The validation of the Arabic version of the resilience scale 14 (RS-14).

BACKGROUND/OBJECTIVES: Nurses in Lebanon are facing multiple crises and the severity of the situation calls for an empirical examination of their resilience status. Evidence indicates that resilience can buffer the negative effect of workplace stressors on nurses and is associated with favorable patient outcomes. The objective of this study was to test the psychometric properties of the Arabic Resilience Scale-14 that was utilized to measure resilience among Lebanese nurses, METHODS: Data was collected from nurses working in health care centers using a cross-sectional survey design. We estimated the confirmatory factor analysis using the Diagonally Weighted least Squares. Fit indices for the confirmatory factor analysis model included Model chi-square, root-mean squared error of approximation and Standardized Root Mean Square Residual. Statistical significance was set at p < 0.05. RESULTS: 1,488 nurses were included in the analysis. The squared multiple correlations values ranged from 0.60 to 0.97 thus supporting the construct validity of the originally hypothesized five factor model (self-reliance, purpose, equanimity, perseverance, and authenticity). CONCLUSIONS: The Arabic version of the Resilience Scale 14 tool is considered a valid tool for measuring resilience in any situation involving Arabic speaking nurses.

Transformational leadership and predictors of resilience among registered nurses: a cross-sectional survey in an underserved area.

BACKGROUND: High resilience increases nurses' ability to cope with job-related stressors and enhances job satisfaction and, consequently, their retention. The study aims to identify resilience predictors and perceptions of transformational leadership in a convenience sample of registered nurses in Lebanon. METHODS: An anonymous cross-sectional survey of a convenience sample of 240 registered nurses working for more than a year at three private hospitals in an underserved area in South Lebanon was used. The survey instrument included demographic questions, the True Resilience Scale ©, and the Global Transformational Leadership Scale. Multiple linear regression was used to assess the predictors of resilience after a descriptive analysis of the study variables. RESULTS: The survey response rate was 85%. The nurses' mean resilience score was 119.4 (SD 15.3), and their perception of transformational leadership score was M = 25.0, SD = 6.8. Compared to bedside nurses, nurse managers, nurses with more than five years of experience, and nurses in critical nursing units had statistically significant higher resilience scores (p < 0.05). Resilience scores and perception of global transformational leadership were moderately correlated (r = 0.53, p < 0.05). In the final multiple linear regression model, 30% of the variation in resilience scores was explained by designation (p < 0.05) and perception of Global Transformational Leadership (p < 0.01). Perception of global transformational leadership scores explained 29% of the variance in resilience scores. Designation and perception of global transformational leadership predicted resilience in this sample. CONCLUSIONS: A national survey of the Lebanese nursing workforce is needed to achieve an improved predictive model and support policy developments to increase resilience among bedside nurses and retain them in the nursing workforce. Nurse administrators can help by strengthening their transformational leadership behaviors. Consistent use of transformational leadership styles will strengthen bedside nurses' resilience, increase nurse retention, and help sustain the Lebanese nursing workforce.

Can interprofessional education change students' attitudes? A case study from Lebanon.

BACKGROUND: Interprofessional collaboration is key to improving the health of individuals and communities. It is supported by provision of Interprofessional education (IPE) which has recently emerged in the Middle East region. This study investigated changes in healthcare students' attitudes towards interprofessional collaboration after undertaking the Interprofessional Education and Collaboration (IPEC) course. METHODS: A paper-based anonymous survey using the Interprofessional Attitude Scale (IPAS) was administered to a sample of 346 health students (nursing, medicine, and public health) pre/post undertaking the IPEC course. Less than half of the students provided a post response, with pre/post survey results of 111 pairs subsequently matched and analyzed. RESULTS: Results showed elevated pre-course scores, an improvement in students' attitudes towards the interprofessional biases domain of the IPAS, and a slight decline in their scores in the remaining 4 domains (team roles and responsibilities, patient centeredness, community centeredness, and diversity and ethics). These changes were not statistically significant, except for the patient centeredness domain (p = 0.003**). CONCLUSIONS: The study provided important results about attitudes towards interprofessional collaboration. These findings are essential because our institution is one of few in Lebanon that provides this mandatory course to a large group of health professionals. Future studies should investigate these changes in attitude scores in a larger sample size, and how these attitudes would influence collaboration post-graduation.

Work environment-related factors and nurses' health outcomes: a cross-sectional study in Lebanese hospitals.

