AZZEH/BEIRUT: “God’s mercy is what is keeping the people healthy.” As he gives a tour of the tiny health center in the village of Azzeh in the Bekaa Valley, Mohammad Kheir Faraj lists all the reasons nurses want to quit their jobs.
They earn low salaries and even lower respect compared to doctors, rare employment opportunities, poor transport infrastructure to take them to hospitals and centers in other towns, harassment at work, a cultural imperative to stay at home, a desire to leave for more lucrative pay in Gulf countries, and virtually nonexistent career advancement.
“How can I smile at the face [of a patient] when I’m thinking about how to provide food for my children?” said Faraj, the director of nursing at Al-Abrar center in the Bekaa Valley village of Azzeh.
There are currently about 6,000 nurses in Lebanon, according to the Order of Nurses, for a population of more than 4 million, which is further stretched by the arrival of around a million Syrians fleeing the conflict next door.
A fifth plan to leave to work abroad, and two thirds plan to quit their job here in the next three years.
The exodus poses a health care crisis and worsens a major shortage in the country’s most vulnerable areas, according to the findings of a new study.
Many of the best-qualified nurses are migrating to the Gulf, North America and Europe to escape poor salaries, difficult working hours, workplace violence and low social prestige, in addition to limited prospects for career advancement – a “brain drain” of nurses.
“We definitely have shortage of nurses in addition to maldistribution,” said Fadi al-Jardali, associate professor at AUB and lead author of the study, who has worked with the World Health Organization on issues related to health policy and recruitment and retention of health care workers.
By contrast, there is an oversupply of doctors in the country, linked to cultural factors that bestow prestige on the profession.
The study, which will be published in Human Resources for Health journal in November, surveyed 857 nurses at 63 hospitals and health centers throughout underserved areas in Lebanon. These are defined according to WHO criteria as areas where the population has limited access to health care.
In Lebanon, this effectively includes rural and far-flung communities that have long suffered poor employment opportunities and neglect by the state.
Just 35 percent of nurses surveyed said they planned to stay in their current jobs in the next one to three years. Less than a third said they would choose nursing as a career again if they started over, and less than 20 percent would encourage their children to pursue careers as nurses.
This means that the number of nurses could fall further as parents advise their children to avoid the profession, exacerbating the shortage.
Most of the nurses surveyed were women and below 30 years of age. Married nurses were more likely to stay in their jobs, probably because they had a greater desire for career stability.
The figure matches another survey by the authors of Lebanese nurses in urban areas, two thirds of whom plan to quit their jobs, with a third reporting that they intend to leave the country.
Nurses also appear to suffer more incidents of workplace violence than other professions. A survey published in 2011 in the Journal of Occupational Health showed that four in five emergency department employees in Lebanese hospitals were verbally abused, and one in five was physically assaulted.
Researchers estimate that an “alarming rate” of one out of five nurses in Lebanon leave the country within two years of graduation, for places where they are likely to find better pay, more respect for their essential role in health care, flexible hours, and have greater responsibilities that include discharging or admitting patients and writing prescriptions.
And the nurses leaving are mostly the qualified ones that are most needed in the country.
“Employers abroad provide attractive job offers to the nurses who are more educated and competent,” Jardali said.
He warned the consequences could be tragic and lead to loss of lives.
“One of the first things that will suffer is patient safety and quality of care,” he said. “I would expect more errors and injuries to patients and more medication errors if things stay as they are.”
In addition to limited salaries and benefits, nurses often find it difficult to balance work and life commitments.
Many have to work late-night shifts, for up to 12 hours at a stretch.
Part of the problem in Lebanon is that the draft nursing practice law remains in parliamentary limbo after 10 years.
An up-to-date law concerning the nursing profession, with different degree levels and certifications, would strengthen the field, improve training and establish which disciplines are most in need of specialized health care workers, according to Jardali.
The study’s authors assert that a national nursing strategy is needed which includes better benefits and salaries for nurses, in addition to training and opportunities for career advancement, flexible working hours and the development and implementation of a law regulating nursing.
But some see pervasive inequality at the heart of the disparity in health care between the city and Lebanon’s rural communities.
The nursing shortage is just another manifestation of a gap in health care and quality of life. For instance, health insurance does not cover primary health care centers, which are much more common than hospitals in villages and towns far from Beirut.
The inequality is “very clear,” said Faraj, the director of Al-Abrar, adding that it transcends sect and religion to the abandonment of Lebanon’s distant communities by the state, amid a dearth of employment opportunities and an influx of refugees competing for Lebanese jobs.
“There is no interest, they only come to us during funerals,” he said, referring to politicians.
Al-Abrar, which provides basic health care services that include dental care, general medicine, a blood lab, and an eye, ear and nose specialist, is one of about five centers that serve 65,000 people in the qada of Rashaya in the Bekaa Valley, according to Faraj.
His center receives between 500 and 800 patients a month, and is a nonprofit that relies on donations and limited funding from the government.
Most centers are “basically rooms, an office and a stethoscope,” he quipped.
Zuhat al-Khatib, 37, a nurse at the center, echoed many of the findings of the study.
She said that nurses in rural communities were frustrated by low salaries, long working hours, frequent nighttime shifts and poor transport facilities as well as difficulties interacting with male patients in conservative rural communities.
Khatib, who worked for 10 years at a medical lab before switching to nursing, knows of many others in her profession who are trying to leave. Many want to find jobs in the Gulf.
But she wants to stay because, for her, nursing is about fulfillment and doing good.
“Medicine is wonderful,” she said. “The kind way you interact with people and the kind way you are treated in return.”