Exploring nurse staffing and policy implications in times of crisis: the case of North Lebanon

Abstract

Background

Since late 2019, Lebanon’s healthcare system has been severely affected by three crises, the economic collapse worsened by the pandemic and the Beirut Port explosion. This led to a drastic shortage of competent nurses due to an upsurge in nurse migration. This study explores nurse migration rates, causes, and replacement in north Lebanese hospitals located in an underserved area affected by public health outbreaks especially the COVID-19 pandemic and the economic crisis.

Methods

This study employs a convergent mixed methods design to investigate nurses’ migration and replacement rates in North Lebanon between 2020 and 2023. The migration and replacement rates were based on secondary data analysis of hospital administrative records from the sampled twelve hospitals. The qualitative component explored the reasons behind nurse migration and departure through interviews with designated hospital personnel. To ensure thorough and transparent reporting, the findings from both quantitative and qualitative parts are presented following the Good Reporting of a Mixed Methods Study (GRAMMS) checklist.

Results

Nurses from adult “medical-surgical” units and “critical care” departments migrated at a greater rate due to financial reasons, job insecurity, and job opportunities made available to them. University-prepared nurses out of the total number of nurses in private hospitals have decreased from “47.2%” in 2020 to “41.9%” in 2023. The same category that is already underrepresented in the public sector also declined, from 26.2% to 23.2% in the same period, reflecting a further loss of qualified nurses in this underserved area. To compensate for their losses, public hospitals predominantly hired technically prepared nurses, whereas private hospitals prioritized university-prepared nurses. Despite recruitment and replacement efforts, North Lebanon’s hospitals experienced a 10.24% loss in their nursing workforce, mainly university-prepared nurses, further challenging the healthcare system ability to provide high-quality care.

Conclusion

The protracted economic crisis and the COVID-19 pandemic have a serious effect on the hospitals’ abilities to replace the departing nursing staff. A noteworthy finding of this study is the increasing reliance on hiring technically-prepared nurses to fill the gap left by the nurse migration. These factors have serious implications on the quality of care delivered to patients in the study hospitals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-04148-9.

Background

Nurse shortages in the Eastern Mediterranean region (EMR) are widespread, with progress stalling despite efforts at both national and institutional levels. The shortage is expected to worsen due to high out-migration rates and poor working conditions [1]. Lebanon, one of the EMR countries, is no exception, especially that it has long been a donor country of nurses [2, 3].

Lebanon’s health system has been grappling with significant challenges since the 1970s including wars, population displacement, economic decline, and political instability. The country has been hosting 500,000 Palestinian refugees since 1948 and has experienced a 30% population increase due to the influx of Syrian refugees since 2011 [4]. The ongoing economic downturn since October 2019 has severely impacted hospitals, healthcare providers, and medical supplies, putting tremendous strain on the healthcare system [5–7]. The Beirut port explosion in August 2020 caused over 7000 injuries, 218 fatalities, and 300,000 people displaced from their homes. That was accompanied by two public health outbreaks, the coronavirus disease (COVID-19) that caused a significant increase in cases and deaths [8] and the cholera outbreak that affected mainly North Lebanon [9, 10], in October 2022 and lasted a few months. Lebanon is classified as a weak state due to high per-capita refugee numbers, overburdened healthcare services, and a critical shortage of nurses [11].

As a result of the compounded crises, nurses in Lebanon are facing financial struggles, shortages of fuel supply affecting their ability to reach work, layoffs or furloughs, and work-overload resulting in burnout and job dissatisfaction, all of which drive them to mass migration [6, 8, 12, 13]. In 2021, the president of the Order of Nurses in Lebanon (ONL) reported that “More than 3,500 nurses have left the profession, and more than 55% of those who remained, primarily the younger generation, hope to leave their jobs and the country within the next two years” [7, 14]. It is noteworthy that the number of nurses working in hospitals during 2021 was 10,040 (Order of Nurses website) thus the country lost 35% of its nursing workforce then. In 2024, it was reported that only 9000 nurses and midwives work in hospitals indicating further shortage of nurses. Lebanon has a low nurse-to-population ratio of 1.67 per 1000 people [7, 15], compared to an international average of 9 per 1000 [16]. This grave situation is even more profound in underserved areas like North Lebanon. North Lebanon has been classified as underserved using the World Health Organization’s 2010 (WHO) definition and research findings of a study addressing nurse retention in underserved areas [17]. These alarming statistics demonstrate the severity of the nursing shortage and the potential harm it could cause to the Lebanese healthcare system. The significant willingness of younger nurses to relocate suggests a long-term challenge with workforce sustainability.

