Factors Associated with Nurses’ Intention to Leave in Saudi Arabia: A Literature Review

| ABSTRACT The nursing workforce represents a critical component of the healthcare system in Saudi Arabia, which is facing significant challenges related to retention and job satisfaction. High turnover rates among nurses not only compromise patient care quality but also place additional strain on the healthcare system. This study aims to investigate the factors associated with nurses' intention to leave their positions in Saudi Arabia, providing insights into the underlying causes of nursing turnover and suggesting potential strategies for retention. A comprehensive literature review was conducted, examining peer-reviewed articles, official reports


Introduction
Undoubtedly, the largest workforce in the healthcare system is nurses, with an estimated 19.3 million nurses out of a total of 43.5 million health workers worldwide (World Health Organization, 2020).Thus, the quality of hospital services, nursing care and patient care cannot be improved without the contribution of this workforce (Salahat & Al-Hamdan, 2022).Nursing intention to leave and turnover have been identified as one of the greatest threats regarding both the quality of healthcare and patient safety in the health-care sector worldwide (Eriksson et al., 2022).
According to Tadesse et al. (2023), nurses are an essential workforce and constitute the largest professional group that constitutes the healthcare workforce within the healthcare system.They make a significant contribution to the delivery of quality healthcare services and assist in the improvement of health outcomes for individuals, families, and communities through preventative and curative healthcare measures.Nurses who have the intention of quitting their job provide difficulty for administrators working in healthcare and hospitals in a variety of nations (Bagwell et al., 2023).
The nursing profession continues to face challenges that include inadequate working conditions, ineffective public policy, insufficient hiring, low recognition, and restricted autonomy.These are just some of the concerns that continue to persist.The ability to work and the intention to leave the profession are both influenced by these many elements, which may have an effect on both outcomes (Hult et al., 2020).
The intention of nurses to leave healthcare facilities may significantly affect patient care and bring down the standard of treatment.Growing rates of nurses' intention to leave hospitals lead to a shortage of manpower, which in turn increases the workload and stress levels of other nurses (Andel et al., 2022).The issue of nurses' intention to leave their existing workplaces is a serious one in Saudi Arabia, and the quality of life characteristics, such as physical and psychological health, are able to predict nurses' intention to resign from their current positions (Albougami et al., 2020).
Moreover, hospitals are having trouble providing a consistent level of quality nursing care in a health setting that is rapidly changing as a result of the scarcity of experienced nurses, which is a serious problem on a worldwide scale (Tadesse et al., 2023).Impaired work capacity and early withdrawal from the profession have a detrimental influence on the labor market, as well as on health and pension systems, in terms of maintaining a sufficient and high-quality workforce (Martinez et al., 2022).Moreover, the intention of nurses to leave might result in modifications and inadequate staffing, which can lead to an increase in the number of infections and deaths, as well as prescription errors and treatment blunders, respectively (Andel et al., 2022).
The significance of studying factors associated with nurses' intention to leave Saudi Arabia lies in its potential to address critical issues within the healthcare system.Nurses' intention to leave poses significant challenges globally, impacting patient care, organizational costs, and overall healthcare quality.In the context of Saudi Arabia, understanding the factors contributing to nurses' intention to leave is vital for several reasons.The findings can inform targeted retention strategies tailored to the hospital's specific context, thereby enhancing nurse satisfaction and reducing turnover rates.This is particularly crucial in Saudi Arabia, where the healthcare sector is rapidly expanding, and retaining skilled nurses is essential for maintaining quality care.Moreover, identifying the factors associated with nurses' intention to leave can help pinpoint areas for intervention and improvement within the hospital's organizational culture, work environment, and support systems.Addressing these factors can enhance job satisfaction, increase morale, and ultimately contribute to better patient outcomes.Furthermore, this research can serve as a benchmark for similar healthcare institutions in Saudi Arabia and globally, offering insights into common challenges and effective retention practices.The main aim of this study is to investigate the factors associated with nurses' intention to leave Saudi Arabia.

Search Strategy
To conduct a thorough literature review, a systematic search strategy was developed to identify studies related to nurses' intention to leave their positions, focusing on the context of Saudi Arabia.The databases searched included PubMed, Scopus, Web of Science, CINAHL, and PsycINFO, covering publications up to December 2023.Keywords used in the search included combinations of: "nurses," "intention to leave," "turnover," "Saudi Arabia," "healthcare workforce," and " Boolean operators (AND, OR) were utilized to refine the search.

Inclusion and Exclusion Criteria
Studies were selected based on the following inclusion criteria: (1) empirical research articles published in peer-reviewed journals, (2) studies focused on nurses working in Saudi Arabia, (3) articles that specifically address factors influencing nurses' intention to leave, and (4) publications in English.Exclusion criteria included: (1) non-empirical studies, such as opinion pieces and editorials; (2) studies not specifically related to nursing or healthcare settings; (3) articles that do not explicitly discuss the Saudi Arabian context, and (4) studies published in languages other than English.

