Background: In Khyber Pakhtunkhwa (KP), Pakistan, the number of institutions offering Bachelor of Science in Nursing (BSN) programs has increased in recent years. Despite this expansion, enrollment in nursing education is experiencing a declining trend, creating a paradox between supply and student interest. This gap may be influenced by factors such as negative perceptions of the nursing profession, the demanding nature of clinical work, and limited awareness of career opportunities. As a result, concerns are emerging regarding the future availability of a qualified nursing workforce in the region.
Methodology: This study employs a structured narrative policy analysis, drawing on publicly available workforce data, policy documents, and peer-reviewed literature published between 2019 and 2026. A thematic synthesis approach was used to identify and analyze structural determinants of enrollment decline. The study employs policy, market, and workforce narrative analysis to demonstrate the disconnect between graduate employment and the education system.
Key Findings: The analysis reveals three primary drivers of enrollment decline: (1) oversupply of nursing graduates relative to local job availability, (2) erosion of economic incentives through stagnant salaries and unpaid clinical internships, and (3) reduced international mobility due to workforce nationalization policies in destination countries. The author proposes a strategic framework encompassing workforce planning, regulatory reform, economic reformation, and professional empowerment. If these are addressed, the author believes that nursing as a profession will be more attractive to candidates and that healthcare workforce sustainability in KP will improve.

Nursing education, Enrollment decline, Workforce saturation, Bachelor of Science in Nursing expansion, International migration, Salary disparities, Unpaid internships, Healthcare workforce.

The contribution of nurses to healthcare is invaluable and multifaceted. They are involved in care delivery from the points of health promotion and disease prevention to curative interventions and rehabilitation.[1] In regions of low- to middle-income economic status, like Khyber Pakhtunkhwa (KP), Pakistan, the value of healthcare services provided by nurses is heightened. This phenomenon is largely the result of rapid population growth combined with the high incidence and prevalence of both communicable and non-communicable diseases and inadequate health care services.[2,3] In the past, healthcare policy in the region has aimed to provide more educational opportunities to nurses through the opening of more Bachelor of Science in Nursing (BSN) degree-granting institutions to produce more nurses to help resolve gaps in the delivery of healthcare. Unfortunately, student enrollment has drastically declined.[4] Ironically, this is in the wake of widespread investment in building more educational institutions. This decline in enrollment may indicate that high availability of educational opportunities is not sufficient to stimulate interest in the field of nursing.[5]

Many studies have looked at the socio-cultural dimensions, particularly the gender-related issues and professional stereotypes, and how they adversely affect recruitment into the nursing profession. These socio-cultural dimensions are certainly important and relevant.[6] The economic and structural dimensions are now more impactful, at least, from the prevailing situation in nursing in KP.[7] The rapid increase in the number of nursing educational institutions has also resulted in a higher number of nursing graduates. However, this increase in the number of nursing graduates has not been matched by the availability of nursing jobs to absorb them, especially in the local job market. The new graduates are, therefore, left in greater numbers to face unemployment and underemployment, which further devalues a nursing degree for new graduates.[8] The lack of jobs, paired with low salaries, minimal pay, and sometimes no pay for nursing students who are required to do clinical placements, coupled with long periods of unpaid clinical placements, is further reducing the interest in the nursing profession. This situation has resulted in many prospective nursing students choosing not to enter the nursing profession.[9]

The problem has been compounded by dwindling international job opportunities, which have led to even more challenges. For example, Kuwait, Canada, and the United Arab Emirates have instituted more licensing requirements and workforce nationalization policies, which have restricted the international mobility of Pakistani nurses. In this context, the paper analyzes these cross-cutting factors and their impact on nursing education and the sustainability of the workforce and suggests some relevant strategic options for reforming KP.

This study employs a structured narrative policy analysis, drawing on publicly available workforce data, policy documents, and peer-reviewed literature published between 2019 and 2026. A thematic synthesis approach was used to identify and analyze structural determinants of enrollment decline. The study employs policy, market, and workforce narrative analysis to demonstrate the disconnect between graduate employment and the education system.

Structural determinants of declining enrollment
Expansion of BSN colleges and labor market misalignment: There has been considerable investment in nursing education by the public and private sectors in KP in the past 10 years. This investment has resulted in improving access but has not resulted in equal access to jobs. BSN programs have been implemented without regulatory oversight, and, consequently, there has been a surplus in graduates compared to jobs available, leading to increased competition and underemployment.[10] Workforce planning has been lacking, resulting in a decreased economic and professional value of a nursing credential and a decreased value of a nursing credential.

Saturation of nursing graduates in communities: There is a large disparity in the number of nursing graduates, especially in rural areas, and as a result, there are not a large number of nursing graduates in the community. This has created a shift in the community’s perception of the nursing profession. Having a large number of nursing graduates not having jobs has created a disincentive for families to encourage their children to pursue nursing, as well as a disincentive for nursing graduates to go to nursing school. Community role modeling and having a large number of observable outcomes have an impact on career choosing and making decisions.[11] If nursing does not provide an income, especially a decently paying income, disinterest will be prevalent.