Nurse migration negatively impacts the patient-nurse ratio, leading to increased workload, medication errors, exhaustion, and absenteeism. This places a financial burden on health institutions, affects patient outcomes, and lowers care standards due to the lack of qualified nurses [2]. The migration of nurses endangers patient safety while challenging the remaining nurses to preserve their health and safety as they provide care for patients [6, 8, 12, 13]. This leaves primary healthcare centers and hospitals in Lebanon face challenges due to staffing shortages and unequal labor distribution. Nursing teams, comprising 56% of the healthcare workforce [18], play a vital role in achieving universal health coverage and delivering high-quality care. Nurse scarcity can negatively impact healthcare effectiveness and service quality, potentially jeopardizing patient treatment safety [2] and lowering healthcare service standards [18].

Public health outbreaks like the COVID-19 pandemic exposed significant flaws in the nursing industry, including unequal funding, lack of worker protection, and the perception that nursing is a form of servitude. These factors have led to escalating burnout, physical and emotional tiredness, and a lack of trust in hospital administrators [19]. The crisis has worsened nurses’ stress [5] and pushed many of them to leave the profession, contributing to the nursing shortage [5, 19]. This shortage is particularly severe in developing nations, especially in Low- and Middle-Income Countries (LMICs), leading to poor health indicators irrespective of the lack of accurate data on the size and credentials of their nursing staff.

Administrators of health systems have imposed mandatory overtime or forced nurses to work additional shifts to compensate for the nursing shortage, leading to a “culture of guilt and shame” and eroding trust. Nurses’ knowledge and contributions to patient care have been weakened by the healthcare industry’s reluctance to recognize them as “talent”, adding to the nurses’ burnout, low morale, and decision for migration in the presence of active recruitment by recipient countries [19]. Moreover, the lack of career opportunities and poor working conditions have forced countless nurses to leave the nursing profession, resulting in a long-term, if not permanent, loss of valuable human resources in the local nursing labor market [2].

Nurses’ job dissatisfaction contributes to nursing shortage and emigration with “push factors” including unattractive pay, gender inequality, undervaluation of the nursing profession, understaffing, subpar patient care [2], and unhealthy work environment [20]. The literature identifies several reasons for the nursing shortage, such as inadequate compensation [19, 21], recruitment and retention issues, global demographic changes, and care requirements by the aging population [21]. On the other hand, “pull factors” include better pay, improved working conditions, career progression opportunities, and flexible schedules that attract nurses to recipient countries [2].

Given the above-mentioned circumstances affecting the country and subsequently the nursing workforce retention and amplified migration, there is a need to explore the perspectives of the directors of nursing (DON), general supervisors (GS), and human resource (HR) managers (participants thereafter) in North Lebanon regarding the percentages and characteristics of nurses who left and those who remained, between 2020 and 2023. In addition, it is important to explore the managers’ perspectives on the reasons behind the increase in nurse migration and the nurse replacement measures to help decision-makers develop strategies addressing the nursing workforce shortage in underserved areas. Understanding these issues will help in designing solutions for retaining nurses and controlling the drain of experienced nurses.

Methodology

Aim of the study

The study has two aims, (1) to explore the impact of two crises, the public health outbreaks especially COVID-19 pandemic and the ongoing economic collapse, on nurse migration rates in hospitals located in a major underserved area in north Lebanon, with a particular emphasis on the main migration drivers; and (2) to examine the replacement of nurses in terms of qualifications and rates as undertaken by hospitals to replace the nurses who left.

Study design

To gain an in-depth understanding of the nurse migration rates and reasons, and nurses’ replacement, this study used a convergent mixed-methods design. This design entails that the researcher concurrently conducts the quantitative and qualitative elements in the same phase of the research process, weighs the methods equally, analyses the two components independently, and interprets the results together [22], therefore allowing a thorough grasp of nurse migration during the Lebanese crises.

