Journal of Research in Nursing

2020, Vol. 25(8) 699–719

Determinants and mitigating ! The Author(s) 2020
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factors of the brain drain sagepub.com/journals-permissions

DOI: 10.1177/1744987120940381
journals.sagepub.com/home/jrn
among Egyptian nurses:
a mixed-methods study
E Abou Hashish
Assisstant professor, Faculty of Nursing, Alexandria University, Alexandria, Egypt
College of Nursing – Jeddah, King Saud Bin Abdul-Aziz University for Health Sciences, Saudi Arabia

HM Ashour
Lecturer, Faculty of Nursing, Alexandria University, Alexandria, Egypt

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’

Corresponding author:
Ebtsam Aly Abou Hashish, Nursing Administration Department, Faculty of Nursing, Alexandria University, Edmon Fremon
St. Smouha, Alexandria 21527, Egypt; College of Nursing, King Saud bin Abdul-Aziz University for Health Sciences, Jeddah
21423, Saudi Arabia.
Email: ebtsam_ss@hotmail.com
700 Journal of Research in Nursing 25(8)

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.

Keywords
brain drain, mitigating factors, mixed-methods, nurses, pull-push factors, triangulation

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.
Abou Hashish and Ashour 701

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.
702 Journal of Research in Nursing 25(8)

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 ¼ 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.
Abou Hashish and Ashour 703

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 ¼ strongly disagree, 5 ¼ 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
704 Journal of Research in Nursing 25(8)

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
Abou Hashish and Ashour 705

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.

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 ¼ 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 ¼ 0.996 and R2 ¼ 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 ¼ 1330.333, p < 0.001; F ¼ 2497.511, p < 0.001).
706 Journal of Research in Nursing 25(8)

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 ¼ low mean,
2.5–3.75 ¼ moderate mean, >3.75 ¼ high mean.

Table 2. Multiple regression analysis between push-pull factors and overall brain drain.

Factors r R2 F p

Push factors 0.879 0.996 1330.333 <0.001a

Pull factors p < 0.001a 0.975 2497.511 <0.001a

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

a
Statistically 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).
Abou Hashish and Ashour 707

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 Push-pull factors 4. Shortage/adequacy of staff and workload on nurses
and related factors 5. Shortage/adequacy of equipment and supplies
6. Modern technology
7. Management support
8. Workplace safety and security
3. Skill and career Push factors 9. Skill development and career promotion opportunities
development
4. Political issues Push factors 10. Political situation and security in the country
5. Nursing image and Push factors 11. Bad nursing image
power difference 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 16. Workplace retention strategies
factors 17. Shared governance and participative decision-making
18. Training and education
19. Nursing syndicate role
20. Marketing the profession

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. . .).

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
708 Journal of Research in Nursing 25(8)

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
Abou Hashish and Ashour 709

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, morals 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
710 Journal of Research in Nursing 25(8)

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)
Abou Hashish and Ashour 711

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.

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.
712 Journal of Research in Nursing 25(8)

Table 4. Summary of determinants and mitigating factors of nurses’ brain drain derived from quantitative
and qualitative data analysis.

Determinants of brain drain Mitigating factorsa

(potential causes) (potential solutions)

Push factors: - Workplace retention strategies

Economic reasons - Shared governance and Participative
Social reasons decision making
Political reasons - Training and education
Quality of health system - Nursing governance/nursing syndicate role
Professional reasons/skill and career development - Marketing the profession
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
a
New themes added from the qualitative findings.

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
Abou Hashish and Ashour 713

(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
714 Journal of Research in Nursing 25(8)

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
Abou Hashish and Ashour 715

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.
716 Journal of Research in Nursing 25(8)

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.
Abou Hashish and Ashour 717

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.
718 Journal of Research in Nursing 25(8)

Declaration of conflicting interests

The author(s) received no financial support for the research, authorship, and/or publication of
this article.

Ethics statement
Approval was obtained from the Ethics Committee of the Faculty of Nursing, Alexandria University
(April, 2018). The privacy and confidentiality of data were maintained and assured by obtaining
participants’ consent to participate in the research before data collection. They had the right to
withdraw from the study at anytime.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of
this article.

