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Almalki et al. BMC Health Services Research 2012, 12:314 http://www.biomedcentral.com/1472-6963/12/314

RESEARCH ARTICLE Open Access

The relationship between quality of work life and turnover intention of primary health care nurses in Saudi Arabia Mohammed J Almalki1,2*, Gerry FitzGerald2 and Michele Clark2

Abstract

Background: Quality of work life (QWL) has been found to influence the commitment of health professionals, including nurses. However, reliable information on QWL and turnover intention of primary health care (PHC) nurses is limited. The aim of this study was to examine the relationship between QWL and turnover intention of PHC nurses in Saudi Arabia.

Methods: A cross-sectional survey was used in this study. Data were collected using Brooks’ survey of Quality of Nursing Work Life, the Anticipated Turnover Scale and demographic data questions. A total of 508 PHC nurses in the Jazan Region, Saudi Arabia, completed the questionnaire (RR = 87%). Descriptive statistics, t-test, ANOVA, General Linear Model (GLM) univariate analysis, standard multiple regression, and hierarchical multiple regression were applied for analysis using SPSS v17 for Windows.

Results: Findings suggested that the respondents were dissatisfied with their work life, with almost 40% indicating a turnover intention from their current PHC centres. Turnover intention was significantly related to QWL. Using standard multiple regression, 26% of the variance in turnover intention was explained by QWL, p < 0.001, with R2 = .263. Further analysis using hierarchical multiple regression found that the total variance explained by the model as a whole (demographics and QWL) was 32.1%, p < 0.001. QWL explained an additional 19% of the variance in turnover intention, after controlling for demographic variables.

Conclusions: Creating and maintaining a healthy work life for PHC nurses is very important to improve their work satisfaction, reduce turnover, enhance productivity and improve nursing care outcomes.

Keywords: Nurse, Nursing workforce, Primary health care, Quality of work life (QWL), Saudi Arabia, Turnover intention

Background Nurse turnover has been a major challenge for many health care organisations. Turnover of qualified nurses has consequences for health organisations as well as the profession as a whole. Nurse turnover can have a nega- tive impact on the capacity to meet patient needs and provide quality care [1]. In addition, the loss of nurses leads to inadequate staffing, which in turn, may decrease morale and create more stress on the ‘stayers’ due to increased workloads [2-4]. This can lead to critical

* Correspondence: [email protected] 1Faculty of Public Health and Tropical Medicine, Jazan University, Jazan, Saudi Arabia 2School of Public Health and Institute of Health and Biomedical Innovation (IHBI), Queensland University of Technology, Kelvin Grove, QLD, Australia

© 2012 Almalki et al.; licensee BioMed Central Commons Attribution License (http://creativec reproduction in any medium, provided the or

changes in the behaviour of nurses towards their jobs resulting in low work satisfaction, low productivity, and finally, leaving the organisation. Additionally, without adequate and experienced staff, error rates may increase and patient satisfaction may decrease [5]. Nurse turn- over is also costly for healthcare organisations and it “consumes resources that could be directed at core busi- ness activities, such as quality improvement programs, and staff development or nurse retention activities” [6] (p. 562). Previous research has argued the importance of quality of work life (QWL) to the commitment of health professionals, including nurses [7,8]. Brooks [9] defined QWL as “the degree to which registered nurses are able to satisfy important personal needs through their

Ltd. This is an Open Access article distributed under the terms of the Creative ommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and iginal work is properly cited.

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experiences in their work organisation while achieving the organisation’s goals” (p. 9). Assessing QWL allows organisations to understand how work environments and home life challenges affect the nurses’ work experi- ence, work satisfaction and organisational commitments [8,10]. According to Lees and Kearns [11], high QWL is essential for organisations to attract new employees and retain their workforces. However, research studies on QWL and turnover intention of primary health care (PHC) nurses are limited. A number of studies have explored QWL among

nurses; however, the majority comes from hospital- based research in western countries. To date, no such studies focus specifically on PHC nurses. Nor is there any published research on the relationship between QWL and turnover intention among this category of nurses. There is a real need to conduct further studies of QWL in different health settings, including PHC fa- cilities. This need is increased in Saudi Arabia, which has a chronic shortage of Saudi health care profes- sionals, especially nurses, which is accompanied by a high level of turnover [12,13]. Findings from a few studies conducted in the major