Setting

Twelve hospitals in North Lebanon were chosen to collect data from based on the following criteria: hospital bed capacity (more than 35 beds); geographic distribution covering the two administrative districts of North Lebanon (Akkar and the North); availability of diverse health services in the hospital (Medical/Surgical; Obstetric; Paediatric; and critical care areas); and ownership of the hospitals (Public vs. Private).

Private hospitals sampled

Out of 21 private hospitals in North Lebanon, six were not included for the following reasons: lack of targeted departments; currently are not fully operational; or having bed capacities of 35 or less. Additionally, six hospitals declined to participate, ending with a total of nine private hospitals. These nine hospitals collectively represent more than 60% of the total private hospital bed capacity in North Lebanon.

Public hospitals sampled

In terms of public hospitals participating in this study, we identified three out of the nine eligible public hospitals serving the selected regions. The reasons for not choosing the other six hospitals were: having low bed capacities, not having the targeted departments, or refusing to participate in the study.

Sample of participants

To assess the rates and reasons for nurse migration in the North Lebanese hospitals while experiencing the Lebanon crises, interviews were conducted with “12” participants designated by administrators of the study hospitals. These participants were chosen based on their roles and experiences in the hospitals before, during, and after the crises. Specifically, this study included six directors of nursing services, three human resource managers, and three general supervisors.

Quantitative data were collected from the administrative databases of the sampled hospitals on the number of nurses who have left the sampled hospitals since October 2020 and their characteristics. This data was grouped by hospital type and included: the number of actual nurses currently working and their degrees, the total number of nurses in year 2020, the type of degrees held by nurses who migrated in the past three years, the rate of nurses’ migration per department during the past three years, and the total number of newly recruited nurses over the past three years with their type of degrees.

Data collection

Data collection started after obtaining relevant ethical and administrative approvals We obtained hospital contact information from the Syndicate of Private Hospitals for private institutions and from the Ministry of Public Health for public institutions. Data collection took place between April and the end of May 2023.

Quantitative administrative data collection

Quantitatively, we used data of hospital administrative records from the twelve hospitals to determine the degree of migration and replacement rates between 2020 and 2023. It is noteworthy to mention that the Ministry of Public Health and the Order of Nurses in Lebanon, the primary sources for nursing workforce data, lacked data registry and statistics on nurses’ departures, qualifications, and migration patterns among others, not only within Northern Lebanese hospitals but also across the country. Therefore, direct extraction of data from hospital administrative records became the only viable method to quantify nurse migration and workforce changes. Each hospital was visited on average three times to gather information on nurse departures and new hires because there were no consolidated databases.

The data collection instrument consists of eight closed-ended questions and one open-ended question. The closed ended question was designed to assess the number of nurses who have left the sampled hospitals since October 2020, as well as their characteristics. The questions cover the following: type of hospital, the total number of nurses in 2020, the number of nurses who are currently working there, the number of nurses who migrated and their type of degrees, the migration rates per department, and the total number of newly hired nurses and their degrees over the past three years.

We followed the WHO guidelines on translation and adaptation of instruments [23]. The data collection instrument was first developed by the first author in English based on the study aims then translated into the Arabic language by a qualified translator fluent in the two languages. An independent translator fluent in English and Arabic, blinded to the original questionnaire back translated the Arabic tool into English. The translation and back translation showed alignment except for a few edits in the Arabic language specifically using simple terms closer to colloquial words.

Qualitative data collection

For the qualitative data collection, the participants, designated by the hospital administrators, were sent the consent form and the question in advance and were asked to participate in a face-to-face interview to explore the reasons for migration of their nurses. A date for an in-person meeting was arranged according to the preference of the participants. The participants were asked to share their perspectives based on de-identified data from exit interviews of the nurses who left because of the recent crises. The exit interviews were the primary context in which nurses articulate their reasons for leaving the hospital and the country. The question was, “In your opinion, and based on the exit interviews of the nurses who left the hospital and the country due to the recent crises, specify and explain 3 reasons for this nurse migration by priority.” While this qualitative component, consisting of a single question, provided a limited perspective, its integration with the quantitative data allowed for a more nuanced and better understanding of the migration phenomenon than either method could achieve independently.

The first author conducted the face-to-face interviews, guided by a structured interview instrument with 8 closed questions and one open-ended question, developed purposefully for this study (Supplementary file 1). All of the participants’ comments were captured via audio-recording during each interview, and field notes were gathered simultaneously to record any nonverbal clues, reflections, and contextual elements that might have influenced the participants’ statements.

