Increasing nursing turnover is a key issue that affects the profitability and performance of healthcare organisations. The healthcare sector requires a fully engaged, highly trained and stable nursing staff. A shortage in qualified nurses leads to the deterioration of the quality of the provided healthcare services and patients’ outcomes, as well as overstressed nursing staff (El-Jardali, Dimassi, Dumit, Jamal, & Mouro, 2009; Bae, Mark & Fried, 2010). In Saudi Arabia, high nurse turnover is attributed to the fact that the country’s healthcare system relies on the services of expatriate nurses. Lamadah and Sayed (2014) estimated that there were about 77 946 expatriate nurses in 2009, and only 21.9% of the total workforce were Saudi nationals. Likewise, in 2010, 30% of the chronic staff shortage was caused by the migration of expatriate nurses (Lamadah & Sayed, 2014). A majority of foreign employees utilise Saudi Arabian healthcare resources for training and gaining experience (Al-Ahmadi, 2014; Lamadah & Sayed, 2014). After achieving their objectives, they migrate to developed nations, such as Australia, Canada, the United Kingdom and the United States to apply their skills (Al-Ahmadi, 2014). Thus, nursing turnover has various effects on distinct levels of the healthcare sector in Saudi Arabia. It results in poor quality care, increased medical errors, nurse burnout and increased expenditures, as new nurses need to be trained and recruited. The aim of this paper is to analyse the driving factors of increased nurse turnover in Saudi Arabia from three distinct perspectives: socio-cultural, politico-economic and professional-organisational. In addition, it includes a discussion of the resulting issues of this trend and offers beneficial recommendations for the improvement of the clinical settings in Saudi Arabia.
Nurse Turnover Trends in Saudi Arabia
A large proportion of Saudi Arabian healthcare expenses are related to training and recruiting medical staff. However, most paramedical staff, nurses and doctors in the Kingdom of Saudi Arabia migrate to developed countries, especially Western nations, because of improved training facilities and better opportunities (Alonazi & Omar, 2013; Al-Ahmadi, 2014). Furthermore, the existing Saudi regulations for Saudisation, which is the substitution of foreign nurses with qualified citizens, continue to escalate the costs of staffing local nurses. The rising population of Saudi citizens indicates that the region is in dire need of trained medical staff. According to the World Health Organization, approximately 170 000 nurses are required to meet the needs of patients in the kingdom (as cited in Alamri & Zuraikat, 2011). Apart from the nurse shortage, teaching facilities in the country are also limited (Alonazi & Omar, 2013). Therefore, the Saudi government should direct resources towards establishing educational institutions that are career-centred, such as nursing colleges, with the primary objective of increasing the number of local healthcare staff.
Factors that Contribute to High Nurse Turnover in Saudi Arabia
As discussed previously, the majority of nurses in Saudi Arabia are expatriates. Thus, most of the employees in the profession resign from their positions within few years of service because of contractual limitations on foreign labour. According to a survey by Aldossary, While and Barriball (2008), expatriate nurses are offered a two-year employment contract, and financial incentives are awarded after contract termination. In addition, the ability of the employees to adapt to the country’s cultural environment determines whether they renew or complete their contracts. However, on a yearly basis, only qualified staff members are allowed to renew their contracts based on their competency and familiarity with their expectations related to work (Aldossary, While, & Barriball, 2008). Other attributes, such as their educational qualifications, marital status, age, nationality and ability to cope with occupational stress are also factors in contract renewal in the Saudi Arabian healthcare sector (Al-Ahmadi, 2014).
Further, cultural issues are a major factor that contribute to increased turnover among nurses in Saudi Arabia. Limited freedom of movement and the living conditions in Saudi Arabia are not easy to accept for most nurses, especially expatriates (Al-Ahmadi, 2014; Mumenah & Al-Raddadi, 2015). There are certain personal factors that can influence nurse turnover, such as age. For instance, individuals who are aged forty years and above stay in one organisation for longer durations compared to their younger counterparts because they occupy senior positions. In addition, older staff members are experienced in distinct nursing fields and have the necessary skills to handle difficult tasks. With older employees, organisational commitment, productivity and satisfaction levels tend to be higher. In contrast, younger professionals are believed to exhibit higher job dissatisfaction levels, which increase the rate of turnover (Flinkman, Isopahkala-Bouret, & Salanterä, 2013). The psychological stresses forced on young registered nurses are believed to be a major motive to leave job as well as the inequity between the job efforts that nurses make and the payments that they get in return (Flinkman, Isopahkala-Bouret, & Salanterä, 2013). However, Al-Ahmadi (2014), in her survey of 5 423 nurses working in 80 hospitals from different regions of Saudi Arabia, reported a significantly higher intention of older professionals to leave their jobs. Given the requirements of working in the nursing profession, it is extremely difficult for aged people to perform effectively (Al-Ahmadi, 2014). For example, frequent movements to examine patients and handling people who are in critical conditions are demanding tasks that nurses must perform. Further, for those who work night shifts, remaining awake to monitor the health status of patients is a crucial requirement (Lim, Bogossian & Ahern, 2010). These tasks can be executed more effectively by young and middle-aged individuals who have the required skills and knowledge to work in the profession.
