of employees in their quest for an improved level of livelihood and living condition, greater earnings, access to advanced technology, a chance to work in a better resource system and secure political conditions in diverse places worldwide (Kadel and Bhandari, 2019). The challenge posed by the brain drain (migration) of health workers from low- and middle-income countries to high-income countries has been recognised to global public health for decades (Oladeji and Gureje, 2016). This resettlement of health professionals for better opportunities, both within countries and beyond universal boundaries, is a cause of increasing concern due to its resulting effects on health systems in developing countries over many years (Misau et al., 2010).

The healthcare sector and the nursing profession are in deep crisis partially because many nurses are migrating abroad looking for better employment conditions and this ends up in a negative impact on the population health (Pretorius, 2018; Dywili et al., 2013). The reduction of manpower in the source country has a negative consequence affecting not only the health managers but also nurses on the ground level, and patients who need the nursing services that only skilled nurses can deliver. Also, nursing staff remaining in the source country are left with a heavier workload, leading to chronic job dissatisfaction, demoralisation and burnout (Pretorius, 2018).

Likewise, the health sector in Egypt suffers from a severe shortage of healthcare professionals specifically qualified nurses as proven by Egyptian studies (Bakr, 2012; Mahran et al., 2017). One major reason for this shortage is voluntary migration of nurses to developed countries that may be a contributor to health system weakening, economic loss and delays in providing care. This is also a primary threat to achieving health-related sustainable development goals, threatening the well-being of vulnerable populations and effectiveness of world health intervention (Salami, 2017; Mokoena, 2017).

Over the last 20 years, migration flows of highly skilled migrants from Egypt are growing and most of the Egyptian migration is directed toward the Gulf Cooperation Council (GCC) countries (Bacchi, 2014). Specifically, a report of the World Health Organization (WHO, 2012) showed that nursing in Egypt is a profession that has seen little institutional recognition or support in the workplace, besides which nurses' shortages combined with insufficient nursing funding hinder the decision-makers from setting rules to support nursing. However, healthcare organisations are challenged to retain the generation of nurses and to understand why they are leaving their nursing career prematurely or leaving their country. Specific aspects that led to a decision to leave were the lack of support, guidance, and concerns from hospital management (Abou Hashish, 2020; 2017).

A variety of factors were identified influencing both temporary and permanent migration, inflicting nursing shortage and the brain drain. So, identification of these factors and how to manage them is a timely topic in nursing research, particularly in the Egyptian context. It is assumed that this study could contribute more information to the nursing profession, society and the hospital managers about the problem of brain drain among nurses and what factors could be amenable to amendment. In addition this could identify what drives the opportunities that are so attractive for nurses and therefore facilitate in retaliating against the opposing push factors and encourage nurses' stay and retention. It is pivotal for policymakers to understand the interaction between these forces in orderto take enlightened decisions about how to retain employees and improve the overall health system (Krasulja et al., 2016).

Migration has been commonly analysed in terms of the ‘push-pull’ factors model. This study adopts Lee's theory (Lee, 1966) to explore the factors at play driving migration and brain drain. Lee's push and pull theory states that there is a relationship between push factors within the country of origin and therefore the pull factors in the destination country, and contrariwise. These factors are contrary to each other, and a combination of them usually leads to a net outflow of health professionals from African countries (Pretorius, 2018).

Push factors refer to national conditions within source countries that have forced nurses to leave the country (Lee, 1966). These factors would possibly include economic, social, political, health-system, professional and work-related reasons. While pull factors display characteristics in beneficiary countries that might attract nurses. These factors might combine social/family factors, career and professional development, work environment, job security, wage and associated benefits (Baral and Sapkota, 2015; Chimenya and Qi, 2015; Dimaya et al., 2012; Kadel and Bhandari, 2019; Lee, 1966; Thapa and Shrestha, 2017).

Significance of the study

Certain studies have been conducted in Asia and Africa to investigate health workers' migration (Chimenya and Qi, 2015; Dimaya et al., 2012; Misau et al., 2010). Although nurses' migration is publicised and admired as a radical issue with profound ethical, socioeconomic and health implications (Pretorius, 2018), there is a dearth of literature internationally about what are the determinants and factors influencing the nurses' brain drain (Pretorius, 2018). Even though previous researchers have determined the causes of brain drain, they have not developed an appropriate assessment of measures against brain drain (Chimenya and Qi, 2015). There is a gap in our knowledge of how nurses perceive their work conditions and what factors could aggravate their potential/intention for migration. Hence, there is a significant need to examine, understand and identify how to mitigate all factors that may contribute to potential or actual migration of nurses.

To the knowledge of the current researchers, there is no study that has been carried out to explore factors that might provoke a brain drain among Egyptian nurses. A compelling prospect of this research might lie in using a mixed-method research approach. With this approach, the researchers endeavoured to understand nurses' experiences of reasons and factors that could make Egyptian nurses likely to migrate in searching for employment. Also, they explored what strategies nurses suggest for mitigating the effect of brain drain phenomena which are expected to be more authentic and valid when integrating their perspectives.

Aim of the study

The main aim of this study was to investigate the determinants (push-pull) of the nurses' brain drain and mitigating factors from nurses' perspectives using a mixed-methods study.

Methods

Research setting and design

This study was conducted at the Main University Hospital, which is a large university hospital in Alexandria City, Egypt. A mixed-methods research design using ‘concurrent triangulation’ was conducted in this study, in which both quantitative and qualitative data were simultaneously collected to determine convergences, differences and combinations among them, develop a comprehensive understanding of the research phenomena, and more precisely establish relationships among variables of interest (Cresswell et al., 2003; Sharon and Halcomb, 2009). A quantitative study was carried out with a cross-sectional design while the qualitative investigation was guided by semi-structured interviews to elicit more insight of nurses’ personal experiences and understanding of potential factors to migrate causing brain drains and how to manage these. The findings from the qualitative descriptive part may be of special relevance to practitioners and leaders in developing strategies to address workplace issues that increase nurses’ retention.