Interviews were conducted in a private room within the chosen hospitals, ensuring a quiet and comfortable environment where participants could speak freely and without interruptions. Each participant was assigned a unique code number to ensure confidentiality. The audio-recorded interviews typically lasted around 30 min to complete. Since all the participants were native speakers, interviews were done in Arabic to satisfy their linguistic preferences, ensure clarity and cultural relevance.

Data analysis

Quantitative data analysis involved descriptive statistics, comparing the “rate of nurses’ migration among hospitals” type between 2020 and 2023, “migrating nurses’ type of degrees”, “migration rate per department”, the “number of recruited nurses,” and “their educational level”. These data were analysed using the Statistical Package for the Social Sciences (SPSS 25.0) to explore patterns in nurse departures and replacements.

Qualitative data investigating the three primary reasons for nurses’ migration were analyzed using thematic analysis, following Braun and Clarke’s approach [24]. To ensure that the transcripts accurately mirrored the original interviews, a bilingual nurse researcher transcribed the audio recordings verbatim in Arabic. To preserve the accuracy and integrity of the data, a two-step translation procedure was used after transcription. First, a qualified translator with experience in medical and hospital settings translated the Arabic transcripts into English. The translated materials were then examined by a third-party bilingual specialist who was fluent in both Arabic and English to verify accuracy in meaning and cultural subtleties. Discussions were held to settle any translation errors, and the original interview subjects were occasionally consulted to elucidate particular comments. A line-by-line coding approach was applied to identify initial codes and ensure that all relevant data were captured. The patterns in the data were then represented by grouping these codes into more general themes [24]. Data saturation was achieved by the 10th interview when no new patterns emerged; the last two interviews confirmed the previous ones.

To guarantee comprehensive and transparent reporting of the findings, the quantitative and qualitative aspects of the study are presented using the Good Reporting of a Mixed Methods Study (GRAMMS) checklist [25].

Results

Current nurses with educational degrees in 2023

The study revealed that 1551 nurses are currently employed in all sampled hospitals serving 1550 hospital-bed capacity. The nurses’ degree varies, including university degrees [Master of Science in Nursing (MSN) and Bachelor of Science in Nursing (BSN)], and technical degrees [License Technique (LT), Technique Superior (TS), and Baccalaureate Technique (BT)]. Private hospitals have a higher percentage of nurses with university degrees (MSN degrees 8.2% and BSN degrees 33.7%) in comparison to public hospitals that have only 3.7% with MSN and 19.5% with BSN. On the other hand, public hospitals employed the highest percentage of nurses with technical education (37.9% LT, 12.5% TS, 26.4% BT degrees) compared to private hospitals (15.0% LT, 14.1% TS, and 29.0% BT degrees).

Nurses who left by degrees and hospital type during the 3-year period

Table 1 shows a total of 721 nurses of different degrees (Masters prepared, bachelor, or technical) who left the sampled hospitals during the past three years: 614 from the private and 107 from the public hospitals. The table below shows that higher percentages of nurses with university degrees left the private hospitals (47.2%) than the public ones (26.2%).

Table 1.

Nurses who left by degrees and hospitals during the 3-year period

Number of hospitals	Hospital Type	University MSN	University BSN	Technical LT	Technical TS	Technical BT	Total
9	Private	38	252	93	87	144	614
		6.2%	41.0%	15.1%	14.2%	23.5%	100.0%
3	Public	5	23	51	6	22	107
		4.7%	21.5%	47.7%	5.6%	20.6%	100.0%
12	Total	43	275	144	93	166	721

Nurses recruited by degrees and hospital type during the 3 years- period

Table 2 displays the number of nurses recruited in private and public hospitals over the past three years to replace those who left, categorized by hospital type and educational degrees. A total of 544 nurses were recruited: 381 in private hospitals and 163 in public hospitals. Private hospitals hired more nurses with university degrees (48.3%) compared to public hospitals (20.9%).

Table 2.

