Between duty and despair: the ethical toll of brain drain on Nepalese nurse managers

This study employed a qualitative descriptive design to explore the ethical implications of brain drain on the nursing workforce in Nepal [32], as nurse managers perceive. The study was guided by an interpretive description approach [33] situated within the constructivist paradigm [34]. This paradigm recognizes that knowledge is socially constructed and that reality is interpreted through individual experiences and interactions. In this study, the constructivist paradigm explored the multiple realities and perspectives of nurse managers regarding the ethical implications of brain drain, acknowledging that their experiences are shaped by their unique contexts and interactions within the healthcare system. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to ensure transparency and rigor in the research process [35].

This study was conducted in two hospitals representing diverse healthcare settings within Nepal: an urban hospital in Bagmati Province and a rural hospital in Karnali Province. Bagmati Province is home to Kathmandu, the nation's capital and largest metropolitan area, and represents the most developed and resource-rich region of the country [36]. Conversely, Karnali Province is Nepal's least developed and most geographically remote province, characterized by limited infrastructure, challenging terrain, and significant disparities in access to healthcare services [37, 38]. This geographical isolation is reflected in key development indicators: with 28.9% of its population living below the poverty line and a per capita income of just USD 606 [39], substantially below the national average of USD 1380 [40]. Furthermore, multidimensional poverty affects 51.2% of Karnali's population, and its Human Development Index (HDI) is a mere 0.427, both considerably below the national averages of 28% and 0.49, respectively [39]. These socio-economic disparities translate into significant health challenges, with an average life expectancy of 67 years (the lowest of all provinces), a child malnutrition rate of 58%, and limited access to basic sanitation, with 35.9% of the population lacking access to safe water and only 50% of households having proper toilet facilities [39]. This strategic selection of these two provinces provided a crucial contrast, allowing for the exploration of how brain drain impacts healthcare delivery and the experiences of nurse managers in vastly different contexts within the same country.

The recruitment process for this study aimed to select participants who had a minimum of five years of experience as a nurse manager and could provide rich insights into the ethical implications of brain drain. This selection criterion was deemed appropriate to ensure that participants had sufficient experience navigating the complexities of the healthcare system and witnessing the impact of nurse migration over time. The recruitment process involved a combination of purposive sampling [41], convenience [42], and snowball techniques [43]. Potential participants were initially contacted through invitations distributed by the hospital administrations at each site. These invitations outlined the study's purpose, eligibility criteria, and contact information for the research team. Additionally, flyers with a QR code for self-registration were displayed in prominent locations within the hospitals, allowing for self-selection, which aligns with a convenience sampling approach. Purposive sampling was then used to select participants who volunteered to participate and had direct experience with ethical dilemmas related to nurse migration. In this study, ethical dilemmas refer to situations where nurse managers face difficult choices between competing values or obligations, often arising from the conflict between the needs of individual nurses considering migration and the needs of the healthcare system and the patients it serves. This is distinct from moral distress, which is the psychological distress experienced when one knows the right course of action but is constrained from taking it [44]. While moral distress can be a consequence of ethical dilemmas, the focus here was on identifying participants who had encountered and navigated these challenging situations. To further ensure diverse perspectives within each site (urban/rural), snowball sampling was employed to reach potential participants through existing contacts. While acknowledging the potential for snowball sampling to lead to a homogenous sample, several strategies were implemented to mitigate this risk. Initial contacts were chosen from different departments and levels of seniority within each hospital to ensure a broad starting point. Furthermore, participants were explicitly asked to recommend colleagues with diverse experiences and viewpoints, including those who might have different perspectives on nurse migration. These efforts were combined with maximum variation sampling based on factors such as years of experience as a nurse manager, department (e.g., emergency, medical-surgical), and educational background to capture a range of experiences [45].

Data collection involved face-to-face, semi-structured interviews facilitated by the primary investigator (AG) from June 2024 to September 2024. Prior to the interviews, there was no established relationship between the investigator and the participants, ensuring an unbiased interaction during the data-gathering process. Written informed consent was obtained from all participants before the interviews commenced. The interviews were audio-recorded and conducted in Nepali and English, allowing participants to respond in their preferred language. Both authors are registered nurses and academics in Nepalese healthcare settings who are fluent in Nepali and English. The first author (AG) transcribed all audio-recorded interviews verbatim and translated them into English where necessary. To ensure accuracy, a second author (MSN) independently reviewed a random selection of interview transcripts, including translations. The final transcribed interviews were returned to all participants for validation before the data analysis. The interviews lasted approximately 40–45 min each and were scheduled at the participant's convenience.