Data Extraction
A standardized form was used to extract relevant data from the selected articles.This form included bibliographic details (authors, year of publication), study objectives, methodology (study design, sample size, data collection methods), main findings related to nurses' intention to leave, and specific factors identified as contributing to the intention to leave.Initially, 47 studies were identified through database searches and other sources.After the removal of duplicates, 40 studies were screened for eligibility, of which 35 were assessed in detail.Ultimately, 28 quantitative studies met our inclusion criteria and were included in the final analysis.This process ensures a comprehensive and transparent approach to identifying relevant literature, adhering to the PRISMA guidelines for systematic reviews.

Quality Assessment
To ensure the reliability and validity of the included studies, a quality assessment was performed using the Critical Appraisal Skills Programme (CASP) checklist for qualitative studies and the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement for observational studies.Studies that did not meet the minimum quality criteria were excluded from further analysis.

Data Analysis
Data analysis involved synthesizing findings from the selected articles to identify common themes and factors associated with nurses' intention to leave.Thematic analysis was employed to categorize these factors into broader themes, such as work environment, job satisfaction, personal life balance, management and leadership, recognition, and opportunities for professional development.

Ethical Considerations
This study involves the review and synthesis of published literature and does not directly involve human participants; formal ethical approval not required.However, all reviewed articles were treated with respect to the ethical principles of research, ensuring confidentiality and integrity of the authors' work.

PRISMA Flow Diagram
Figure 1: PRISMA of the process of identifying and including references.

Findings
This comprehensive review elucidated the multifaceted determinants influencing Saudi Arabian nurses' job satisfaction levels and their propensity to vacate their current positions.The cross-sectional studies encompassing diverse healthcare settings revealed a moderate degree of both job satisfaction and intentions to leave among the nursing staff.Notably, income level and nationality emerged as significant variables correlating with the intent to leave and job satisfaction, respectively.Furthermore, an inverse relationship was established between job satisfaction levels and the inclination to resign, accentuating the criticality of satisfaction in retention strategies (Alanazi et al., 2023).
Diverse demographic factors, including marital status, ethnicity, employment sector, and remuneration, substantially predict nurses' intentions to resign.Specifically, being unmarried, of Filipino or Indian descent, engaged in medical and surgical domains, or receiving lower wages were strongly associated with a heightened desire to leave (Albougami et al., 2020).Moreover, the interplay between physical and psychological well-being and turnover intentions underscores the significance of quality of life in influencing employment outcomes.2021) categorized the influencers of employee turnover into nine distinct dimensions, including professional growth, leadership style, compensation, workload, interpersonal relations, and facilities-related aspects.Among these, professional development opportunities received the highest consensus on their importance, contrasting with the lower valuation of housing and hospital facilities.These dimensions collectively offer a nuanced understanding of the factors contributing to turnover intentions.

Alreshidi et al. (
Further exploration into the determinants of job satisfaction and turnover intentions reaffirmed the moderate levels of both constructs, with substantial disparities observed across income and nationality groups.This delineation underscores the complex interplay between job satisfaction, financial considerations, and cultural background in shaping nurses' employment experiences (Alanazi et al., 2023).
The analysis extended to examining the influence of age and professional tenure on turnover intentions.Nurses within the 29-33 age bracket exhibited a statistically significant propensity towards job transition, highlighting age as a pivotal factor in employment stability.Moreover, a unique cohort of nurses, characterized by 5-6 years of local clinical experience without international exposure, demonstrated a markedly reduced inclination to leave, suggesting the potential moderating role of diverse professional experiences on turnover intentions (Mariano et al., 2023).
Investigations into nurse turnover rates unveiled varied determinants, including demographic profiles, job satisfaction, leadership dynamics, and job-related attributes (Falatah & Salem et al., 2018).Additionally, the perceived quality of the work environment and communication satisfaction emerged as critical elements inversely related to nurses' intentions to depart.This relationship, mediated by communication satisfaction, illuminates the pivotal role of environmental perceptions and communicative efficacy in shaping retention (Alsufyani et al., 2021).

