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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.

Purpose The first stage of this QNRF funded study includes a series of key informants' interviews with stakeholders in the PHC sector in Lebanon and Qatar to formulate an understanding of the recruitment and retention strategies of health human resources (HHR) and understand the obstacles and challenges that they face. This abstract reports on the findings obtained in Lebanon, as data collection remains ongoing in Qatar. Participants & Methods Study utilized a qualitative design involving semi-structured key informant interviews with stakeholders in the PHC sector. An initial list of key stakeholders was acquired from a review of public and private information sources while ensuring maximum variability across institutions, disciplines and geographical locations. Overall, 22 key informants participated in the study. They included decision and policy makers in the PHC sector, managers/directors of PHCCs, human resources coordinators in PHCCs, physicians and nurses, and academicians. Analysis Thematic and content analysis, using Nvivo 8, was conducted on the data collected from the key informant interviews. After coding the responses into similar concepts, axial coding allowed for the emergence of five comprehensive themes: perception of PHC, PHC services, recruitment of HHR in PHC, retention of HHR in PHC, and recruitment and retention in rural areas. Results Responses of stakeholders with regards to the definition of PHC revealed a lack of a unified understanding of the concept. With regards to services offered at PHCCs, there was a consensus that there is a deficiency in various services, most notably was mental health, as well as various preventive functions such as vaccination, women's health, and health behavior modification. Thematic analysis identified a number of impediments to the recruitment of HHR, mainly related to shortage in the overall supply of HHR, of qualified HHR, and HHR gender imbalances. Despite recruitment strategies in place, factors including financial constraints and poor leadership/management hinder the effectiveness of recruitment efforts. Although stakeholders report an acceptable retention of HHR, they relate turnover to poor working environment and lack of professional development. There was consensus that challenges faced are more pronounced in PHCCs of rural areas. Conclusions The study findings reveal that the current status of recruitment and retention within the PHC sector is not conducive to a solid and stable workforce. There is an evident need for the establishment of a unified contextualized definition of PHC to be applied across all PHCCs operating nationally. Moreover, the adoption of a system's thinking approach is crucial for PHC capacity building, in which the existent structure is better supported by qualified personnel. Extensive efforts need to be exerted towards directing health care professionals to the PHC field especially in rural areas, while concurrently enhancing the working conditions within PHCCs. Accordingly, essential services may be more adequately provided to the community. Of particular importance is the integration of mental health services into community care. Decision and policy makers are urged to reflect upon the recommendations developed in order to not only stabilize the PHC workforce but to also ensure the longevity of its services.

After 5 years of brutal civil war, Syria has been paralysed by what has been described as the worst humanitarian crisis since World War 2. From March, 2011, to August, 2015, 47 000 people have been killed and almost 1·8 million wounded as a result of this conflict, most of whom are civilians. This crisis had also left its heavy toll on Syrian’s health infrastructure and human resources with over 60% of hospitals and clinics destroyed and approximately 700 medical staff killed, tortured, or executed. Thousands more have fl ed to neighbouring front-line countries where they struggle to continue practising. On February, 2016, at the Syria donor conference in London, the agenda was devoted to job creation and livelihoods for refugee and host community populations. Little mention was made to health and health services or coherent plans given of how highly skilled groups, such as physicians and medical workers, could be used and helped to fi nd work within host countries. No mention was made as to how these groups can help to design and rebuild Syria after the confl ict. Evidence from previous crises shows that when physicians are forced to migrate they are unlikely to return to their home countries. The exodus of highly skilled workers not only aff ects the ability of aid organisations and governments to deliver emergency humanitarian assistance to people in Syria and the region but this migration poses serious risks for the future reconstruction of the country. Two important questions need to be addressed by donors and aid agencies before this vital workforce is dispersed throughout the world. First, how can Syrian physicians and other human resources displaced to neighbouring countries be better used to address the needs of the refugee populations? Second, what policy changes in neighbouring countries can be implemented now to provide them with formal employment that supports their return to Syria after the confl ict? These questions outline an agenda for research and policy that will be pivotal in helping to assist the humanitarian response and better serve the Syrian population inside and outside the country. Addressing these issues now could help to increase the impact and cost-eff ectiveness of donor funds and most importantly ensure that human resources are not permanently lost, making Syria’s postconfl ict future even worse.

