Abstract
BACKGROUND:
Nursing turnover is a significant concern in healthcare systems. This study aimed to explore the influencing factors of nurses’ turnover in Saudi Arabia.
MATERIALS AND METHODS:
This cross-sectional study was conducted between August 2023 and December 2023 at various hospitals in Saudi Arabia. A total of 397 nurses were enrolled using the convenience sampling method. Data on turnover intentions were collected through a structured questionnaire designed to capture various factors influencing nurses’ decisions to leave their current positions. The questionnaire included items on demographics, work environment, job satisfaction, and potential reasons for turnover. Statistical analyses in SPSS included descriptive statistics, Chi-square tests, and multiple logistic regression to identify and predict factors influencing serious turnover intentions.
RESULTS:
A significant proportion expressed their intention to leave their current hospital with 38.6% contemplated leaving. Notably, 53.7% intended to turnover, with 18.4% seriously considering it. Non-Saudi nurses were more inclined to cite excessive workload and poor management. Predictors of serious turnover intentions included non-Saudi nationality, lower salary, shorter experience as a registered nurse, and working in critical care. Dissatisfaction with salary, organizational communication, and lack of recognition also contributed.
CONCLUSION:
The study emphasizes the need for targeted interventions to address factors driving nurse turnover in Saudi Arabia. Health policymakers and managers should improve salary structures and managerial support to reduce turnover intentions. Implementing these measures will not only improve job satisfaction among nurses but also ensure a more stable and effective healthcare workforce, ultimately leading to better patient care and outcomes.
Keywords: Employee retention, job satisfaction, nurses, organizational culture, personnel turnover, Saudi Arabia
Introduction
Nursing has emerged as a vital profession in Saudi Arabia, driven by the increasing demand for healthcare services fueled by a growing population, rising prevalence of chronic illnesses, and an aging demographic. This surge in demand has exacerbated the shortage of healthcare workers, particularly nurses, posing significant challenges for hospitals across the country in retaining qualified nursing staff. Numerous factors contribute to high turnover intentions and low retention rates among nurses in Saudi Arabia, ranging from societal pressures to cultural perceptions of the nursing profession. Additionally, challenges such as limited benefits, inadequate training opportunities, and unsatisfactory supervisory experiences further compound the issue.[1,2] The leadership style of nursing managers plays a crucial role in shaping the work environment and directly impacts nurses’ job satisfaction and retention. Studies have shown that leadership development programs based on concept mapping can significantly enhance the components of nurses’ leadership styles, leading to improved job satisfaction and reduced turnover intentions. Effective leadership practices that emphasize supportive and transformational leadership styles can create a positive work environment, fostering a sense of value and belonging among nursing staff. This, in turn, can mitigate some of the challenges associated with turnover intentions by addressing the core issues related to job dissatisfaction and professional development.[3,4]
Despite efforts to address the nursing shortage, Saudi hospitals continue to rely heavily on expatriate nurses to fill staffing gaps. While expatriate nurses are common in healthcare systems worldwide, the situation in Saudi Arabia is unique due to the higher turnover rates observed among Saudi nurses compared to their expatriate counterparts. Research indicates a turnover rate of 41% among Saudi nurses, significantly higher than the approximately 14% turnover rate reported in the United States.[1,5,6,7] This disparity underscores the urgency of understanding and addressing the factors driving turnover intentions among Saudi nurses, especially in a context where the demand for nursing professionals is rapidly increasing.[1,2,5] The role of nursing managers and their leadership styles is particularly significant in this context. The selected leadership style of nursing managers, as perceived by nurses, especially during critical periods such as the COVID-19 pandemic, has been shown to impact nurses’ turnover intentions. Leadership approaches that are perceived as supportive, transparent, and empowering can enhance nurses’ job satisfaction and commitment to their organizations, thereby reducing turnover rates and improving overall healthcare delivery.[3,4,8,9]
The consequences of high turnover and low retention rates among nurses in Saudi hospitals extend beyond staffing challenges, with profound implications for patient care quality and organizational efficiency.[1,2,5] Inadequate attention to patient needs, compromised treatment effectiveness, and increased likelihood of errors are among the adverse outcomes associated with high turnover rates. Moreover, the financial costs of nurse turnover are substantial, encompassing recruitment expenses, reduced productivity, and the emotional toll on remaining staff.[10,11,12,13] Despite existing research shedding light on factors influencing nurse retention in Saudi Arabia, there remains a need for a deeper understanding of the underlying drivers of turnover intentions and the effectiveness of retention efforts.[1,2,5]
Various factors can influence reasons for leaving the job among nurses. These factors include having responsibility for patient care, management and leadership in nursing, work pressure, job fatigue, care burden, fear of being infected with an infectious disease, fear of transmitting the disease to one’s family, and lack of work motivation.[8,14,15] Job stress, particularly in high-stake environments such as COVID-19 wards, has been shown to significantly affect nurses’ mental and physical health, leading to increased turnover intentions.[16] Occupational fatigue and the inability to recover adequately from work-related exhaustion further exacerbate the desire to leave the profession, highlighting the need for effective strategies to manage work-related stress and fatigue. Moreover, work–family conflict is a critical factor that impacts nurses’ quality of life and job satisfaction, ultimately influencing their decision to remain in their positions.[9,16]
The exploration of turnover intentions among Saudi nurses is particularly timely and relevant, given the ongoing transformations in the Saudi healthcare landscape. With initiatives such as Vision 2030 aiming to enhance the quality and accessibility of healthcare services, understanding the factors driving nurse turnover is essential for ensuring the sustainability and effectiveness of healthcare delivery in the Kingdom of Saudi Arabia.[17,18,19,20] By shedding light on the reasons behind nurses’ intentions to leave their jobs, this study provides stakeholders with valuable insights that can inform targeted interventions aimed at improving nurse retention rates and promoting a stable and skilled nursing workforce.[10,21,22]
To achieve its objectives, this study employs a comprehensive approach that examines both individual and organizational factors contributing to nurse turnover intentions. By exploring a wide range of potential reasons for turnover, including work environment factors, organizational dynamics, and social influences, this research seeks to capture the multifaceted nature of turnover intentions among Saudi nurses. Additionally, the study investigates the predictors of turnover intentions, allowing for a deeper understanding of the factors that significantly influence nurses’ decisions to leave their current positions.