cities of Saudi Arabia have indicated that nurses, par- ticularly PHC nurses, are dissatisfied with their work [14,15]. According to Al Juhani and Kishk [14], in a sur- vey study conducted in the Al-Madinah region to assess the level of work satisfaction among PHC professionals, 52.4% of staff nurses were highly dissatisfied. This dissat- isfaction among PHC nurses can have a negative impact on their performance and in turn affect the quality of healthcare outcomes. Furthermore, it can result in a be- havioural intention to leave their work, which they may do ultimately. Previous studies of PHC nurses in Saudi Arabia fo-

cused on job satisfaction only, omitting other important factors such as work life/home life, work design, work context and other external factors, which form the QWL approach [16]. Consequently, there is a need to conduct a research study to explore and assess QWL and related factors among PHC nurses in the Saudi health system. The findings may assist in developing strategies to at- tract and retain more nurses to PHC organisations, par- ticularly during this era of transition into PHC. Otherwise, in light of competition to attract qualified nurses, the PHC centres in Saudi Arabia may lose skilled nurses who may prefer to work for other systems and organisations, either nationally or internationally, that provide appropriate working environments. According to Alamri et al. [17], a number of expatriate nurses leave Saudi Arabia as soon as they have obtained sufficient ex- perience to work in developed countries. This study is part of a larger study aiming to improve

the retention of PHC nurses in the Jazan region, Saudi

Arabia, through exploring and assessing their QWL and turnover intention. The purpose of the present paper, therefore, was to examine the relationship between QWL and turnover intention of PHC nurses in the Jazan region, Saudi Arabia. The main questions of this study were as follows: (a) are there significant relationships be- tween turnover intention and the selected demographic variables of PHC nurses; and (b) are the QWL dimen- sions (i.e. work life/home life, work design, work context and work world) useful in predicting turnover intention.

Primary healthcare in Saudi Arabia Saudi Arabia is one of the leading countries that has adopted and implemented the PHC approach in the Middle East [18]. In accordance with the Alma-Ata declaration at the WHO General Assembly in 1978, a ministerial decree was issued in Saudi Arabia to inte- grate the existing services such as former health offices, maternal and child health centres and small dispensaries into single unites named PHC centres [19]. PHC centres supply primary healthcare services, both preventive and curative, to the public. Using a structured referral system, cases that require advanced care are referred to the second level of care (public hospitals). Cases that need more complex levels of care are transferred to the third level of health care (refer- ral hospitals) [19]. The top-to-down relationship be- tween healthcare organisations at various levels is not clearly organised. For example, there are no communi- cation channels or planned regulations for sending patients back to PHC services from specialist or sec- ondary care sectors [20]. The Ministry of Health in Saudi Arabia (MOH) found

that approximately 82% of client visits to its facilities during 2009 were to PHC centres, comprising more than 54 million PHC clients [21]. Taking such data into ac- count, the MOH has continued to develop healthcare services in general and PHC in particular by initiating many contemporary projects. The best example for such development is the project of the Custodian of the Two Holy Mosques that aims to establish 2000 advanced PHC centres and to develop the existing ones in terms of buildings, capital resources, workforce and services provided [19]. Due to the importance of human resources in provid-

ing quality PHC services, it is integral for PHC leaders to assess their QWL and to understand their organisa- tional and career intentions. Such procedures may as- sure the continuous and improvement of the health services being provided.

A theoretical framework A theoretical framework was developed to guide this study. It incorporates the four-dimension model of

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Quality of Nursing Work Life (QNWL) (work life/home life, work design, work context and work world) [16], and a set of demographic variables that were reported in the literature as variables commonly correlated with nurses’ satisfaction and turnover intention. The ‘work life/home life’ dimension refers to “the interface between the life experiences of nurses in their place of work and in the home”, while ‘work design’ is “the composition of nursing work, and describes the actual work nurses do” [16]. The third dimension of ‘work context’ encompasses “the practice settings in which nurses work and explores the impact of the work environment on both nurse and patient systems”, while ‘work world’ takes account of “the effects of broad societal influences and changes on the practice of nursing” [16]. Demographic variables incorporated into the QWL

and Turnover Intention Model include gender, age, marital status, dependent children, dependent adults, nationality, ethnicity, level of education, nursing tenure, organisational tenure, positional tenure, location of the PHC, and payment per month. Demographic variables are frequently used in nursing research as predictors of turnover and turnover intention [22]. According to Bluedom [23], demographic variables display independ- ent effects: thus, they could not be omitted as contri- butors to turnover.

