Around 48 000 Italian nurses left to work abroad from 2000 to 2022. The most common destinations included the UK, Switzerland, Germany, France, and Belgium (Nisi, 2023). In addition to the migration phenomenon, it is important to consider that the trend for nurses leaving the profession accelerated during the COVID-19 pandemic years, with about 17 000 nurses leaving during that period (Lopes, 2025).
According to the Italian National Federation of Nursing Professionals (Federazione Nazionale Ordini Professioni Infermieristiche – FNOPI), many Italian nurses have been stimulated to stay abroad by the search for better professional opportunities, more rewarding career opportunities and better working conditions (FNOPI, 2020). Other reasons include wage stagnation, low salaries, and restrictions on staff turnover. Reports for the European Commission, on the other hand, have emphasised that increased remuneration remains a critical need for European nurses, noting that countries offering higher wages are more attractive (Organisation for Economic Co-operation and Development (OECD) and the European Union, 2024). Public perception of the nursing profession is strongly influenced by economic recognition, a factor that represents a significant limitation for Italian nurses in the national context (Lodini et al, 2024). For instance, the annual gross salary of a nurse in Italy is approximately €32 600, compared with €79 200 in Luxembourg (OECD and European Union, 2024).
A recent qualitative study on nurses' self-perception revealed that Italian nurses often attribute the low social recognition of their profession to a lack of unified awareness of their role, potential and professional value within the healthcare system; this resonates internationally (Gunawan et al, 2018; Godsey et al, 2020; Rodríguez-Pérez et al, 2022). Emigration of Italian nurses to more attractive professional environments presents a double challenge. On one hand, it results in a financial loss for the nation, estimated at approximately €22,500 per nurse trained through the university system (Nisi, 2023). On the other, it exacerbates the already critical shortage of nursing staff, a situation worsened by the ageing population. This shortage is projected to intensify between 2022 and 2027, with approximately 21 050 nurses expected to retire, given that the average age of Italian nursing staff is 47.3 years (Agenzia Nazionale per i Servizi Sanitari Regionali, 2022).
The shortage of nursing professionals is not confined to Italy but is a widespread issue across Europe. Before the COVID-19 pandemic, the shortage was estimated at a minimum of 53 000 nurses (Biondino, 2018), a figure that has since worsened. In 2022 Italy had significantly fewer nurses than the European average, with a nurse-to-population ratio of 6.5 per 1000 inhabitants, compared with the European average of 8.4 (OECD and European Union, 2024). Countries such as Finland, Ireland, Germany, Norway, Switzerland, and Iceland boast significantly higher ratios. Moreover, Italy's nurse-to-physician ratio in 2022 was 1.5:1, considerably lower than the European average of 2.2:1, and far behind Switzerland, Finland and Luxembourg, where there are around four nurses per physician (OECD and European Union, 2024). These disparities further jeopardise the sustainability of Italy's public healthcare system, underscoring the urgent need for structural interventions to improve nurse distribution and retention.
Addressing these shortages requires a series of strategic interventions. FNOPI advocates for initiatives to enhance nurse retention by improving working conditions and professional recognition. The Health at a Glance report emphasised the importance of economic incentives to enhance the profession's social prestige (OECD and European Union, 2024). Another measure already seen has been increasing the number of nursing students admitted to university programmes (OECD and European Union, 2024). However, this strategy would require years to yield significant results, and Italy currently ranks among the lowest in Europe for available university slots for nursing students.
One strategy that could have significant impact is the development of advanced and specialised nursing roles in hospitals and primary care. Countries such as Finland, the UK and Ireland have demonstrated that implementing advanced nursing roles improves service accessibility, reduces waiting times, and delivers care quality comparable with that of physicians, with high patient satisfaction rates (OECD and European Union, 2024). This approach could not only boost nurse retention and motivation but also reduce healthcare costs and enhance the sustainability of the national healthcare system.