Burnout and job dissatisfaction are considered principal causes of turnover, and they affect the delivery of services to patients (Lim, Bogossian & Ahern, 2010; Akosa & Bowblis, 2016). Compared to people who work in other industries, nurses are more likely to shift from one organisation to another for job-related reasons. Job dissatisfaction among healthcare professionals results in high staff turnover, expensive labour disputes and increased medical risks to patients (El-Jardali et al., 2009). The major causes of job dissatisfaction among nurses in the Saudi Arabian healthcare system include unattractive health benefits, work overload, stress and low salaries (Al-Ahmadi, 2014; Alotaibi, Paliadelis & Valenzuela, 2016). Additionally, intention to leave job especially among newly recruited nurses may rise up when they do not receive adequate information about their tasks and stay uncertain about their responsibilities. Job dissatisfaction is also caused by not being promoted and receiving less training opportunities (Lephalala, 2008; Alotaibi, Paliadelis & Valenzuela, 2016). It is important for nurses’ working conditions to be improved by decreasing their workloads, enhancing employment benefits and instituting clear communication channels.
Nurses with appropriate educational qualifications, such as bachelor’s degrees, are less likely to resign from their jobs compared to those with certificates offered by low level colleges (Aldossary, While, & Barriball, 2008). Most nurses with higher educational qualifications are satisfied with their jobs because they earn better salaries or work in senior positions. However, another study conducted in the kingdom reported that owners of bachelor and master’s degrees are more likely to leave their jobs compared to those with college diplomas or high school graduates because of their ability to find better job opportunities (Al-Ahmadi, 2014). Given that expatriate nurses in the country are not permitted to enrol for training in local educational institutions, they are often compelled to return to their home countries to advance their education or pursue better job opportunities. Like employees in other sectors, nurses are in pursuit of better pay, a flexible work schedule and improved working conditions. Thus, they are willing to offer their services in nations that can meet their expectations.
Synthesis of Driving Factors of Nurse Turnover in Saudi Arabia Using a Conceptual Framework
The primary objective of this section is to discuss the driving factors associated with nurse turnover using a conceptual framework. The argument will be based on three perspectives: socio-cultural, politico-economic and professional-organisational. According to Sanderson (2010), the socio-cultural perspective describes the mental processes and behaviours of people as they are shaped by cultural factors. Some of the elements that affect such behaviours include nationality, gender and race. In Saudi Arabia, cultural differences are a main cause of staff shortages and high nurse turnover in the healthcare sector (Al-Ahmadi, 2014; Feleman, O’Connor, & McKenna, 2014). As discussed earlier, a majority of employees are expatriates whose inability to cope with Saudi Arabia’s work settings compels them to leave the country in pursuit of better work environments and opportunities (Al-Ahmadi, 2014; Feleman, O’Connor, & McKenna, 2014). These foreign workers are of various races and come from different nations, such as North America, South Asia, the Philippines, Eastern Europe, Western Europe and Australia, and their ways of life in their home countries are much different (Aldossary, While, & Barriball, 2008; Feleman, O’Connor, & McKenna, 2014). For instance, in Saudi Arabia, women are prohibited from driving, and this makes commuting to and from the workplace quite challenging for female professionals due to the lack of reliable and safe transportation services in the country (Mumenah & Al-Raddadi, 2015).
Individuals often consider remuneration as a measure by which to value an organisation. The Saudi community’s perception of nursing as a middle-class job is a major factor that contributes to increased turnover in the nursing profession. As such, individuals view nursing as a low-paying profession that cannot enable them to lead a fulfilling life (Lephalala, 2008; Feleman, O’Connor, & McKenna, 2014). Even though fringe benefits play an essential role in motivating employees, they are not influential in reducing high turnover rates in the healthcare sector . As such, nurses in the Saudi healthcare sector are often interested in going to countries where they are well-compensated for their work, such as Western countries (Al-Ahmadi, 2014). Apart from competitive remuneration, working in developed countries provides nurses with the opportunity to widen their skills and enjoy other benefits, including paid vacations (Feleman, O’Connor, & McKenna, 2014).
From a professional-organisational approach, the healthcare sector is transforming at a rapid rate, and it is becoming increasingly complex. Contemporary nursing leadership needs to clearly define the scope of the profession and fulfil the philosophical commitments of the job with the primary objective of enhancing the quality of the care provided to patients. One of the major factors linked to nurse turnover in the Saudi Arabian healthcare sector is job dissatisfaction. According to Alotaibi, Paliadelis & Valenzuela (2016), job dissatisfaction among Saudi nurses is caused by a wide range of factors, including a lack of fringe benefits, hospital policies, poor working conditions, a lack of recognition for performance and relationship and personal factors. The organisational factors result in experienced and quality nurses leaving the nursing profession. Others cite factors such as low morale and increased stress as the main reason for leaving the nursing profession. For all these reasons, the Saudi government needs to design personnel benefits and policies to retain experienced nurses (Hayes et al., 2012). Examples of such policies include the availability of career development opportunities, permanent professional development programmes, competitive salaries, flexible scheduling and improved working conditions (Alotaibi, Paliadelis & Valenzuela, 2016).