Nurses recruited by degrees and hospital type during the 3 years-period

Number of hospitals	Hospital type	University MSN	University BSN	Technical LT	Technical TS	Technical BT	Total
9	Private	9	175	51	52	94	381
		2.4%	45.9%	13.4%	13.6%	24.7%	100.0%
3	Public	0	34	68	18	43	163
		0.0%	20.9%	41.7%	11.0%	26.4%	100.0%
12	Total	9	209	119	70	137	544

Change in nurses’ distribution by hospital type between 2020 and 2023

Examining the percentage of change in nurses’ distribution in hospitals between 2020 and 2023 is essential to understand the changes in nurses’ mobility. This analysis shows whether there was a positive or negative change, by nurse category, over the three-year period.

During this period of acute crises, nurses in the sampled hospitals experienced considerable mobility in terms of migration and recruitment, as shown in Table 3. Private hospitals endured a decrease of 233 nurses over the past three years, with 74.1% (1150) of the total nurses employed in 2023 compared to 80.0% (1383) in 2020.

Table 3.

Change in nurses’ distribution by hospital type between 2020 and 2023

Number of hospitals	Hospitals type	Total number of nurses in 2020	Number of left nurses for a 3-year period	Number of recruited nurses for a 3-year period	Total number of nurses in 2023	Difference in total number of nurses (2023 − 2020)	Percent of change (Reference 2020)
9	Private	1383	614	381	1150	-233	-16.84%
		80.0%	85.15%	70.03%	74.1%
3	Public	345	107	163	401	+ 56	+ 16.23%
		20.0%	14.84%	29.97%	25.9%
12	Total	1728	721	544	1551	-177	-10.24%
		100%	100%	100%	100%

For the private hospitals, the percentage of change is -16.84%, indicating that throughout the past three years, the sampled private hospitals in North Lebanon had lost 16,84% of their competent nurses. In contrast, public hospitals, witnessed a rise in the number of nurses by 56 indicating an increase of 16.23%.

Accordingly, the overall change across both private and public hospitals was a decrease of 177 nurses, representing a 10.24% loss in nursing staff, which has aggravated the shortage that had been prevailing before the crisis.

Qualitative results

A variety of push and pull factors contribute to the complex issue of nurse migration. Using interview data from Human Resource Managers (HR), General Supervisors (GS), and Directors of Nursing (DON), this study qualitatively investigated the causes of the high migration rates among nurses. Two main groups of reasons have been identified through the methodical coding of responses and related emerging themes: push factors, which drive nurses to leave their country, and pull factors, which attract them to opportunities overseas.

Theme 1: push factors

Push factors include economic challenges, socio-political and security conditions, family needs, and threats to livelihood, along with a demanding work environment with decreased resources, all of which pushed the nurses to leave.

Economic situation leading to low salaries and job instability

There was general agreement among the interviewees on the impact of the worsening economic situation in the country, primarily characterized by poor salaries exacerbated by the devaluation of the currency by 98%. “The real worth of incomes has fallen,” DON-1 stressed, “despite nominal increases [in salary], particularly in light of the rising living expenses,” as an HR-1 said. One participant, GS-1 remarked, " … with delays in payment [salaries]. Salaries were enough for about US $500 [per month] before the crisis, but now they are barely worth US $50.” Many interviewees shared this view and added that delayed salary payments and the depreciating value of the local currency made it nearly impossible for nurses to make ends meet, thus pushing them to leave.

Socio-political and security situation

The political situation also had a big impact on migration. The interviewees stated that the ongoing political turmoil and social unrest, especially in the aftermath of events like the Beirut port explosion and the increasing burden of Syrian refugees, led to a general perception that the country was unstable and unsafe. This viewpoint is reflected in GS-2 statement: “The country is not safe in all social, economic, and political aspects.” HR-2 observed that “the uncontrolled influx of Syrian immigrants into the country has made the political and security landscape more unstable, particularly after the port explosion.” The participants demonstrated their fear of social instability and political insecurity relating it to the surge of refugees and the Beirut port explosion pushing them to look for employment opportunities abroad.

Family needs and threats to livelihood

Nurses cited the need to care for family members or to find better living conditions for their dependents as key reasons forcing them to quit their jobs for better opportunities outside the country. “Many nurses were forced to travel or leave their work to take care of their family members,” as DON-2 stated. According to GS-3, “nurses are traveling to secure a decent life, medical care, and medicines for their families as well.” Nurses felt forced to pursue stable employment abroad to support their families, secure their livelihoods, and ensure family needs especially with medicines, in light of the economic crisis.