Study participants

The total population of nurses working at the above-mentioned hospital is 600 nurses. All nurses with experience of one year and more were eligible for the study as an inclusion criterion (n = 480). Exclusion criteria included any nurse who had less than 1 year of experience or was unwilling to participate in the study. The sample size was determined using the Raosoft sample size calculator using the following parameters: population size 480, margin error of 5, confidence interval 95%, and significance level of p ≤ 0.05. Thus, the minimum recommended sample size was 214.

To ensure that we obtained the recommended sample, 480 questionnaires were distributed to the nurses. Out of them, 325 nurses returned the study questionnaire. For the qualitative part, 35 nurses were interviewed based on purposive sampling until data saturation was reached (the point where no new information emerges from the study participants). Participants of a purposive sample were derived from the quantitative sample, as some nurses who participated in the quantitative phase also constituted the purposive sample. They were invited and included based on their availability and willingness as an inclusion criterion to participate at the time of data collection. Participants were chosen to include different working units, current position and educational levels to capture a range of perspectives.

Study instruments and technique

Brain Drain Questionnaire (BDQ)

A structured questionnaire was developed by the researchers after an extensive literature review. It is a self-administered questionnaire that consists of three main sections:

• Section 1: includes questions about nurses' demographic and work variables.

• Section 2: comprises 30 items to measure reasons that could ‘push’ nurses to emigrate from their home country. It addresses six main reasons: social (four items), economic (four items), political (three items), health-system quality (three items), professional (seven items), and work-related reasons (nine items).

• Section 3: comprises 29 items with five categories intended to measure factors in other countries (host country) that could ‘pull’ nurses to migrate including; social/family (three items), career and professional development (10 items), work environment and job security (seven items), managerial support (five items), salary and related benefits (four items).

Responses on sections 2 and 3 were measured using a five-point Likert scale ranging from 1–5 (1 = strongly disagree, 5 = strongly agree). Values of the mean were categorised as follows; <2.5 low mean, 2.5–3.75 moderate mean and >3.75 high mean.

The BDQ was developed in English, then translated into Arabic to suit the Egyptian culture and different educational levels of nurses. To identify the content validity and the fluency of the translation, the questionnaire was given to a jury of five expert academic members. According to their recommendations, some items were modified for more clarity. The BDQ was back-translated into English by a language expert. The back-translation was reviewed by the authors and members of the jury to ensure accuracy and to minimise potential threats to the study's validity. Also, a pilot study was conducted with 40 nurses (10%). Accordingly, a few changes were made to the final tool. In addition, the BDQ was tested for internal reliability and the results suggested the tool to be reliable with a value of Cronbach's coefficient alpha of 0.979 for the overall questionnaire, and 0.957 and 0.967 for push factors and pull factors, respectively.

Face-to-face semi-structured interviews (SSIs)

The SSI guide was developed consisting of a set of fixed questions that was used to solicit the qualitative data. The interview was based on three central questions. In addition, six demographic questions were incorporated about gender, age, educational qualification, job title, working unit and years of experience. The interview guide was sent to research peers to check and establish its face validity with a result of all agreeing on the interview guide. A pilot interview was conducted utilising the developed guide to pretest the questions before data collection, support refinement of the questions as needed, and assess the researcher's competency with the interview technique which was followed by data collection (Grove et al., 2015: 45).

Data collection

After obtaining the approval of the ethics committee and the hospital, the researchers explained the aim of the research to all participants. The BDQs were hand-delivered in the Arabic form to the nurses who agreed to participate in the study by the authors with relevant instructions to complete the survey. Participants were given one week to complete the questionnaire. The authors then went to the units to collect the completed surveys, which were usually left with the unit nurse manager.

Face-to-face SSIs were conducted with nurses in the Arabic language in the nursing unit office. At the start of each interview, the researcher informed the participant of the nature of the study, the associated ethical considerations, the duration estimated for the interview, confidentiality of data and voluntary participation, and obtained the nurse's consent to participate in the study and to be quoted along with information. Owing to the sensitive nature of the topic, the anonymity of participants and the right to withdraw from the study at any time were granted.

The interviews focused on the three overarching questions that started with asking the participants about their potential to leave and work abroad.

1. In your opinion, what reasons are present in the Egyptian workplace that would increase the desire and potential of staff to migrate or working in another country?

2. What are workplace factors present in a foreign country that attracts nurses to migrate?

3. What measures can be put in place to stem/prevent nurses' brain drain in Egypt or other countries?

These primary questions were followed with further probes. The length of the interview ranged from 30–45 minutes. All interviews were audio-recorded, and detailed notes were made soon after every interview. The researchers transcribed literally the interviews upon permission and prior to the data analysis.

All types of data were collected in nurses' break times with the approval of nurse managers to fit in with their shift schedules and enable them to freely express their opinions. The concurrent collection of quantitative and qualitative data occurred over a four-month period (1 May to end of August 2018).

Data analysis and management

Quantitative data were coded by the researchers and analysed using IBM SPSS software package version 22.0. Frequency and percentages were used for describing demographic characteristics. Descriptive statistics such as mean and standard deviation (SD) were applied to summarise the quantitative data. Pearson's correlation test was applied to determine the relationship between push and pull factors. Regression analysis (R²) was used to test the predictive power of the independent variable (push-pull factors) on the dependent variable (overall brain drain). Change in R² was tested with the F-test (analysis of variance (ANOVA)). A value of p ≤ 0.05 was set as the level of statistical significance.

