Nurse Job Satisfaction and Turnover Intention in Saudi Arabia

Introduction

In Saudi Arabia, a large number of nurses come from other nations because the domestic demand for nurses exceeds the available supply. This is not an unusual situation, as there is a global shortage of nurses and retention rates remain consistently low (Almalki et al., 2011). This situation has also been exacerbated by population growth, which has required the Saudi healthcare system to accommodate increasing numbers of patients. As a result, there is a pressing need to handle nurse recruitment and retention more effectively (Almalki et al., 2011).

There is a serious need for better strategies to address nurse recruitment and retention because where retention is low and nurses are fewer, more patients are lost and failure-to-rescue rates are higher (Needleman et al., 2011). Where strategies are in place to improve the job experience of nurses, patients also benefit from the higher quality of care they receive (Hayes et al., 2010). Nurses who have an unsatisfactory work experience are more likely to leave their positions sooner and are less able to provide optimal care.

For a country like Saudi Arabia, which has a high demand for nurses, there is a genuine need to identify and evaluate the factors that contribute to a negative work experience and cause nurses to leave the profession. There is a gap in this area, as it has not been methodically examined. While studies have been carried out elsewhere, their findings cannot be generalized to the Saudi Arabian context. Nurses in the country face unique challenges, and the dynamics differ considerably from those in other nations. Culture is a particularly pertinent issue in Saudi Arabia; furthermore, the structures of healthcare institutions, organizational systems, and the nature of the work environment all differ significantly from those in other countries (Alasmari and Douglas, 2012).

This study aims to add to the available knowledge on how nurses' decisions to leave critical care employment relate to their job satisfaction. It is an exploratory study focused on Saudi Arabia that seeks to expand understanding of how job satisfaction and intention to leave are related, so that effective strategies to reduce nurse turnover can be developed. The study centers on the perspectives of nurses working in Saudi Arabia regarding job satisfaction and its impact on their intention to leave both their employment and the profession.

Context and Background of the Study

Saudi Arabia stands apart from other nations in terms of its cultural setting, religion, and the lifestyles of its people. This Islamic nation forms the focus of the study, and its unique characteristics are described here to provide appropriate context. The country's history, economy, demographics, social structure, and healthcare system are each addressed in turn.

Historically, the Saudi Arabian kingdom did not rely on oil for its wealth, as petroleum had not yet been discovered. Instead, activities such as fishing, agriculture, and trade were the primary economic pursuits. The country's economy also depended on income from religious tourists travelling to Makkah and Madinah as part of their pilgrimage. Oil was eventually discovered after the nation permitted geological exploration by American prospectors, who concentrated their efforts on the eastern region of the country (Alshmemri, 2014).

According to statistics provided by the Central Department of Statistics and Information of Saudi Arabia, the country's population in 2012 was just under 30 million, with 31% comprising foreign nationals. Among Saudi nationals, approximately 90% were of Arab descent and 10% were of other ethnic backgrounds (CDSI, 2013).

The Kingdom of Saudi Arabia follows the accepted practices of Islam as well as Arab cultural traditions. In the Islamic faith, Allah is regarded as the one who ends life, brings disease, and grants vitality. The influence of religion is felt across all spheres of society. Family values are upheld within the Muslim context, and interactions among family members are governed by Islamic principles such as loyalty, truthfulness, mercy, and respect for others. The education system also reflects Islamic values, with males and females educated separately through to university level. However, both have equal access to scholarships for study abroad. Historically, men in the country held greater privileges than women, though this situation has been gradually changing over time (Alshmemri, 2014).

In the Kingdom of Saudi Arabia, the healthcare system has been improving steadily, incorporating advances in technology, modern infrastructure, and the benefits of a stronger economy. Significant developments have been made in recent years, and the country now boasts highly advanced systems comparable to those found in developed nations. Healthcare has been a priority for the government, with high levels of expenditure directed toward improving the quality of care and expanding the number of healthcare institutions. Entities providing healthcare in Saudi Arabia include government-run hospitals, hospitals operated by the Ministry of Higher Education, Medical Services for Security Forces, Armed Forces Medical Services, the National Guard Health Affairs, the Royal Commission for Jubail and Yanbu, and the Aramco Hospitals (Alshmemri, 2014).

The Saudi government views healthcare development as a key component of national development and gives it considerable attention. The Ministry of Health provides three levels of healthcare: primary, secondary, and tertiary. The primary level is the most widely accessible, with over 2,000 centers distributed across the country. The secondary level consists of government-run hospitals, while the tertiary level encompasses specialized centers for the treatment of major conditions such as heart disease, kidney disorders, and diabetes (MOH, 2011). As the country continues to develop, healthcare services are also expected to become increasingly advanced (Alshmemri, 2014).

Statement of the Problem and Purpose

Healthcare systems and structures in Saudi Arabia have been improving over the last several decades. With this improvement, it has become clear that the job satisfaction of nurses is crucial for the future stability of the sector and for adequate healthcare provision (Al-Dossary et al., 2012). Studies have revealed that various factors contribute to nurse job satisfaction, including — but not limited to — the nurse's level of education, the work environment, the nurse's age, and their level of experience. Through this study, factors affecting the job satisfaction of nurses within Saudi Arabia will be established, and this information can help the Ministry of Health formulate policies aimed at enhancing nurse job satisfaction. Such information will also allow strategies to be developed that reduce the number of nurses leaving their positions, thereby guaranteeing greater stability. The study therefore seeks to address the problem of nurse turnover by identifying the factors that influence job satisfaction.