Objective Utilize the concept of stickiness to examine the retention of community nurses across time and draw comparisons by subsector, nurse group and work status. Methods Secondary analysis of College of Nurses of Ontario (CNO) registration database (2004–2010). Nurses’ yearly registration records were linked to create a longitudinal database of nursing employment which was used to generate year-to-year stickiness figures. Analysis was carried out by sector/subsector of employment, nurse group and work status. Results Analysis revealed an active movement of nurses between the hospital and community sectors during the period of analysis, with a positive balance of 3002 nurses toward the latter. A wide variation in the stickiness of community subsectors of employment was noted, with those subsectors involving direct patient care and community visitation displaying relatively lower stickiness figures. Subsector stickiness increased with the offering of full-time jobs and the employment of Registered Nurses. Conclusion Examining the working conditions and human resources management practices in the subsectors with lower stickiness, especially those involving patient care at home, and enhancing career stability of Registered Practical Nurses are priority issues. Decision-makers should support the offering of full-time jobs focusing attention on subsectors offering direct patient care in the community.

Background Critical shortages of health human resources (HHR), associated with high turnover rates, have been a concern in many countries around the globe. Of particular interest is the effect of such a trend on the primary healthcare (PHC) sector; considered a cornerstone in any effective healthcare system. This study is a rare attempt to investigate PHC HHR work characteristics, level of burnout and likelihood to quit as well as the factors significantly associated with staff retention at PHC centers in Lebanon. Methods A cross-sectional design was utilized to survey all health providers at 81 PHC centers dispersed in all districts of Lebanon. The questionnaire consisted of four sections: socio-demographic/ professional background, organizational/institutional characteristics, likelihood to quit and level of professional burnout (using the Maslach-Burnout Inventory). A total of 755 providers completed the questionnaire (60.5% response rate). Bivariate analyses and multinomial logistic regression were used to determine factors associated with likelihood to quit. Results Two out of five respondents indicated likelihood to quit their jobs within the next 1–3 years and an additional 13.4% were not sure about quitting. The top three reasons behind likelihood to quit were poor salary (54.4%), better job opportunities outside the country (35.1%) and lack of professional development (33.7%). A U-shaped relationship was observed between age and likelihood to quit. Regression analysis revealed that high levels of burnout, lower level of education and low tenure were all associated with increased likelihood to quit. Conclusions The study findings reflect an unstable workforce and are not conducive to supporting an expanded role for PHC in the Lebanese healthcare system. While strategies aiming at improving staff retention would be important to develop and implement for all PHC HHR; targeted retention initiatives should focus on the young-new recruits and allied health professionals. Particular attention should be dedicated to enhancing providers’ role satisfaction and sense of job security. Such initiatives are of pivotal importance to stabilize the workforce and ensure its longevity.

Economic downturns and recession lead to budget cuts and service reductions in the healthcare sector which often precipitate layoffs and hiring freezes. Nurses, being the largest professional group in healthcare, are strongly affected by cost reductions. Economic downturns destabilize the nursing labour market with potential negative outcomes, including serious shortages, extending beyond the recessionary period. The objectives of this manuscript are to provide an overview of the potential short- and long-run impact of economic downturns on the supply and demand of nurses, and present healthcare decision makers with a framework to enhance their ability to strategically manage their human resources through economic cycles. A narrative review of the literature on the effects of economic downturns on the nursing labour market in developed countries was carried out with a special focus on studies offering a longitudinal examination of labour force trends. Analysis indicates that economic downturns limit the ability of public payers and institutions to finance their existing health workforce. As salaried healthcare workers, nurses are especially susceptible to institutional budget cuts. In the short run, economic downturns may temporarily reduce the demand for and increase the supply of nurses, thereby influencing nursing wages and turnover rates. These effects may destabilise the nursing labour market in the long run. After economic downturns, the market would quickly display the pre-recessionary trends and there may be serious demand–supply imbalances resulting in severe shortages. Potential long-term effects of recession on the nursing labour market may include a downsized active workforce, difficulty in retaining younger nurses, a decreased supply of nurses and workforce casualisation. Lack of understanding of labour market dynamics and trends might mislead policy makers into making misinformed workforce downsizing decisions that are often difficult and expensive to reverse. In the aftermath of an economic downturn, the costs of attracting nurses back often outweigh the short term cost savings. Effective management should support the nursing workforce by creating attractive and stable work environments to retain nurses at a manageable cost.