BACKGROUND: Worldwide, studies show a relationship between nurses' health and some work environment factors; however, data on nurses' health and self-perceived workload and nursing task allocation are lacking, particularly for Lebanese nurses. We assessed the relationship of several work environment factors: overall workload and specific temporal, physical, mental, effort, frustration, and performance demands (NASA Task Load Index), staffing resources and adequacy and leadership (Practice Environment Scale of Nursing Work Index), teamwork climate (Safety Attitudes Questionnaire), and nursing task allocation (Basel Extent of Rationing of Nursing Care)) with self-reported musculoskeletal, cardiovascular, skin, and mental health diseases (Work Ability Index) and emotional exhaustion (Maslach Burnout Inventory) among Lebanese nurses. METHODS: A cross-sectional self-report survey was distributed to all 289 registered nurses (RNs) in the medical, surgical, and pediatric units in two Lebanese university-affiliated hospitals; 170 RNs had complete data. Adjusted multivariable logistic regression models were used to estimate the association between work environment factors and health outcomes. RESULTS: The most prevalent outcomes were musculoskeletal disease (69%), emotional exhaustion (59%), and mental health problems (56%); 70% of RNs had ≥2 and 35.29% had ≥4 co-occurring health problems. Musculoskeletal disease was associated with higher overall (OR = 1.36 (95%CI = 1.03, 1.80)), temporal (OR = 1.30 (95%CI = 1.09, 1.55)), and physical demands (OR = 1.20 (95%CI = 1.03, 1.49)), higher task allocation to RNs (OR = 1.11 (95%CI = 1.01, 1.23)) and lower teamwork climate (OR = 0.60 (95%CI = 0.36, 0.98). Higher odds of mental/emotional problems were associated with higher overall, temporal, frustration, and effort demands, and lower teamwork climate, performance satisfaction, and resources adequacy (increased odds ranging from 18 to 88%). Work environment indicators were associated with higher co-occurrence of health problems. CONCLUSIONS: Results show elevated health burden and co-morbidity among Lebanese RNs and highlight the value of comprehensive approaches that can simultaneously improve several work environment factors (namely self-perceived workload, teamwork,, resources, and nursing task allocation) to reduce this burden.

Paediatric oncology providers' perspectives on early integration of paediatric palliative care.

BACKGROUND: Healthcare providers' perceptions of palliative care in children with cancer influence care management, specifically that of its early integration. Thus, it is crucial to understand the perspectives of the providers on early integration of palliative care so that measures to create informed care decisions are based on reconciling their views. AIMS: To explore the perceptions of paediatric oncology providers at the Children's Cancer Institute (CCI) in Lebanon regarding the integration of early paediatric palliative care (PPC) in the management of children with cancer. METHODS: A qualitative descriptive research design with focus groups was used in a leading paediatric oncology setting. FINDINGS: The thematic analysis yielded four themes: (1) healthcare providers understood palliative care as pain relief and psychological support mainly at the end of life; (2) the timing of integrating PPC is linked to end of life, advanced disease or treatment failure; (3) interdisciplinary collaboration is important for addressing patients' and families' needs effectively; and (4) communication with the child and family is one of the most difficult aspects of integrating PPC. CONCLUSION: This study demonstrated the perceptions of healthcare providers about early palliative care in paediatric oncology in Lebanon. It also highlighted the importance of interdisciplinary collaboration and effective communication with the child and family for better management of PPC.

Trends and variability of implicit rationing of care across time and shifts in an acute care hospital: A longitudinal study.

BACKGROUND: Implicit rationing of nursing care is associated with work environment factors. Yet a deeper understanding of trends and variability is needed. AIMS: To explore the trends and variability of rationing of care per shift between individual nurses, services over time, and its relationship with work environment factors. METHODS: Longitudinal study including 1,329 responses from 90 nurses. Intraclass correlation coefficients (ICC) were computed to examine variability of rationing per shift between individual nurses, services, and data collection time; generalized linear mixed models were used to explore the relationship with work environment factors. RESULTS: Percentage of rationing of nursing activities exceeded 10% during day and night shifts. Significant variability in rationing items was observed between nurses, with ICCs ranging between 0.20 and 0.59 in day shifts, and between 0.35 and 0.85 in night shifts. Rationing of care was positively associated with nurses' self-perceived workload in both shifts, but not with patient-to-nurse ratios. CONCLUSION: Most variability in rationing over time was explained by the individual. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers and leaders need to develop and implement educational programs on implicit rationing of nursing care to strengthening nurses' skills related to decision-making, prioritization and time management.