Before beginning the interview, the interviewer explained the purpose of the study and provided definitions for key terms, including "brain drain" and "ethical dilemmas." Brain drain was defined as the emigration of skilled healthcare professionals from Nepal to other countries for better opportunities, often resulting in workforce shortages and impacting the quality of care in the home country [46]. Ethical dilemmas were defined as situations where nurse managers faced difficult choices between competing values or obligations [47], particularly in the context of nurse migration and its impact on staffing, patient care, and the overall healthcare system. The distinction between ethical dilemmas and moral distress was also clarified, with moral distress being explained as the psychological distress that arises when one knows the ethically appropriate action to take but is prevented from doing so due to internal or external constraints [44]. Participants were encouraged to ask questions and seek clarification on any terms or concepts before and during the interview. The interview guide (Table 1) outlines the key questions explored during the interviews. These questions were designed to elicit rich descriptions of the participants' experiences and perspectives related to the ethical implications of brain drain.

Inductive qualitative content analysis was employed to analyze the interview transcripts [48]. This approach involved systematically coding the data to identify underlying concepts and relationships, ultimately developing themes and subthemes. Open coding was followed by categorization and theme generation. The findings were then interpreted and presented in a report that included direct quotes and descriptions of the phenomenon within the framework of the identified concepts and themes (Table 2). In line with the approach suggested by Rahimi and Khatooni [49], the study aimed for code and thematic saturation rather than data saturation, recognizing participants' diverse experiences and prioritizing the analysis's depth and richness.

To ensure the trustworthiness of the qualitative data and subsequent analysis, this study adhered to established criteria for rigor, encompassing credibility, dependability, confirmability, and transferability [50].

Credibility, the confidence in the truth of the findings, was established through several strategies. Member checking was a crucial component. After data collection and transcription, an initial thematic analysis, including a summary of the key themes and supporting quotes, was compiled and sent to all 10 participants via email. This summary was presented in both English and Nepali to ensure comprehension. Participants were invited to review the summary and provide feedback on the accuracy and resonance of the themes with their experiences. They were specifically asked to confirm whether the interpretations accurately reflected their intended meanings and if any crucial aspects were missed. Participants were given two weeks to respond, with follow-up reminders sent via phone calls. All participants responded. Feedback received was carefully considered and incorporated into the final analysis.

Dependability refers to the consistency and stability of the findings over time, which was enhanced through a rigorous and transparent research process. The semi-structured interview guide was developed based on a comprehensive literature review on brain drain, nursing workforce challenges, and ethical dilemmas in healthcare. This review involved searching databases such as PubMed, CINAHL, and Scopus using keywords like "brain drain," "nurse migration," "ethical dilemmas," "moral distress," and "healthcare workforce." The search was limited to articles published in English within the last ten years. The identified articles were then screened for relevance to the research question, and those meeting the inclusion criteria were critically appraised to inform the development of the interview guide. The guide was also informed by both authors' insider experience as registered nurses and academics in Nepalese healthcare settings, providing valuable contextual knowledge. Furthermore, the interview guide was reviewed by two specialists: one in nursing education with expertise in workforce issues and another with expertise in qualitative methodology. This expert review ensured the appropriateness and clarity of the interview questions and their alignment with the research question. The detailed documentation of the data collection and analysis processes, including the coding framework and examples of code development, further contributes to the study’s dependability.

Confirmability, ensuring that the findings are grounded in the data and not influenced by researcher bias, was addressed through several strategies. Reflexivity was a central focus. The research team, comprised of nursing academics and nurses, engaged in ongoing reflection throughout the study. Recognizing that our own experiences as educators and clinicians in the Nepalese context might influence our interpretations, we maintained reflexive journals to document our assumptions, preconceptions, and potential biases. These journals served as a tool for critical self-reflection, allowing us to examine how our perspectives might shape the research process, from data collection to analysis and interpretation. Furthermore, regular bi-weekly team meetings provided a platform for open dialogue and reflexive discussions, where we challenged each other's interpretations and ensured that the emerging themes were grounded in the data rather than our own preconceived notions. For example, during one meeting, the team discussed the potential for their own experiences as nurses in Nepal to influence the interpretation of the theme "Moral Distress on the Frontlines." One researcher initially interpreted the data through the lens of their own experiences of feeling overwhelmed by workload pressures. However, through discussion and a re-examination of the transcripts, the team recognized that the participants' descriptions of moral distress were more closely tied to their inability to provide adequate care due to systemic constraints, such as lack of resources and staff shortages, rather than simply feeling overwhelmed. This led to a refinement of the theme's definition and a more nuanced understanding of the participants' experiences. An audit trail, including detailed transcripts, coding frameworks, and memos documenting analytical decisions, was maintained throughout the study. This audit trail provides evidence of the analytical process and allows for external scrutiny of the findings.