Moreover, in the past few years, several European countries have sought to address nursing shortages by recruiting from abroad (Brugnolli and Dimonte, 2024). However, this approach has failed to resolve the issue and has, in fact, exacerbated shortages in the source countries. Italy's National Institute of Health has also considered addressing its nursing shortage by recruiting foreign nurses (Brugnolli and Dimonte, 2024). Yet, this effort remains limited due to competition from countries offering better working conditions and higher salaries. The foreign nurses currently working in Italy predominantly come from Poland, Romania, Peru, Albania, Serbia, and India (Brugnolli and Dimonte, 2024). This situation highlights a striking paradox. On one hand, Italy invests significantly in training its nurses, who then emigrate to more attractive countries. On the other, Italy struggles to recruit foreign nurses who are willing to accept the working conditions offered by the national healthcare system. Nurse retention thus remains a critical issue to prevent future shortages, particularly given the pivotal role nurses play in supporting the national health service, a role that became even more evident during the COVID-19 pandemic.
There are no studies that investigate the experience and perception of Italian nurses who worked abroad, to our knowledge. The aim for this study was to explore the motivations, challenges, and experiences of these professionals to gain valuable insights that can inform future strategies for both nurse retention and professional enhancement.
Material and methods
Study design
This was a cross-sectional study conducted using an ad hoc online questionnaire.
Population
Italian nurses working abroad in any healthcare context were included in the study, provided they had received comprehensive information about the study and had a good command of the Italian language. Participants were also required to be professionally recognised as registered nurses in the host country and actively working in a healthcare facility at the time of completing the questionnaire. Those no longer working abroad were excluded. Although the sample included nurses from multiple countries, the study aimed to capture shared experiences among Italian nurses in diverse international settings, rather than conducting country-specific comparisons. This broader perspective was intended to identify common challenges and needs across varied healthcare contexts.
Recruitment
The recruitment process took place between July 2023 and June 2024 using the Microsoft Forms platform. Participants were recruited on a voluntary basis through the online dissemination of the questionnaire link via personal Facebook pages, specific Facebook groups dedicated to Italian nurses working abroad, and Instagram accounts. This approach aimed to reach a broad audience of nurses through platforms commonly used for professional and community networking.
When the survey was launched, the initial 20 responses were regarded as ‘pilot’ responses and were checked by the first and fourth authors to ensure that respondents were able to answer the questions in the way envisaged. As there did not appear to be any need to alter the questionnaire, these data were included in the overall analysis.
Measurements
The questionnaire was developed based on previously published questionnaires and item lists from scientific journals, adapted to meet the specific objectives of this study. Specifically, the questionnaire collected the following data: work experience abroad, information on economic aspects, job satisfaction and future plans, and sociodemographic characteristics.
For the assessment of job satisfaction, the McCloskey/Muller Satisfaction Scale (MMSS) (Tourangeau et al, 2006) was used, specifically, the validated Italian language version developed by Taddia et al (2007). The questionnaire consists of 30 items. Participants were asked to rate each item on a five-point Likert scale, ranging from 1 (minimum satisfaction) to 5 (maximum satisfaction). Total scores ranged from 30 (minimum satisfaction) to 150 (maximum satisfaction), providing a Global Job Satisfaction (GJS) score.
Data analysis
The data were analysed using SPSS (Statistical Package for Social Science) version 27.0 for Windows. Descriptive statistical analysis (mean, standard deviation (SD), medians, frequencies, and percentages) was conducted to characterise the sample. Inferential statistical analysis was performed to assess the perception and experience of nurses who emigrated abroad in relation to their sociodemographic characteristics. One-way analysis of variance (ANOVA) was performed to assess the differences among groups, followed by Bonferroni post-hoc tests. Pearson's chi-squared test was used for nominal variables, and Fisher's exact test was used for dichotomous variables.
Ethical considerations
The study was approved by the Ethics Committee of the University of Bologna (28 June 2023, protocol no. 0174800) and adhered to the ethical principles outlined in the Declaration of Helsinki. Participants were required to provide informed consent before completing the questionnaire. Responses were recorded only after participants pressed the ‘Submit’ button. In cases where the questionnaire was abandoned before completion, the responses were not collected. The questionnaire was entirely anonymous, thereby ensuring the confidentiality of the data provided.
Findings
Participants
The questionnaire link was accessed by 338 individuals, of whom 333 (98.5%) provided informed consent to participate in the study. However, 89 nurses were excluded from the analysis because, at the time of completing the questionnaire, they reported no longer working abroad. Consequently, the final analysis was conducted on a sample of 244 nurses. This corresponds to a final inclusion rate of 72.2%, which reflects the challenges of conducting survey-based research via social media platforms.