Perspectives of Registered Nurses on refugee healthcare in Lebanon and Jordan (PROfILE): A multi-site cross-sectional study protocol.

AIM: This is a study protocol to investigate nurses' perspectives on refugee health care in two countries. The aims are to: (a) explore self-reported work environment factors, including work stressors, self-rated leadership, staffing and resources adequacy, and teamwork among Jordanian and Lebanese nurses caring for refugees; (b) investigate the relationship between nurse related outcomes (physical health; emotional exhaustion) and their psychosocial work environment; and (c) assess the association between nurses' perceived work environment factors and implicit rationing of care and quality of patient care. BACKGROUND: Globally, the care of refugees is achieving increased attention. Over 6.3 million people are internally displaced and 4.8 million recorded Syrian expatriates are residing in and receiving healthcare services in the neighbouring host countries. DESIGN: This is a cross-sectional, comparative study using a survey design. METHOD: The study setting involves both private and public hospitals and primary healthcare centres that provide care to refugees on regular basis in Lebanon and Jordan. The estimated sample size includes 3,000 Registered Nurses from Lebanon and 2,500 nurses and midwives from Jordan. DISCUSSION: Workplace factors affecting quality of nursing care and psychosocial status of nurses caring for refugees will be identified. Potential findings will help leaders design interventions to support nurses who are serving refugees for safer care and better patient outcomes. Findings will assist in more efficient resource allocation and management. IMPACT: New knowledge on the impact of providing health care for refugees will be generated based on the structure of nursing care (e.g., work environment), on the nursing process (e.g., implicit rationing of care), and nurse outcomes (health) in two hosting communities. Moreover, factors enabling resilience in patients, providers, and systems will be identified and be of potential use in addressing the growing global problem of caring for displaced persons.

Patients' knowledge and attitudes about myocardial infarction.

Delay in seeking emergency care contributes significantly to the mortality associated with myocardial infarction. The aims of this descriptive study were to determine Lebanese patients' knowledge, attitudes, and beliefs about heart disease following their hospitalization for acute myocardial infarction, the factors associated, and to investigate the education they receive about heart disease. The study targeted 50 participants diagnosed with myocardial infarction who were interviewed about their knowledge, attitudes, and perceived control related to heart disease in their home 1 month after being discharged from hospital using the Acute Coronary Syndrome Response Index and the Control Attitude Scale-Revised. The findings showed inadequate knowledge, with only 26% scoring over 70%. Moreover, only 16% reported having received education about heart disease. The participants reported confidence in recognizing symptoms and getting assistance during a myocardial infarction. However, their beliefs regarding the importance of prompt seeking of emergency care for myocardial infarction and control over their disease were inconsistent. Patient education and counseling about recognizing and responding adequately to symptoms of myocardial infarction must be improved in both acute and primary healthcare settings.

What made Lebanese emigrant nurses leave and what would bring them back? A cross-sectional survey.

BACKGROUND: The nursing workforce is critical for the provision of quality health-care and positive patient outcomes. There is a global trend of migration of nurses from under-developed to developed countries due to attractive job offers in the host countries. Lebanon presents such a case where nurses are migrating abroad, leading to shortages in the nursing workforce in their home country. OBJECTIVES: The aim of this study was to investigate reasons for the migration of Lebanese nurses, and incentives that would attract them back to their home country in order to enhance the nursing workforce in Lebanon. DESIGN: This study is a cross-sectional survey of emigrant Lebanese nurses. SETTINGS: Recipient countries where Lebanese nurses emigrated. PARTICIPANTS: 440 Emigrant Lebanese nurses were identified through the registration database of the Order of Nurses in Lebanon. The survey was sent to all of them via email; 153 responses were received. METHODS: Data were collected from November 2017 to March 2018. Analysis included univariate and bivariate tests to present descriptive statistics of the respondents, and to examine region of residence and gender in relation to their current job satisfaction, reasons for leaving Lebanon, intention to return to Lebanon, and aspects that would attract them back to their home country. Logistic regression analysis was used to determine the socio-demographic and work-related characteristics associated with the odds of returning to practice nursing in Lebanon. RESULTS: A total 136 completed responses were considered. Emigrant Lebanese nurses were highly educated, with more years of work experience, and older than nurses remaining in their home country. Top reasons for nurses to leave Lebanon included unsatisfactory salary or benefits, better work opportunities in other countries, and lack of professional development or career advancement. The majority of surveyed nurses (59%) expressed willingness to return to practice nursing in Lebanon. Aspects that would attract emigrant Lebanese nurses back to their home country include attractive salary or better benefits and opportunities for professional development, career advancement, or continuing education. Emigrant Lebanese nurses residing in the Gulf, staff nurses, and nurses with more years of work experience were more likely to return to practice nursing in Lebanon. CONCLUSION: Highly educated and experienced nurses are departing from Lebanon. This presents a challenge for the less experienced nurses remaining in the country, who could benefit from the mentorship and experience of their migrating peers. Creating an environment that could enhance the professional development of nurses in Lebanon, with financial incentives could retain the nursing workforce in the country.

