Middle East Nurses Turnover Intention and its Correlates Amid the COVID-19 Pandemic: A Systematic Review

Abstract

Global nursing scarcity was more evident during COVID-19. This study investigated the rates and contributing factors of turnover intention in the middle east through meta-analysis. Medline EMCARE, Cochrane, CINAHL, EMBASE, Ovid, Psych Info, PubMed, Science Direct, Scopus, and Web of Science databases searched, Protocol PROSPERO Registration Number was CRD42022337686. The turnover intention rate was 42.3% [CI: 40%, 44.6%]. Working environment, stress, deployment to COVID, fear of infection, long working hours, shift duties, and lack of social support were the major contributing factors.

Keywords:

• TOI
• Middle East
• Nurses
• Intention to leave
• Resign

Introduction/Background

Nurses and midwives are the largest healthcare professional group, constituting around 50% of the global healthcare workforce. However, according to a recent estimate by the WHO, 9 million more nurses and midwives will be needed by 2030. The emotional and physical stability of frontline nurses is very significant for safe and effective patient care (Hashim et al. 2012). Nurses’ turnover refers to the proportion of nurses that had to be replaced in each period to an average number of nurses and is generally viewed as the movement of nurses out of an organization (Gebregziabher et al. 2020).

Nurses’ turnover intention has been used in the nursing literature with different terms such as intention to leave, intention to quit, intention to stay, risk of quitting, and job retention intention (Kilańska, Gaworska-Krzemińska, and Karolczak 2020). The turnover intention has been allied to several adverse results such as medication error, falls, and pressure injuries. Moreover, it has been linked to increased healthcare system costs due to its impact on both financial and time resources (Falatah 2021).

Nurses in their everyday practice are dealing with various stressors, such as critical situations, workload, grief, death, nurses–physician collaboration and conflicts, and uncertainty about the effectiveness of the provided care (Kwiecień-Jaguś et al. 2018). According to a recent study that investigated stressors in the nursing profession during the pandemic, which 455 nurses expressed that nowadays have to deal with new sources of stress, such as personal protective equipment/supplies, exposure to SARS–COV2 and the possibility of infection. Nurses that are exposed to various stressors are not satisfied with their profession or the provision of low-quality care (Nashwan et al. 2021) which may increase their intention to leave nursing. In the COVID-19 outbreak, for example, turnover intention was studied as one of the consequences of COVID-19 caused by factors such as nurses’ anxiety and fear of COVID-19 (Lotfi et al. 2022). However, the rate of nurses’ turnover intention were not specified in the COVID-19 period, and only the presence of this problem in nurses has been reported in some studies.

Pandemic demands workload on nurses in an extreme work environment. The number of critical cases, the uncertainty about the disease, and the frequency of death from the disease impose psychological stress on nurses (Nikkhah-Farkhani and Piotrowski 2020). Considering the alarming issues of stress, burnout, and turnover among nurses even before the pandemic (Khattak et al. 2021), the pandemic might have amplified the issue of intention to leave among nurses. Thus, it was significant to study the influence of the COVID-19 pandemic on Nurses’ turnover intention in the middle east region. The aim of this review is to Explore the turnover intention rate and contributing factors among nurses during the COVID-19 Pandemic in the middle east region.

Method

This review followed the Joanna Briggs Institute (JBI) methodology for prevalence systematic reviews (Munn et al. 2018) and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (Liberati et al. 2009). The review protocol has been published in PROSPERO (Registration Number CRD42022337686).

Search Strategy

An initial electronic search of MEDLINE and CINAHL MEDLINE and CINAHL was commenced to identify articles on the topic. The text words are contained in the titles and abstracts of relevant articles, and the index terms. Medline, EMCARE, Cochrane Database of Systematic Reviews, CINAHL, EMBASE, Journals Ovid, Psych Info, PubMed, Science Direct, Scopus, and Web of Science were searched for studies published between 2020 and 2022. On the three PEO components (Bettany-Saltikov 2016) population (i.e., nursing staff), exposure (i.e., COVID-19 pandemic), and outcome (i.e., turnover intention), This study refers to all types: “Turnover intention” was used as an umbrella term and (Turnover Intention OR Intention to Leave) AND (Nurses) AND (COVID-19) AND ("Qatar" OR "Jordan" OR "Saudi Arabia" OR "Iran" OR "United Arab Emirates" OR "Bahrain" OR "Oman" OR “Kuwait” OR “Egypt” OR “Iraq”) was used as key Words.