Quality Life

Work Life/Home Life Dimension •Family and family needs •Energy after work •Working hours/shifts •Policy for vacations

Work Design Dimension •Job satisfaction •Workload •Autonomy •Non-nursing tasks •Interruptions •Time to do jobs •Workforce (Staffing) •Patient care

Work Context Dimension •Management •Co-workers •Growth opportunities •Work environment

Work World Dimension •Image of nursing •Payment •Labour market •Security of Job •Belief in nursing

Turnove

Figure 1 QWL and turnover intention framework.

The proposed model assumes a correlation among work life related factors, employees’ demographic char- acteristics, QWL level and turnover intention. QWL is affected by work life factors as presented by Brooks and Anderson [16] as well as a number of demographic fac- tors, leading either to a high or low level of QWL, which can result in critical changes in the behavioural intention of the nursing employee. This intention is translated into the behaviour action of staying with the current organ- isation or leaving. The correlation between the level of QWL and the employees’ behaviour action, however, can be further affected by the selected employees’ demo- graphic factors. For example, when QWL is low, it is expected that this would lead to turnover intention, and finally, to actual turnover. In some cases, besides the QWL level, the employees’ demographic factors may have a significant impact on the final decision of turn- over (see Figure 1).

Methods Design and sample A cross-sectional survey was used in this study. All PHC nurses in the Jazan region, Saudi Arabia, were eligible for inclusion in the sample. There were 134 PHC centres employing approximately 585 Saudi and non-Saudi

of Work Level

Demographics •Gender •Age •Marital status •Dependent children •Dependent adults •Nationality •Ethnicity •Education level •Nursing tenure •Organisational tenure •Positional tenure •Location of PHC •Salary per month

r Intention

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nurses. A total of 508 PHC nurses returned a usable questionnaire, yielding an 87% response rate.

Instruments In addition to the demographic questions, two instru- ments where used in this study. These include the Anticipated Turnover Scale (ATS) and the Brooks’ sur- vey of QNWL. The ATS survey was developed by Hin- shaw and Atwood in 1978 to study turnover intention among nurses [24]. The ATS is a 12-item self-adminis- tered instrument with a 7-point Likert scale ranging from ‘agree strongly’ to ‘disagree strongly’ [24]. The instrument’s items were related to an employee’s antici- pated length of time to leave and certainty of leaving the job. The total score was obtained by calculating the sum of all items in the scale divided by the number of items in the scale. Higher scores reflect greater intent to leave the present position or job. Responses with means over 3.5 were considered as an indication for turnover intention [25]. According to Hinshaw and Atwood [24], the construct validity for the ATS was estimated using principal component factor analysis. Findings identified two factors which accounted for 55% of the variance. The internal consistency reliability estimated with Cron- bach’s α was .84 [24]. The ATS has been used frequently to measure turnover intention among nursing work- forces in various healthcare settings [25-32]. Barlow and Zangoro [33] conducted a meta-analysis study aimed at determining the consistency of reliability estimates and evidence of construct validity of the ATS scores across nursing studies in the USA. The overall mean weighted effect size of reliability from 12 studies was .89, indicat- ing excellent reliability and construct validity. In the present study, Cronbach’s alpha for ATS is (.90). The QNWL survey was developed by Brooks [9] to

measure QWL among Registered Nurses. It consists of 42 items related to four dimensions: (a) work life/home life, (b) work design, (c) work context and (d) work world. The instrument asks respondent nurses how much they agree or disagree with each item on a 6-point scale ranging from 1 ‘strongly disagree’ to 6 ‘strongly agree’. The test-retest reliability was determined in a traditional 14-day manner with Pearson’s r = .90 (n = 53), where 1.00 indicated ‘perfect’ reliability. In terms of construct validity, the total calculated for the 42-item survey using Cronbach’s α is .89 (n = 265) where 1 indi- cates ‘perfect’ validity [9]. In this study, Cronbach’s alpha for Brooks’ scale is (.89). Brooks’ survey of QNWL has been used by other published works in the USA and Iran [10,16,34,35], with increasing interest globally [36]. The instruments used were contextualized to the local con- text and the multicultural nursing workforce in Saudi Arabia. In addition to the original English format, the questionnaire used was translated into Arabic using a

translating and back translated technique and a commit- tee approach [37]. Two bilingual researchers blindly translated the instruments: one from English to Arabic, and the other back-translated the questionnaire [37]. A panel of three bilingual experts in health research and in health management reviewed the questionnaire and assured its validity. Two pilot studies were conducted to ensure the clarity and appropriateness of the question- naire [20].