ORCID iD
E Abou Hashish https://orcid.org/0000-0003-0492-7615

Supplemental material
Supplemental material for this article is available online.

References
Abdel El-Halem GE, El Hawashy ZI, Gamal El-Dein AA,
et al. (2011) Undergraduate male nursing students’
perception about the image of the nursing profession.
Journal of American Science 7(3): 614–623.
Abou Hashish E (2020) Nurses’ perception of organizational
justice and its relationship to their workplace deviance.
Nursing Ethics 27(1): 273–288.
Abou Hashish E and Fargally S (2018) Assessment of
professional nursing governance and hospital magnet
components at Alexandria Medical Research Institute,
Egypt. Journal of Nursing Education and Practice 8(3): 37–47.
Abou Hashish E, Abdel-All N and Mousa A (2018) Nurses’
perception of psychological empowerment and its
relationship to work engagement and job insecurity. Journal
of Nursing Education and Practice 8(9): 36–44.
Abou Hashish EA (2017) Relationship between ethical work
climate and nurses’ perception of organizational support,
commitment, job satisfaction and turnover intent. Nursing
Ethics 24(2): 151–166.
Adkoli VB (2006) Migration of health workers: Perspectives
from Bangladesh, India, Nepal, Pakistan and Sri Lanka.
Regional Health Forum 10(1): 49–58.
Arabi A, Rafii F, Cheraghi MA, et al. (2014) Nurses’ policy
influence: A concept analysis. Iran Journal of Nursing
Midwifery Research 19(3): 315–322.
Bacchi A (2014) The contributions of highly skilled migrants
to the development of their country of origin: Highly
skilled Egyptian migrants in the OECD countries.
Available at: https://pdfs.semanticscholar.org/6474/
67dea4480b8abdf3c974f21ef0d6597d4683.pdf (accessed 20
January 2019).
Baddar F( 2006) The Image of Nursing as a Profession among
Undergraduate nursing Students and Interns. Second
international conference for Health, environment, and
improvement-High Health Institute. cited in Ibrahim A,
Akel D and Alzghoul M (2015). Image of nursing profession
as perceived by Egyptian and Jordanian undergraduate male
nursing students: A comparative study. Journal of Education
and Practice 6(14): 24–36.
Bakr M (2012) Impact of nursing shortage on quality of care at
Shebin El-Kom Teaching Hospital. Journal of American
Science 8(10): 822–831.
Baral R and Sapkota S (2015) Factors influencing migration
among Nepalese nurses. Journal of Chitwan Medical College
5(12): 25–29.
Burke S (2016) Influence through policy: Nurses have a unique
role. Available at: https://www.reflectionsonnursingle
adership.org/commentary/more-commentary/Vol42_2_
nurses-have-a-unique-role (accessed 23 January 2019).
Chimenya A and Qi B (2015) Investigating determinants of
brain drain of health care professionals in developing
countries: A review. Net Journal of Business Management
3(2): 27–35.
Creswell JW, Plano Clark VL, Gutmann ML, et al. (2003)
An expanded typology for classifying mixed methods
research into designs. A. Tashakkori y C. Teddlie,
Abou Hashish and Ashour
Handbook of mixed methods in social and behavioral research.
209–240.
Cristian E and Baragan G (2015) Identification of main
economic and social causes of Romanian migration.
Ecoforum 4(2): 164–169.
Dimaya R, McEwen M, Curry L, et al. (2012) Managing
health worker migration: A qualitative study of the
Philippine response to nurse brain drain. Human Resources
for Health 10(47): 1–8.
Dywili S, Bonner A and O’Brien L (2013) Why do nurses
migrate? – a review of recent literature. Journal of Nursing
Management 21(3): 511–520.
Fong T and Hassan H (2017) Factors contributing brain drain
in Malaysian. International Journal of Education Learning
and Training 2(2): 14–21.
Freeman M, Baumann A, Akhtar-Danesh N, et al. (2012)
Employment goals, expectations, and migration intentions of
nursing graduates in a Canadian border city: A mixed
methods study. International Journal of Nursing Studies
49(12): 1531–1543.
Garner SL, Conroy SF and Barner SG (2015) Nurse migration
from India: A literature review. International Journal of