Study Type and Participants

Quantitative studies that investigated turnover intention rates and contributing factors among nurses in Middle east region were included in this review. Only studies conducted in different hospital settings in the middle east region, were eligible for inclusion.

Methodological Quality Evaluation

Two reviewers [KM,JK] independently appraised the included studies using the JBI critical appraisal checklists for analytical cross-sectional studies (scoring out of 8 questions) (Moola et al. 2017). Discrepancies were resolved through an appropriate discussion with a third reviewer (Lockwood, Munn, and Porritt 2015). Not Applicable answers were considered not achieved. If a study received a score of <60% on the quality assessment questions, it was excluded.

Results

The initial search resulted in 158 citations and the ongoing review process in 6 further records. Out of the 164 articles which entered the screening of titles, 40 articles were received after the screening, and 22 were received after the duplicate screening. Finally reached 11 articles after considering the inclusion and exclusion criteria of the review. Four articles received conflicting judgments from the two reviewers involved and were excluded because their scores were <60%. see Figure 1 for the search strategy and PRISMA chart.

Figure 1. PRISMA flow diagram.

Description of Studies

A total of seven publications was included in the final analysis. The studies selected were conducted only in the middle east region with Three studies from Iran, two studies from Saudi Arabia (n = 2,) and one study each from Egypt (n = 1) and Qatar (n = 1). All the studies were conducted between the years 2020 and 2022. The sample size for the studies ranges from 156 to 1101 (mean = 432.5). Most of the studies used a five-point Likert scale to assess the turnover intention (n = 5). Among these two studies utilized the TIS-6 scale which is a six-item tool, and the remaining three studies used three-item, 12-item, and 15-item tools. Two studies utilized yes or no questions.

Turnover Intention

Six studies reported the percentage of nurses who had the intention to leave the organization and among them lowest rate was 20.6% and the highest rate was 48.6%. The highest turnover reported study was done in Saudi Arabia among adult and pediatric critical care nurses. One study from Qatar did not report the rate of intention to Turnover (Nashwan et al. 2021). However, they compared the turnover intention rate before and during COVID-19. The mean score revealed that turnover intention was significantly high (15.5) during the period of COVID-19 compared with before (13.2). The Meta-analysis was done with JBI SUMARAI and Turnover intention rates were reported in 6 included studies. The pooled data from six studies demonstrated that 42.3% (95% confidence interval [CI]: [40%, 44.6%]) of nurses have the intention to leave their organization, please see Figures 2 and 3 and Table 1.

Figure 2. Pooled estimation with meta analysis.

Figure 3. Factors contributed to turnover intention among nurses.

Table 1. Data extraction table: Turnover intention and contributing factors.

Sl no.	Authors, year	Country	Study design, study setting, population, sample size, response rate	Mean age, gender	Turn over intention rate among nurses
1	Alenazy, Dettrick, and Keogh (2021)	Saudi Arabia	Cross-sectional correlational (observational) design, critical care, Nurses from adult and pediatric intensive care units, adult intensive isolation unit and emergency care unit, 156,98%	32.10 ± 6.16 Male 11.20%Female 88.20%	48.6%
2	Al-Mansour (2021)	Saudi Arabia	Cross-sectional study, primary health centers, health workers (physicians, nurses, paramedics, and administrative staff), 1101(340 nurses),73.4%	38.9 ± 8.1 Male—56% Female—44%	39.4%
3	Karimi, Raei, and Parandeh (2022)	Iran	Cross-sectional study,2 referral hospital, nurses,170, 85%.	35.15 ± 10.12 Male—60% Female—40%	20.6%
4	Nashwan et al. (2021)	Qatar	Descriptive cross-sectional study, secondary hospitals, nurses, 512,4.3%	Majority between 31 and 40 years Male—32.4% Female-67.6%	Turnover intention is high during COVID-19 compared to before COVID-19
5	Said and El-Shafei (2021)	Egypt	Comparative cross-sectional study, one COVID-19 Triage Hospital and one hospital dealing only with suspected COVID-19 patients, nurses at two hospitals, 420, 71%	Hospital 1 24.22 ± 5.16 Male—14.8% Female—85.2% Hospital 2 Male—21.4% Female—78.6%	Hospital 1 Intent to leave current position-40% Intent to leave current organization-45.2% Intent to leave nursing-24.8% Hospital 2 Intent to leave current position-30.5% Intent to leave current organization-34.3% Intent to leave nursing-10%
6	Mirzaei, Rezakhani Moghaddam, and Habibi Soola (2021)	Iran	Descriptive–analytical study, pre-hospital emergency and educational and medical centers to fight COVID-19, nurses, 479,62.6%.	33.43 ± 6.77 Male—38.4% Female—61.6%	Mean TIS—41.73
7	Lotfi et al. (2022)	Iran	Descriptive correlational study, Perioperative and anesthesia nurses of public hospitals, nurses,190,43.18%	27.2 ± 4.7 Male—38.9% Female—61.1%	Low—30% Moderate—60% High—10%