Research Purpose and Objectives
The main purpose of this study was to investigate the factors influencing turnover intentions among nurses working in Saudi hospitals. The specific objectives were to 1) assess the proportion of nurses who intended to leave their current job, 2) analyze the relationship between potential reasons for these turnover intentions and the nurses’ nationality, 3) conduct a multiple logistic regression analysis to predict serious turnover intentions among the nurses, and 4) identify the key predictors of serious turnover intentions through this regression analysis.
By identifying the proportion of nurses contemplating leaving their jobs, analyzing the reasons behind these intentions, and predicting serious turnover intentions through rigorous statistical methods, this research aims to provide actionable insights that can help healthcare policymakers and nursing managers develop strategies to enhance nurse retention, improve the work environment, and ultimately ensure the stability and efficiency of the healthcare workforce in Saudi Arabia. Furthermore, understanding the factors influencing nurse turnover is crucial for the sustainability of healthcare systems, especially in regions facing significant staffing challenges such as Saudi Arabia. High turnover rates among nurses not only disrupt patient care but also lead to increased recruitment costs, reduced productivity, and additional burdens on remaining staff. Despite existing research on nurse retention, there is a paucity of studies that comprehensively address the unique sociocultural and economic context of Saudi Arabia. This study is innovative in its approach by considering both Saudi and non-Saudi nurses, thereby providing a nuanced understanding of turnover intentions within a diverse workforce. Additionally, the use of multiple logistic regression analysis to predict serious turnover intentions adds a robust analytical dimension to the research, allowing for the identification of key predictors that can inform targeted interventions.
Materials and Methods
Study design and setting
This study employed a descriptive, cross-sectional design to examine turnover intention among nurses in Saudi Arabian hospitals. The purpose of this design was to gather data from a varied sample across multiple healthcare environments, capturing a snapshot of nurses’ intentions and related factors at one point in time. The objectives were to determine the prevalence of turnover intention, investigate the reasons behind nurses’ intentions to leave their jobs, and identify factors that might influence future turnover. Additionally, the study aimed to predict turnover intention by analyzing demographic and employment-related variables.
The study was conducted in seven hospitals located in Madina city, a major urban center in the northwestern region of Saudi Arabia. These hospitals were chosen to represent both governmental and private healthcare sectors, covering a wide range of medical and surgical specialties. This selection was designed to reduce setting selection bias and provide a comprehensive understanding of turnover intention among nurses within the region’s healthcare landscape. All selected hospitals offered a full spectrum of medical services, ensuring the inclusion of nurses from various clinical settings and departments. By situating the research within the Saudi Arabian healthcare context, the findings could inform tailored interventions to address retention challenges and ultimately enhance nurse retention and workforce stability within Saudi hospitals.
Study participants and sampling
A convenience sampling method was employed to recruit participants, specifically targeting registered nurses actively working within the selected hospitals. Inclusion criteria were established to ensure the sample’s eligibility and relevance. Participants needed to hold at least a bachelor’s degree in nursing science or higher and could be of either Saudi or non-Saudi nationality. Additionally, only full-time nurses proficient in English, both verbal and written, were included. Nurses with less than 6 months of job experience at the selected hospitals were excluded to ensure participants were adequately familiar with their workplace environment and policies. This criterion aimed to capture the perspectives of nurses well acquainted with their job dynamics, thereby enhancing the study’s validity and reliability.
Power analysis determined the sample size, indicating that at least 374 subjects were needed to achieve a moderate effect size with a power of 0.80, at a significance level of 0.05. A total of 425 questionnaires were distributed among eligible nurses, with strict measures to ensure anonymity and confidentiality during data collection. Upon retrieval, 18 questionnaires were empty, and 10 were incomplete, leaving a final sample of 397 completed questionnaires for analysis.
Ethical considerations
This study prioritized the ethical principles of voluntary participation, confidentiality, and informed consent. Formal approvals were diligently obtained from various ethical bodies, including the Institutional Review Board (IRB) at Al-Ghad international colleges, the ethical committee for health researches of the Ministry of Health in Madina city, and the medical and nursing directors of the selected hospitals. These approvals served as a testament to the commitment to upholding ethical standards and protecting the rights and welfare of the participants.
The ethical framework of this study was firmly rooted in the principle of voluntary participation. Following the guidelines of the Declaration of Helsinki,[23] eligible nurses were approached individually and provided with comprehensive information regarding the study’s purpose, objectives, and procedures. It was emphasized that participation was entirely voluntary, and participants had the autonomy to decline or withdraw from the study at any time without any repercussions.
Informed consent was a critical component, obtained from all participating nurses prior to data collection. Each nurse received a written consent form detailing key aspects of the study, including its purpose, potential risks and benefits, confidentiality measures, and their rights as participants. The consent form explicitly stated that participation was voluntary and that refusal to participate would not result in any negative consequences.
Participants were assured that their personal information would be kept strictly confidential, with access restricted to authorized researchers only. This emphasis on voluntary participation and informed consent reflected the ethical commitment to respecting the autonomy and dignity of the participating nurses, while ensuring the integrity and validity of the research process.
Data collection tool and technique
In this study, a structured questionnaire was employed to address the specific objectives of the research. The questionnaire comprised three distinct parts, each designed to gather essential information relevant to the study’s focus. The first part focused on demographics and employment data, encompassing questions related to participants’ gender, age, nationality, level of education, job position, and years of experience as registered nurses. This section provided valuable insights into the characteristics and background of the study participants.