Nursing Studies 52(12): 1879–1890.
Grove SK, Gray JR and Burns N (2015) Understanding nursing
research: building an evidence-based practice. 6th ed. St Louis:
Saunders Elsevier Publishe.
Ibrahim A, Akel D and Alzghoul M (2015) Image of nursing
profession as perceived by Egyptian and Jordanian
undergraduate male nursing students: A comparative study.
Journal of Education and Practice 6(14): 24–36.
Iwu CG (2014) Rethinking issues of migration and brain drain
of health-related professionals: New perspectives.
Mediterranean Journal of Social Sciences 5(10): 198–204.
Kadel M and Bhandari M (2019) Factors intended to brain
drain among nurses working at private hospitals of
Biratnagar, Nepal. BIBECHANA 16: 213–220.
Krasulja N, Blagojevic M and Radojevic I (2016) Brain drain –
The positive and negative aspects of the phenomenon.
Scientific Review Article 62(3): 131–142.
Lartey S, Cummings G and Profetto-Mcgrath J (2014)
Interventions that promote retention of experienced
registered nurses in health care settings: A systematic review.
Journal of Nursing Management 22(8): 1027–1041.
Lee ES (1966) A theory of migration. Demography 3(1): 47–57.
Likupe G (2013) The skills and brain drain what nurses say.
Journal of Clinical Nursing 22(9-10): 1372–1381.
Mahran GS, Taher AA and Saleh NM (2017) Challenges and
work crisis facing critical care nurses. Egyptian Nursing
Journal 14(3): 235–241.
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.
719
Misau Y, Al-Sadat N and Gerei A (2010) Brain-drain and
health care delivery in developing countries. Journal of Public
Health Africa 1: 20–21.
Mokoena MJ (2017) Perceptions of professional nurses on the
impact of shortage of resources for quality patient care in a
public hospital: Limpopo Province, Master of arts,
University of South Africa.
O’Connor H and Gipson N (2003) A step by step guide to
qualitative analysis. Pimatiziwin: A Journal of Aboriginal and
Indigenous Community Health 1(1): 64–90.
Okafor CJ and Chimereze C (2020) Brain drain among
Nigerian nurses: Implications to the migrating nurse and the
home country. International Journal of Research and
Scientific Innovation 7(1): 15–21.
Oladeji B and Gureje O (2016) Brain drain: A challenge to
global mental health. BJPsych International 13(3): 61–63.
Pretorius MC (2018) A phenomenological study of South African
nurse migration and workplace reintegration upon return. MSc
Thesis, Stellenbosch University, South Africa.
Salami H (2017) Medical brain drain: Exploring predictors of
self- and collective entrepreneurial intention among Nigerian
nurses in North America. PhD Thesis, North Central
University, Nigeria.
Sapkota T, Teijlingen E and Simkhada P (2014) Nepalese
health workers’ migration to the United Kingdom: A
qualitative study. Health Science Journal 8(1): 57–74.
Schmiedeknecht K, Perera M, Schell E, et al. (2015) Predictors
of workforce retention among Malawian nurse graduates of
a scholarship program: A mixed-methods study. Global
Health: Science and Practice 3(1): 85–96.
Sharon A and Halcomb E (2009) Mixed Methods Research for
Nursing and the Health Sciences. Hoboken: Wiley-Blackwell.
Sheikh A, Naqvi SHA and Bandukda MY (2012) Physician
migration at its roots: A study on the factors contributing
towards a career choice abroad among students at a medical
school in Pakistan. Global Health 8(43): 1–11.
Shenton AK (2004) Strategies for ensuring trustworthiness in
qualitative research projects. [Online]. Available:
www.crec.co.uk [2016, July 12]. accessed 20 January 2019.
Ten-Hoeve Y, Jansen G and Roodbol P (2014) The nursing
profession: Public image, self-concept and professional
identity. A discussion paper. Journal of Advanced Nursing
70(2): 295–309.
Thapa B and Shrestha K (2017) Factors influencing brain
drain among Nepalese nurses. Kathmandu University Medical
Journal 15(57): 35–39.
World Health Organization (WHO) (2012) Egypt nursing
profile. Available at: http://www.emro.who.int/images/
stories/cah/fact_sheet/Nursing_Profile.pdf (accessed 22 June
2018).