A national study on nurses’ retention in healthcare facilities in underserved areas in Lebanon

The maldistribution and shortages of human resources for health (HRH) in underserved areas is gaining the attention of both policy makers and researchers worldwide [1]. According to the World Health Organization (WHO), underserved areas include geographical areas where the population has limited access to quality health-care services and to qualified health-care providers [2]. WHO’s designated underserved areas may include: ‘remote and rural areas, small or remote islands, urban slums, conflict and post-conflict zones, refugee camps, minority and indigenous communities, and any place that has been severely affected by a major natural or man-made disaster’ [2] (page 9). According to the WHO (2006), half of the world’s population resides in rural areas; however this population is served by only 38% of the global nursing workforce [3]. The inequitable distribution of HRH in rural areas is a major problem contributing directly to the global burden of disease and negatively influencing health outcomes in these areas [4]. This shortage is most pronounced for nurses who are the linchpin of a healthcare system and who are responsible for delivering the majority of healthcare to their communities [5].

A multitude of strategies, with varying degrees of success, have been implemented by governments to address this problem and attract nurses to underserved areas. These strategies include financial incentives, non-financial incentives, educational or recruitment interventions and regulatory interventions [2, 6, 7]. Within the context of the Eastern Mediterranean Region (EMR), there has been a dearth of studies that have systematically investigated the factors significantly associated with nurses’ retention in underserved areas.

A total of 103 facilities were approached; 71 initially consented to participate but 8 did not return the surveys, yielding a 61% facility response rate (63 of 103 facilities). Out of a total of 1,135 nurses working in these 63 facilities a total of 857 nurses responded to the questionnaire (75.5% response rate). P-values in the bivariate analysis have been labeled ‘p’.

This study was the first of its kind in both Lebanon and the EMR to investigate the retention of nurses working in underserved areas. Findings from this study revealed that several demographic and personal characteristics of nurses were associated with their intent to stay in their current job.

Study findings revealed that nurses less likely to report intent to stay had fewer years of experience and were thus younger. The fact that age was only significantly associated with intent to stay at the bivariate level and not significant at the multivariate level could be attributed to the fact that age and years of experience go in parallel; more experienced nurses are typically older. The direct association between years of experience/age and intent to stay is consistent with other studies in literature [28, 29]. Our findings prompt nurse planners, policy and decision makers to design and implement targeted retention initiatives aimed at retaining new nurse graduates, less experienced and younger nurses in rural and remote communities [30]. Such initiatives must be designed in an engaging approach to involve younger and less experienced nurses in planning and implementation [7].

Study findings further indicated that married nurses and those married with children were twice as likely to indicate intention to stay in their current job as compared to their unmarried counterparts. Such findings are also in accordance with previously reported studies in the literature [31]. Sociocultural factors related to the perceived role of married women in society may also play a role in enhancing married nurses’ job retention. Most married females in Lebanon (and other Middles Eastern countries) are expected to take the lead in terms of caring for their families and children [32]. They do thus prefer job stability close to their homes and their children’s schools. They are also less mobile compared to their single counterparts since married nurses with children may find it difficult to relocate with the whole family and have a higher sense of financial responsibility [33]. They generally also display higher levels of job commitment [34].

Analysis of the MMSS reveals that surveyed rural nurses were most satisfied with the ‘relationship with co-workers’ aspect of work. Such a relationship appears to be an important motivator that is enhancing rural nurses’ retention and possibly mitigating the negative aspects of employment in rural and remote communities. Furthermore, encouraging peers to move to the nurse’s place of employment is also indicative of significantly higher odds of staying in current job. A strong relationship with co-workers has been found to be important in modern healthcare systems and has been linked to improved work environment which has a critical impact on patient safety. Managers of rural health facilities are encouraged to organize programs and activities that strengthen team work and enhance professional collaboration. Such programs are found to not only enhance the quality of patient care but also the retention of nurses [35, 36].

Study findings revealed a clear issue with motivating and rewarding nurses with extrinsic rewards. There is overwhelming evidence in the literature that motivating nurses would increase their job satisfaction and positively influence their intention to stay [37, 38]. This is particularly significant for nurses working in rural and remote communities [39, 40]. Examples of extrinsic rewards include bonuses, raises, paid vacations, tuition reimbursement, and paid or unpaid leave to pursue further education [41‐43]. Some countries have employed a number of strategies to improve the retention in rural areas, including financial incentives, trainings and continuing education programs and introducing supportive supervision and participatory management [7]. Nurse planners, managers and stakeholders are invited to offer an assortment of rewards targeting nurses working in rural communities in particular. Such rewards need not be expensive and their effects would need to be assessed in order to decide on the proper configuration that would enhance the satisfaction and retention of nurses in rural and remote communities [1, 44].