Demanding work environment with decreased resources

Interviewees revealed that the work environment was becoming more difficult, with increased workloads and fewer resources affecting the quality of care. “Workload with very low quality of care and lots of complaints,” as stated by DON-3, was a recurring issue in the interviews. Moreover, DON-4 noted: “The low employment rates, especially with the presence of Syrian refugees [who need care], created a hard-working environment where nurses were driven to relocate in pursuit of better working conditions.” Another participant explained “Sometimes, even basic supplies like gauze and gloves, and more importantly personal protective equipment, are in short supply during crises, leaving nursing staff feeling fearful …”. These quotes reflect the decreased resources for nurses to provide healthcare services leaving them in distress.

Theme 2: pull factors

Pull factors include job opportunities, the global demand for nurses, and attractive offers from neighbouring countries that enticed nurses to migrate.

Job opportunities and the global demand for nurses

The availability of attractive employment openings both regionally and internationally was a major pull factor that drew nurses to relocate. There was a high need for nurses in many countries, according to the participants, and many nurses were receiving “tempting offers and assistance from colleagues” already working abroad, as DON-5 stated. For many nurses thinking about moving, the prospect of obtaining “better living standards and educational opportunities,” as verbalized by HR-1, stood out as a driving force. The demand for nurses, regionally and internationally, coupled with employment opportunities encouraged nurses to migrate for better jobs.

Attractive offers from neighbouring countries

The competitive pay packages offered by neighbouring countries were underlined in the interviews as a key pull factor. Participants observed that nurses were dissatisfied with their local pay, as countries abroad, especially the neighbouring ones such as the gulf countries provide significantly higher salaries. “Countries abroad are offering more than $3000 [per month] for the same tasks and grades; spotlighting the difficulty to manage with local salaries,” explained HR-3. Nurses’ decision to look for work out of the country was greatly impacted by this striking salary in neighbouring countries disparity.

Summary of qualitative findings

The findings show that a complex interaction of push and pull forces drives nurse migration. Nurses are compelled to seek opportunities overseas because of the harsh economic conditions, insecure political situation, demanding work environments, and family responsibilities. In addition, the high demand for professional nursing and the enticing job offers abroad further reinforce these migration trends.

Discussion

This study explored nurse migration rates in an underserved area in Lebanon during the COVID-19 pandemic and the protracted economic crisis. It focused on understanding the impact of the crises on the nursing workforce in that area, identifying the main causes of migration. The study brings new findings for the first time specifically differences in migration and replacement between university prepared and technically-prepared nurses and those in public versus private hospitals. The results uniquely reveal the public sector’s reliance on technically prepared nurses to address migration-induced shortages, contrasting with private hospitals’ preference for university-educated nurses, a distinction not previously documented in Lebanese nursing literature.

To our knowledge and based on the literature review, no study compared migration rates between public and private hospitals specifically in relation to the nurses’ degrees. Prior studies either compared nurses’ preference to work in private versus public hospitals [26]; intent to stay [3, 27]; or concluded that university prepared nurses are more likely to migrate [2, 28]. One plausible explanation for more university-educated nurses to leave private hospitals compared to public hospitals could be the security-seeking nature of employment in Lebanese public sector including public hospitals that, by law, prioritize stable income, job protection, and retirement plans, guarantying long-life employment [29]. Another possible explanation could be the nurses’ risk-averse disposition that may make them less likely to seek job opportunities abroad. This constitutes a notable particular finding of our research. However, we still need to dig deeper to understand why migration patterns differ between public and private hospitals, especially when it comes to nurses with university degrees.

The reliance of public hospitals on the technically prepared nurses has proven implications for the quality of care, as demonstrated by several authors, including Aiken et al. 2021, who highlighted that greater investment in professional nurses could lead to higher quality of care [30]. A 10% increase in BSN nurses is associated with a 4% decrease in patient fatalities and failure to rescue [31], and each 10-percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death [32]. Moreover, higher hospital proportions of BSN nurses, regardless of educational pathway, are associated with lower odds of 30-day inpatient surgical mortality [33]. This is consistent with the National Academy of Medicine’s guidelines that emphasize the need for a nursing workforce in which 80% of nurses hold bachelor’s degrees or higher [33]. The clear connection between nurses holding a Bachelor of Science in Nursing and improved patients’ outcomes as described in the aforementioned studies highlights the serious consequences of this inequality for the overall quality of healthcare. While public hospitals may see using nurses with primarily technical training as a realistic way to deal with budget constraints, it brings up concerns about the potential long-term impact on how safe and effective patient care truly is.