The average age of nurses who completed the questionnaire was 33.3 years (SD: 6.50; range: 22–55). The majority were women (n=157; 64%) and childless (n=177; 73%). Participants obtained their nursing qualifications between 1992 and 2023, with a median graduation year of 2015. Additionally, 21% (n=50) reported having completed further postgraduate studies in nursing or other fields. Further details are provided in Table 1.
| Variables | n | % |
|---|---|---|
| Gender | ||
| Female | 157 | 64.3 |
| Male | 80 | 32.8 |
| I prefer not to disclose | 7 | 2.9 |
| Marital status | ||
| Single | 100 | 41.0 |
| Cohabiting/married | 89 | 36.5 |
| Divorced | 6 | 2.5 |
| In a relationship but not cohabiting | 49 | 20.1 |
| Children | ||
| No | 177 | 72.5 |
| Yes | 67 | 27.5 |
| Region where the professional qualification was obtained | ||
| Abruzzo | 12 | 4.9 |
| Basilicata | 14 | 5.8 |
| Calabria | 14 | 5.7 |
| Campania | 10 | 4.1 |
| Emilia Romagna | 46 | 18.9 |
| Lazio | 32 | 13.1 |
| Liguria | 8 | 3.3 |
| Lombardia | 25 | 10.2 |
| Marche | 5 | 2.0 |
| Molise | 1 | 0.4 |
| Piemonte | 16 | 6.6 |
| Puglia | 7 | 2.9 |
| Sardegna | 7 | 2.9 |
| Sicilia | 14 | 5.7 |
| Toscana | 8 | 3.3 |
| Trentino Alto-Adige | 1 | 0.4 |
| Umbria | 7 | 2.9 |
| Veneto | 17 | 7.0 |
| Do you believe the Italian university system provided you with adequate training? | ||
| Very much | 106 | 43.4 |
| Somewhat | 111 | 45.5 |
| A little | 23 | 9.4 |
| Not at all | 4 | 1.6 |
| Other qualifications obtained abroad | ||
| No | 187 | 76.6 |
| Yes | 57 | 23.4 |
The majority of participating nurses were employed in Europe, with England (n=95; 39%) and Germany (n=44; 18%) being the most common destinations. Other reported destinations included Switzerland (n=27), Belgium (n=19), Spain (n=14), Norway (n=13), Ireland (n=6), the Netherlands (n=6), France (n=7), the USA (n=4), Sweden (n=2), Austria (n=2), Australia (n=1), Canada (n=1), Denmark (n=1), and Wales (n=1). The duration of employment abroad among respondents ranged from a few months to 29 years. Specifically, 35% (n=86) had worked abroad for 2 months to 1 year, 40% (n=98) for 1 to 5 years, 21% (n=52) for more than 5 but less than 10 years, and 2% (n=6) for more than 10 years.
Motivations for working abroad
The motivations driving participating nurses to work abroad included a desire for personal growth (213/706 responses) and dissatisfaction with their economic conditions in Italy (176/706 responses). Other motivations, in descending order of frequency, were the wish to experience other cultures (130/706 responses), the need or willingness to work (116/706 responses), the desire to learn a new language (66/706 responses), and personal or family reasons (5/706 responses).
A total of 9% (n=23) of respondents reported being influenced by the COVID-19 pandemic in their decision to work abroad. Specific reasons tied to the pandemic included excessive stress (5/23), disorganisation and deterioration of Italy's National Health Service (2/23), work overload (2/23), mandatory vaccination policies (2/23), employment in COVID-19 units (1/23), consecutive shifts without rest (1/23), and a toxic work environment (1/23).
From an emotional perspective, the majority of nurses reported no significant difficulty in separating from their families (57%, n=138). However, a larger proportion (60%, n=146) indicated that distancing themselves from friends was more challenging.
Experiences with integration and recruitment abroad
The preparation of the necessary documentation to work abroad was considered relatively straightforward by 71.0% (n=174) of the participating nurses. Among those who encountered challenges, the most commonly reported issues included the recognition and translation of qualifications (30%, n=21) and the time required to prepare the necessary documents (23%, n=16).
On arrival in their host country, 77% (n=188) of the nurses reported finding a welcoming and supportive work environment, whereas 23% (n=56) expressed difficulties adjusting. Some participants elaborated on their experiences:
‘Initially, it was difficult to adjust, but I found a very welcoming work environment.’