Qualitative data were analysed using the thematic analysis approach described by O'Connor and Gipson (2003). The interviews were transcribed verbatim. The researchers started with the familiarisation stage, in which the transcripts were read several times to obtain the sense of wholeness and to get the general sense of the content then they were subjected to content analysis to identify the emerging themes. The researchers developed initial codes by highlighting key phrases and searching for themes among these codes. Then categories were created by searching for similarities and differences among transcripts to formulate evolving themes. Data analysis was conducted simultaneously with the data collection; it was begun after the first interview and continued throughout the data collection phase.

To maintain data quality and rigour, all criteria of academic rigour including credibility, transferability, dependability and conformability were considered (Shenton, 2004). To enhance the credibility of the findings, peer researchers undertook checking on each other throughout to ensure that the true meaning was portrayed. Some interviewed nurses read the transcript, to ascertain that the interviewer was representing their perspectives. The participants did not suggest any changes. Transferability was attained by providing a rich and thick description of study processes and data in the final research report to determine whether the findings could apply to another similar population or study. Dependability was considered by giving a detailed methodological description. To ensure the reliability and conformability of the data analysis, consistency checks were performed through a peer researcher to establish congruent opinions between two independent researchers about the data's accuracy, relevance or meaning. The findings represent interview data by using direct quotations from participants.

Results

Findings from the quantitative data

Demographic characteristics

Pertaining to the background characteristics of participants, the majority (90.2%) of nurses were female. About one-third (30.2%) were in the age group of 41–50 years. Also, 38.5%, 35.4% were working in intensive and medical care units, respectively. About one-half (51.7%) of nurses had a diploma degree from secondary nursing school, while 24.0% of them had a bachelor's degree of nursing. About two-thirds of nurses (65.5 %) had more than 10 years of experience. The highest percentages of nurses (63.4%, 64.9%) had not travelled before and had the desire and potential to travel abroad, respectively. Nearly half of nurses (46.5%) were not satisfied with work in their country. See Supplementary Material Table 1 for more values.

Table 1.

Descriptive analysis of nurses' perception of push and pull factors of brain drain.

Brain drain factors	Mean ± SD
Push factors of brain drain
Overall push factors	3.71 ± 0.65
Economic reasons	4.31 ± 0.23
Social reasons	4.26 ± 0.55
Political reasons	3.14 ± 1.12
Health system quality	3.54 ± 1.05
Professional reasons	3.79 ± 0.99
Work-related reasons	3.37 ± 0.77
Pull factors of brain drain
Overall pull factors	3.36 ± 0.61
Social/family factors	3.12 ± 0.71
Professional and career development factors	3.20 ± 0.75
Work environment and job security	3.02 ± 0.54
Managerial support	3.34 ± 0.71
Salary and related benefits	4.54 ± 0.33
Overall brain drain factors (push and pull)
Mean ± SD	3.54 ± 0.61
% Score	63.39 ± 15.27

SD: standard deviation.

Value of means for the response on a five-point Likert scale: <2.5 = low mean, 2.5–3.75 = moderate mean, >3.75 = high mean.

Nurses' perception of push and pull factors of the brain drain

Table 1 (below) reveals moderate nurses' perception of overall factors of brain drain represented by mean and SD (3.54 ± 0.61). The mean and SD of nurses' perception of push factors was 3.71 ± 0.65. Economic and social reasons had the highest mean scores (4.31 ± 0.23, 4.26 ± 0.55) respectively, whereas political reasons had the lowest mean score (3.14 ± 1.12). As for the pull factors of the brain drain, the mean of nurses' perception was 3.36 ± 0.61 with the highest mean for salary and related benefits (4.54 ± 0.33) and managerial support (3.34 ± 0.71).

Correlation and regression analysis between push and pull factors of the nurses' brain drain

Table 2 reflects a statistically significant strong positive correlation between overall push and pull factors where (r = 0.879, p < 0.001). In addition, the regression coefficient values between push factors as well as pull factors as independent variables and overall brain drain as the dependent variable were R² = 0.996 and R² = 0.975, respectively. This meant that both push and pull factors could independently contribute to a significant prediction of 99.6% and 97.5% of the nurses' brain drain, respectively, where the regression model is significant (F = 1330.333, p < 0.001; F = 2497.511, p < 0.001).

Table 2.

Multiple regression analysis between push-pull factors and overall brain drain.

Factors	r	R 2	F	p
Push factors	0.879 p < 0.001a	0.996	1330.333	<0.001a
Pull factors		0.975	2497.511	<0.001a

F: analysis of variance; r: Pearson coefficient; R²: coefficient of determination.

^aStatistically significant at p ≤ 0.05.

Findings from the qualitative data

Participants' characteristics

A total of 35 nurses were successfully interviewed. They were predominantly female nurses (91.43%). Of the interviewees, 54.29% were between 30–50 years old. Ten nurses had a bachelor's degree (28.57%) and the rest (71.43%) had a diploma degree in nursing. Nearly half (49.57 %) of the nurses had less than 10 years experience. The majority (77.14%) were bedside nurses, while 22.86% were senior nurses. The highest percentage of nurses (74.29%) reported that if they have a chance of travel, they will migrate. The most reported countries for migration to work were Gulf countries including Saudi Arabia (68.57%), Kuwait (37.14%), while United Arab Emirates, Qatar and Oman were represented by 31.43% for each (see Supplementary Material Table 2).