Transferability, pertaining to the potential applicability of the findings to other contexts, was supported through detailed descriptions of the study participants, including their professional roles, years of experience, and the characteristics of the urban and rural hospital settings. This contextual information allows readers to assess the relevance and transferability of the findings to their own settings and situations. While the findings are specific to the experiences of nurse managers in Nepal within the context of brain drain, the identified themes related to moral distress, ethical dilemmas, and the impact on healthcare systems may resonate with similar contexts in other LMICs facing healthcare workforce migration.

This study was approved by the Nepal Health Research Council (approval number- 333/2024) and the institutional review committee (IRC) from Civil Service Hospital, Kathmandu, Nepal, and Mugu District Hospital, Karnali, Nepal. All participants provided written informed consent and were assured confidentiality and anonymity throughout the study. The informed consent process emphasized the voluntary nature of participation, explicitly stating that participants had the right to withdraw from the study at any time without any negative consequences. It was also made clear that there would be no penalty or loss of benefits for refusing to participate or withdrawing from the study. The potential risks and benefits of participation were thoroughly explained. Participants were informed that there were no direct personal benefits anticipated from participating in the study. However, it was emphasized that their participation could contribute to a better understanding of the ethical challenges faced by nurse managers in Nepal due to brain drain. This knowledge could potentially inform policy changes and interventions aimed at improving working conditions and promoting a more sustainable healthcare workforce. The principle of "do no harm" was strictly adhered to throughout the research process. Participants were assured that all information shared would be treated with the utmost confidentiality and that their identities would be protected. All study data, including audio recordings and transcripts, were stored securely on password-protected devices and were only accessible to the research team. Identifying information was removed from the transcripts during the analysis phase to further ensure anonymity. Data will be retained for five years after the completion of the study, after which it will be securely destroyed.

Ten nurse managers (five from an urban hospital and five from a rural hospital) participated in the study. The mean age of the participants was 31, and their average work experience was 7 years. All participants were female, four having a Master’s degree and employed by public hospitals (Table 3). The sample's exclusively female composition reflects the prevailing gender dynamics in Nepal's nursing landscape, where nursing is predominantly perceived as a female-dominated field. This observation is further substantiated by a report from the International Labor Organization indicating that the nursing workforce in Nepal is entirely female [10].

Thematic analysis of the interview data revealed five core themes that encapsulate the experiences of Nepalese nurse managers in the context of brain drain: (1) Moral Distress on the Frontlines; (2) Unequal Burden, Unequal Access; (3) The Ripple Effects of Exodus; (4) Beyond the Hippocratic Oath; and (5) Policy at the Crossroads. These themes are presented in detail below, with illustrative participant quotes. A comprehensive overview of the data analysis process, including identifying meaning units, codes, categories, and sub-themes, is provided in Table 2 within the Data Analysis section (Fig. 1).

In the heart of Nepal's healthcare system, nurse managers stand as the last line of defense against the relentless tide of brain drain. They frequently find themselves in situations where they must balance their professional obligation to provide optimal patient care with the significant limitations caused by understaffing and a lack of resources. This conflict between their internal moral compass and external constraints creates a breeding ground for moral distress, a state characterized by psychological distress and feelings of powerlessness. As vividly expressed by NM2:

“Each time a seasoned nurse leaves, it's like losing a limb. We scramble to fill the gaps, stretching ourselves thin, but there's only so much one person can do. The fear of making a mistake, of not being there for a patient in need, it gnaws at you. You question your every decision, wondering if you're doing enough.” (NM2)

This quote highlights the immediate impact of nurse migration on the workload and the emotional burden placed on those who remain. The fear of making mistakes due to overwork and inadequate staffing is a significant source of moral distress. Nurse managers, particularly in rural settings, often face even more daunting challenges:

“We're forced to prioritize, to triage care based on limited resources. It's a constant battle between what's ideal and what's possible. Witnessing the desperation in patients' eyes and their families pleading for help, you're torn between your duty to care and the harsh reality of the situation. It's a moral injury that never fully heals.” (NM8)

This statement underscores the agonizing choices nurse managers must make when resources are scarce, forcing them to compromise ideal care and live with the consequences. The phrase "moral injury" powerfully conveys the lasting psychological impact of these impossible decisions. The cumulative effect of these challenges takes a significant toll, as described by NM7:

“The weight of responsibility is crushing. "You're not just managing a ward; you're holding together a crumbling system. The constant stress and guilt [...] takes a toll. You try to stay strong for your team and patients, but deep down, you're battling a sense of helplessness. It's a silent struggle that few understand.” (NM7)

This quote reveals the sense of responsibility nurse managers feel for the overall functioning of the healthcare system, despite its systemic deficiencies. It also highlights the often invisible emotional labor involved in leading during a crisis, further contributing to their moral distress.