‘I felt like an outsider in the setting.’
Regarding language skills, 66% (n=161) of the nurses had the opportunity to attend a language course, while 42 participants did not require additional support, as they already possessed a certified level of proficiency in the language of their host country.
When asked about how they secured their jobs abroad, 43% (n=165) reported using recruitment agencies, while 29% (n=111) found job opportunities through online advertisements. A smaller proportion mentioned leveraging pregraduation Erasmus placements (13%, n=48) or participating in specific recruitment competitions (7%, n=28). Other methods included direct contact with hospitals (n=12), university connections (n=4), the European job portal EURES (n=2), and recommendations from friends or colleagues (n=2).
In terms of recruitment processes, the majority of nurses (76%) underwent only a single interview for selection. Meanwhile, 17% (n=41) completed an interview followed by a written test, and 5% (n=12) faced an interview, a written test, and a practical examination. A smaller group (2%, n=7) underwent both written and practical assessments without an interview.
Compensation abroad
When asked about their current salary abroad, 57% (n=140) of the nurses rated it as ‘very good’, 39% (n=94) as ‘good’, and 4% (n=9) as ‘sufficient’. Only one participant considered their salary to be ‘poor’.
Regarding economic difficulties, 76% (n=186) of the participants reported no financial challenges during their initial period abroad, whereas 24% (n=58) admitted to facing such difficulties. Among those who experienced challenges, 17% (n=10) managed independently: 7% (n=4) used personal savings, one participant requested a salary advance, and another worked extra shifts to increase earnings. Additionally, 3% (n=2) secured a bank advance. The remaining participants sought financial support from close relations: 27% (n=16) from family, 14% (n=8) from parents, 2% (n=1) from a sibling, 8% (n=5) from their partner, and 2% (n=1) from friends.
Finally, concerning the relationship between quality of life and salary abroad compared with Italy, most participants perceived their earnings abroad to be higher. Specifically, 66% (n=160) stated that the cost of living abroad was significantly lower than in Italy, whereas 28% (n=68) considered it higher. Only 7% found the quality of life-to-salary ratio abroad comparable to that in Italy.
Advantages and disadvantages of working abroad
Although 93% (n=227) of participating nurses recommended the experience of working abroad to their Italian colleagues, they also highlighted several strengths and weaknesses.
Among the advantages of working abroad, 5% (n=14) highlighted job satisfaction and financial stability, with 18% (n=44) specifically citing salary as the primary benefit. Work-related advantages included nursing autonomy (3%, n=8), flexible working hours (2%, n=6), reduced stress levels (n=1), job security (n=2), better organisation (n=2), and positive relationships with colleagues (1%, n=3).
On a professional level, participants emphasised recognition of advanced skills (2%, n=5), gratification, and respect from peers (6%, n=15), as well as acknowledgment of the nurse's societal role (4%, n=10). Additionally, 16% (n=39) reported personal and professional growth, with 7% (n=18) either pursuing or having completed a specialisation, 3% (n=7) of which were funded by their employing institution. Other benefits included improved quality of life (n=3), language acquisition (n=2), and cultural enrichment (n=3). Only two respondents did not identify any positive aspects.
On the other hand, 14% (n=36) pointed to the distance from home and family as a significant drawback, followed by language barriers (7%, n=18) and cultural challenges (5%, n=12). Other cited issues included the climate (4%, n=10) and limited social life (n=2). Regarding the work environment, participants noted challenges such as racism (n=2), stress (n=3), staff shortages (n=2), long shifts (2%, n=6), bureaucratic hurdles (1%, n=3), and inadequate salaries (1%, n=3). Other difficulties included the cost of living (2%, n=4) and challenges in balancing family and work life (n=1). A small group of respondents (5%, n=13) stated that they did not experience any significant disadvantages.