Thematic analysis framework

The qualitative content analysis resulted in the identification of seven major themes related to factors influencing the brain drain from nurses’ perspectives, which were also supported by the quantitative survey data. Table 3 presents a summary of the themes, categories and associated sub-factors. Six themes with 15 sub-factors were categorised under push-pull factors including economic factors, work environment, skill and career development, political issues, nursing image-power difference and personal ambition. In addition, the ‘mitigating factors theme’ is represented with five sub-factors. These themes are described here, with representative sample quotations from key responses of participants. Statements of interviewed nurses were identified with codes using the letter ‘P’ for participant and a corresponding number in the order that interviews were performed (P1, P2, P3…).

Table 3.

Emerged themes, categories and sub-factors from qualitative content analysis.

Themes (7)	Category (3)	Sub-factors (20)
1. Economic factors	Push-pull factors	1. Salaries, remuneration, insurance
		2. Living conditions and life requirements
		3. Children education and tuition fees
2. Work environment and related factors	Push-pull factors	4. Shortage/adequacy of staff and workload on nurses
		5. Shortage/adequacy of equipment and supplies
		6. Modern technology
		7. Management support
		8. Workplace safety and security
3. Skill and career development	Push factors	9. Skill development and career promotion opportunities
4. Political issues	Push factors	10. Political situation and security in the country
5. Nursing image and power difference	Push factors	11. Bad nursing image
		12. Lack of respect, recognition and appreciation to nurses
		13. Perceived power difference between physician and nurses
6. Personal ambition	Pull factors	14. Religious factors: Hajj and Umrah
		15. Curiosity to travel and international nursing experience
7. Mitigating factors	Mitigating factors	16. Workplace retention strategies 17. Shared governance and participative decision-making 18. Training and education 19. Nursing syndicate role 20. Marketing the profession

Theme 1: Economic factors (push-pull factors)

Almost all interviewed nurses specified economic and financial reasons as the most critical factors that forced them to think about potential migration in order to raise their standard of living. They blamed low wages and salaries, weak incentives, remuneration and health insurance. Some married nurses focused on school tuition fees for their child's education as another concern. Consequently, they had become distressed and compelled to work in public and private hospitals to afford their monetary commitments which impacted their family life negatively.

The main reason is the economic one … I mean the low pay rates and health problems that result from long working hours without adequate insurance, remuneration and compensation especially for night shifts and exposure to infection sources. Extremely, it's hard to live on. What about the higher tuition fees of my daughter? This question consumes my reasoning space. (P1)

Salaries and incentives are very inadequate to match the difficult living conditions and multiple life requirements. I joined a private hospital after my governmental work to meet my family needs. (P13)

On the opposite side, the availability of these factors in other countries is attracting nurses to work away:

Although, I realise that I cannot [be] earning that much if I get my family, but at least I can have a better salary and living condition than Egypt instead of this crowdedness and traffic problems … secured future for the children and being able to send money to family were distinguished factors in the hosting countries comparable with Egyptian economic condition. (P8)

Theme 2: Work environment and related factors (push-pull factors)

Participants depicted the work environment as the physical work condition e.g. sets of structure, facilities, resources and technologies, adequate staffing, availability of supportive workforce besides feeling secure in the workplace. All interviewed nurses acknowledged that they suffered from a shortage of staff and supplies, and reported an overload of work on them, especially those who were working in special care units. They also challenged unfair assignment and unsupportive management and leadership which had a negative influence on nurses' overall experience and their ability to perform well on the job, and this increased their dissatisfaction and discontent with their work conditions. Participants expressed that they were emotionally drained from the challenge of being unable to provide quality care to the patient as a human right due to lack of resources.

My work is my second house, which should be properly supplied with adequate resources, besides being secure. However, we suffer from a severe staff shortage and inadequacy of supplies and equipment, dearth of technology, unsatisfactory management and work assignment with a paucity of training opportunity. We sometimes collect donations to buy supplies such as gloves and masks to save our health. Healthy working condition is crucial. I felt guilty and depressed when I cannot provide the desired patient care. (P6)

Many participants had the same kind of reflection.

Nurses who experience job insecurity and dissatisfaction are more likely to leave their employment. Some nurses felt vulnerable at their work and referred to workplace insecurity as they encountered verbal abuses specifically from visitors staying overnight. Their feeling insecure may have increased their absenteeism and searching for more secure opportunity:

I feel threatened and insecure. Patients and/or their families charge nurses and blame them for everything instead of asking the treating physician (P30).

I love nursing, but I don't feel secure working in this place. I go to work because I have no alternative at this time. I am always looking for a new job (P4).

Contrasting to push factors, interviewed nurses reflected on several pull factors for an enticing work environment:

From my experience with colleagues who have been travelled to work elsewhere, they set forth that there are supportive structure and regulations, resources, advanced technologies and expert skills with preparations for future and research opportunities in large hospitals at Gulf countries. (P32)

Theme 3: Skill and career development (push factors)

Participants alluded to skills and career professional development as accessibility of chances for further training and career advancement, skills utilisation that could grant international acknowledgment. Interviewees pointed out the limited opportunities for skill development and career promotion in the hospital which affected their professional development in comparison with other countries. Some reported that their managers showed no concern for their training and failed to provide flexible schedules to allow them to participate in such training. This lack of concern affected their aspiration and inspiration to improve their skills and increased their resentment.