Though Lebanon has been suffering from a nursing shortage for a long time, this situation got worse nationally including in North Lebanon hospitals, as shown in this study. This study showed that the sampled public hospitals were able to replace open nursing positions with technical nurses, while private hospitals were unable to do so because they prioritized university-prepared nurses over technical program graduates. Additionally, private hospitals were compelled to close several services and consolidate departments during the crises, while hiring only the minimum number of nurses required due to the economic crisis and devaluation of the Lebanese currency that prevented them from staffing extra wards [5, 8]. Due to the absence of stable employment, many highly skilled and experienced nurses were compelled to leave the country or give it extensive consideration [14]. In response to the high cost of private hospitals and the rise in number of patients during the COVID-19 pandemic and the cholera outbreak that happened in October 2022, which mainly affected the North of Lebanon, the public sector has been compelled to expand existing hospitals and increase the number of beds by 20% [9, 10] thus hiring more technical nurses to meet healthcare demand. Due to the severe shortage of nurses, in conjunction with financial constraints, government hospitals have resorted to hire less qualified and unskilled technically trained nurses who lack competence to compensate for nursing shortage. Nevertheless, selected hospitals in North Lebanon still generally experience a 10.24% shortfall of nurses, as shown in this study. The differing plans for public and private hospitals’ shortage replacements show how the crisis has had varying effects on these sectors. In contrast to public hospitals, which have adopted a more practical—though potentially compromised—approach to staffing issues, private hospitals struggle to maintain their standards. This raises questions about the long-term sustainability of both models and the need for innovative solutions to the nursing workforce crisis.

The absence of comprehensive databases on nurses in Lebanon makes it hard to assess the adequacy of nurses’ numbers and qualifications, as well as the equity in nurse distribution across geographic areas and healthcare organizations. This prevents hospital administrators and policymakers from making evidence-based policies to improve nurse staffing. The data from the ONL mainly focuses on the aggregate number of migrant nurses without considering their qualifications, geographic distribution, or migration motivations. This data gap is a critical obstacle to effective planning and management of the nursing workforce. The lack of comprehensive data hinders the development of targeted initiatives and policies to address the nursing shortage and provide equitable access to care [communication with the Director of the Order of Nurses].

Participants in this study identified several reasons for migration, which align with push factors reported in the literature, including economic factors [34, 35], job instability [21], pursuit of better opportunities [2], political insecurity [2, 34, 35], unsatisfactory salary/benefits [2, 19], lack of professional development/career advancement, and family reasons [2, 3]. A lot of these factors impact on job satisfaction and engagement, which are known to impact on retention and increase turnover. The participants also identified international demands as a pull factor that is driving them to migrate, citing the rise in demand for experienced nurses as highlighted in other studies [34–36]. The intersection of these push and pull forces highlights the complex interplay between professional and social factors influencing nurse migration. To solve this conundrum, a comprehensive approach that considers the internal and external factors impacting nurses’ decisions is required.

The study’s findings reflect the impact of the prevailing compounded crises, which exacerbate pre-existing challenges in Lebanon’s healthcare system, forcing nurses to relocate and aggravating staffing shortages, heavy workloads, and low job satisfaction because of demanding working conditions. The lack of resources was particularly highlighted as a major concern. The demanding working conditions existed even before the crises, as highlighted by Dumit and Honein-AbouHaidar, stating that Lebanon’s healthcare system was under strain prior to the Syrian refugee crisis, especially in some of the country’s less developed regions with subpar medical facilities [9], such as the North. According to the interview data, specifically those of nursing directors, healthcare workers face significant psychological stress due to lack of resources and challenging work situations. This stress contributes to the burnout of nurses and exacerbates the current shortage of nurses. Therefore, adequate staffing numbers and nurses’ psychological well-being must be prioritized in managing a healthy nursing workforce.

Implications for nursing research

Based on this study, we recommend conducting future research to explore the perspectives of the remaining nurses on nurse migration, their perception of the crises’ impact on the nursing workforce, specifically the high workloads on nurses and the quality of care, nurses’ satisfaction, and their work environment. Another important direction for future research is expanding this study to a national level, examining variations across geographic areas, hospital type and capacity, teaching versus non-teaching hospitals, and profit versus non-profit institutions.

