Written by Laura El Mir

Long before COVID-19 exposed the vulnerabilities of health sectors worldwide, nurses in Lebanon persevered through less than ideal circumstances for years with issues such as abuse, discrimination, and underpayment. Even though these issues have been repeatedly raised to the Order of Nurses, no significant development came to be. These issues, coupled with the current pandemic, could potentially turn this shortage into a national crisis.

Registered nurses hold a key role in healthcare provision and health status improvement at the individual, community, and national levels. Their active presence is, therefore, key to improving the overall public health value.

The multidisciplinary Global Advisory Group of the World Health Organization has recognized a worldwide shortage of nurses.¹ Lebanon has an alarmingly low nurse-to-population ratio. The World Bank revealed the Lebanese health sector to have 1.674 nurses to each 1000 person,² compared to an average of 9 to 1000 internationally.³ Many factors contribute to the age-old challenge of nursing shortage, from recruitment to retention. Nursing programs in Lebanon suffer from low enrollment numbers,⁴ a concerning fact considering that 6.73% of registered nurses are expected to reach retirement age within the next 10 years. Additionally, as of 2019, only 70.95% of nurses registered to the Lebanese Order of Nurses have declared to be currently working in Lebanon.⁵ The remaining having retired early early, changed their career plans, or immigrated.

Being at the frontline of the pandemic, nurses play a vital role in the detection, management, and containment of the disease. It is, therefore, more critical than ever to advocate for the rights of nurses to be improved.

Following the confirmation of the first case on the 21st of February,⁶ nurses and healthcare providers received a lot of popular praise, with people cheering them and media outlets setting up donation campaigns in their support. To someone watching from the outside, it seemed as if nurses were appreciated and adequately remunerated. However, nurses risking their lives fighting a highly contagious infection found that there are many systemic gaps challenging the resilience of the remaining workforce.

Recently, in September 2020, a hospital’s CCTV documented an incident in which a registered nurse was physically abused by a physician at work. Though the Order of Nurses published an official statement to condemn the event,⁷ on Facebook, multiple nurses frustrated by the inaction of the Order commented and expressed their concern. The Order’s president personally replied to the outcry with the aforementioned nurse’s statement of appreciation to the Order’s emotional support. In a country where 62% of nurses report having been subjected to verbal abuse and 10% to physical violence,⁸ the Order of Nurses has the obligation to go beyond emotional support and advocate for safe working conditions. Due to the prevalent nature of workplace abuse, this case should have been utilized to urge authorities to implement strict, zero tolerance policies to protect nurses and prioritize their safety.

In 2020 as well, the Order launched a campaign titled “It is our right to demand our rights” with the aim of shedding light on the injustices facing nurses and the importance of demanding rights. As part of the campaign, the syndicate’s president held meetings with multiple stakeholders to highlight the gravity of the nursing shortage and the work conditions nurses have to endure. Each meeting ended with the same promises that all efforts will be made to improve nurse retention.⁹ No significant measures or policies were put in place.

After years of government inaction, the Order of Nurses called for a nation-wide strike planned on August 5, 2020. However, due to the August 4th explosion, the strike was cancelled.¹⁰ Although strikes are essential and justified, much more is expected from the Order to be effective in advocating for its members. Considering what nurses have endured for years, including low and late pay and under-staffing, the call came too late. Many nurses already quit their jobs and changed careers, while others have opted for working abroad.

The interaction of nurses with the Order’s Facebook page and their comments on their campaign reveal a level of dissonance between the needs of nurses and their syndicate’s discourse and actions. How could it be “our right to demand our rights” if every disapproving comment posted by a nurse is met with negativity and victim-blaming? The Order should provide nurses with a safe environment to voice their concerns, and input should be utilized to improve the practice. The comment section on the Syndicate’s page is filled with anger over many issues: low pay, negligible protection, minimal response to concerns, and poor advocacy. The Order's president personally replies to most comments claiming the nurses in question are not doing enough research to know how much the Order works to improve the profession. If that was the case, active research would not be necessary as the Order's work would speak for itself and nurses would gain far greater satisfaction from their work.

Another common response to complaints claims that nurses who do not attend general assemblies and are not active members of the Order have no right to criticize its performance. This argument disenfranchises a large percentage of practicing nurses. To attend general assemblies, nurses are required to pay their yearly subscription fees a month prior to the meeting.¹¹ A nurse who has not received their salary in months cannot afford such a fee, particularly in the current economic situation. Many have demanded that the money collected from the COVID-19 donation campaigns be used to cover the Order's fees, but according to the Order’s president such decisions can only be made in general assemblies, bringing the debate to a full loop excluding affected nurses. How can the nurses that need this decision the most participate in the general assembly to make their voice heard?

Another factor contributing to the shortage of nurses in Lebanon is corporate greed. Over the globe, hospitals have stepped up recruitment of registered nurses to form a resilient task force against the current pandemic. In Lebanon, however, the American University Medical Center (AUBMC) took advantage of the unprecedented situation to lay off 150 nurses, leaving them vulnerable amid economic instability and an international health emergency.¹² Nationwide, nurses are being dismissed from their jobs or driven to unemployment or career change. As of November 2019, 35-40% of nurses working in Lebanon were discharged from their positions.¹³ Generally, the marketization of healthcare is rooted within capitalist systems, implying that health provision is viewed as a profit-driven industry. As a result, it comes as no surprise that hospitals prioritize revenue at the detriment of job security and stability.

Furthermore, patriarchy jeopardizes the sustainability of the nursing sector. In 2019, 79.52% of Lebanese nurses registered to the Order were female.¹⁴ Historically, professions predominated by women, particularly in the care sector, are often devalued and plagued by lower working conditions.

At the moment, COVID-19 incidence is increasing, and that trend is expected to continue, further increasing the need for hospitalization. In Lebanon, where the health sector is strained, under-staffed, and under-equipped, this could turn into an unparalleled country-level crisis. As hospital beds fill up, healthcare provider's workload will increase, further aggravating the nurse-to-patient ratios. This has been proven to result in greater nursing burnout, dissatisfaction, and intent to leave the profession. However, this shortage does not only affect nurses, it is a key challenge to the determinants of a population's health since it leads to more medical errors, and higher mortality and morbidity rates.¹⁵ Therefore, now more than ever, the Ministry of Health, the Order of Nurses, and hospital administrators should be working to improve nurse retention and work conditions if we are to avoid the devastating effects that will arise from this shortage.

Laura El Mir is a Registered Nurse who graduated with a Bachelor of Science in Nursing from Notre Dame University. Her main areas of practice are neonatology, pediatrics, and emergency care. She is currently pursuing her Master of Public Health at the University of Saskatchewan. Through her education and work experience, she has developed deeper interest in community health issues, specifically social determinants of health. Laura aspires to influence the restructuring of the Lebanese healthcare sector as well as forming more sustainable policies to support change.