While regression analysis reveals that working towards a higher degree negatively influenced nurse retention, the findings from the MMSS show that satisfaction with access to professional development opportunities had a positive impact on intent to stay. The consolidation of these two findings indicate that while working towards a higher degree might push rural nurses to seek a job in the more competitive urban areas (thus decreasing their intent to stay), providing opportunities for professional development through seminars, short courses and access to conferences (among others) would enhance the job retention of rural nurses. In that regards, the findings of this study are consistent with other studies in literature that indicate that rural nurses’ access to professional development and short term educational opportunities enhance their job satisfaction and support their retention [2, 44, 45]. Such programs are particularly important for health care providers working in rural and remote communities due to professional isolation and high cost of travel to acquire up to date knowledge [46]. Professional development programs were found to strengthen both the recruitment and retention of nurses in rural and remote areas, being valued even more to nurses than material rewards [1, 29]. Establishing a continuing education and professional development program for nurses in underserved areas is a top priority for health policy and decision makers; particularly the order of nurses in Lebanon. Such programs do not only contribute to delivery of evidence based patient care but also have the potential to enhance nurses’ retention in rural and remote communities.

Study findings highlight differences between responses of nurses working in hospitals versus PHC centers. Nurses working in PHC centers were more likely to report an intent to stay. The literature points out some advantages to working in PHC centers in rural settings; mainly greater autonomy in caring for patients and ability to better utilize professional skills [2]. Furthermore, the shorter working hours in PHC centers might be a key reason for married nurses with children to prefer working in PHC centers particularly as evidence in the literature points out to nurses’ preference to work shorter hours [47]. This could also explain why more experienced nurses were more likely to work in PHC centers. Moreover nurses working in PHC centers had more positive attitudes towards nursing but they were less likely to report working towards a higher degree than nurses working in hospitals. While such findings are encouraging in regards to nurse retention within the expanding primary healthcare and community care network in Lebanon, they also highlight a policy priority to investigate and address the underlying causes behind nurse dissatisfaction with the hospital work environment in rural and remote communities in Lebanon. Identifying and addressing these causes would be a prerequisite to enhancing nurses’ job satisfaction and consequently retention in rural health facilities.

One of the main limitations for this study was the lack of information on the number and distribution of nurses across health facilities in Lebanon. The country also lacks clear cut boundaries that define rural areas from urban areas which made the mapping exercise a challenge. Having clearer boundaries and a more comprehensive database would have enabled a more thorough examination of the distribution of nurses in understaffed areas in Lebanon and allowed the authors to place the findings in the greater context of the Lebanese health care system. However, an extensive mapping of health facilities in the identified underserved areas was conducted to ensure that study findings represent the views of this stratum of the nursing workforce. The response rate could also be deemed one of the limitations of the study as we could not ascertain whether non-respondents carry a different opinion/experience than nurses that have responded to this study. However, the study had a relatively good response rate from nurses, with more than three quarters of targeted nurses (75.5%) responding to the questionnaire. In terms of facilities, and as portrayed in Figure 1, 62% of hospitals and 61% of PHC centers returned the surveys, indicating the majority of health facilities were able to participate in the study. Although these facilities were not different from the responding ones with regards to geographic location or the socioeconomic status of the catchment area, they tended to be smaller in size than the responding ones. The most common reasons for not participating in the study as reported by the facilities were: having too few or no nurses (particularly in PHC centers) or inability to designate a contact person at the facility to coordinate data collection. This indicates that the facilities may have been poorly staffed and lacked nursing personnel to complete the survey. Despite these challenges, we believe that the study had a very good response rate (75.5%) which enhances the external validity of the findings. An additional limitation relates to the inability of cross-sectional survey design to establish causality. However, the results of this manuscript outlines the association between factors influencing intent to stay which can provide lessons for decision makers on how to improve the available incentives for nurses in underserved areas. Finally, despite every attempt to ensure clarity of the questionnaire (pilot testing), it cannot be ascertained that all questions were well understood by nurses; especially among those with lower levels of education.

Study findings reflect a generally unstable and dissatisfied nursing workforce in rural and underserved areas in Lebanon. Such findings are disquieting to nursing planners, policy and decision makers as they cast a doubt on the sustainability and equity of providing health services to rural populations. Nevertheless, the study identifies multiple opportunities for intervention in order to rectify the situation and enhance the satisfaction and retention of the rural nursing workforce, with particular attention to the work setting.

Our findings highlight that the nursing workforce is not homogeneous, and nurses may want different things at different life stages and in different settings. Primary healthcare, often seen as the poorer and less desirable cousin of the higher status hospital sector, comes out rather well in this survey. The less demanding nature of the job in this sector meant that it was better able to retain nurses despite the relatively poor amenities. The issue of how hospitals in those underserved areas can create a contented workforce that is willing to commit to the longer term seems to be a much greater challenge. Stakeholders are urged to work collaboratively to devise strategies and initiatives that would bolster the retention of nurses in underserved areas; especially younger nurses and those working in the hospital. Such strategies would help enhance access, quality and equity of care delivered in rural settings and would contribute to improving the retention of the healthcare system’s most valuable asset…nurses.