The place here will not accomplish my aspirations. I feel frustrated and give up all hope of my future career, there's no possibility of career promotion, and there are inadequate training opportunities to upgrade myself and increase my knowledge. The fiscal return is remarkably inadequate, which cannot assist me with covering the private training fees. (P11)

I had no support at all from my head nurse. I could not get my schedule adjusted to attend a workshop I paid it from my salary. (P15)

Theme 4: Political issues (push factors)

Few nurses referred to political issues such as the degree of political solidness, health-system management, governance structure and human issues. They indicated that the previous instability in the political scene made them worried about the healthcare system and pushed them to think of migration, although now there is a better political establishment in Egypt:

We experienced a lot of political changes in our country [in the] last period, although it has a positive side, it influences the economic place and resulted in life alterations in terms of high prices, routine, moral and value in the society even traffic and transportation congestion making us think in travelling. It is one of my human right[s] to work in a stable atmosphere. (P27)

Theme 5: Nursing image and power difference (push factors)

The nursing image is a new theme derived from the qualitative data, which refers to how the public perceive nursing and appreciate nurses' effort. Many of the interviewees disclosed that they suffered from the social nursing image which influenced their life, family and social relationships. One of them had a divorce because of this image:

My husband could not understand the difficult nature of my role and arguing me about night shifts, but I had no alternative to look after my kids, it frustrated me as he should not value my job … . All of the people ought to honour this field. I was just divorced. I am much happier now. (P23)

I did not inform neighbours with my job because of the old public idea of nursing in our Arabian countries. (P25)

I have a responsibility to my family … . I need to keep my job even with this image challenge. (P9)

Also, they perceived power differences between physicians and nurses with a lack of respect and recognition. Nurses felt that they had no voice and were powerless, which negatively affected their ability to meaningfully contribute to decisions affecting their units. Some participants struggled to advocate for their autonomy and important role in the health team but felt their contributions were not accepted or valued, so they stopped contributing.

We perceived power difference between physicians and nurses with under-estimation of our practice or opinion in addition to the non-involvement in the treatment plan. Really, I feel powerless and my identity is abstract as a result of bad nursing image and being unvalued. (P28)

My opinion does not count, and some physicians really do not care to hear what I have to say. So, I stopped contributing. (P15)

Many nurses reported the same type of statement.

Theme 6: Personal ambition (pull factors)

Another newly derived theme from the qualitative data is personal ambition. For some respondents, achieving personal goals, interests, curiosity, breaking habitual work and style of life, performing spiritual rituals and gaining international experience and culture competency are among the leading drivers that raise the potential to leave and seeking for employment in a specific country.

I hope to find a suitable opportunity to migrate. Although I look for better living standard, I want to travel for a religious purpose. I think Saudi Arabia is the best choice for me to perform Hajj and Umrah. (P7)

I love travelling, I am curious about new places and culture. (P5)

I need to be away from home and my routine life and work. Seeing distinct places with a different culture, languages and work environment could be helpful in gaining international nursing experience and improve my cultural awareness and competency. Yes … it is possible to migrate as it may be a chance to detect myself away from my routine environment. (P1)

Theme 7: Mitigating factors

Mitigating factors is the seventh theme extracted from the qualitative content analysis which relate to measures or instances that decrease the chance of migration and could improve the working conditions from nurses' perspectives. Five elements were found under this theme and proposed from nurses' perspectives for mitigating the phenomena of nurses' brain drain including workplace retention strategies, shared governance, training and education, nursing syndicate role and marketing the profession.

All interviewed nurses emphasised the role of hospital and nurse managers in the work environment and sustaining shared governance and participative decision-making to retain nurses and increase their job satisfaction. They exemplified the effective manager who works hard on building an effective team and being fair in assigning shifts and time off, enhancing communication and collaboration among staff:

Hospital administrators and nurse managers should make every effort to maintain a healthy and empowering and resourced working environment that stands for justice work climate, collaboration and teamwork. (P22)

I suspect that nurses' participation in decision-making and development of policy and rules governing the nursing profession is the most and meaningful thing to boost nurses' condition. (P17)

One nurse described her manager as follows

My manager is aware of what I want. Since my hiring, she always assigns me in a fair way … she allowed me the opportunity to improve myself, to learn in a conducive and friendly environment … because she tracked me, supported me and allowed me to flourish … I think this is what nurses need from their managers to get vested in their work. (P35)

Also, most of the interviewed nurses referred to training and professional education as essential factors having a great impact on their professional image and work performance and suggested that managers should plan to provide nurses with adequate opportunities to improve their practice:

Knowledge and skills that could be gained from workshops, attending conferences and scholarships can strengthen nurses' professionalism and image. I wish that our administrators broaden training programmes that suit all of the different qualifications and permit a time for participation. It will reflect on nursing performance. (P31)

In addition, many of the interviewed nurses described the nursing syndicate as the arm of professional nursing in Egypt with responsibility for advocating, monitoring and regulating nurses' practice, conditions, licensure and developing, controlling nursing policies. Equally, they recommended marketing the profession through the public and social media and suggested applying a penalty for those who disgrace the profession:

Nursing profession should have good governance among the health profession regulation and nursing syndicate has a vital role in advocating nurses' rights and policies. (P29)

All of us should cooperate to defend the nurse image in all media (social and public) and claiming for the significant nurses' role in saving the population health. Law should punish people, [who] insult the profession. (P16)

To sum up, the research findings provide an insight into the determinants of the brain drain from the perspective of a sample of Egyptian nurses. Integration of quantitative and qualitative findings is a key process in mixed-methods study. All factors of the developed BDQ are supported and strengthened by the emerged themes from qualitative content analysis and reported by the interviewed nurses as both push and pull factors. Although qualitative findings reported six leading themes from the content analysis, all the dimensions of BDQ were proved under the sub-factors of these themes. In addition, three discovered themes including nursing image, personal ambitions and the mitigating factors could be combined and assist in further refining of the developed BDQ to measure causes and solutions of the brain drain in future studies. See Table 4 for a summary of determinants and mitigating factors of the nurses' brain drain derived from quantitative and qualitative data analysis.