A longitudinal study on implicit rationing of nursing care among Lebanese patients - Study protocol.

AIM: To gain an in-depth understanding of the variations and trends of implicit rationing of nursing care, of its associated factors and of its relation to with nurse and patient outcomes. BACKGROUND: Maintaining and improving the quality of nursing care and patient safety have been the focus of health services researchers over the last decade. Cross-sectional studies have showed the magnitude of implicit rationing of nursing care and its associations with negative patient and nurse outcomes. DESIGN: Observational longitudinal study. METHOD: Two-year funded study (between 2018-2020), including a sample of 317 Registered Nurses working on 19 units in two large Lebanese urban hospitals. The study included a cross-sectional baseline survey followed by multiple follow-up assessments over 90 days. The repeated measurements on each of the units include repeated surveys on nurses' rationing of care, hospital administration reported nurse-sensitive indicators, nurse staffing levels, and patient mortality data. DISCUSSION: The study results will describe variations and trends of implicit rationing of nursing care in hospital units over time and whether and which elements of the nurses' work environment are associated with these variations. Data will inform on the impact of implicit rationing of care on patient and nurse outcomes. These data are needed to advance future planning and interventional research to efficiently reduce rationing of nursing care and improve the quality of care. IMPACT: Generating new knowledge (variations and trends) on the association between rationing of care and other element of nurses' work environment and nurse and patient outcomes.

The Impact of the Syrian Refugee Crisis on Nurses and the Healthcare System in Lebanon: A Qualitative Exploratory Study.

PURPOSE: To explore Lebanese nurses' perspectives on the impact of the protracted Syrian refugee (SR) crisis on nurses working in hospitals and primary healthcare centers in Lebanon. DESIGN: A qualitative research design drawing on a semistructured in-depth interview approach. METHODS: We recruited participants through the Order of Nurses in Lebanon. We interviewed six primary healthcare nurses and six nursing directors working in regions with high concentration of SRs. We used the thematic inductive approach to analyze the data. FINDINGS: Two themes emerged. In Theme I, nurses and nursing directors described the SR health profile as poor at baseline, and as the crisis was protracting the type of diseases shifted from acute to chronic with convoluted complications. As for determinants of health, SRs had poor health literacy and poor living conditions. In Theme II, nurses and nursing directors voiced the impact of the SR crisis on nurses, nursing practice, healthcare system, and host community. They cited fatigue, burnout, and depleted compassionate care at the individual level; rationing and stressed interpersonal relationships at the practice level; shortage in resources and poor performance at the healthcare system level; and a shift in the patient population that led the host community to seek health care elsewhere. Alternatively, more money was injected, and new services and clinical programs were introduced. CONCLUSIONS: Lebanese nurses bore a profound burden as a result of the SR crisis. Should this crisis be replicated in other contexts, the important lessons learned encompass (a) increasing access to care to refugees, coupled with an emergency plan to increase human health resources; (b) improving preparedness of nurses in handling priority health conditions; (c) documenting and reporting the challenges and resilience of health workers, especially nurses facing the crisis; and (d) engaging more nurses to be at the policy table. CLINICAL RELEVANCE: There is a need to prepare nurses for efficient response to crisis related to refugee health by increasing human resources and training them to be competent in delivering safe and high-quality care necessary to respond to the special healthcare needs of the refugees.

Anaphylaxis management: a survey of school and day care nurses in Lebanon.