Job satisfaction abroad
Almost all participating nurses (99%; n=233) stated that working abroad provided a significant opportunity for professional growth. This is reflected in the high level of job satisfaction reported by Italian nurses working abroad (mean=135.13, SD = 16.69; range: 39–150). Detailed responses to the questionnaire are presented in Table 2.
| Very dissatisfied | Moderately dissatisfied | Neither satisfied nor dissatisfied | Moderately satisfied | Very satisfied | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | |
| Salary | 1 | 0.4 | 2 | 0.8 | 9 | 3.7 | 80 | 32.8 | 152 | 62.3 |
| Vacation | 1 | 0.4 | 2 | 0.8 | 3 | 1.3 | 56 | 23.0 | 182 | 74.6 |
| Benefits | 1 | 0.4 | 3 | 1.2 | 16 | 6.6 | 97 | 39.8 | 127 | 52.0 |
| Working hours | 2 | 0.8 | 8 | 3.3 | 18 | 7.4 | 78 | 32.0 | 138 | 56.6 |
| Flexibility of work schedule | 2 | 0.8 | 4 | 1.6 | 17 | 7.0 | 55 | 22.5 | 166 | 68.0 |
| Opportunity for daytime shifts | 0 | 0 | 2 | 0.8 | 9 | 3.7 | 57 | 23.4 | 176 | 72.1 |
| Part-time opportunities | 2 | 0.8 | 2 | 0.8 | 10 | 4.1 | 50 | 20.5 | 180 | 73.8 |
| Flexibility in planning your weekends | 2 | 0.8 | 3 | 1.2 | 8 | 3.3 | 62 | 25.4 | 169 | 69.3 |
| Holiday work incentives | 3 | 1.2 | 3 | 1.2 | 6 | 2.5 | 48 | 19.7 | 184 | 75.4 |
| Maternity leave | 4 | 1.6 | 8 | 3.3 | 44 | 18.0 | 44 | 18.0 | 144 | 59.0 |
| Parental leave | 0 | 0 | 48 | 20.0 | 52 | 21.3 | 4 | 1.6 | 133 | 54.5 |
| Direct supervisor | 1 | 0.4 | 3 | 1.2 | 25 | 10.2 | 68 | 27.9 | 147 | 60.2 |
| Colleagues | 1 | 0.4 | 3 | 1.2 | 12 | 4.9 | 70 | 28.7 | 158 | 64.7 |
| Doctors you work with | 0 | 0 | 4 | 1.6 | 12 | 4.9 | 67 | 27.5 | 161 | 66.0 |
| Use of nursing methodologies in the department | 3 | 1.2 | 5 | 2.0 | 16 | 6.6 | 64 | 26.2 | 156 | 63.9 |
| Opportunities for social interactions at work | 4 | 1.6 | 6 | 2.5 | 19 | 7.8 | 66 | 27.1 | 149 | 61.1 |
| Opportunities for social interactions with colleagues | 6 | 2.5 | 8 | 3.3 | 31 | 12.7 | 61 | 25.0 | 138 | 57.0 |
| Opportunities for social interactions with colleagues outside of work hours | 1 | 0.4 | 5 | 2.5 | 26 | 10.7 | 68 | 27.9 | 143 | 58.6 |
| Opportunities for integration with other professional roles | 2 | 0.8 | 5 | 2.5 | 12 | 4.9 | 67 | 27.5 | 158 | 64.8 |
| Opportunities to engage with universities or other training centres | 1 | 0.4 | 6 | 2.5 | 26 | 10.7 | 68 | 27.9 | 143 | 58.6 |
| Opportunities to participate in organisational projects and workgroups | 1 | 0.4 | 7 | 2.9 | 23 | 9.4 | 62 | 25.4 | 151 | 61.9 |
| Supervision/monitoring of your work | 1 | 0.4 | 4 | 1.6 | 15 | 6.2 | 76 | 31.1 | 148 | 60.7 |
| Career advancement opportunities | 1 | 0.4 | 2 | 0.8 | 11 | 4.5 | 54 | 22.1 | 176 | 72.1 |
| Recognition of your work by supervisors | 1 | 0.4 | 7 | 2.9 | 10 | 4.1 | 58 | 23.8 | 168 | 68.9 |
| Recognition of your work by colleagues | 1 | 0.4 | 5 | 2.0 | 10 | 4.1 | 55 | 22.5 | 173 | 70.9 |
| Encouragement and positive reinforcement | 1 | 0.4 | 6 | 2.5 | 17 | 7.0 | 55 | 22.5 | 165 | 67.6 |
| Opportunities to participate in research or continuing education activities | 0 | 0 | 4 | 1.6 | 23 | 9.4 | 64 | 26.2 | 153 | 62.7 |
| Opportunities to write and publish articles | 3 | 1.2 | 8 | 3.3 | 56 | 23.0 | 57 | 23.4 | 120 | 49.2 |
| Level of responsibility | 1 | 0.4 | 5 | 2.0 | 13 | 5.3 | 75 | 30.7 | 150 | 61.5 |
| Ability to contribute to solving work-related problems | 1 | 0.4 | 4 | 1.6 | 9 | 3.7 | 66 | 27.0 | 164 | 67.2 |
| Involvement in organisational decision-making | 2 | 0.8 | 6 | 2.5 | 17 | 7.0 | 64 | 26.2 | 155 | 63.5 |
The analyses revealed a significant difference in job satisfaction based on perceived salary differences abroad. Participants who reported earning higher salaries compared with Italy and saving money due to a lower cost of living exhibited greater job satisfaction than those who, despite higher salaries, could not save money or found no significant salary differences with Italy (138.29 vs. 127.91 and 134.25, respectively; P<0.001).
