Meleis-Based Training: Perceived Stress, Professional Self-Efficacy, and Social Adaptation of Migrant Turkish Nurses

AIM AND SIGNIFICANCE OF THE PROJECT:

To address the shortage of skilled labor, the German government passed a law in 2020 (Fachkräfteeinwanderungsgesetz) regarding the immigration of skilled workers from outside the European Union to Germany (Bundesregierung der Bundesrepublik Deutschland, 2019). This law facilitates the immigration of nurses and other skilled workers, and currently, Germany and the United Kingdom are among the countries with the highest number of migrant nurses (OECD, 2016). As of 2023, migrant nurses constitute 14.5% of the nursing workforce in Germany, with Turkish nurses playing a significant role in this group (Bibliomed Pflege, 2023).

Migrant nurses face a series of transition processes such as international migration, learning a new language, adapting to a different culture, and adjusting to a new healthcare system and work environment. These processes involve not only individual transformation but also serious challenges in professional life and social integration (Nortvedt et al., 2020; Schilgen et al., 2019; Villamin et al., 2024; WHO, 2020). Issues such as language barriers, lack of social support, discrimination, inadequate orientation processes, and excessive workloads complicate the integration of migrant nurses (Davda et al., 2018; Smith et al., 2022).

These challenges have negative effects not only on psychological well-being but also on professional satisfaction and perceptions of competence. For example, differences in educational levels and insufficient language skills can lead to a loss of professional skills, feelings of devaluation, and general dissatisfaction among nurses (Davda et al., 2018). Additionally, changes in living conditions and difficulties adjusting to climate conditions further complicate the overall adaptation processes for migrant nurses (Villamin et al., 2024). It is believed that these factors may increase the perceived stress levels among migrant nurses, leading to deficiencies in social adaptation and perceptions of professional competence. In this context, the process of adapting to perceived differences is considered a complex transition process that should be addressed not only through personal efforts but also through supportive strategies. Meleis's Transition Theory provides a framework for understanding the effects of major life changes - i.e., transition processes - on health and well-being (Meleis, 2010).

This study aims to explore the transition processes of migrant nurses in Germany using Meleis's Transition Theory, focusing on factors such as stress, adaptation, and self-efficacy, to gain a deeper understanding of how to support them during these transitions. The results of this study will contribute to the development of strategies to enhance social adaptation in nursing practice, improve healthcare quality, and support the professional development and migration adaptation processes of migrant nurses. This is a randomized controlled experimental study that examines the effects of an education program based on Meleis's Transition Theory on perceived stress, professional self-efficacy, and social adaptation among Turkish migrant nurses who have migrated to Germany for work.

GENERAL INFORMATION:

As the global shortage of nurses grows, the World Health Organization (WHO) predicts that by 2035, the global demand for nurses will reach 12.9 million. Nurses migrate for various reasons (financial, professional, political, social, and personal) (Dywili et al., 2013). Today, one in every eight nurses works outside their country of birth or education (WHO, 2020). These nurses are referred to in the literature as internationally educated nurses, foreign nurses, or migrant nurses (Dywili et al., 2013; Villamin et al., 2024; WHO, 2020).

Nurse migration has both positive and negative impacts on individuals and healthcare systems (Li et al., 2014). Migrant nurses can facilitate the transfer of knowledge and skills between source and destination countries, contribute to the labor market, and enrich healthcare services through cultural diversity. Nurses who typically migrate to developed or developing countries for better job, income, and education opportunities are driven by factors such as career prospects, cultural diversity, and economic contributions (Agbede \& Asmah, 2024; Li et al., 2014; Villamin et al., 2024). However, alongside these positive aspects, they encounter numerous challenges during their integration process in the destination country and require support (Agbede \& Asmah, 2024). For example, when financial incentives lead to economic recovery, or when partially achieved, other needs such as family welfare, community support, recreation, and professional satisfaction may become more important (Villamin et al., 2024). Migrant nurses face challenges such as adaptation difficulties, language barriers (Nortvedt et al., 2020; Schilgen et al., 2019), lack of social support, discrimination (Davda et al., 2018; Smith et al., 2022; Villamin et al., 2024), insufficient orientation processes, excessive workload, harsh living conditions, and difficulties adapting to climate (Villamin et al., 2024). Additionally, differences in educational levels, language skills, and cultural disparities are known to lead to dissatisfaction, devaluation, and loss of professional skills (Davda et al., 2018).

A study conducted with Filipino migrant nurses reported that nurses felt devalued in the countries they migrated to and struggled with language learning and finding housing or work (Nortvedt et al., 2020). Results from a study on migrant nurses in Germany found that language differences were identified as a major stress factor affecting teamwork and nurse-patient relationships (Schilgen et al., 2019). Furthermore, in Germany, differences in work environments, professional competence, ethical understanding, language barriers, cultural alienation, high perceived pressure for adaptation, and changes in professional identity are also issues that can accompany the process (Lauxen et al., 2019). In summary, migrant nurses face challenges related to adapting to a new culture and work environment, and they deal with numerous stress factors during this process. The challenges faced by migrant nurses not only affect their interactions with colleagues and patients but also their cultural adaptation and job satisfaction. Therefore, it is essential to implement and evaluate strategies that support the integration and well-being of migrant nurses (Al-Btoush \& El-Bcheraoui, 2024).