Issues Resulting from Increased Nurse Turnover in Saudi Arabia
According to Almalki, FitzGerald and Clark (2012), nurse turnover reduces the ability of healthcare organisations to provide high-quality service to patients. In fact, high turnover among experienced and qualified nurses has negative repercussions for both the healthcare profession and individual organisations. For instance, increased nurse turnover lowers the healthcare organisation’s capacity to deliver quality care and meet the needs of patients (Bae, Mark & Fried, 2010; Almalki, FitzGerald, & Clark, 2012). Further, the loss of competent nurses in pursuit of better opportunities in other countries results in staff shortages. The remaining nurses in Saudi hospitals suffer from stress and burnout as a result of their increased workloads, as they have to deal with a larger number of cases and adhere to the instructions of physicians at the same time. Donoghue and Castle (2007) suggested that increased workloads lead to critical transformations in nurses’ behaviours, especially their attitudes towards the job. Reduced job satisfaction, low productivity and resignation from the organisation are among the outcomes of a negative attitude towards work (Castle & Engberg, 2007). In addition, long work hours that result from staff shortages make it difficult for nurses to perform familial duties and raise children. Consequently, the perceptions of the nursing profession have lowered in society.
Moreover, the lack of experienced and adequate staff could lead to a rise in medical errors and the level of patient satisfaction declines when medical facilities begin offering low-quality services (Akosa & Bowblis, 2016). In addition, high nurse turnover is costly for Saudi healthcare organisations because they are forced to utilise more resources to recruit employees on a regular basis. These resources could be invested in other vital areas, including nurse retention programmes, staff development and quality improvement plans (Almalki, FitzGerald, & Clark, 2012). The ongoing recruitments of new nurses may result in unstable work environment because it requires time for new professionals to adapt to their job requirements and engage with their new colleagues. (Dawson, Stasa, Roche, Homer, & Duffield, 2014).
Recommendations
The main challenge for the Saudi Arabian healthcare sector is to overcome its overreliance on expatriate nurses. Even though the government is directing a large amount of resources to training and education, the demand for expatriate nurses remains high due to the inadequacy of local professionals in the medical field (Feleman, O’Connor, & McKenna, 2014). However, overdependence on foreign workers carries with it the high risk of increasing turnover rates and instability in the healthcare sector. To address the challenge, it is crucial for the Saudi government to design and implement strategies to attract and retain local citizens in health and medical professions such as nursing (Hayes et al., 2012). The government should also channel more resources towards the establishment of more institutions and colleges that offer nursing education and training programmes. With an increase in the number of institutions that provide nursing education, a large number of young students in Saudi Arabia could acquire the necessary knowledge to hold various positions in the healthcare sector (Lamadah & Sayed, 2014). Qualified locals with nursing skills would be able to provide care for patients more efficiently than expatriate nurses since they are not affected by cultural differences or language barriers (Feleman, O’Connor, & McKenna, 2014).
The Ministry of Health in the Kingdom of Saudi Arabia should set realistic long-term goals to be achieved by the existing workforce. To address staff shortages, the Ministry of Health should also collaborate with the private sector to increase the number of Saudis enrolling in healthcare programmes. Nurses’ benefits should also be revised to minimise the number of people who are shifting to developed countries in pursuit of better opportunities (Lamadah & Sayed, 2014). In addition, to reduce the gaps in knowledge and any chances for misunderstandings between nurses and patients because of cultural differences, it is important to increase development programmes and improve training for foreign staff (Feleman, O’Connor, & McKenna, 2014). Through educational programmes, expatriate nurses could acquire the necessary skills for interacting and communicating with their patients, which would result in both reduced medical errors and improved care.
Conclusion
As evidenced by the research, high nurse turnover rates jeopardise the quality of the care provided to patients. Consequently, they affect the performance of the entire healthcare sector. In Saudi Arabia, high nurse turnover is caused by overreliance on expatriate workers, whose employment contracts are limited to specific durations. As a result, the Saudi healthcare system is constantly suffering from nurse shortages that increase the workload of the nurses who remain in the profession. To address this problem, the government needs to invest in medical institutions and colleges with the goal of raising the number of local healthcare workers. With an adequate number of qualified professionals, it would be possible for organisations to meet the needs of their patients at minimal costs. Likewise, it is important for the Saudi healthcare workforce, especially for expatriate nurses, to be educated about the local culture and language to minimise mistakes when collecting information and medical errors when delivering care.
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