The purpose of this study is to determine the degree of job satisfaction experienced by nurses working in Saudi Arabian public hospitals, with a specific focus on nurses in Najran. The research aims to identify and examine the aspects that cause and increase job satisfaction, which is expected to have a positive impact on the quality of patient care. The literary gap that this study seeks to address is the lack of research into nurse job satisfaction in Saudi public hospitals and the general scarcity of research in this area.

To measure organizational commitment using affective and continuance scales, the study will use Meyer and Allen's (2004) revised TCM Employee Commitment Survey — a validated instrument for measuring affective, continuance, and normative commitment. A self-administered questionnaire will be employed. The researchers will adapt the Index of Work Satisfaction Questionnaire developed by Paula L. Stamps to measure nurses' job satisfaction levels. Perceived organizational support will be measured using the 36-item Survey of Perceived Organizational Support (POS) developed by Eisenberger. This one-dimensional scale measures employees' perceptions of organizational support. Turnover intention will be assessed using the two-item Turnover Intentions Scale adapted from Cammann et al. (1979), as presented in Cook et al. (1981), to gauge nurses' views on the likelihood of voluntarily leaving their current positions.

The study aims to determine the level of job satisfaction among public hospital nurses in Saudi Arabia and to understand what nurses perceive as the reasons behind the large numbers leaving their positions. The research's significance lies in identifying the elements that impact job satisfaction so that the Saudi healthcare system can be stabilized and protected from the risk of collapse if the trend of nurse departures continues. This is a crucial national issue, as it ultimately affects healthcare provision for the country's citizens. It is therefore a matter of priority for policymakers, directors, managers, and all stakeholders in the healthcare industry. The Ministry of Health stands to benefit by gaining the tools needed to promote stability in the industry and to attract more nurses into the system.

The research will also add to the existing body of knowledge on job satisfaction and its impact on the decision to leave in Saudi Arabia's care environment, particularly in critical care settings. The study hopes that by identifying the factors affecting job satisfaction and addressing them, the number of nurses leaving employment can be reduced, thereby improving retention rates. It is a matter of utmost importance to the Ministry of Health and to policymakers seeking to address turnover rates among critical care nurses.

Literature Review: Job Satisfaction and Intention to Leave

Job satisfaction is a term that has been described differently by various studies and scholars. Alasmari and Douglas (2012) cite the definition proposed by Cumbey and Alexander (1998), who described it as an affective feeling that depends on how one relates to colleagues, one's own attributes and values, and what one expects from the workplace and organization (p. 40). Some authors define it in terms of how one feels about or perceives their work. Hayes et al. (2010) grouped factors related to nurse job satisfaction under intra-personal, interpersonal, and extra-personal categories. Intra-personal factors are those internal to the nurse, such as their coping mechanisms. Interpersonal factors relate to colleagues, including levels of autonomy and quality of interaction. Extra-personal factors are those in the nurse's broader environment, such as organizational policies and opportunities for further education (Hayes et al., 2010). Alasmari and Douglas (2012) note that interpersonal factors have been thoroughly researched and linked to job satisfaction levels and work-related stress, including the degree of independence and the quality of doctor–nurse teamwork.

The intention to leave is defined by Vandenberg and Nelson (1999, p. 1315) as an individual's perceived likelihood of leaving their job or organization in the near future (Alasmari and Douglas, 2012). According to some scholars, this intention is a strong indicator of an actual decision to leave. It is therefore paramount that the reasons for leaving be identified and addressed through staff retention plans. Literature has remained inconclusive about the relationship between the decision to leave and job satisfaction, a discrepancy attributed to differences in assessment methods. It is expected that standardizing definitions will lead to more conclusive research. Alasmari and Douglas (2012) note that while a single universal definition is unlikely, further research is expected to clarify the nature of this relationship.

A further problem identified in studying nurse job satisfaction is the variation in the measurement instruments employed. Some instruments used in past studies have not had their psychometric properties reported, as they were modified by individual researchers. Some studies have also been limited by using cross-sectional methods that do not allow causal inferences to be drawn. However, some researchers have employed longitudinal studies with greater success in evaluating nurses' intention to leave. It is also notable that no experimental studies have been conducted examining how organizational strategies to improve job satisfaction affect turnover intention (Alasmari and Douglas, 2012).

A review of the available literature reveals that there is very little data collected in Saudi Arabia specifically on nurse job satisfaction or on nurses' intention to leave their employment. Alasmari and Douglas (2012) cite the work of Al-Aameri (2000), who collected data from registered nurses in Saudi government hospitals. That study found that, on a 5-point scale, nurses had a mean satisfaction score of 3.67, while on a 7-point scale their job commitment score was 4.87. The most satisfied nurses were those with the most experience, who were older, and who were divorced. The most committed nurses were predominantly married. A study by Al-Ahmadi (2002) in Ministry of Health hospitals in Riyadh similarly found that among 366 participating nurses, there was only a fair level of job satisfaction. That study was able to link satisfaction to working conditions, supervision quality, pay, and how effectively nurses' skills were utilized. Nurses with more advanced education reported lower satisfaction, while those with more experience showed a slight positive correlation with satisfaction (Alasmari and Douglas, 2012).

Only a small number of studies have evaluated how job satisfaction relates to the intention to leave. Among the 923 nurses studied by Al-Ahmadi in 2009 in Riyadh, those with high satisfaction levels and stronger job commitment also had higher performance records (Alasmari and Douglas, 2012). A study of 267 nurses in a university hospital found that job difficulty and the supervisor's leadership style were strong predictors of intention to leave (Alasmari and Douglas, 2012). Hayes et al. (2010) emphasize that patient outcomes and quality of care are directly related to nurse job satisfaction, and that dissatisfaction often leads to nurses leaving both their jobs and possibly their profession.