Background Complementary and alternative medicine (CAM) is widely used for the treatment of infertility. While the Middle East and North Africa region has been shown to house one of the fastest growing markets of CAM products in the world, research describing the use of CAM therapies among Middle-Eastern infertile patients is minimal. The aim of this study is to examine the prevalence, characteristics and determinants of CAM use among infertile patients in Lebanon. Methods A cross sectional survey design was used to carry out face-to-face interviews with 213 consecutive patients attending the Assisted Reproductive Unit at a major academic medical center in Beirut. The questionnaire comprised three sections: socio-demographic and lifestyle characteristics, infertility-related aspects and information on CAM use. The main outcome measure was the use of CAM modalities for infertility treatment. Determinants of CAM use were assessed through the logistic regression method. Results Overall, 41% of interviewed patients reported using a CAM modality at least once for their infertility. There was a differential by gender in the most commonly used CAM therapies; where males mostly used functional foods (e.g. honey & nuts) (82.9%) while females mostly relied on spiritual healing/prayer (56.5%). Factors associated with CAM use were higher household income (OR: 0.305, 95% CI: 0.132–0.703) and sex, with females using less CAM than males (OR: 0.12, 95% CI: 0.051–0.278). The older patients were diagnosed with infertility, the lower the odds of CAM use (p for trend Conclusions The considerably high use of CAM modalities among Lebanese infertile patients, added to a poor CAM use disclosure to physicians, underscore the need to integrate CAM into the education and training of health professionals, as well as enhance infertile patients' awareness on safe use of CAM products.

Background The regulation of the markets for Complementary and Alternative Medicine (CAM) products presents a global challenge. There is a dearth of studies that have examined or evaluated the regulatory policies of CAM products in the Eastern Mediterranean Region (EMR). We investigate the regulatory frameworks and the barriers for the proper regulation and integration of CAM products in Lebanon, as an example of an EMR country with a weak public infrastructure. Methods We utilized a qualitative study design involving a series of semi-structured interviews with stakeholders of the CAM market in Lebanon. Snowball sampling was used to identify interviewees; interviews continued until the "saturation" point was reached. A total of 16 interviews were carried out with decision makers, representatives of professional associations, academic researchers, CAM product importers, policy makers and a media representative. Interviews were transcribed and thematic analysis of scripts was carried out. Results There was a consensus among all stakeholders that the regulation of the market for CAM products in Lebanon needs to be strengthened. Thematic analysis identified a number of impediments jeopardizing the safety of public consumption and hindering the integration of CAM therapies into mainstream medicine; including: weak infrastructure, poor regulation, ineffective policies and politics, weak CAM awareness and sub-optimal coordination and cooperation among stakeholders. With respect to policy instruments, voluntary instruments (self regulation) were deemed ineffective by stakeholders due to poor awareness of both users and providers on safe use of CAM products. Stakeholders' rather recommended the adoption of a combination of mixed (enhancing public awareness and integration of CAM into medical and nursing curricula) and compulsory (stricter governmental regulation) policy instruments for the regulation of the market for CAM products. Conclusions The current status quo with respect to the regulation of CAM products in Lebanon is not conducive to public safety, nor does it support the integration of CAM products into the healthcare system. The Ministry of Health indeed plays a dominant role in the regulation of these products through a combination of mixed and compulsory policy instruments. Yet, the proper implementation of these regulations requires political resolve coupled with the cooperation of all CAM stakeholders.