OBJECTIVE: Children are at a high risk of developing allergic reactions. Since they spend lots of time at the school or day care, the odds of having an allergic event in this setting is high, hence placing the onus of properly managing their event on nurses. In Lebanon, little is known whether a standardised policy for managing allergic and anaphylactic reaction exists, leaving children unsafe and the school personnel liable. Thus, the aim of this study is to describe the current practices in the management of severe allergies and anaphylaxis by Lebanese nurses working in schools and day cares and to explore the perceived need for a protocol to manage anaphylaxis reaction. METHODS: A cross-sectional survey with nurses working at schools and day cares in Lebanon was conducted. RESULTS: A total of 59 school and day care nurses participated. Eighteen of the school and day care nurses reported having a written policy describing the management steps. Only 12 had witnessed an anaphylactic event. Of those, 10 reported administering an antihistamine medication orally instead of epinephrine intramuscular. Most respondents (56) believed that a standardised guideline for the management of anaphylaxis was essential, and 9 indicated being hesitant to give the epinephrine intramuscular even in the presence of a policy. Finally, 55 stated the need for training nurses in identifying and managing anaphylaxis as a must. CONCLUSION: Currently, the management of anaphylaxis reaction in schools and day cares is suboptimal. Hence, there is a need for a standardised nursing guideline and training for nurses in these settings.

Perspectives on barriers and facilitators to self-care in Lebanese cardiac patients: A qualitative descriptive study.

BACKGROUND: Cardiovascular disease is the leading cause of mortality worldwide. Cardiac self-care practices are essential for managing cardiac illness and improving quality of life. However, these practices may be affected by factors that may hinder or facilitate self-care especially in countries that experience political and economic instabilities. OBJECTIVES: The purpose of this study was to explore self-care practices among Lebanese cardiac patients. Another aim was to reveal factors that might influence these self-care practices. DESIGN: This is a qualitative descriptive study. SETTING: Participants were recruited from a referral medical center in Beirut, Lebanon and interviews took place in their homes. PARTICIPANTS: Purposive sample of 15 adult participants, seven females and eight males, diagnosed with coronary artery disease at least a year ago and not in critical condition recruited from the cardiology clinics of the medical center. METHODS: Data were collected through semi-structured audio-recorded interviews that took place in their places of residents. RESULTS: Three themes emerged from the data: I. The behaviors of cardiac patients demonstrated selected self-care practices; II. Patients identified barriers to self-care reflective of the Lebanese political and socio-economic situation; and, III. Patients described facilitators to self-care consistent with the Lebanese socio-cultural values and norms. The most common self-care practices included taking medications and eating properly. Participants emphasized avoiding stress and being upset as a self-protective measure for cardiac health. Health care costs, family responsibilities, psychological factors and the country's political situation impeded self-care practices whereas family support facilitated them. CONCLUSION: Lebanese patients reported select self-care practices in dealing with their cardiac illness. Barriers and facilitators to their self-care behaviors reflected the Lebanese context and culture. Thus health care providers must assess their patients' practices within their sociocultural context so that interventions to promote self-care are tailored accordingly.

The Cultural Meaning of Cardiac Illness and Self-Care Among Lebanese Patients With Coronary Artery Disease.

BACKGROUND: Cardiac disease is the leading cause of death in Lebanon, accounting for 22% to 26% of total deaths in the country. A thorough understanding of perceptions of cardiac illness and related self-care management is critical to the development of secondary prevention programs that are specific to the Lebanese culture. PURPOSE: To explore the cultural perceptions of cardiac illness and the associated meaning of self-care among Lebanese patients. DESIGN: Using a qualitative descriptive method, semistructured interviews were conducted with a purposive sample of 15 Lebanese cardiac patients recruited from a medical center in Beirut, Lebanon. FINDINGS: The qualitative descriptive analysis yielded one overarching and two other themes describing perceptions of cardiac illness and self-care within the Lebanese cultural context. The overarching cultural theme was, "Lebanese cardiac patients were unfamiliar with the term concept and meaning of self-care." Lebanese cardiac patients thanked God and accepted their fate (Theme I). The participants considered their cardiac incident a life or death warning (Theme II). IMPLICATIONS FOR PRACTICE: Health care providers need to consider patients' cultural perception of illness while planning and evaluating cardiac self-care programs.

What do nurse managers say about nurses' sickness absenteeism? A new perspective.