Salary structures and limited domestic opportunities: The main reason for why people choose a profession is the economic return that the profession has to offer. In KP, the public sector’s nursing wages are dependent on the availability of funds and the duration of the recruitment cycle, while the private sector nursing wages are low as well as unpredictable. This puts nursing at a disadvantage compared to other health-related professions, such as medicine, pharmacy, and allied health sciences, which offer better financial returns and financial security.[12]

International employment barriers: International mobility has been a strong motivator for pursuing nursing in Pakistan for many years. For example, many Pakistani nurses have been using Kuwait, the UAE, and Canada as their primary migration destinations. However, in recent years, policy shifts such as national workforce prioritization in the Gulf states and stricter licensure requirements in Canada have emerged and limited the international employment opportunities for nurses.[13] These changes have diminished the global economic attraction of the nursing profession and deterred many potential new entrants into the profession.

Unpaid clinical internships: The prolonged unpaid internship requirements also create stronger disincentives for students. These practices financially burden trainees, as well as their families, and extend the amount of time until they can be economically autonomous, as well as reinforcing the idea that they are being exploited. The literature highlights that failing to provide financial support during training significantly lowers both the retention and the enrollment of professionals in that field [14,15].

Literature synthesis and critical discussion: Allied health professions, including nursing, are influenced by a myriad of factors, including structural, social, and economic factors. Though sociocultural barriers are still an impediment, recent studies focus on other factors, especially operational (or systemic) efficiencies within education and labor absorption, as a primary reason for reduced enrollment.[16]

The same factors (sociocultural barriers) exist in most other low- and middle-income economies. Inadequate labor and professional regulation understandably lead to underemployment and stagnant wages of nursing graduates in Bangladesh.[17] On the other hand, if a country combines educational regulation with labor market forecasting and planning, it can maintain enrollment in its nursing education institutions and retain its nursing graduates.[18]

Research on Pakistan has identified socio-cultural barriers and, to a lesser extent, awareness of labor market regulation, though there is little exploration of global employment. This observation justifies the current analysis.[19]

Implications for workforce sustainability: The drop in nursing enrollment causes significant challenges for KP’s healthcare system. The first consequence concerns staffing inequities in graduate-oversupplied, underserved regions. Second, more compromised enrollment may lead educational institutions to diminish admission standards to ensure their own sustainability. Third, continued nurse attrition amidst fewer available opportunities may result in more local shortages.[20]

Additionally, the systemic inequities in employment opportunities weaken the nursing profession’s identity and societal esteem, which may further complicate the system-wide KP healthcare strengthening initiatives.

Strategic pathways for revitalization: In order to reverse declining enrollment, it is necessary to take a multi-level strategic approach, which entails the following:

• Workforce planning: Evidence-based workforce forecasting by regulatory bodies is needed to ensure educational outcomes match the demand on the labor market.
• Economic reforms: Nursing’s economic attractiveness can be improved by standardizing salaries, paid internships, and offering incentives to deploy to rural areas.
• Educational reforms: To increase employability of graduates, modernizing the curriculum, introducing competency-based training, and developing faculty are essential.
• Global mobility support: Some elements of global retention strategies could be claimed to support local retention strategies.
• Policy and community engagement: Advocacy and media engagement are needed to address the myth and improve the narrative on nursing.

The reduction in nursing education enrollment in KP is due to a combination of systemic, economic, and global factors rather than socio-cultural factors. Decreased attractiveness to nursing has been a result of an oversupply of graduates, unpaid clinical requirements, stagnant wages, and limited job opportunities in both domestic and international markets. To restore interest in nursing education, a coordinated approach involving professional development, planning of the nursing workforce, economic reforms, and nursing education regulatory reforms is necessary. Without these changes, the quality of care and the healthcare workforce sustainability in KP are threatened.

The author would like to express their sincere gratitude to Dr. Sabiha for her invaluable supervision, guidance, and continuous support.

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

Shah Hussain
Department of Nursing
Janbar College of Nursing, Swat, Pakistan
Email: [email protected]

Shah Hussain has conducted analysis and interpretations.

Not Applicable

The author declares that there is no conflict of interest regarding the publication of this paper.

Shah Hussain is the guarantor of this study and takes full responsibility for the integrity of the data and the accuracy of the data analysis.

https://doi.org/10.63096/medtigo3062429

Hussain S. Reigniting Interest in Nursing Education in Khyber Pakhtunkhwa: Structural Determinants and Strategic Pathways for Sustainable Workforce Development. medtigo J Med. 2026;4(2):e3062429. doi:10.63096/medtigo3062429 Crossref