Significant Factors Contributing to the Turnover Intention

Socio-Demographic and Personal Characteristics and Turnover Intention

A study conducted in Saudi Arabia reported that female health workers including nurses (37.4%) had more turnover intention than their male counter partners (28%) (Al-Mansour 2021). Whereas a study done at Iran showing that mean of turnover intention was significantly correlated with the variable of gender with a higher turnover intention seen in men compared to women (β = −0.131, p = .002) during COVID-19 (Lotfi et al. 2022). A study done at Qatar reported that turnover intentions during COVID-19 among single (mean rank = 294.41) have high mean rank (p = 0.007) compared with nurses other marital status (mean rank = 225) and also there is a statistically significant difference (p = 0.023) among participants with different work experience, with nurses having 5–10 years of experience had higher mean rank (mean rank = 282.19) for the turn over intention compared with less than five year experience group (mean rank = 240.48)more working experience were likely to have higher turnover intention (Nashwan et al. 2021).

Organizational Factors, Working Environment, and Turnover Intention

Nurse practice environment(NPE) is reported as a significant predictor of nurses turnover intention (Alenazy, Dettrick, and Keogh 2021). Nurses’ sense of commitment, work conscience and their interesting in attending the organization had a positive influence on intention to stay at the organization and they are less likely to leave (Karimi, Raei, and Parandeh 2022). Safety climate of the organization is an important factor to stay back during the pandemic period. Inadequately organized atmosphere at the hospital, shortage of protective measures and measures taken to promote safety by the high-level management influencing the turnover intention of nurses (Lotfi et al. 2022). Job satisfaction is also a contributing factor to the intention to stay back in the organization (Karimi, Raei, and Parandeh 2022).

Stress, General Health, Social Support, Job Characteristics and Turnover Intention

The percentage of nurses with much and extreme stress were significantly increased(p = 0.000) during the pandemic period compared to before (Nashwan et al. 2021). Turnover intention had a significant and positive relationship with the post-traumatic stress disorder score (r = 0.348, p ˂ .01), job strain (r = 0.271, p ˂ .01) and general health (r = 0.311, p ˂ .01) (Mirzaei, Rezakhani Moghaddam, and Habibi Soola 2021). However, the social support and support from senior managers in the organization can mediate the effect of stress and reduce the turnover intention (Al-Mansour 2021). The personal accomplishment component of the Burn out is positively influencing the job leaving tendency (regression coefficient = −0.265, p = 0.01) of the nurses (Karimi, Raei, and Parandeh 2022). A positive significant correlation was found between turnover intention with job demand (r = 0.298, p ˂ .01) and job insecurity (r = 0.269, p ˂ .01) (Mirzaei, Rezakhani Moghaddam, and Habibi Soola 2021).

The job type, the area of work, timing and the type of hospital are also affecting the turnover intention. Those nurses had a better position showed less tendency to leave (p = 0.02), with nurse having less mean turn over intention score (6.40 ± 3.17) compared with nursing assistant (8.04 ± 2.65) (Karimi, Raei, and Parandeh 2022). Nurses working more than 40 h/week (p = .000), 3 or more night duties per week (p = .006) had more intention to leave from the current job (Said and El-Shafei 2021). Also, nurses working COVID-19 facilities, working in critical area, and deployed to critical area during COVID-19 had more intention to leave compared with others (Nashwan et al. 2021; Said and El-Shafei 2021).