AIM: To explore nurses' sickness absenteeism from the perspective of nurse managers. BACKGROUND: Sickness absenteeism among health-care providers, especially nurses, remains a significant problem in an era of challenges to provide high quality care with the required skill mix. This in turn compromises the quality of care and adds to the costs of an organisation. METHODS: A qualitative descriptive design was used. Data were collected from a governmental academic hospital in Lebanon. In-depth tape-recorded interviews were conducted with a total of 20 nurse managers. Data were analysed through a content analysis approach. RESULTS: Data analysis yielded three domains as follows: work-related, individual and organisational factors that lead to nurses' sickness absenteeism. CONCLUSION: This study conceptualised nurses' absenteeism from the nurse managers' perspective, and it revealed absence antecedents that are rarely reported elsewhere in the literature. IMPLICATIONS FOR NURSING MANAGEMENT: The findings from this study can be utilised to design reform initiatives concerned with nurses' absenteeism and to decrease its negative consequences in terms of quality and cost.

Role of the Lebanese family caregivers in cardiac self-care: a collective approach.

AIMS AND OBJECTIVES: The purpose of this study was to explore perceptions of cardiac self-care among Lebanese family caregivers of cardiac patients. The specific aims were to describe the cultural context of cardiac care-giving in Lebanon and to explore the roles of family caregivers in enhancing self-care practices in patients with cardiac diseases. BACKGROUND: The role of family caregivers in Lebanon, a country in the Middle East, is assumed to extend beyond care-giving to making decisions on behalf of the patient and assuming responsibility for patient care. To date, there has been no study done to empirically validate this impression. DESIGN: The design of the study is qualitative descriptive that used semi-structured individual interviews with family caregivers of Lebanese cardiac patients. METHOD: Thirteen family caregivers of cardiac patients were recruited from a referral medical centre in Lebanon. The participants were designated by their patients and interviewed in a place of their choice. RESULTS: One overarching and three themes emerged from data analysis describing roles of family care givers in cardiac self-care. The overarching theme was: Family caregivers of Lebanese cardiac patients were unfamiliar with the term, concept and meaning of Self-Care. The moral and emotional duty to care for the family member stemmed from obligation and responsibility towards patients (theme I). Interdependent care (theme II) between cardiac patients and their families emerged as a significant cultural role. Family members play multiple supportive roles in care-giving namely emotional, informational and instrumental role (theme III). CONCLUSION: In this study, family caregiver role is shown to be based in the sense of obligation and duty towards the sick family member who collectively provide different types of supportive care. RELEVANCE TO CLINICAL PRACTICE: Nurses have to give significant importance to the family caregiver role as an integral part of any culturally sensitive patient/family intervention.

Deciding to Seek Emergency Care for Acute Myocardial Infarction.

The purpose of this qualitative descriptive study was to explore how patients who experience acute myocardial infarction (AMI) decide to seek emergency care. Fifty patients with AMI were interviewed at two hospitals in Lebanon. The perspective of 22 witnesses of the attack was also sought about the cardiac event. The themes that transpired from the data were as follows: making sense of the symptoms, waiting to see what happens, deciding to come to the hospital, and the family influenced the decision to seek care. The witnesses of the cardiac event, mostly family members, supported the decision to seek emergency care. Deciding to seek emergency care for AMI is complex. Nurses must solicit their patients' perception of the cardiac event to provide them with tailored education and counseling about heart attack symptoms and how to respond to them in case they recur. Family members must be included in the education process.

The JOINT model of nurse absenteeism and turnover: a systematic review.

BACKGROUND: Absenteeism and turnover among healthcare workers have a significant impact on overall healthcare system performance. The literature captures variables from different levels of measurement and analysis as being associated with attendance behavior among nurses. Yet, it remains unclear how variables from different contextual levels interact to impact nurses' attendance behaviors. OBJECTIVES: The purpose of this review is to develop an integrative multilevel framework that optimizes our understanding of absenteeism and turnover among nurses in hospital settings. METHODS: We therefore systematically examine English-only studies retrieved from two major databases, PubMed and CINAHL Plus and published between January, 2007 and January, 2013 (inclusive). FINDINGS: Our review led to the identification of 7619 articles out of which 41 matched the inclusion criteria. The analysis yielded a total of 91 antecedent variables and 12 outcome variables for turnover, and 29 antecedent variables and 9 outcome variables for absenteeism. The various manifested variables were analyzed using content analysis and grouped into 11 categories, and further into five main factors: Job, Organization, Individual, National and inTerpersonal (JOINT). Thus, we propose the JOINT multilevel conceptual model for investigating absenteeism and turnover among nurses. CONCLUSIONS: The JOINT model can be adapted by researchers for fitting their hypothesized multilevel relationships. It can also be used by nursing managers as a lens for holistically managing nurses' attendance behaviors.