The second part of the questionnaire incorporated the English version of Employee Retention Questionnaire, adapted from a previous study conducted by Mobley et al. (1978)[24] This questionnaire aimed to assess participants’ intention to leave their current job, thereby capturing their turnover intention. Consisting of four items, participants responded to statements using a 5-point Likert scale ranging from “strongly agree” to “strongly disagree.” The total score for this questionnaire ranged from 4 to 20, with lower scores indicating higher turnover intention and lower job retention.[24] The Employee Retention Questionnaire was chosen for its established validity, reliability, and ease of completion, making it a suitable tool for assessing turnover intention among healthcare professionals.[24]
Moreover, the questionnaire’s third section comprised 20 inquiries aimed at understanding the potential reasons behind participants’ intentions to leave their current positions. Drawing upon the model of anticipated turnover proposed by Lucas et al. (1993)[25] and Alexander et al. (1998)[26] as well as insights from previous studies, the researchers compiled a list of 20 potential reasons for turnover intention among the participants of this study. These potential reasons were carefully categorized into three distinct categories based on existing literature: work environment reasons, organizational factors, and social influences.[1,12,27,28] Participants were presented with the following prompt: “If you contemplate leaving your current job, which of the following reasons (20 items) do you anticipate as factors for your decision?” They were then asked to indicate one or more reasons from the provided list of 20 potential factors influencing turnover intention, offering valuable insights into the multifaceted nature of turnover intention within their current hospital settings.[1,12,27,28]
Overall, the structured questionnaire employed in this study facilitated a comprehensive exploration of turnover intention among Saudi nurses. By incorporating established measures and drawing on previous research, the questionnaire provided a robust framework for investigating the complex interplay of factors influencing nurses’ intentions to leave their current jobs.
The data collection process commenced with researchers acquiring a comprehensive list of eligible nurses from the records maintained by the nursing department heads in the selected hospitals. This approach ensured that all potential participants were accurately identified and included in the study. Following this, eligible nurses were approached individually, and researchers provided an in-depth explanation of the study’s purpose, objectives, and procedures. This step was essential to ensure that participants fully understood the nature of the research and the implications of their participation.
After receiving a detailed overview of the study, eligible nurses were invited to participate on a voluntary basis. They were assured that participation was entirely optional and that they had the right to decline or withdraw from the study at any time without facing any repercussions. For those who agreed to participate, a written consent form was provided, outlining key aspects of the study and their rights as participants. Participants were encouraged to read the consent form thoroughly before signing, thereby indicating their informed consent to take part in the research.
To protect the confidentiality and anonymity of participants, strict measures were implemented. Participants were assured that their personal information would remain confidential and accessible only to the research team. Electronic data collected through online surveys were securely stored in password-protected databases, while hard copies of completed questionnaires were kept in locked cabinets to prevent unauthorized access. Additionally, closed mailboxes were strategically placed in various departments within the selected hospitals to facilitate the confidential and convenient return of completed questionnaires.
Pilot study
The research utilized the English version of the adopted questionnaires as the sample consisted of English-speaking individuals, and adherence to this language criterion was mandatory. This decision was supported by the fact that even Arabic-speaking nurses typically study nursing science in English at Arab universities. To validate the adapted questionnaire, a comprehensive review was conducted by three experts in nursing management and administration, specifically focusing on turnover research, along with one English lecturer. Their collective assessment ensured the questionnaire’s clarity and validity, with minor modifications recommended to better align with the cultural context of Saudi Arabia.
Prior to data collection, a pilot study involving 26 nurses was conducted to evaluate the reliability and clarity of both the employee retention questionnaire and the 20 items related to potential reasons for turnover intention. The internal reliability, as measured by Cronbach’s alpha, was found to be 0.88 for the employee retention questionnaire and 0.93 for the 20 items concerning reasons of turnover intention. Additionally, the test–retest reliability for the employee retention questionnaire was 0.91, while it was 0.92 for the 20 items related to reasons of turnover intention, indicating high reliability.
Feedback from participants in the pilot study confirmed that the questionnaires were clear, concise, and easy to understand and complete. It is worth noting that data collected during the pilot study were excluded from the subsequent statistical analysis of the main study to maintain the integrity and independence of the data analysis process.
Data analysis
For data analysis and management, the Statistical Package for the Social Sciences (SPSS) software program, version 22, was employed. This robust statistical tool facilitated the processing and examination of the collected data. Initial analyses involved computing frequencies and conducting descriptive analyses, which included calculating means and standard deviations. These analyses were instrumental in exploring the demographics and work-related characteristics of the participants as well as examining potential reasons for turnover intention.
To delve deeper into the factors influencing turnover intention, Chi-square analyses were performed. Specifically, these analyses aimed to elucidate any relationships between the potential reasons cited by participants for their intention to leave their current job and their nationality. Additionally, Chi-square analyses were conducted to explore the relationship between anticipating factors for turnover and the seriousness of participants’ intention to leave their current job.
Furthermore, two separate multiple logistic regression analyses were conducted to identify predictors of turnover intention among participants. These analyses incorporated the seriousness of turnover intention as the outcome variable and two subsets of independent variables. The subsets included significant variables identified in the previous Chi-square analyses: significant individual anticipating factors and other significant anticipating factors (potential reasons) for turnover intentions.
A preset significance level of 0.05 was used for both Chi-square and logistic regression analyses, ensuring robust statistical interpretation and inference. These analytical approaches collectively provided comprehensive insights into the factors influencing turnover intention among the study participants, enabling informed decision-making and targeted interventions to address workforce retention challenges within the healthcare setting.
Results
Demographics and employment data
The demographic and work-related details of the study’s 397 participants are presented in Table 1. The age distribution reveals a majority under 30 years old (60.5%), followed by those aged 30–39 (27.2%) and 40–60 years (12.3%). Education-wise, almost all participants held Bachelor’s degrees (97.0%), while a small fraction possessed higher degrees (3.0%). Gender distribution indicated a higher representation of females (77.6%) compared to males (22.4%). The marital status leaned toward married individuals (56.2%), with single participants following closely (42.3%) and a minor percentage being either divorced or widowed (1.5%). Notably, 31.7% of participants reported living with their spouses or family members in Saudi Arabia. Regarding nationality, the majority hailed from the Philippines (44.3%), followed by Indian (29.7%), Saudi (21.2%), and other nationalities (4.3%). In terms of race, the participants were predominantly Asian (47.4%), followed by Arab (25.4%) and Indian (27.2%).