Discussion
The moderate levels of job satisfaction and intention to leave identified in this study reflect a nuanced equilibrium within the nursing workforce in Saudi Arabia.The significant correlations between income level, nationality, and job satisfaction/intention to leave suggest that financial and cultural considerations are pivotal in shaping nurses' employment experiences.This underscores the need for tailored approaches in policy and practice to address the diverse needs of the nursing workforce.The inverse relationship between job satisfaction and the intention to leave emphasizes the central role of job satisfaction in retention strategies.This finding is consistent with the broader literature, which consistently highlights job satisfaction as a critical determinant of employee turnover across healthcare settings globally.
The moderate levels of job satisfaction and intention to leave reported among nurses in Saudi Arabia mirror findings from global contexts, suggesting a universal challenge within the nursing profession.For instance, Almalki, Fitzgerald, and Clark (2012) identified similar patterns of job satisfaction and intention to leave among nurses in Saudi Arabia, underscoring the significant impact of work conditions and management practices on these outcomes.These findings align with international studies, such as those by Hayes et al. (2012), which reported that job satisfaction is a critical predictor of intention to leave among nurses in various countries.
The significant correlation between income level, nationality, nurses' job satisfaction, and intention to leave, which is identified in this study, is supported by the work of AlYami and Watson (2014).They highlighted the role of financial rewards and cultural integration in influencing job satisfaction among nurses in Saudi Arabia.This is consistent with research by Liu et al. (2012), who found that financial incentives and a sense of belonging were crucial in retaining nurses in China, suggesting a cross-cultural relevance of these factors.
The association between demographic factors (e.g., marital status, ethnicity, sector of employment, and income) and the intention to leave is particularly revealing.It highlights the complex interplay of personal, socio-economic, and occupational factors in influencing nurses' decisions to stay or leave their positions.These findings are in line with studies from other regions, indicating that these influences are not unique to the Saudi context but are part of a global pattern affecting healthcare workers.
The emphasis on professional development and growth as key factors influencing nurses' intentions to resign aligns with the literature, affirming that career advancement opportunities are crucial for job satisfaction and retention.The contrast between the high valuation of professional development and the lower scores for housing and hospital facilities indicates a prioritization among nurses of career growth over certain aspects of the immediate work environment.This prioritization mirrors trends observed in other countries, suggesting a universal desire among nursing professionals for career progression and lifelong learning opportunities.
The finding that younger nurses and those with specific ranges of clinical experience have differing intentions to leave introduces an important consideration for workforce planning and management.This suggests a potential generational divide in workplace expectations and retention factors, echoing findings from other healthcare contexts that younger healthcare professionals may have different career expectations and values, influencing their retention differently than their more experienced counterparts.
The importance of professional development opportunities for nurse retention identified by Alreshidi et al. (2021) echoes the findings of Tumulty, Jernigan, and Kohut (2011), who emphasized the need for career advancement pathways to enhance job satisfaction and reduce turnover intentions among nurses.This parallels the conclusions drawn by Halter et al. (2017) in the UK context, where opportunities for professional growth were significantly associated with lower intentions to leave, highlighting the universal value of career development in nursing retention strategies.
Furthermore, the influence of demographic factors, such as age and marital status, on nurses' intention to leave, as reported in this study, resonates with the findings of Mariano et al. (2023).These demographic variables have been similarly reported by Kovner et al. (2011), who examined the predictors of nurse turnover in the United States, finding that younger age and being unmarried were associated with a higher propensity to leave the nursing profession.This suggests a global trend where younger, unmarried nurses represent a demographic at higher risk of turnover.
Lastly, the negative impact of poor work environments and inadequate communication on nurses' intention to leave is corroborated by the study of Alsufyani et al. (2021).This finding is in line with the broader literature, including Aiken et al. (2012), who demonstrated that work environment quality and effective communication are paramount in retaining nurses and ensuring patient safety across healthcare systems worldwide.
The inverse relationship between the quality of the work environment, satisfaction with communication, and intentions to leave underscores the importance of a supportive work environment and effective communication in nursing retention.This finding is supported by a wealth of literature indicating that environmental factors and communication quality are critical to employee satisfaction and retention across various sectors, including healthcare.

Implications
The findings of this review have profound implications for healthcare policy and management within Saudi Arabia.They underscore the necessity of implementing multifaceted strategies to address the determinants of nurse turnover.Specifically, enhancing job satisfaction through improved work conditions, competitive remuneration, and acknowledgment of cultural diversity is crucial.Furthermore, the study highlights the importance of providing ample professional development opportunities as a key retention strategy.These insights suggest that healthcare administrators should adopt a holistic approach to workforce management, one that not only focuses on the immediate needs of the healthcare system but also prioritizes the well-being and career aspirations of its nursing staff.Addressing these factors effectively could lead to a more stable and committed nursing workforce, ultimately improving the quality of patient care in Saudi Arabia.

Conclusion
This review reveals the complex interplay of factors influencing nurses' intentions to leave their positions in Saudi Arabia, emphasizing the roles of job satisfaction, work environment, professional development, and demographic characteristics.It calls for targeted interventions to enhance job satisfaction and retention among nurses, highlighting the importance of a supportive work environment and opportunities for career advancement.Successfully addressing these issues is critical for maintaining a stable nursing workforce and ensuring high-quality healthcare delivery in Saudi Arabia.