Discussion

This is the first comprehensive systematic review on turnover intention among nurses in the middle east region. However, during the pandemic, this trend increases all over the world and a significant portion of nurses left their profession (Falatah 2021) but this review findings provide a comprehensive reflection of nurses’ TOI in the middle east region. The turnover intention is closely linked with the various extrinsic and intrinsic factors. The factors contributing to turnover intention before the pandemic was mainly due to personal, professional, patient, and organization-related factors (Ayalew et al. 2015; Falatah and Conway 2019). Whereas, during the pandemic, the major contributing factors of turnover intention were associated with a dramatic increase in workloads, lack of or adequate supply of material resources, emotional exhaustion, stress, and fear of infection (ICN 2020; Poku et al. 2022). This review revealed that the factors contributing to TOI were working environment, stress, current role, deployment to COVID facility, fear of infection to self and others, long working hours, shift duties, and lack of social support.

Women have higher attachment toward families and have concerns about infecting their families than men. Turn over intention also depends on differences reflect how social roles of women and men differ (Khalid et al. 2009; Zhang, Yang, and Wang 2021). However few studies highlights turn over intention is high among males, where men have more difficulty bearing a work setting that is stressful and out of control, especially during an outbreak of an infectious disease, and they are more likely to suffer from stress (Mirzaei, Rezakhani Moghaddam, and Habibi Soola 2021). Unmarried respondents are more likely to quit than those married, married medical professionals appeared to experience higher levels of job satisfaction than their counterparts. Married people have commitments and responsibilities which prevent them to take immediate decision to leave the job (Chen 2006; Ali Jadoo et al. 2015). Nurses with more working experience were likely to have higher turnover intentions that need the required work experience and specialized area of work may require to apply for nursing work abroad (Bautista et al. 2020).

Nurses facing such higher stress more likely to quit their jobs (Qureshi et al. 2013). Nurses who work during an outbreak of infectious disease often worry about their families due to the possibility of infection, which is a major barrier to their willingness to work. Varasteh, Esmaeili, and Mazaheri (2022), found nurses were more afraid of infecting their families than being infected themselves. As per evidence people with more social support were less likely to think about leaving their jobs. Talking with friends and getting support helps the nurses to face challengers (Tetteh et al. 2020). Studies highlights that support from organization and colleagues act as great source of motivation. Nissly, Barak, and Levin (2005) found organizational support (supervisor support), desirable job conditions and development of their job goals are operative ways to reduce stressors and ultimately reduce turnover intention. Evidences highlights that Poor mental and physical health of staff nurses’ has been linked to emotional exhaustion and low levels of empowerment leads to lack of career satisfaction and turnover intentions (Duran et al. 2021).

The previous studies identified many organizational factors and the working environment was associated with nurse turnover intention. A study found that the turnover intention was positively correlated with job insecurity and job demand which includes physical and psychological demands required for their current position (Barzideh, Choobineh, and Tabatabaei 2013). Supporting peer groups with sharing experience or formal peer supporters may improve the working atmosphere (Maben and Bridges 2020). The present study identified nursing practice environment, work position, personal accomplishments, lack of protective equipment, long working hours, shift work and interest in attending the organization were important factors associated with nurse turnover intention. During COVID, the reputation of the nursing profession has grown but the health and safety of nurses remained at risk. Healthcare institutions must take this opportunity to learn and reassess their system through a well-planned workplace protocol which consists of sets of actions to appropriate during a pandemic or epidemic outbreak, guidelines or pathways for caring for infected patients, safety practices among healthcare workers, necessary training and emergency response plans in collaboration local and national level agencies (Hirshouer, Edmonson, and Hatchel 2020).

Limitation

A limitation of the review was the inclusion of studies in English and limited to Middle east region only. In addition, various studies conducted about Turnover Intention in different region other than middle east which could not be included to obtain a comprehensive result.

Conclusion

The Frontline nurses are the backbone of health care delivery system. Unfolding emergency caused by the COVID-19 created significant stressors which are related to their physical working environment, increasing number of confirmed cases and heavy workload are putting nurses under intense pressure and high tendency to leave their organization. Retaining skilled and competent nurses are vital in any healthcare organization to improve the quality of their healthcare system. Leadership needs to focus on addressing their problems and protecting rights and benefits. Organizations that provide more support to their employees’ well-being are more likely to reduce stress and ultimately increase the employees’ intention to stay in the organization. However, organizations should understand the factors influencing employees’ turnover intentions and able to apply effective retention policies.

Acknowledgements

Open Access funding provided by the Qatar National Library.

Disclosure Statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Additional information

Funding

Qatar national Library will be funded for publication.