Table 1.
Demographics and work-related data (n=397)
| Variables | n (%) | |
|---|---|---|
| Age | ||
| <30 years | 240 (60.5%) | |
| 30-39 years | 108 (27.2%) | |
| 40-60 years | 49 (12.3%) | |
| Level of education | ||
| Bachelor degree | 385 (97.0%) | |
| Master degree and doctoral degree | 12 (3.0%) | |
| Gender | ||
| Male | 89 (22.4%) | |
| Female | 308 (77.6%) | |
| Marital status | ||
| Single | 168 (42.3%) | |
| Married | 223 (56.2%) | |
| Divorced or widowed | 6 (1.5%) | |
| Spouse or family members are living with subject in Saudi Arabia | 126 (31.7%) | |
| Nationality | ||
| Saudi | 84 (21.2%) | |
| Indian | 118 (29.7%) | |
| Philippine | 176 (44.3%) | |
| Others* | 17 (4.3%) | |
| Race | ||
| Arab | 101 (25.4%) | |
| Asian | 188 (47.4%) | |
| Indian | 108 (27.2%) | |
| Salary per month | ||
| <5,000 SR** | 95 (23.9%) | |
| 5,000–9,999 SR | 179 (45.1%) | |
| 10,000–14,999 SR | 66 (16.6%) | |
| 15,000–20,000 SR | 39 (9.8%) | |
| >20,000 SR | 18 (4.5%) | |
| Job Position | ||
| Staff nurse (registered nurse [RN]) | 345 (86.9%) | |
| Charge nurse | 28 (7.1%) | |
| Nurse manager | 24 (6.0%) | |
| Type of hospital | ||
| Governmental hospital | 298 (75.1%) | |
| Private hospital | 99 (24.9%) | |
| Area of working | ||
| Critical care unit | 165 (41.6%) | |
| Medical surgical | 89 (22.4%) | |
| Emergency department | 83 (20.9%) | |
| Nursing administration departments | 26 (6.5%) | |
| Other† | 34 (8.5%) | |
| Total experience as a RN | ||
| < 5 years | 216 (54.4%) | |
| 5-10 years | 106 (26.7%) | |
| >10 years | 75 (18.9%) | |
| Total experience as a RN in Saudi Arabia | ||
| < 5 years | 252 (63.5%) | |
| 5-10 years | 90 (22.7%) | |
| >10 years | 55 (13.9%) | |
| Total experience as a RN in selected hospitals in Saudi Arabia | ||
| <5 years | 286 (72.1%) | |
| 5-10 years | 68 (17.1%) | |
| >10 years | 43 (10.8%) |
*Others: Egyptian, Bangladeshi and other nationalities. **1 SR=0.266 UDS. †Others: Operation room, maternal department, and pediatric department
The salary distribution showed that 45.1% of participants earned between 5000 and 9999 Saudi Riyals (SR) per month, while 23.9% earned less than 5000 SR. Regarding job positions, most participants were staff nurses (86.9%), followed by charge nurses (7.1%) and nurse managers (6.0%). The majority of participants worked in governmental hospitals (75.1%) compared to private hospitals (24.9%). Critical care units were the most common work areas (41.6%), followed by medical-surgical departments (22.4%), emergency departments (20.9%), nursing administration departments (6.5%), and other areas (8.5%). Experience-wise, 54.4% of participants had less than 5 years of total experience as registered nurses (RNs), with 26.7% having 5–10 years and 18.9% having more than 10 years. A significant proportion (63.5%) had less than 5 years of experience working as RNs in Saudi Arabia, and the majority (72.1%) had less than 5 years of experience in the selected hospitals in Saudi Arabia. These demographic and work-related insights offer valuable context for interpreting the study’s findings concerning turnover intentions among Saudi nurses.
Subjects’ turnover intention
Table 2 presents the turnover intentions of the 397 participants in the study. Participants were asked to respond to statements indicating their inclination to leave their current hospital position. The responses were categorized into “Agree or Strongly Agree,” “Neutral,” and “Disagree or Strongly Disagree.” The data reveal that a substantial proportion of participants expressed agreement or strong agreement with statements suggesting turnover intentions. Specifically, 38.6% indicated they often contemplate leaving the hospital, while 38.0% reported actively searching for alternative employment. Additionally, 32.2% stated their intention to leave the hospital as soon as possible, and 35.8% indicated they would accept another job offer paying the same salary without hesitation. The total mean score for subjects’ turnover intention was 12.2, with a median of 13 and a range of 4 to 20. Using a cutoff point of 12, 53.7% of participants intended to leave their current job. Moreover, a subset of participants, constituting 18.4%, seriously intended to leave their current job as they answered “agree” or “strongly agree” to all four items of the turnover intention scale.
Table 2.
Subjects’ turnover intention from their current job (n=397)
| Turnover intention scale | Agree or Strongly Agree n (%) | Neutral n (%) | Disagree or Strongly Disagree n (%) | |||
|---|---|---|---|---|---|---|
| 1. I think a lot about leaving hospital | 153 (38.6%) | 101 (25.4%) | 143 (36.0%) | |||
| 2. I am actively searching for an alternative to the hospital | 151 (38.0%) | 95 (23.9%) | 151 (38.0%) | |||
| 3. As soon as it is possible, I will leave the hospital | 128 (32.2%) | 113 (28.5%) | 156 (39.3%) | |||
| 4. If I had another job offer that paid the same as the one I have, I would leave here in a minutes | 142 (35.8%) | 66 (16.6%) | 189 (47.7%) | |||
|
| ||||||
| Mean (±SD) | Median | Range | ||||
|
| ||||||
| Total score of subjects’ turnover intention | 12.2 (± 4.6) | 13 | 4–20 | |||
|
| ||||||
| n (%) | ||||||
|
| ||||||
| Intended to leave the current job based on mean* | 213 (53.7%) | |||||
| Seriously intended to leave the current job** | 73 (18.4%) | |||||
| Subjects’ plan to leave the hospital | ||||||
| In the next 6 months | 91 (22.9%) | |||||
| In the next year | 150 (37.8%) | |||||
| Within the next 5 years | 116 (29.2%) | |||||
| >5 years | 10 (2.5%) | |||||
| Never | 30 (7.6%) | |||||
*Intended to leave the current job based on mean (cut-off point of 12). Intended to stay <12, intended to turnover ≥12 (out of 20). **The subject who answered “agree” or “strongly agree” to turnover from hospital for all 4 items of turnover intention scale
Regarding their plans to leave the hospital within specific timeframes, 22.9% of participants expressed intentions to leave within the next 6 months, 37.8% within the next year, 29.2% within the next 5 years, and only 2.5% after more than 5 years. A notable 7.6% stated they never intended to leave.