Job satisfaction did not differ significantly between those willing to return to Italy if offered similar working conditions and those preferring to remain abroad (P>0.050). However, satisfaction was significantly higher among participants who would recommend their experience to other Italian colleagues compared with those who would not (136.17 vs 121.29, respectively; P<0.001). Moreover, job satisfaction was unrelated to marital status (P>0.050) but showed a significant difference regarding parenthood: participants with children reported higher satisfaction than those without (138.67 vs 133.79, respectively; P=0.041). Regarding future plans, 9% (n=21) of nurses expressed willingness to return to Italy. However, if offered the same working conditions as abroad, 72% (n=176) indicated they would return, but 28% (n=68) stated their intention to remain abroad under any circumstances.
Proposals to retain nurses in Italy
In response to the question, ‘What changes would you make to the Italian National Health Service to retain nurses?’, 37% (n=90) of participants identified salary increases as a top priority, while 5% (n=12) highlighted the importance of broader pay raises. Additionally, 6% (n=15) called for comprehensive reforms to the National Health Service, whereas less than 1% (n=2) suggested specific adjustments to the managerial system. Another key issue raised was the recruitment process, with 10 participants advocating for the abolition of public selection exams, which they considered inadequate.
Participants provided qualitative insights that emphasised the need for professional and economic recognition. Examples include:
‘Abolish public selection exams, ensure true recognition of professional autonomy, and create master's programmes that are both professionally and economically recognised, enabling real professional growth.’
‘Eliminate public selection exams, respect workers, and increase salaries.’
Economic and professional recognition were among the most frequently cited themes. Some participants expressed this as follows:
‘Adequate salary and opportunities for specialisation.’
‘More dignified salaries, true recognition of master's degrees, alignment of the Italian nursing profession with European standards, and a cultural shift that views us as more than just doctors' assistants. Stop arguing about tasks and start discussing competencies. Making a bed or helping with hygiene doesn't diminish my skills; teamwork is key in the ward.’
Discussion
The objective of this study was to evaluate the perceptions and experiences of Italian nurses who decided to work abroad, marking, to the best of the authors' knowledge, the first investigation of this topic in the Italian nursing population. Over 75% of participating nurses are currently employed in European countries, particularly in England and Germany, with a smaller proportion residing in non-European countries such as the USA and Canada. These findings align with Moreno's study (2024), which identified the UK as a primary destination for migrating nurses.
This study reveals that nurse migration is a phenomenon encompassing both newly graduated nurses and professionals with over 10 years of experience working in Italy. As described in a review by Ejebu et al (2024), various challenges encountered throughout a nurse's career contribute to intentions to abandon nursing education or work in Italy, exacerbating the workforce shortage and driving migration abroad.
In general, nurse migration is characterised by push and pull factors. The main push factors identified in this study, consistent with those reported by Konlan et al (2023), Cagnazzo et al (2021) and de Vries et al (2023), include economic and professional dissatisfaction, unfavourable working environments, lack of professional recognition, emotional exhaustion, and the impact of the COVID-19 pandemic. Economic dissatisfaction, in particular, relates to the lower wages in Italy compared with countries such as the UK and Germany, where nurses earn 46.2% and 56.0% more, respectively (Lopes, 2025).