Table 4.

Summary of determinants and mitigating factors of nurses' brain drain derived from quantitative and qualitative data analysis.

Determinants of brain drain (potential causes)	Mitigating factorsa (potential solutions)
Push factors:	- Workplace retention strategies - Shared governance and Participative decision making - Training and education - Nursing governance/nursing syndicate role - Marketing the profession
Economic reasons
Social reasons
Political reasons
Quality of health system
Professional reasons/skill and career development
Work-related reasons
Bad nursing image and power differencea
Pull factors:
Salary and related benefits
Social/family factors
Working environment and security
Professional and career development factors
Management support
Political and economic stability
Personal ambitiona

^aNew themes added from the qualitative findings.

Discussion

Conducting mixed-methods research allows for the identification of the convergence and divergence of qualitative and quantitative data, contributing to results that complement each other. This integration gave the current researchers a better awareness of the determinants of the brain drain among nurses in terms of causes and possible solutions to manage this issue. The discussion will start with the identified causes of the brain drain (push-pull factors) from both of quantitative and qualitative findings, followed by suggested solutions (mitigating factors) from the qualitative data on nurses' perspectives.

In general, the quantitative findings confirmed that many economic, social, professional, work, political and personal factors were reported as the major push-pull factors which were significantly associated with the brain drain and increase nurses' potential and/or intention to migrate. The quantitative results did not allow for the understanding of how nurses experience these factors and what helps to maximise nurses' retention, but our qualitative results generated rich information pertinent to the phenomenon of interest in the Egyptian context and the quantitative findings support the discovered themes. For many nurses, leaving their job was not an option but they had the potential to migrate if they found better opportunities in other countries. Their personal experience and social roles influenced their decisions to stay or to think about migration.

Comparable benefits from qualitative and quantitative data integration have been described in another study. In Canada, Freeman et al., (2012) conducted a mixed-methods study which revealed two-thirds of respondents in the quantitative survey were considering migrating for work outside of Canada. Knowing a nurse who worked abroad influenced intention to migrate and living in a border community is a strong predictor of migration. The qualitative part of the study showed that Canadian nurses had substantially higher expectations that their economic, professional development, healthy work environment, adventure and autonomy values would be met in another country than Canada. Expectations influenced their migration intentions and may have applied to their integration and retention in the workforce.

Likewise, previous studies in African and Asian countries corroborate our findings. A study conducted by Likupe (2013) presented five main causes of migration: poor remuneration, lack of professional development in home country, poor healthcare and system, easy availability of jobs in developed countries. In Nigeria, Okafor and Chimereze (2020) declared that migration of nurses to developed nations is due to push factors (low remuneration, poor governmental policies, unsatisfactory working conditions) and pull factors (such as good working conditions, better pay) which are offered by the developed world. It is further supported by a study conducted on health workers' migration in the five South Asian countries – Bangladesh, India, Nepal, Pakistan and Sri Lanka – which reported that migration is attributed to ‘push’ from within the countries, as well as ‘pull’ from Western countries in the background of globalisation and free market economy. The study indicated low pay conditions, political instability and poor workplace security as major push factors and the pull factors included increasing access to global market, better pay opportunities and living standards (Adkoli, 2006).

More explicitly, our quantitative and qualitative findings converged on economic factors as primary reasons for Egyptian nurses' potential to migrate and the most influential push-pull factors for the nurses' brain drain. Qualitative findings enable the understanding of human experiences in relation to this point where almost all interviewed nurses explained how they are disappointed with, and suffered many economic and social circumstances in their social and work life resulting from poor salaries and remuneration. Inadequate financial resources to afford their family and social responsibilities play a pivotal role in making a migration decision for improving their living standards.

Many studies in different countries revealed the same results. An African study conducted by Pretorius (2018) reported economic reasons as the main push factors, especially low salary for nurses which do not match their obligations. While in Asian countries, Kadel and Bhandari (2019) revealed the majority of Nepali respondents were not satisfied with their salary and considered financial reasons as a push and pull factor. In addition, Filipino nurses ranked low salary, within both the public and private sector, as the main push factor (Dimaya et al., 2012).

Another big challenge and source of job dissatisfaction for Egyptian nurses in this study was the work environment and its related conditions. Although quantitative results showed moderate perception of it as push-pull factor for the nurses' brain drain, the qualitative findings portrayed it as an important emerged theme which had a lot of disputes and aspirations influencing nurses in their workplace. Interviewed nurses experienced stress and suffering from unsatisfactory work conditions, work overload because of their hospital being understaffed with inadequate resources, unsupportive managers and workplace insecurity. They felt helpless and frustrated when they could not care for patients in a suitable way. Meanwhile inadequate technology and training opportunities hindered their eagerness to upgrade their knowledge and skills.

Correspondingly, similar findings were repeated in Nepalese studies. For example, Sapkota et al. (2014) found that most of the interviewees pointed to work pressure and an unjustified nurse-to-patients ratio, resulting from the shortage of nurses, as important aspects in the leaving behaviour of nurses, and having a cyclic effect on nursing turnover. Likewise, personal ambition, lack of training and lack of career advancement opportunities are the main causes of Nepalese nurses' migration (Baral and Sapkota, 2015). In the Philippines, Dimaya et al. (2012) also mentioned in their qualitative study poor working conditions, outdated healthcare technologies and lack of opportunities as other key push factors. In comparison, pull factors included higher salaries, quality working conditions, technologies and job vacancies because of local shortages.