Relationship between potential reasons for turnover intention and subjects’ nationality
The analysis in Table 3 examines the correlation between potential reasons for turnover intention among the 397 participants and their nationality. In terms of work environment reasons, disparities emerged between Saudi and non-Saudi nurses. Non-Saudi nurses were notably more inclined to identify excess working hours/shifts, excess workload, and dissatisfaction with poor management as factors influencing their turnover intentions. On organizational factors, such as organizational climate issues and communication with managers, no significant differences were observed between Saudi and non-Saudi nurses. However, regarding social reasons, distinct patterns emerged. Non-Saudi nurses were more likely to attribute turnover intentions to cultural differences, distance from home, spousal factors, and discrimination. These factors were notably more pronounced among non-Saudi nurses, particularly regarding cultural differences and spousal factors.
Table 3.
Relationship between potential reasons for subjects’ intention to turnover from their job and subjects’ nationality
| Potential subjects’ reasons for turnover intention | Total (n=397) n (%) | Subjects’ nationality |
Chi square (χ2) | P* | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Saudi citizens (n=84) n (%) | Non-Saudi citizens (n=313) n (%) | |||||||||
| 1. Work environment reasons | ||||||||||
| Low salary and inequity payment | 172 (43.3%) | 33 (39.3%) | 139 (44.4%) | 0.97 | 0.64 | |||||
| Excess working hours/shift | 251 (63.2%) | 37 (44.0%) | 214 (68.4%) | 9.81 | 0.04 | |||||
| Excess workload | 148 (37.3%) | 61 (72.6%) | 78 (27.8%) | 12.92 | 0.03 | |||||
| Lack of job security | 187 (47.1%) | 34 (40.5%) | 153 (48.9%) | 1.84 | 0.07 | |||||
| Lack of professional advancement and career promotional opportunities | 193 (48.6%) | 49 (58.3%) | 144 (46.0%) | 2.82 | 0.06 | |||||
| Extrinsic rewards including lack benefits and bonuses | 126 (31.7%) | 29 (34.5%) | 97 (31.0%) | 0.79 | 0.25 | |||||
| On-call requirements for coming to work | 202 (50.9%) | 42 (50.0%) | 160 (51.1%) | 1.64 | 0.38 | |||||
| Work complexity and insufficient clinical training | 261 (65.7%) | 53 (63.1%) | 208 (66.5%) | 0.63 | 0.83 | |||||
| 2. Organizational reasons | ||||||||||
| Poor management or dissatisfaction with management | 207 (52.1%) | 24 (28.6%) | 183 (58.5%) | 7.1 | 0.03 | |||||
| Compensation plan issues | 164 (41.3%) | 36 (42.9%) | 128 (40.9%) | 1.4 | 0.13 | |||||
| Organizational climate issues (e.g. no work group relations and teamwork, do non-nursing tasks, unclear job role) | 320 (80.6%) | 59 (70.2%) | 261 (83.4%) | 2.77 | 0.06 | |||||
| Unclear retirement plan | 227 (57.2%) | 18 (21.4%) | 209 (66.8%) | 4.96 | 0.03 | |||||
| Poor managers/supervisor communications and lack of appreciation of nurses | 249 (62.7%) | 27 (32.1%) | 222 (70.9%) | 5.75 | 0.04 | |||||
| Limitations imposed by managers or supervisor or dissatisfied with managers/supervisors leadership styles and behaviors | 261 (65.7%) | 44 (52.4%) | 205 (65.5%) | 2.84 | 0.28 | |||||
| Limitations imposed in workplace | 264 (66.5%) | 52 (61.9%) | 212 (67.7%) | 1.2 | 0.56 | |||||
| 3. Social reasons | ||||||||||
| Cultural differences | 287 (72.3%) | 9 (10.7%) | 278 (88.8%) | 28.4 | <0.001 | |||||
| Work place is too far from house and family living place | 179 (45.1%) | 24 (28.6%) | 155 (49.5%) | 14.7 | 0.01 | |||||
| Spousal factors (e.g., spouse cannot live with them or work in same area) | 295 (74.3%) | 36 (42.9%) | 259 (82.7%) | 22.6 | <0.001 | |||||
| Too much travel as a job requirement | 132 (33.2%) | 33 (39.3%) | 99 (31.6%) | 1.83 | 0.87 | |||||
| Discrimination (e.g., treated unfairly related to nationality or race) | 197 (49.7%) | 6 (7.1%) | 191 (61.0%) | 31.4 | <0.001 | |||||
*Significant P (<0.05) is bold
Overall, while certain factors contributing to turnover intentions were consistent across nationalities, others exhibited significant discrepancies. The findings highlight the need for tailored interventions to address the specific concerns and needs of both Saudi and non-Saudi nurses. Mitigating turnover intentions and fostering a supportive work environment necessitate targeted strategies that account for these disparities and promote inclusivity and support for all nurses, irrespective of nationality. Further exploration and intervention implementation are warranted to address the identified differences effectively.