Additionally, findings highlight that the pandemic exacerbated pre-existing workplace challenges, becoming a major push factor. Nurses who migrated due to the pandemic frequently cited stress as the primary motivation, describing work environments as unfavourable and toxic due to systemic disorganisation. These conditions led to staff shortages, increased workloads, extended shifts without rest, burnout, and the development of psychosomatic disorders (Tamata and Mohammadnezhad, 2023; Tolksdorf et al, 2022). Another contributing factor to migration, as highlighted by this study, is toxic workplace environments. Recent studies underscored how difficult relationships among team members, emotional exhaustion, excessive workloads, and limited autonomy negatively affect nursing care quality, compromising patient safety and increasing risks of falls and mortality (Sasso et al, 2019; Dall'Ora et al, 2020; Gazineo et al, 2021; Gazineo et al, 2022; Godino et al, 2022; Catania et al, 2024).
In contrast, pull factors identified in this research include the desire for personal and professional growth, career advancement opportunities, interest in exploring new cultures and languages, and the prospect of providing better futures for their families. These findings align with previous literature emphasising the appeal of international opportunities for nurses (Brugnolli and Dimonte, 2024; Decaro et al, 2024; Lodini et al, 2024).
Although this study focuses on Italian nurses, it is important to situate the findings within a broader global context. Migrant nurses from countries such as the Philippines and India, who constitute a large portion of the international nursing workforce, often report different motivations and challenges (Villamin et al, 2024). For instance, financial remittances to support families, limited domestic employment opportunities, and government-supported migration programmes are frequently cited push factors. Additionally, studies have shown that nurses from these countries may face more systemic discrimination and marginalisation, particularly in Western healthcare systems, compared with their European counterparts (Zhong et al, 2023).
These comparisons highlight how nurse migration is shaped by distinct socioeconomic, cultural, and political dynamics depending on the country of origin. Although Italian nurses often migrate due to dissatisfaction with working conditions and limited professional recognition within the national health system (Decaro et al, 2024), nurses from major exporting countries such as the Philippines and India are frequently driven by structural economic constraints, lack of domestic opportunities, and government-facilitated migration frameworks. Despite these differing contexts, our findings align with global literature that identifies a combination of push and pull factors, including remuneration, professional development, and workplace climate, as key determinants of nurse mobility (Villamin et al, 2024). These insights underscore the need for transnational strategies that address workforce imbalances while acknowledging country-specific needs and motivations. This study thus contributes to the broader discourse on healthcare workforce mobility by offering a perspective from a high-income European country that functions both as a sender and, increasingly, as a receiver of health professionals.
Regarding the process of working abroad, the most commonly reported method, cited by 43% of participants, was through agencies, followed by 29% who found opportunities online. Although most participants did not face challenges in preparing the necessary documentation, some reported bureaucratic difficulties, particularly in translating and validating their qualifications. However, the Italian Nursing Degree is recognized in certain countries under Law No. 795 of November 15, 1973, which implements the European Strasbourg Agreement of 1967 on nurse education and training. This agreement allows Italian nurses to practise in member states of the Council of Europe.
Most participants described their initial work environment abroad as welcoming, with 77% reporting immediate collegial support. However, 20% experienced cultural and professional adaptation challenges, primarily due to differences in healthcare systems and work practices. A recent systematic review similarly highlights sociocultural barriers and the costs of accessing international work opportunities as deterrents for nurse migration (Toyin-Thomas et al, 2023).
Among the challenges of working abroad, participants also reported instances of discrimination and racism. These themes align with a recent systematic review, which notes that such behaviours often stem from biases related to a nurse's nationality and cultural background (Rajpoot et al, 2024). Language barriers were another common issue, impacting professional relationships, social integration, and patient care. Moreover, accents, tone, and language use in specific contexts can lead to misunderstandings and conflicts among colleagues and patients (Rajpoot et al, 2024). Language proficiency and certifications are therefore crucial prerequisites for employment abroad. In our study, 66% of participants were offered language courses, with nearly half finding them beneficial, while others learned the language independently.
Despite these challenges, many participants highlighted favourable work conditions abroad, including higher salaries and opportunities for professional development, as significant pull factors. These findings align with recent systematic reviews, which emphasise how international opportunities offer nurses greater autonomy and a more respected societal role (Perez-Francisco et al, 2020; Pressley et al, 2022).