Although the political issue was presented as the lowest mean in the quantitative part of the study and described by few nurses in the qualitative analysis, it should be taken into consideration as it was mentioned in other studies as a cause for migration. The political scene is improved now in the Egyptian context, although the instability in the political situation and the security in the country could affect the healthcare system and push nurses to migrate because they think it will be better elsewhere. For example, Romanian and Malaysian studies conducted to identify factors contributing to the brain drain explained that political corruption/legislative instability, was the strongest determinant of the respondents' migration (Cristian and Baragan, 2015; Fong and Hassan, 2017). Also, Sapkota et al. (2014) disclosed that Nepalese nurses worried about the political situation, related unrest and security issues and recognised them as pressures on health workers who found themselves vulnerable in the workplace, specifically nurses. They also expressed that the healthcare workers were obligated to move away from political unrest, violence, crimes and the threat of epidemic and other diseases even though their basic needs were fulfilled in their own country.

Personal ambition is a new theme derived from the qualitative analysis which adds another motivation for migration. Many nurses think of migration seeking for professional experiences, and others would depend on spirituality and religious factors. Interviewed nurses reported that the availability of work environment resources and technologies in Gulf and developed countries in addition, meeting their special goals and interest to travel to work elsewhere and gaining international nursing experience are among major drivers for migration. In previous studies, it was reported that training and up-to-date technology, facilities, and communication system (Sapkota et al., 2014), better working environment, job satisfaction, a better way of work life, and more opportunities for success and career opportunities and personal ambitions are among the most common reasons (pull factors) to migrate (Sheikh et al., 2012; Thapa and Shrestha, 2017).

Nursing image is also an important new theme that emerged from the qualitative findings and this could be added to the dimension of push factors in the BDQ. Although difficult to prove, it is evident from the nurses' perspectives that nursing image influenced how they were treated at work. Bad nursing image and power difference cultures were regarded as factors for nurses' dissatisfaction and lacking autonomy in their work. Interviewed nurses expressed the view that they lacked proper recognition or appreciation for their work and suffered power differences between physicians and nurses. They related this to a bad nursing image and public misconception of the profession which affected their family relationships and social life. The nurses needed to feel appreciated for their hard work and opinions. Recognition for work performance is important as it comprises one of the key elements of support for the development of healthy practice/work environments.

It seems that nursing image in the Egyptian community was not improved significantly even with the increasing number of degree-level nurses (Abdel El-Halem et al., 2011). Also, another study conducted on Egyptian and Jordanian nursing students confirmed that nursing is still suffering from a negative public image in the Arab world. The media plays a part in perpetuating the stereotype of the nurse as an angel of mercy and the doctor's handmaiden (Ibrahim et al., 2015).

Similarly, most of the Indian nurses intended towards immigration citing dissatisfaction with working conditions and unhappiness with prevalent social attitudes toward nurses as motivating factors. Also, Garner et al. (2015) indicated that nurses often migrate to elevate their individual and professional status as locally there is a perception that the nursing profession is for people of low socioeconomic background. A related finding was reported by Schmiedeknecht et al., (2015) who found that Malawian interviewed nurses felt unrecognised for their skill and efforts; they felt rather neglected by their nurse managers, which ultimately pushed them to think of emigration. Also, poor working relationships with managers and peers were likely predictors of wanting to leave. Therefore, it is very important for nurses and those in leadership roles to work towards cultivating an environment where everyone feels supported and valued. It is the leader's responsibility to prevent, stop, and report unprofessional conduct. Also, Iwu (2014) recommended developing channels for communication and constructive feedback with supervisors in order to help nurses to feel valued and appreciated.

Mitigating factors for nurses' migration and the brain drain (the proposed solutions)

In this study, one of the significant strengths is that qualitative data analysis enables the understanding of what nurses need to be retained in their work and prevent migration from their own perspectives. It has shown five mitigating strategies highlighted by the interviewed nurses which could play a significant role including: workplace strategies, shared governance, participative decision making, training and education, nursing governance/syndicate role and marketing the profession. Although increasing the number of nurses is a critical step towards solving the human resource crisis, retaining nurses is equally important. Nurses recommend that managers and governance authorities find ways to maintain and enhance their well-being and increase their workplace retention.

These themes indicated that nurses' retention is possible through support from the nurse management and their work to promote an empowering work environment. Also, participants expressed a desire for further training to pursue continuous education. Although they admitted such opportunities were rare, they believed in training which motivates them to improve themselves, and their image, in order to be able to serve their communities.

This might occur through more organisational concern for enhancing job satisfaction. In this vein, Abou Hashish et al. (2018) and Abou Hashish (2017) highlighted that hospital and nurse managers have to create and maintain a supportive work environment where an ethical work climate, and leadership styles are factors to foster work engagement and job security. Meaningful recognition for the nurses' work contributes to job satisfaction and engagement. Many studies suggested non-salary retention strategies to be associated with increased job satisfaction and retention. These include incorporating opportunities for education and advancement, reducing workload and creating a collaborative work environment, flexible scheduling, rewards, recognition, health benefits and mentorship opportunities, (Iwu, 2014; Lartey et al., 2014; Schmiedeknecht et al., 2015).

Nurses in this study are ambitious to figure out their role, to have a positive impact on the governance and development of regulations and work instructions. They emphasised that the nursing profession should have good governance among the health professions' regulation and the nursing syndicate should assume an active role in advocating nurses' rights and policies. In an Egyptian study, Abou Hashish and Fargally (2018) declared that nurses need to be active in the development of health policies to be better able to control their practice and feel autonomous. In this regard, Arabi et al., 2014 pointed to nurses' influence on health policy to protect the quality of care by access to required resourses and opportunities for shared decisions. Additionally, Burke (2016), stated that to be influential, nurses must see themselves as professionals with the capacity and responsibility to influence current and future healthcare delivery systems.