Anticipating Factors for Seriousness of Subjects’ Intention to Leave Their Current Job: The data presented in Table 4 examine how potential factors affecting turnover intention relate to the seriousness of subjects’ intention to leave their current job among the 397 participants. When considering individual factors, non-Saudi nationality and non-Arab race were notably associated with a higher likelihood of intending to turnover compared to their Saudi and Arab counterparts. Additionally, lower salary and having less than 5 years of experience as a registered nurse (RN) were significantly linked to a more serious intention to turnover. In terms of subjects’ responses regarding potential reasons for turnover intention, certain work environment factors such as low salary, lack of extrinsic rewards, and compensation plan issues showed significant associations with a more serious intention to turnover. Similarly, organizational factors, particularly poor managers/supervisor communications and lack of appreciation of nurses, were significantly linked to a higher seriousness of turnover intention. However, social factors such as cultural differences did not demonstrate a significant association with the seriousness of turnover intention.
Table 4.
Relationship between anticipating factors for turnover and seriousness of subjects’ intention to leave their current job
| Not seriously intended to turnover* (n=324) n (%) | Seriously intended to turnover* (n=73) n (%) | Chi square (χ2) | P** | |||||
|---|---|---|---|---|---|---|---|---|
|
A. Individual factors | ||||||||
| Anticipating factors for subjects’ turnover intention (n=397) | ||||||||
| Ag(>30 years) | 129 (39.8%) | 28 (38.4%) | 0.05 | 0.90 | ||||
| Marital status (has been married) | 187 (58.4%) | 38 (52.1%) | 0.99 | 0.36 | ||||
| Nationality (non-Saudi citizens) | 246 (76.4%) | 65 (89.0%) | 5.68 | 0.017 | ||||
| Race (non-Arab nurses) | 232 (71.6%) | 64 (87.7%) | 8.1 | 0.004 | ||||
| Education level (> bachelor degree [master or PhD degrees) | ||||||||
| Salary (<5,000 SR) | 41 (12.6%) | 54 (73.9%) | 3.4 | 0.03 | ||||
| Total experience as a RN (<5 years) | 184 (56.8%) | 32 (43.8%) | 4.03 | 0.049 | ||||
| Total experience as a RN in Saudi Arabia (<5 years) | 211 (65.1%) | 41 (56.2%) | 2.06 | 0.18 | ||||
| Total experience as a RN in selected hospitals in Saudi Arabia (<5 years) | 234 (72.2%) | 52 (71.2%) | 0.03 | 0.89 | ||||
| Job position (charge nurse or nurse manager) | 47 (14.5%) | 5 (6.8%) | 3.07 | 0.09 | ||||
| Type of hospital (private hospital) | 85 (26.2%) | 14 (19.2%) | 1.58 | 0.23 | ||||
| Area of working (critical care unit) | 126 (38.9%) | 39 (53.4%) | 5.18 | 0.03 | ||||
|
B. Subjects’ responses about their potential reasons for turnover intention | ||||||||
| 1. Work environment factors | ||||||||
| Low salary and inequity payment | 124 (38.3%) | 48 (65.8%) | 18.3 | <0.001 | ||||
| Working hours/shifts | 203 (62.7%) | 48 (65.8%) | 0.24 | 0.69 | ||||
| Excess workload | 128 (39.5%) | 20 (27.4%) | 3.7 | 0.06 | ||||
| Lack of job security | 152 (46.9%) | 35 (47.9%) | 0.03 | 0.89 | ||||
| Lack of professional advancement and career promotional opportunities | 159 (49.1%) | 34 (46.6%) | 0.15 | 0.79 | ||||
| Extrinsic rewards including lack benefits and bonuses | 87 (26.9%) | 39 (53.4%) | 19.4 | <0.001 | ||||
| On-call requirements | 247 (76.2%) | 55 (75.3%) | 0.03 | 0.88 | ||||
| Work complexity and Insufficient clinical training | 206 (63.6%) | 55 (75.3%) | 3.66 | 0.06 | ||||
| 2. Organizational factors | ||||||||
| Poor management or dissatisfaction with management | 165 (50.9%) | 42 (57.5%) | 1.04 | 0.36 | ||||
| Compensation plan issues | 126 (38.9%) | 38 (52.1%) | 4.2 | 0.048 | ||||
| Organizational climate issues (e.g no work group relations and teamwork, do non-nursing tasks, unclear job role) | 263 (81.2%) | 57 (78.1%) | 0.36 | 0.52 | ||||
| Unclear retirement plan | 180 (55.6%) | 47 (64.4%) | 1.89 | 0.19 | ||||
| Poor managers/supervisor communications and lack of appreciation of nurses | 193 (59.6%) | 56 (76.7%) | 7.49 | <0.001 | ||||
| Limitations imposed by managers or supervisor or dissatisfied with Managers/Supervisors Leadership styles and behaviors | 213 (65.7%) | 48 (65.8%) | 0.46 | 0.79 | ||||
| Limitations imposed in workplace | 212 (65.4%) | 52 (71.2%) | 0.90 | 0.41 | ||||
| 3. Social Factors | ||||||||
| Cultural differences | 229 (70.7%) | 58 (79.5%) | 2.54 | 0.28 | ||||
| Work place is too far from house and family living place | 230 (71.0%) | 49 (67.1%) | 0.43 | 0.57 | ||||
| Spousal factors (e.g., spouse cannot work in same area) | 241 (74.4%) | 54 (74.0%) | 0.05 | 0.90 | ||||
| Too much travel as a job requirement | 269 (83.0%) | 63 (86.3)% | 0.47 | 0.60 | ||||
| Discrimination (e.g., treated unfairly related to nationality or race) | 294 (90.7%) | 62 (84.9%) | 2.17 | 0.14 | ||||
*The total percent is not 100%. The subjects selected one or more of the listed reasons for intention to turnover from current hospitals. **significant P (<0.05) is bold
Overall, these findings shed light on several key factors influencing nurses’ intentions to leave their current job. Non-Arab race, lower salary, shorter RN experience, and dissatisfaction with various aspects of the work environment and organizational factors emerged as significant contributors to turnover intention. Addressing these factors through targeted interventions aimed at improving salary equity, communication, and managerial support may help mitigate turnover intentions and foster a more supportive work environment for nurses, ultimately enhancing retention efforts within Saudi hospitals.