The departure of skilled healthcare professionals from Nepal casts a long shadow, particularly over rural communities grappling with limited resources and access to care. The exodus of skilled nurses disproportionately impacts communities already struggling with limited resources, creating an uneven distribution of healthcare services and placing an undue burden on the remaining healthcare workers. As articulated by NM6:

"We're fighting an uphill battle. Every nurse who departs for the city or overseas leaves a void that's nearly impossible to fill. Our patients travel for miles, seeking care they can't find in their villages. They deserve better, but our hands are tied. It's a constant reminder of the injustice of it all." (NM6)

This quote underscores the growing gap between healthcare needs and the availability of skilled professionals in rural areas, highlighting the sense of injustice felt by nurse managers who witness the consequences. The impact on rural communities is further emphasized by NM8:

“The brain drain is like a silent epidemic, eroding the foundations of rural healthcare. We see the consequences every day – delayed diagnoses, untreated complications, preventable deaths. It's a heavy burden to carry, knowing that the most vulnerable among us are paying the highest price.” (NM8)

This statement paints a grim picture of the deteriorating state of rural healthcare, likening brain drain to a "silent epidemic" that disproportionately affects the most vulnerable populations. It also highlights the emotional toll on nurse managers who witness these preventable tragedies. The strain on the remaining workforce is immense, as expressed by NM10:

“We try to be everything to everyone, but it's simply not sustainable. We're spread too thin, our resources stretched to the breaking point [….] The mothers who can't reach a hospital in time for childbirth, the elderly left without proper care, the children suffering from treatable diseases... their faces haunt us. It's a moral outrage that demands attention.” (NM10)

Adding to this complex situation is the financial burden faced by patients:

“It's heartbreaking to see families forced to choose between food on the table and life-saving treatment. The cost of care has skyrocketed, and many can't afford it. We witness the desperation in their eyes as they plead for help, knowing that without financial assistance, their loved ones may be turned away or forced to abandon treatment altogether. It's a cruel reality that deepens the divide between those who can afford care and those who cannot.” (NM3)

This statement highlights the intersection of brain drain and socioeconomic disparities, revealing how the lack of access to care is compounded by financial constraints, creating a deeply inequitable system. This theme demonstrates that brain drain is not just about an inadequate workforce but a social justice issue that exacerbates existing inequalities and undermines the fundamental right to healthcare.

This theme captures the cascading consequences of brain drain, extending beyond immediate staffing shortages to impact various aspects of the Nepalese healthcare system. The departure of skilled nurses creates a domino effect, negatively affecting workload, patient safety, mentorship, and the overall sustainability of the workforce. As described by NM4:

"It's a domino effect," a nurse manager from a busy urban hospital explained. "One nurse leaves, and the workload shifts to those who remain. Fatigue sets in, mistakes become more likely, and patient safety is compromised. We're constantly walking a tightrope, trying to maintain standards while the ground beneath us crumbles.” (NM4)

The loss of experienced nurses also has long-term consequences for the development of future healthcare professionals, as explained by NM5:

“We're losing the next generation of leaders. Experienced nurses leave, taking their knowledge and mentorship with them. New graduates are thrown into the deep end, lacking the guidance they need to thrive. It's a vicious cycle perpetuating the brain drain, leaving us an underprepared workforce.” (NM5)

This statement underscores the crucial role of experienced nurses in mentoring and training new graduates, a role that is severely undermined by their departure. This creates a "vicious cycle" where the lack of mentorship contributes to further brain drain. The challenges are further compounded by systemic issues related to recruitment and retention. NM3 laments:

“It’s a cruel irony,” a nurse manager in Kathmandu lamented. “The Nepalese government signs deal with countries like the UK, knowing we can’t afford to lose more nurses. And yet, they keep leaving, drawn by promises we can’t match. We're caught in the middle, watching our colleagues disappear, our hospitals hollowed out, and there's little we can do to stop it.” (NM3)