Overall, the high job satisfaction of Italian nurses working abroad is evident in the results of the McCloskey/Mueller Satisfaction Scale. Additionally, this study identifies dissatisfaction with Italy's public recruitment system as an emerging theme. Currently, public hospitals in Italy recruit nurses through competitive examinations involving written and oral tests, creating rankings from which hospitals hire based on service needs rather than specific competencies. Participants in this study advocated for abolishing this system in favour of recruitment practices that mirror those in other countries. They suggest emphasising job interviews and skill assessments to better recognise individual expertise and experience.
Strengths and limitations
One of the key strengths of this study is that, to the best of the authors' knowledge, it represents the first quantitative analysis to systematically explore the perceptions and experiences of Italian nurses who have chosen to work abroad. This approach provides a comprehensive overview of a largely under-researched phenomenon, enriching the existing literature and offering valuable insights for the design of targeted interventions.
However, several limitations should be acknowledged. First, its cross-sectional design does not allow for establishing causal relationships between the analysed variables, restricting the findings to descriptive associations. Second, the use of a self-administered questionnaire may have introduced social desirability bias or errors in participants' understanding of the questions. The online recruitment method, while facilitating access to a wide and diverse sample, may have excluded certain groups, such as nurses who are less engaged with social media or digital platforms. Another limitation lies in the limited analysis of contextual variables, such as local healthcare policies, cultural norms, and economic conditions in the destination countries, all of which may significantly influence motivations, experiences, and levels of job satisfaction. Although the study aimed to explore shared experiences across diverse settings, the absence of country-specific analyses reduces the ability to capture the unique dynamics of each healthcare system. Additionally, the exclusive focus on Italian nurses limits the generalisability of the findings to other populations of migrant nurses.
Despite these limitations, this study serves as an important foundation for future research. Longitudinal studies, larger samples, and qualitative approaches could deepen our understanding of migrant nurses' experiences and help develop targeted interventions aimed at improving working conditions and professional wellbeing.
Conclusions
Italian nurses represent an essential pillar of the healthcare system. For those who choose to work abroad, adequate preparation is crucial to address the challenges they may encounter in their host countries, such as language barriers, discrimination, and racism. Measures such as pre- and postdeparture training programmes, including language courses and cultural orientation tailored to the destination country, could significantly ease the integration process for health professionals abroad, reducing the risk of communication misunderstandings within healthcare teams.
It is imperative that the Italian healthcare system learns from the experiences of nurses working abroad by adopting successful models already implemented in other countries to improve working conditions. This approach is vital to effectively counter the ‘intention to leave’ within the nursing sector, preventing ‘brain drain’ and mitigating the risk of shortages of qualified staff that could compromise healthcare quality.
What emerges from this study goes beyond competitive salaries or working conditions; it calls for a deeper reflection on the value attributed to the role of nurses within the healthcare system. Nurses are central to ensuring continuity of care, patient wellbeing, and the overall quality of healthcare delivery. However, they are often not given the recognition, nor the professional and social importance, they deserve. Improving the overall conditions for nursing staff in Italy could significantly reduce the phenomenon of emigration while ensuring adequate staffing levels, thus avoiding reliance on recruiting foreign nurses. Achieving this goal requires profound change, not only in economic terms but also in cultural and organisational dimensions. By fostering a more respectful, empowering, and motivating work environment, it is possible to build a healthcare system that not only meets present challenges but also prepares future generations to provide care with expertise and dedication to the health and wellbeing of the population.
This study highlights the growing potential of international experiences, not just as migration, but as valuable opportunities for professional development. Stakeholders, including universities, professional organisations, and policymakers, should collaborate to change the perception of Italian nurses migrating abroad. Despite the clear benefits, participation in Erasmus programmes within the nursing field remains low compared with other academic areas. This suggests that there is untapped potential in expanding international mobility for healthcare students and professionals. Promoting these programmes more actively could help provide nursing students with global experiences that would significantly enrich their skills and knowledge.
Rather than viewing this movement as a loss, it should be seen as an important opportunity for both personal and professional growth. The migration of health professionals can be viewed as a two-way exchange of knowledge and expertise, benefiting both the individual's career and the global healthcare system. This shift in perspective would help create a more dynamic, interconnected, and resilient healthcare workforce, benefiting both professionals and the communities they serve.