Predictors serious nurses’ intention to turnover from their current job
The results of a multiple logistic regression analysis aimed at predicting serious nurses’ intention to turnover from their current job are summarized in Table 5. This analysis incorporated various independent variables, including demographic and employment-related factors, along with potential reasons for turnover intention. In terms of demographic and employment-related variables, non-Saudi nationality did not show a significant association with serious intention to turnover (OR = 0.79, P = 0.84). Conversely, being a non-Arab nurse was significantly linked to a higher likelihood of serious intention to turnover (OR = 3.39, P < 0.001). Nurses earning less than 5000 Saudi Riyals per month also had significantly higher odds of serious intention to turnover (OR = 2.73, P = 0.02). Additionally, nurses with less than 5 years of experience as an RN demonstrated a significantly higher likelihood of serious intention to turnover (OR = 3.7, P = 0.03). Moreover, working in a critical care unit was associated with nearly twice the odds of serious intention to turnover (OR = 1.98, P = 0.02).
Table 5.
Multiple logistic regression analysis to predict serious nurses’ intention to turnover from their current job*
| Independent variables | Odds ratio (OR) | P † | 95% Confidence Interval (CI) |
|||||
|---|---|---|---|---|---|---|---|---|
| Lower | Upper | |||||||
| Previous significant variables regarding demographical and employment | ||||||||
| Nationality (non-Saudi citizens) | 0.79 | 0.84 | 0.09 | 7.18 | ||||
| Race (non- Arab nurses) | 3.39 | <0.001 | 1.42 | 7.25 | ||||
| Salary (<5,000 SR) | 2.73 | 0.02 | 1.19 | 5.22 | ||||
| Total experience as a RN (<5 years) | 3.7 | 0.03 | 1.10 | 8.41 | ||||
| Area of working (critical care unit) | 1.98 | 0.02 | 1.13 | 3.47 | ||||
| Previous significant variables regarding potential reasons for turnover intention | ||||||||
| Low salary and inequity payment | 3.20 | <0.001 | 1.81 | 5.68 | ||||
| Extrinsic rewards including lack benefits and bonuses | 3.30 | <0.001 | 1.75 | 6.23 | ||||
| Compensation plan issues | 0.96 | 0.89 | 0.51 | 1.78 | ||||
| Poor managers/supervisor communications and lack of appreciation of nurses | 0.67 | 0.19 | 0.37 | 1.21 | ||||
*Outcome variable was coded as 1: subjects who were answered “strongly agree” or “agree” for all four items of employee retention questionnaire; 0: others. **Comparisons (independent variables): nationality (Saudi citizens); race (Arab nurses); salary (≥5,000 SR); total experience as an RN (≥5 years); and area of working (other units). †P value is significant at a level of <0.05
Regarding potential reasons for turnover intention, nurses citing low salary and inequity payment as well as lack of extrinsic rewards including benefits and bonuses were significantly more likely to have a serious intention to turnover (OR = 3.20, P < 0.05 and OR = 3.30, P < 0.05, respectively). However, compensation plan issues and poor managers/supervisor communications showed no significant association with serious intention to turnover.
In conclusion, several factors were found to significantly predict nurses’ serious intention to turnover from their current job. Non-Arab nationality, lower salary, shorter RN experience, and working in a critical care unit emerged as key predictors. Additionally, citing low salary and lack of extrinsic rewards were identified as significant reasons for serious turnover intention. These findings underscore the importance of addressing salary disparities, enhancing communication and managerial support, and implementing targeted retention strategies, especially for nurses in critical care units and those with less experience, to mitigate serious turnover intentions and improve nurse retention within healthcare organizations.
Discussion
This study aimed to explore the factors influencing serious turnover intentions among nurses in Saudi Arabia, finding that a significant proportion expressed intentions to leave their current hospitals due to excessive workload, poor management, cultural differences, and inadequate salary and benefits. These findings align with previous research highlighting job dissatisfaction and work-related stress as key contributors to nurse turnover. The results suggest that targeted interventions, such as improving salary structures, enhancing communication, and strengthening managerial support, are crucial for mitigating turnover intentions and enhancing nurse retention in Saudi hospitals. Addressing these issues is essential for healthcare policymakers and nursing managers to ensure a stable and effective healthcare workforce.
The significance of this study lies in its endeavor to bridge the knowledge gap concerning turnover intentions among nursing staff in Saudi hospitals, particularly against the backdrop of the escalating demand for healthcare professionals and the challenges posed by the global COVID-19 pandemic.[11,29] With healthcare systems worldwide grappling with workforce shortages, particularly among frontline workers like nurses, understanding and addressing turnover intentions are crucial for ensuring the stability and effectiveness of healthcare delivery, especially in a country like Saudi Arabia experiencing rapid healthcare transformation.[1,2,7,13] In the context of the ongoing pandemic and the heightened demand for healthcare professionals, particularly frontline workers, such as nurses, this study’s contribution is especially pertinent.