What is more, nurses want to counteract the effect of nursing stereotyping and improve the public image of their profession. The nursing profession is confronted by multiple image-related disputes affecting its status, prestige, power and ability to grasp attention for its value and magnitude of its humanised practice. The public image of nursing is, to a large extent, affected by the invisibility of nurses and the way they present themselves. Nurses in this study suggested more marketing of the nursing profession. A transformation of how each nurse thinks about themselves may alter their self-image which in turn may reflect on the image of nursing as a whole. In the same line, in Egypt, as Baddar (2006) has emphasised, the main force to change the holistic views of the nursing image is derived from nurses themselves who are interested, satisfied and internally aware of the effective role of the nurse. In addition, Ten-Hoeve et al. (2014) highlighted the importance of having a (social) media strategy (including the internet, TV, internal news, and press) to raise nurses' visibility by informing the public about the significant role of the nursing profession.

Conclusions and recommendations

The current study contributes a step towards the construction of knowledge in the scope of mixed-methods research and to future research in the health and nursing fields overall. Nurses' brain drain reflects wider social issues; therefore, nurses have to be strategic about which issues they seek to address, and how.

This study supports the influence of common pull and push factors for nurses' migration and the causes of nurses' brain drain. Although economic factors are the most reported, they are not the only reasons for brain drain. Nurses in the current study thought they faced several challenges which pushed them to think of migration including low salary, unsatisfactory working environments, lack of supplies, shortage of human resources, limited opportunities for skill development and career opportunities which also influenced by a lack of technological advancement in addition to political issues and bad nursing image. The interviewed nurses seemed to be dissatisfied with nursing representation in the Egyptian Health system.

The recommendations of this study focus on the mitigating factors derived from nurses' perspectives. Internal strengthening of the nursing sector through improving their conditions provides a solution to key problems arising from nurses' shortages and poor conditions. Non-remuneration strategies were recommended to retain nurses. Supportive environments, decision-making power, professional nursing governance and continuing professional development programmes would be fundamental factors to be considered for the solution and mitigation of brain drain. This would require nurse leaders who can influence the work culture, support its importance, authentically live it, and engage others in its achievement.

Professional marketing for the creation of a better nursing image should be undertaken as nurses should not feel devalued, unappreciated, or expend time and mental effort in navigating a non-caring environment. Their full attention is required to provide safe, high-quality care. In this respect, nursing leaders have a significant role in creating empowering and healthy work environments, supportive peer relationships, supervisors and interdisciplinary team-mates to help nurses to grow as autonomous individuals who are able to provide significant contributions to healthcare and quality patient care. Having proper professional training opportunities for learning and personal development to improve their work standards is an equally important consideration.

Strengths and limitations of the study

This study is one of the first efforts to identify factors of potential or actual brain drain among Egyptian nurses from their perspectives using a mixed-methods study which could open the gateway for the future studies. It provides a comprehensive picture of all factors affecting nurses' brain drain and explored some major obstacles for nurses' retention. Also, the thematic framework presented in this paper from the qualitative data may act as a snapshot for possible use by policy makers, health managers and the nursing syndicate, in future improvement and evaluation strategies. However, there are some limitations of this study that must be acknowledged. The sample derived from one large university hospital does not represent all Egyptian nurses or health sectors. This will limit the generalisability of the findings among nurses. Interviewing mainly nurses thinking about migration provides a one-sided opinion, where blending the view of migrant nurses may further provide valuable insight with regard to the process of reintegration. A common limitation of qualitative studies is the generalisability of the findings to the larger population, given a purposive sampling of nurses. Inspite of these limitations, the study has practical applications for improving retention among nurses.

Future research implications

There is a need for large-scale quantitative studies into nurses' problems in Egypt and internationally. For a deeper perspective on the nursing population, future studies should employ samples of administrators and nurses from different health sectors. It is also important to determine the number of nurses immigrating including pattern, magnitude and trend to address the recruitment and retention problems. Additional qualitative research is needed to understand the decision-making processes related to migration and the experiences of individual nurses who migrate to more developed countries. Also, the newly emerged themes from the qualitative analysis such as nursing image, personal ambition and mitigating factors should refine the developed BDQ: this will necessitate retesting it in future studies. Professional interventions such as workshops and training programmes for strengthening nurses' autonomy and governance and leadership are essential and should be supported by evaluations to investigate their significance in producing a difference.

Key points for policy, practice and/or research

• The brain drain of nurses is an ongoing phenomenon that has impacted quality of care.

• The nurses' brain drain is a result of the interplay of many push-pull factors and mainly influenced by economic factors.

• Retention strategies and shared governance are important mitigating factors in the nurses' brain drain in the workplace.

• Nursing syndicates/governance should have an active role in advocating nurses' rights, regulations and improving nursing image.

• Supportive management and professional training are equally important considerations to improve nurses' work standards and decrease the nurses' brain drain.

Biography

Ebtsam Aly Abou Hashish, Assistant Professor of Nursing Administration, Faculty of Nursing, Alexandria University, Egypt; College of Nursing, King Saud bin Abdul-Aziz University for Health Science, Saudi Arabia. Ph.D awarded in 2010. Published more than 25 articles and peer reviewer in nursing journals.

Heba Mohamed Al Anwar Ashour, Lecturer of Nursing Administration, Faculty of Nursing, Alexandria University, Egypt. PhD awarded in 2017.