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

BACKGROUND: Nursing shortages and maldistribution are priority issues for healthcare systems around the globe. Such imbalances are often aggravated in underserved areas, especially in developing countries. Despite the centrality of this issue, there is a dearth of studies that examine the retention of nurses in underserved areas in the Middle East Region. This study investigates the characteristic and the factors associated with the retention of nurses working in rural areas in Lebanon. METHODS: This study uses a non-experimental cross-sectional design to survey nurses working in underserved areas of Lebanon. Underserved areas in Lebanon were identified using WHO definition. A total of 103 health facilities (hospitals and primary healthcare centers) located in these areas were identified and all nurses working at these facilities received a copy of the survey questionnaire. The questionnaire included five sections: demographic, work-life, career plan, job satisfaction, and assessment of work environment. Analysis included univariate and bivariate (chi-square, Student's t-test and ANOVA) tests to describe the respondents and examine the significance between nurses' characteristics and their intent to stay. A logistic regression model was constructed to identify factors associated with nurses' intent to stay in underserved areas. RESULTS: A total of 857 nurses from 63 Primary Healthcare (PHC) centers and hospitals responded to the questionnaire (75.5% response rate). Only 35.1% of nurses indicated their intent to stay in their current job over the coming one to three years. Surveyed nurses were most satisfied with relationship with co-workers and least satisfied with extrinsic rewards. Rural nurses working in PHC centers were more satisfied than their hospital counterparts on all aspects of work and had significantly higher intention to stay (62.5% compared to 31.5% in hospitals, P < 0.001). Regression analysis revealed that nurses less likely to report intent to stay were younger, unmarried, with less years of work experience and were not working towards a higher degree. Analysis reveals a directly proportional relationship between nurses' reported job satisfaction and their intent to stay. CONCLUSION: This study reveals poor retention of nurses in rural and underserved areas in Lebanon, especially in the hospital sector. The status quo is disquieting as it reflects an unstable and dissatisfied nursing workforce. Developing targeted retention strategies for younger nurses and those working in hospitals as well as the offering of professional development opportunities and devising an incentive scheme targeting rural nurses is pivotal to enhance nurses' job satisfaction and retention in rural settings.

Intention to stay of nurses in current posts in difficult-to-staff areas of Yemen, Jordan, Lebanon and Qatar: a cross-sectional study.

BACKGROUND: The nursing workforce shortages in difficult-to-staff areas have implications not only for quality of care but also for population health outcomes. An understanding of attrition and of retention is important to inform policies on the nursing workforce. OBJECTIVES: This paper draws on questionnaire survey data from nurses working in difficult-to-staff areas in four countries in the Eastern Mediterranean Region (Yemen, Jordan, Lebanon and Qatar). It aims to identify the specific and common factors associated with nurses' intention to stay in their current post for the coming 1-3 years in three countries with an internally trained nursing workforce and in a fourth where the workforce is externally recruited. METHODS: Nurses working in 'difficult to staff' areas in Yemen, Jordan, Lebanon and Qatar were surveyed. A conceptual model composed of 6 dimensions based on that of the World Health Organization was constructed with 'intent to stay' (Career Decisions) as the main outcome. Regression models were constructed for each of the dimensions in the conceptual model with 'intent to stay' as the dependent variable for each of the study countries. Subsequently, a collective model that combined Lebanon, Jordan and Yemen was constructed to identify common factors that are associated with intent to stay. RESULTS: Factors associated with intent to stay differed for study countries. Marriage was positively associated with intent to stay in Lebanon and Jordan whereas years of experience were positively significant for Lebanon and Yemen. Shorter commuting time was significantly associated with intent to stay in Jordan whereas a preference for village life was significant for Lebanon. Job satisfaction was significantly associated with intent to stay in all study countries. Nurses in Lebanon, Jordan and Qatar who indicated that they would choose nursing if they had the opportunity to choose a career all over again were significantly more likely to intend to stay in their current post. CONCLUSIONS: Studies of nurses working in these areas can help national policymakers and local nursing directors better manage the sparse nursing workforce in these localities and to provide them with appropriate incentives and support to encourage them to stay.