Background The existence of publicly-accessible datasets comprised a significant opportunity for health services research to evolve into a science that supports health policy making and evaluation, proper inter- and intra-organizational decisions and optimal clinical interventions. This paper investigated the role of publicly-accessible datasets in the enhancement of health care systems in the developed world and highlighted the importance of their wide existence and use in the Middle East and North Africa (MENA) region. Discussion A search was conducted to explore the availability of publicly-accessible datasets in the MENA region. Although datasets were found in most countries in the region, those were limited in terms of their relevance, quality and public-accessibility. With rare exceptions, publicly-accessible datasets - as present in the developed world - were absent. Based on this, we proposed a gradual approach and a set of recommendations to promote the development and use of publicly-accessible datasets in the region. These recommendations target potential actions by governments, researchers, policy makers and international organizations. Summary We argue that the limited number of publicly-accessible datasets in the MENA region represents a lost opportunity for the evidence-based advancement of health systems in the region. The availability and use of publicly-accessible datasets would encourage policy makers in this region to base their decisions on solid representative data and not on estimates or small-scale studies; researchers would be able to exercise their expertise in a meaningful manner to both, policy makers and the public. The population of the MENA countries would exercise the right to benefit from locally- or regionally-based studies, versus imported and in 'best cases' customized ones. Furthermore, on a macro scale, the availability of regionally comparable publicly-accessible datasets would allow for the exploration of regional variations and benchmarking studies.

Title. Career trajectories of nurses leaving the hospital sector in Ontario, Canada (1993–2004). Aim. This paper is a report of an analysis of the career trajectories of nurses 1 year after leaving hospitals. Background. Although hospitals are traditionally the largest employers of nurses, technological advances and budgetary constraints have resulted in many countries in relative shrinkage of the hospital sector and a shift of care (and jobs) into home/community settings. It has been often assumed that nurses displaced from hospitals will move to work in the other workplaces, especially the community sector. Method. Employment patterns were tracked by examining a longitudinal database of all 201,463 nurses registered with the College of Nurses Ontario (Canada) between 1993 and 2004. Focusing on the employment categories Active (Working in nursing), Eligible-Seeking nursing employment or Dropout from the nursing labour market, year-to-year transition matrixes were generated by sector and sub-sector of employment, nurse type, age group and work status. Findings. For every nurse practising nursing in any non-hospital job or in the community a year after leaving hospitals, an average of 1·3 and four nurses, respectively, dropped out of Ontario’s labour market. The proportion of nurses leaving hospitals transitioning to the Dropout category ranged from 63·3% (1994–95) to 38·6% (2001–02). The proportion dropping out of Ontario’s market was higher for Registered Practical Nurses (compared to Registered Nurses), increased with age and decreased with degree of casualization in nurses’ jobs. Conclusion. Downsizing hospitals without attention to the potentially negative impact on the nursing workforce can lead to retention difficulties and adversely affects the overall supply of nurses.

Background Patients with Type 2 Diabetes Mellitus (T2DM) are increasingly using complementary and alternative medicine (CAM) therapies due to difficulty in adhering to the therapeutic regimens and lifestyle changes necessary for disease management. Little is known about the prevalence and mode of CAM use among patients with T2DM in Lebanon. Objective To assess the prevalence and modes of CAM use among patients with T2DM residing in Beirut, Lebanon. Methods A cross-sectional survey of T2DM patients was conducted on patients recruited from two major referral centers in Beirut- a public hospital and a private academic medical center. In a face-to-face interview, participants completed a questionnaire comprised of three sections: socio-demographic, diabetes characteristics and types and modes of CAM use. Descriptive statistics, univariate and multivariate logistic regression analyses were utilized to assess the prevalence and correlates of CAM use, as well as whether the use was complementary or alternative to mainstream medicine. The main outcome in this study, CAM use, was defined as using CAM at least once since diagnosis with T2DM. Results A total of 333 T2DM patients completed the survey (response rate: 94.6%). Prevalence of CAM use since diagnosis with the disease was 38%. After adjustment, CAM use was significantly associated with a “married” status, a longer duration of T2DM, the presence of disease complications, and a positive family history of the disease. Folk foods and herbs were the most commonly used CAM followed by natural health products. One in five patients used CAM as alternative to conventional treatment. Only 7% of CAM users disclosed the CAM use to their treating physician. Health care practitioners were the least cited (7%) as influencing the choice of CAM among users. Conclusion The use of CAM therapies among T2DM patients in Lebanon is prevalent. Decision makers and care providers must fully understand the potential risks and benefits of CAM therapies to appropriately advise their patients. Attention must be dedicated to educating T2DM patients on the importance of disclosing CAM use to their physicians especially patients with a family history of diabetes, and those who have had the disease for a long time.