By shedding light on the factors driving nurses’ intentions to leave their jobs, the study offers insights that are invaluable for informing targeted interventions aimed at improving nurse retention rates and promoting a stable and skilled nursing workforce.[10,19,27,30] Amid the challenges posed by infectious diseases and the increased strain on healthcare systems, addressing turnover intentions assumes heightened significance, underscoring the urgency of implementing effective retention strategies.[11,13,27,29] Moreover, the previous studies showed that nurses working in COVID-19 wards often face heightened levels of work–family conflict due to the demanding nature of their job and the constant fear of infecting their loved ones. Telenursing has been suggested as a potential intervention to alleviate the care burden on family caregivers of COVID-19 patients, indirectly supporting nurses by reducing the overall stress and responsibility they bear.[4,9,16,31] By addressing these multifaceted challenges through targeted interventions and supportive policies, healthcare organizations can enhance nurse retention, improve patient care quality, and maintain a stable and effective nursing workforce.[3,4,8,9,15,16,31]
In details, the demographic and employment data of the study’s 397 participants provide valuable insights into the composition of the Saudi nursing workforce. The majority of participants were young and female and held Bachelor’s degrees, which is consistent with global trends in nursing demographics.[5,17] Additionally, the distribution of participants across different job positions, hospital types, work areas, and experience levels offers context for understanding turnover intentions. These findings underscore the diverse nature of the nursing workforce in Saudi Arabia and the need for tailored retention strategies that address the unique needs of different groups of nurses.[2,17,18]
Regarding turnover intentions, the study revealed a concerning prevalence of turnover intentions among Saudi nurses, with a substantial proportion expressing serious intentions to leave their current positions. These findings align with previous research indicating high turnover rates within the nursing profession globally.[27,32,33,34] Factors contributing to turnover intentions may include job dissatisfaction, burnout, workload, and inadequate support from management. Addressing these factors is essential for mitigating turnover intentions and improving nurse retention in Saudi hospitals. Additionally, the prevalence of turnover intentions underscores the need for targeted interventions aimed at addressing the underlying factors driving nurses’ intentions to leave their jobs.[1,2,5,33]
Furthermore, the analysis of potential reasons for turnover intention revealed significant disparities between Saudi and non-Saudi nurses. While some factors were consistent across nationalities, others, such as cultural differences and spousal factors, were more pronounced among non-Saudi nurses. These findings highlight the importance of culturally sensitive retention strategies that address the specific needs of different nursing populations.[1,2,17] By promoting inclusivity and support for all nurses, healthcare organizations can create a more positive work environment conducive to retention.
The examination of factors predicting the seriousness of nurses’ intention to turnover further elucidated the multifaceted nature of turnover intentions. Non-Arab nationality, lower salary, shorter nurses’ experience, and working in critical care units emerged as significant predictors of serious intention to turnover. Additionally, citing low salary and lack of extrinsic rewards were identified as significant reasons for serious turnover intention. These findings underscore the importance of addressing salary differentials, enhancing communication, and providing managerial support to improve nurse retention.[1,2,17,35] By implementing evidence-based guidelines and best practices, healthcare organizations can reduce nurse turnover and improve productivity.
In conclusion, this study provides valuable insights into the reasons and significant influencing factors of serious turnover intentions among Saudi nurses. By understanding the demographic composition, turnover intentions, and predictors of serious turnover intentions, healthcare organizations can develop targeted interventions to improve nurse retention and enhance organizational performance. Implementing these interventions is essential for creating a positive work environment that supports nurse satisfaction and ultimately improves patient care outcomes.
Study implementations and recommendations
Implementing tailored interventions is crucial to address the specific concerns and needs identified among Saudi and non-Saudi nurses, given the observed disparities in turnover intentions between the two groups. Prioritizing the enhancement of the work environment involves tackling issues such as excessive working hours, heavy workloads, and discontent with management.[2,7,17,32] Implementing measures to foster work–life balance and alleviate stressors can help mitigate turnover intentions.
Organizational support plays a pivotal role in retention efforts. Improving communication channels between managers/supervisors and nurses is crucial, along with implementing strategies to recognize and appreciate nurses’ contributions. Cultivating a culture of appreciation within healthcare organizations can significantly enhance morale and reduce turnover rates.[32,33,34]
To promote fairness and equity, it is imperative to improve salary payment practices, particularly in private hospitals and among non-Saudi nurses. Ensuring that nurses are adequately compensated for their efforts and providing avenues for career progression and financial incentives are paramount.[6,32,33] Additionally, developing targeted retention strategies tailored to the needs of nurses in critical care units and those with less experience can bolster retention efforts. Emphasizing cultural sensitivity and promoting inclusivity within the workplace are also essential aspects of fostering a supportive environment for all nurses.[28,36] Ongoing research into additional factors contributing to turnover intentions and continuous evaluation of implemented interventions are crucial for refining strategies and improving nurse retention in the long term.[28,32,36]
Study limitations
The study’s limitations encompass several factors that may affect the generalizability and robustness of its findings. First, the study’s focus on Saudi hospitals raises concerns about the generalizability of the results to other healthcare settings or geographical regions as these hospitals may have unique contextual factors influencing nurses’ turnover intentions. Additionally, the use of convenience sampling may introduce sampling bias, potentially resulting in a sample that does not fully represent all nurses within Saudi hospitals. Furthermore, the reliance on self-reported data could lead to response bias as participants may provide socially desirable responses or inaccurately recall their intentions. Moreover, the cross-sectional design of the study limits the ability to establish causal relationships between variables, necessitating caution when interpreting associations. Despite efforts to control for confounding variables, there may be unmeasured factors influencing nurses’ turnover intentions, such as personal experiences or external factors. Last, the reliance on self-reported measures may introduce further bias as participants’ perceptions and interpretations of the questions may vary. Future studies addressing these limitations could employ more rigorous sampling methods, longitudinal designs, and objective measures to deepen understanding of the factors influencing nurses’ turnover intentions within Saudi hospitals.
Conclusion
A high proportion of nurses intend to leave their current hospital, with more than one-third contemplating leaving. Key predictors include non-Saudi nationality, low salary, short RN experience, critical care work, and poor management. This study highlights the need for targeted interventions to address nurse turnover in Saudi hospitals. Improving the work environment, enhancing organizational support, and addressing salary equity are crucial. Tailored interventions that recognize the unique concerns of both Saudi and non-Saudi nurses are essential.
Healthcare policymakers and nursing managers should focus on improving salary structures, communication channels, and managerial support. Addressing work-related stress, cultural differences, and providing adequate training opportunities are also vital. Despite its valuable insights, this study acknowledges limitations like potential sampling bias and a cross-sectional design. Future research with more rigorous methods and longitudinal designs could further elucidate nurse turnover dynamics in Saudi hospitals. By addressing identified factors and implementing targeted retention strategies, healthcare organizations can enhance nurse retention and patient care quality in Saudi Arabia.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
The authors would like to thank the nurses who participated in this study. Additionally, thanks are extended to the medical and nursing administrators for providing the ethical approval letter and for their efforts in facilitating the conduct of this study.
Funding Statement
Nil.
References
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