This quote highlights the complex interplay between national policies and the global demand for nurses, revealing a sense of powerlessness among nurse managers who witness the depletion of their workforce despite government efforts. The difficulties in recruiting and retaining nurses, especially in rural areas, are further emphasized by NM10:

“Recruiting and retaining nurses has become an uphill battle," a nurse manager from a rural clinic shared. "The allure of better pay and opportunities abroad is hard to compete with. We're forced to make do with less, sometimes compromising on years of experience to keep the lights on. It's a constant ethical dilemma, balancing the need for staff with the imperative to provide safe and effective care.” (NM10)

This statement underscores the challenges of attracting and keeping qualified nurses in the face of global competition, forcing difficult decisions that can compromise the quality of care. It also highlights the ethical dilemmas inherent in balancing staffing needs with the imperative to provide safe and effective care.

The decision to leave one's home country to pursue better opportunities abroad is complex and emotionally fraught for Nepali nurses. Their decisions are often filled with conflicting emotions, torn between personal and professional aspirations and a sense of duty to their home country. As observers and confidantes, nurse managers are privy to these internal struggles. NM2 articulates this duality:

“It's bittersweet to see them go. On the one hand, I'm happy for them, knowing they'll have access to better resources and opportunities. But on the other hand, it's a loss for us and our patients. It's a constant reminder of our systemic challenges, the push and pull factors that drive our brightest minds away.” (NM2)

The departure of each nurse is perceived as a dual phenomenon: it signifies a celebration of individual career advancement while simultaneously representing a collective loss within the healthcare team. This sentiment reveals the underlying tension between acknowledging the systemic issues that push nurses to leave and the personal desire to retain valuable members of the healthcare team. NM4 offers further insight into the moral weight carried by migrating nurses:

“Sometimes, I wonder if they feel guilty about leaving behind a system in need. They've dedicated their years to serving their communities and are now walking away. It's a difficult decision, one that weighs heavily on their conscience. You can see the conflict in their eyes, the sadness mixed with hope.” (NM4)

The moral landscape faced by these nurses is complex. They are not simply abandoning their posts but grappling with a decision that pits their sense of duty against the need for personal and professional advancement. This theme illuminates the often-overlooked emotional and ethical dimensions of brain drain, revealing that the decision to migrate is not merely a career move but a complex moral negotiation for Nepali nurses.

Acutely aware of the ethical and systemic implications of brain drain, nurse managers advocate for change rooted in equity, sustainability, and moral standards. NM5, from a large urban hospital, challenges the narrative that blames individual nurses for seeking opportunities abroad:

“We can't simply blame nurses for seeking better opportunities," a nurse manager from a large urban hospital stated. "The WHO's code of ethics emphasizes the right to decent working conditions and fair remuneration. Until we address these systemic issues, the brain drain will persist. We need policies that value our nurses, invest in their growth, and create an environment where they feel respected and supported.” (NM5)

This perspective shifts the focus from individual choices to the systemic issues that drive brain drain, emphasizing the need for policies that uphold the rights and well-being of healthcare workers. From a rural perspective, NM7 highlights the discrepancy between governmental rhetoric and the reality on the ground:

“The Nepalese government stresses the importance of nurses' role in promoting health equity and social justice. But it's often limited to words, not actions. Brain drain undermines these principles, leaving vulnerable populations behind. We need policies prioritizing rural healthcare, incentivizing nurses to serve in underserved areas, and ensuring equitable access to care for all.” (NM7)

This critique exposes the urgent need for concrete policy actions that prioritize rural healthcare and address the widening disparities in access to care, moving beyond mere lip service to tangible change. The need for long-term, sustainable solutions is a common thread, voiced by both urban and rural nurse managers. NM1 cautions against relying on temporary fixes:

“Sustainability is key. We can't rely on foreign aid and volunteers to solve our problems. They are here temporarily and are gone […]” (NM1)

This statement serves as a stark reminder of the limitations of short-term solutions and the imperative of building a self-reliant healthcare system. Echoing this sentiment, NM6 calls for a fundamental shift towards a more resilient healthcare system:

“We need to build a resilient health system, one that can withstand the challenges of brain drain and other crises. This requires long-term investment in education, infrastructure, and the development of a strong and dedicated domestic workforce.” (NM6)

This vision for a robust healthcare system emphasizes the interconnectedness of education, infrastructure, and workforce development, advocating for sustained investment in these areas to create a system capable of retaining its skilled professionals. This theme underscores a critical juncture for Nepal’s healthcare policy, where decisive action is needed to address the systemic drivers of brain drain and build a future where healthcare is equitable, sustainable, and accessible to all.