Healthcare settings are notorious for exposing their employees to high levels of verbal and physical violence. A recent study on occupational violence at Lebanese Emergency Departments (EDs) revealed that 70% of surveyed ED workers were exposed to at least one incidence of violence over the last twelve months. Acting on the findings of this study a multi-stakeholder policy forum was held with key ED stakeholders to discuss possible policy and practice changes to reduce health workers’ exposure to occupational violence. Stakeholder deliberations revealed that the root causes of violence in EDs could be classified under three main categories relating to the administration of EDs including the presence of antiviolence policies, the management of human resources, and balancing patient expectations. Stakeholders built a consensus on a number of remedial actions at the societal, health care facility and policy levels. Engaging with various stakeholders in an open forum was a unique initiative that contributed to building a consensus among key stakeholders on a road map to help protect health workers in EDs and beyond.

Background Successful endorsement of quality indicators hinges on the readiness and acceptability of care providers for those measures. This paper aims to assess the readiness of care providers in the primary health-care sector in Lebanon for the implementation of quality and patient safety indicators. Methods A cross-sectional survey methodology was utilized to gather information from 943 clinical care providers working at 123 primary health-care centres in Lebanon. The questionnaire included two sections: the first assessed four readiness dimensions (appropriateness, management support, efficacy, and personal valence) of clinical providers to use quality and safety indicators using the Readiness for Organization Change (ROC) scale, and the second section assessed the safety attitude at the primary care centre utilizing the Agency of Health Research and Quality (AHRQ) Safety Attitude Questionnaire (SAQ)-Ambulatory version. Results Although two thirds (66 %) of respondents indicated readiness for implementation of quality and patient safety indicators in their centres, there appear to be differences by professional group. Physicians displayed the lowest scores on all readiness dimensions except for personal valence which was the lowest among nurses (60 %). In contrast, allied health professionals displayed the highest scores across all readiness dimensions. Generally, respondents reflected a positive safety attitude climate in the centres. Yet, there remain a few areas of concern related to punitive culture (only 12.8 % agree that staff should not be punished for reported errors/incidents), continuity of care (41.1 % believe in the negative consequences of lack in continuity of care process), and resources (48.1 % believe that the medical equipment they have are adequate). Providers with the highest SAQ score had 2.7, 1.7, 7 and 2.4 times the odds to report a higher readiness on the appropriateness, efficacy, management and personal valence ROC subscales, respectively (P value

Background Breast cancer patients are increasingly seeking Complementary and Alternative Medicine (CAM) therapies with the hope of alleviating the burden of the disease and improving their quality of life (QOL). The objective of this study was to assess the prevalence, types, socio-demographic and disease-related correlates as well as characteristics of CAM use (including disclosure to treating physicians) among breast cancer patients in Beirut, Lebanon. A secondary objective was to evaluate the association between CAM use and QOL. Methods A cross-sectional survey was conducted on breast cancer patients recruited from two major referral centers in Beirut: a philanthropic hospital and a private academic medical center. In face-to-face interviews, participants completed a questionnaire of three sections: socio-demographic and lifestyle characteristics, breast cancer condition, and CAM use. Three to four weeks following these interviews, the secondary QOL assessment was carried out via telephone using the Arabic version of the Functional Assessment of Cancer Therapy-Breast questionnaire. The main outcome in this study, CAM use, was defined as using CAM at least once after breast cancer diagnosis. Results A total of 180 breast cancer patients completed the survey (response rate: 94.6 %). Prevalence of CAM use was 40 %. Using multivariate logistic regression, CAM use was negatively associated with age (OR: 0.96, CI: 0.92-0.99), treatment at the philanthropic hospital (OR: 0.13, CI: 0.05-0.35) and was positively associated with an advanced stage of the disease (OR: 4.20, CI: 1.65-10.69). Among study participants recruited from both sites, the most commonly used CAM was ‘special food’ followed by ‘herbal teas’, ‘diet supplements’ and ‘Spiritual healing’. Only 4 % of CAM users cited health professionals as influencing their choice of CAM and only one in four patients disclosed CAM use to their treating physician. There was no significant association between CAM use and QOL. Conclusions The findings of this study revealed a prevalent CAM use among Lebanese breast cancer patients. Furthermore, physicians’ role in orienting CAM use was found to be marginal as patients relied mainly on family and media for their choice of CAM and were less likely to disclose CAM use to their treating physicians. Electronic supplementary material The online version of this article (doi:10.1186/s12906-015-0969-9) contains supplementary material, which is available to authorized users.