Transition, in the literature, is defined as the process of an individual moving from one state or status to another, including the time span, phases, and how the individual perceives this process. In this context, the migration of nurses to practice in a different country is a transition process (Meleis, 2010). Migrant nurses undergo various transition processes, such as international migration, living with a new language, adapting to a new culture, adjusting to a new healthcare system, and integrating socially (WHO, 2020). These transitions are long-term processes that require adaptation to new roles and situations. An individual's transition may be influenced positively or negatively by others, and the support needs of each individual during the transition process differ (Meleis, 2019).

Nurses are at the heart of change and transition processes. They are representatives of a profession that supports individuals who encounter change and those preparing for it (Meleis, 2010, 2019). Immigrant nurses become individuals who need support to successfully adapt to a new culture, different working conditions, and professional environments in this process. This highlights the importance of professional solidarity as well as strategies, resources, and knowledge sharing to support the adaptation of immigrant nurses (Dywili et al., 2013; Villamin et al., 2024; WHO, 2020).

In light of this information, Meleis' Transition Theory can provide a framework to understand the perceived stress, professional self-efficacy, and social adaptation, which are critical dimensions in the professional transition processes of Turkish nurses who have migrated to Germany. It can also evaluate and support the difficulties they experience in these processes. Most studies on immigrant nurses in the international literature are qualitative (Ryan, 2008; Schilgen et al., 2019), reviews (Al-Btoush \& El-Bcheraoui, 2024; Correa-Betancour et al., 2024; Smith et al., 2022), or case reports (Lauxen et al., 2019), and recent studies show limitations in their quantitative nature (Al-Btoush \& El-Bcheraoui, 2024; Correa-Betancour et al., 2024; Lauxen et al., 2019; Schilgen et al., 2019; Smith et al., 2022). In the national literature, no studies focusing on immigrant nurses have been found.

Considering that a large part of the existing literature consists of qualitative, review, or case report studies, and there is no study focusing on this issue in the national context, it is important to note that nurses, who become individuals in need of support due to challenges such as language barriers, different professional standards, social isolation, and cultural differences after migration. Thus, investigating the effects of a training program designed within the framework of Meleis' Transition Theory on perceived stress, professional self-efficacy, and social adaptation through a randomized controlled experimental design constitutes the unique aspect of this study.

METHOD OF THE THESIS:

1. Research Type The research is planned to be conducted as a randomized controlled experimental study to determine the effects of an educational program developed within the framework of Meleis's Transition Theory on perceived stress, professional self-efficacy, and social adaptation of Turkish nurses who have immigrated to Germany to work. 2. Research Hypotheses H₀₁: The educational program developed within the framework of Meleis's Transition Theory does not affect the perceived stress levels of Turkish immigrant nurses.

H₁₁: The educational program developed within the framework of Meleis's Transition Theory affects the perceived stress levels of Turkish immigrant nurses.

H₀₂: The educational program developed within the framework of Meleis's Transition Theory does not affect the professional self-efficacy levels of Turkish immigrant nurses.

H₁₂: The educational program developed within the framework of Meleis's Transition Theory affects the professional self-efficacy levels of Turkish immigrant nurses.

H₀₃: The educational program developed within the framework of Meleis's Transition Theory does not affect the social adaptation levels of Turkish immigrant nurses.

H₁₃: The educational program developed within the framework of Meleis's Transition Theory affects the social adaptation levels of Turkish immigrant nurses. 3. Research Variables Dependent variables: perceived stress, professional self-efficacy, and social adaptation levels.

Independent variable: the educational program implemented within the framework of Meleis's Transition Theory. 4. Research Location and Characteristics There are various application methods for nurses who have immigrated to Germany. One of these is the individual application process for equivalence procedures. In this process, nurses can apply to practice their profession in Germany by collecting necessary documents and meeting requirements such as language proficiency. Alternatively, immigrant nurses can receive support from equivalence agencies to manage the application process. One of these centers is the Sprachportal Akademie, located in Wetzlar. The research will be conducted at the Sprachportal Akademie Wetzlar, located in Germany, on Turkish immigrant nurses residing in Gießen. 5. Population and Sample The population of the research will consist of Turkish immigrant nurses who have immigrated to Germany and are served by Sprachportal Akademie, providi

• Perceived Stress [Срок оценки: From the start of the educational program to the end of the 7-week intervention period]
• Nursing Professional Self-Efficacy [Срок оценки: From the start of the educational program to the end of the 7-week intervention period]