Implications for nursing policy

In terms of policy, there is a dire need for legislation to ensure a minimum nurse-to-patient ratio in hospitals that reflects the adequacy of the number of nurses to hospital beds. Another area that needs regulation is the establishment of specialized group of nurses trained and ready to respond to public health emergencies, disasters, and crises who can be deployed promptly to areas in need. Organizational policies need to include incentives for nurses working in underserved or rural areas, as well as improvements in retirement compensation and healthcare benefits.

The ONL, with the support of the MOPH, should conduct a comprehensive census of all nurses, whether working in hospitals or other sectors, both in Lebanon and abroad. Policies that mandate safe work conditions and occupational health standards are also required.

To motivate nurses to stay, retention strategies should be implemented. Examples of such strategies include improving the work environment, redesigning jobs, creating a wage system that rewards experience, and developing succession planning initiatives, giving nurses more power in decision-making, promoting a culture of respect with zero tolerance for workplace violence, and providing career advancement pathways along with organized mentorship programs [37–39].

Policy implications should address supporting and protecting nurses during public health outbreaks by infection prevention and control, using of and access to personal protective equipment; decent working conditions, including occupational health and safety; mental health and psychosocial support; and remuneration and incentives. Other implications include developing nurses’ competencies through education and training to strengthen and optimize their roles and increasing capacity and strategic nurse deployment based on rational distribution in times of crises, ensuring a manageable workload.

Implication for professional development in evidence-based management

This study underscores the need for training nursing directors and hospital administrators in evidence-based management to improve retaining nurses and creating a better work environment. The training should be focused on staffing that includes “effective retention strategies,” “sustaining the workforce,” “mental health support,” and “improving the work environment.”

Limitation of the study

This study has three main limitations: First, the research was limited to interviews with directors, supervisors, and HR managers, some of whom may not have updated or comprehensive data on nurses, particularly the newly employed HR managers, who might lack precise information about nurses’ reasons for migration. Second, the results of this study cannot be generalized as each region in the country has unique challenges and resources. Third limitation is the reliance on the recollection of the HR managers and nursing directors/supervisors for the reasons for migration in the absence of documented exit interview data. However, these findings provide essential information for decision-makers and valuable insights into future research.

A key strength of this study is that, to our knowledge, it is the first to evaluate nurse migration throughout the compounded crises (2020–2023) in hospitals in underserved areas of Lebanon.

Conclusion

The current study in Northern Lebanon shows that a significant number of nurses, particularly those with university degrees, are leaving the country due to job instability, low pay, political upheaval, and financial difficulties. This has exacerbated the situation of nurse staffing in the sampled hospitals, weakening the health system and hampering the adaptive capacity of both private and public hospitals. This study holds several recommendations: acting promptly to improve salaries and working conditions of nurses to reduce migration, retaining the remaining experienced nurses, and facilitating the return of those who have left; supporting technically prepared nurses to pursue university nursing degrees; and prioritising university graduates for safer care, while focusing on public hospitals that are more vulnerable to patient complications due to the qualifications of their nursing staff.

A comprehensive understanding of these issues will help hospital executives and policymakers develop strategies to improve working conditions and retain nursing talent within the country.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

MJD, WA and NYD conceptualized and designed the study. MJD collected the data. MJD and NYD conducted the analysis and interpretation of data. MJD. drafted the manuscript, NYD made substantial editing, and all authors participated in revising the manuscript and approved the final version.

Funding

The authors declare that they have no funding.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Declarations

Ethical approval and consent to participate

Permission to conduct the study was obtained from the hospitals’ administrations, and all protocols were approved by the Research Ethics Committee of the Saint-Joseph University of Beirut, (Protocol Number: USJ-2023-103) that follows the declaration of Helsinki prior to data collection. Informed consent was obtained from participants after briefing them on the purpose, benefits, and risks of the study. They were also informed that their participation entailed no monetary benefits, participation was on a voluntary basis, and that they can withdraw from the study anytime they wish to do so. All participants signed a consent before proceeding to answer the questionnaire, indicating their willingness to participate in the study. The study employed an anonymous survey method, ensuring that no personal identifiable information was collected from the participants. The data were kept in a password protected personal computer of the first author, and access was only given to the research team members.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.