Background: Peer evaluation is increasingly used as a method to assess physicians’ interpersonal and communication skills. We report on experience with soliciting registered nurses’ feedback on physicians’ non-clinical performance in the ED of a large academic medical center in Lebanon. Methods: We utilized a secondary analysis of a de-identified database of ED nurses’ assessment of physicians’ non-clinical performance coupled with an evaluation of interventions carried out as a result of this evaluation. The database was compiled as part of quality/performance improvement initiatives using a cross-sectional design to survey registered nurses working at the ED. The survey instrument included open ended and closed ended questions assessing physicians’ communication, professionalism and leadership skills. Three episodes of evaluation were carried out over an 18 month period. Physicians were provided with a communication training carried out after the first cycle of evaluation and a detailed feedback on their assessment by nurses after each evaluation cycle. A paired t-test was carried out to compare mean evaluation scores between the three cycles of evaluation. Thematic analysis of nurses’ qualitative comments was carried out. Results: A statistically significant increase in the averages of skills was observed between the first and second evaluations, followed by a significant decrease in the averages of the three skills between the second and third evaluations. Personalized feedback to ED physicians and communication training initially contributed to a significant positive impact on improving ED physicians’ non-clinical skills as perceived by the ED nurses. Yet, gains achieved were lost upon reaching the third cycle of evaluation. However, the thematic analysis of the nurses’ qualitative responses portrays a decrease in concerns across the various dimensions of non-clinical performance. Conclusions: Nurses’ evaluation of the non-clinical performance of physicians has the potential of improving communication, professionalism and leadership skills amongst physicians. For improvement to be realized in a sustainable manner, such programs may need to be offered in a staged and incremental manner over a long period of time with proper dedication of resources and timely monitoring and evaluation of outcomes. Department directors need to be trained on providing peer evaluation feedback in a constructive manner.

Background: Emergency departments (EDs) workers are at higher risk of exposure to occupational violence. The prevalence of occupational violence is potentially higher and consequences are more serious in areas with poor security conditions. Objectives: We investigated the prevalence, characteristics and factors associated with the exposure of ED workers to violence at Lebanese hospitals. Methods: All ED employees at six tertiary hospitals in Lebanon were surveyed using a cross-sectional design. The survey instrument included four sections collecting demographic/professional information and measuring exposure to violence, degree of job satisfaction and degree of professional burnout. The questionnaire was distributed to all ED employees at participating hospitals and was completed by 256 ED workers (70.3% response rate). Multinomial and binary logistic regressions were used to investigate factors significantly associated with verbal and physical violence. Results: Over the past 12 months, four in five ED employees were verbally abused and one in four was physically assaulted. Exposure to verbal abuse was associated with serious outcomes including significantly higher levels of occupational burnout and an increased likelihood to quit current job. Exposure to physical violence was associated with increased likelihood-to-quit, nurse status and "public hospital" employment. Conclusion: Violence largely prevails at Lebanese EDs. Most vulnerable are nurses and employees of public hospitals who are disproportionally exposed to violence. ED stakeholders must work collaboratively to investigate the root causes of violence and devise and implement effective antiviolence policies and measures. Such measures will be necessary to protect the well-being and decrease the turnover of ED workers. Language: en