Data collection and analysis Following permission from the MOH in Saudi Arabia to conduct the study, ethics approval from Queensland University of Technology was obtained (no.0800000406). The survey was sent to PHC nurses through the Depart- ment of PHC in Jazan. Each nurse was provided with a survey package including a cover letter, questionnaire, and an individual envelope. The cover letter explained the research, provided contact details of the researchers, and outlined the steps taken to maintain confidentiality. No names or other identifiable information of respon- dents were required. Each respondent in every PHC centre was requested through the information letter to seal the completed survey separately within the provided individual envelope. Then, all nurses in the same work- place were instructed to seal their surveys together in another labelled large envelope (provided) and return them to the Department of PHC through the internal mail service. Participants were informed of the voluntary nature of participation. The returned completed ques- tionnaires indicated consent to participate. More details on the data collection procedure are reported in an- other paper published elsewhere [38]. Descriptive sta- tistics, t-test, ANOVA, General Linear Model (GLM) univariate analysis, standard multiple regression, and hierarchical multiple regression were applied for ana- lysis using SPSS v17 for Windows.

Results The majority of nurses were Arab (73.8%), Saudi (72.2%), females (67.3%) and aged between 20 and 29 years (44.1%). The majority of respondents declared that they were married (73.8%), and had children (61%) and/or dependent adults (54.9%). Approximately half of the sample (47.4%) had a Diploma, 33.7% had an Institute Certificate, 12.8% had an Associate Degree, and 5.3% had a Bachelor Degree or higher. About 46% of the sample received a monthly salary of 5,000 to 10,000 Saudi Riyals (SR) (1US$ = SR 3.75) (46.3%). Among the respondents, 62% stated that they cover two departments or more dur- ing their duties. The mean work experience as an RN was 11.3 years, with about 6.6 years in the current PHC organisation and 6.1 years in the current position.

Table 1 Turnover intention by demographic variables using t-test and ANOVA

Variable Mean SD t/F-value P-value

Gender

Male 43.99 13.61 3.48 0.001

Female 39.71 11.62

Age

20-29 years 43.20 11.87 7.24 <0.001

30-39 years 41.79 13.48

40-49 years 35.93 11.58

50-59 years 38.36 9.46

Marital status

Never married 43.37 12.89 2.98 0.052

Married 40.48 12.29

Divorced/Widowed 37.42 12.21

Dependent children

Yes 39.97 12.56 −2.59 0.010

No 42.89 12.12

Education level

Institute 38.87 13.66 3.12 0.026

Diploma 41.86 11.73

Associate 43.66 12.69

Bachelor or higher 41.96 8.75

Nursing tenure

≤ 4 years 44.37 130.05 9.49 <0.001

5-9 years 41.93 10.76

≥ 10 years 38.82 12.51

Organisational tenure

≤ 4 years 43.52 12.21 16.50 <0.001

5-9 years 41.06 11.50

≥ 10 years 36.28 12.31

Positional tenure

≤ 4 years 43.84 12.45 20.64 <0.001

5-9 years 39.92 10.92

≥ 10 years 35.62 11.85

Payment per month

< SR 5,000 42.45 10.53 9.60 <0.001

SR 5,000-10,000 42.98 12.80

> SR 10,000 37.25 12.82

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The total possible score for Brooks’ scale can range from 42–252. A low total scale score indicates a low overall QWL, while a high total score indicates a high QWL. Respondents had a range score of 45–218 (M = 139.45), which is lower than the average score on Brooks’ scale, indicating that the respondents were dis- satisfied with their work life [39]. This part of the find- ings will be reported and discussed elsewhere [38]. In terms of turnover intention, findings suggested that about 40% of the respondents indicated that they intended to leave their current PHC centre.

Demographic variables and turnover intention An independent samples t-test and an ANOVA were conducted to examine if there is any relationship be- tween the turnover intention and the demographic vari- ables. Significant associations were found between turnover intention and demographic variables of gender, age, marital status, dependent children, education level, nursing tenure, organisational tenure, positional tenure, and payment per month. The eta squared test for these demographics indicates small to medium effect size of the variation in turnover intention scores. The associa- tions between turnover intention and demographic vari- ables of dependent adults, nationality, ethnicity, and location of PHC were not significant. Results of t-test and ANOVA procedures are presented in Table 1. The demographics were also examined as a set using the GLM univariate. The results found that only four demo- graphic variables had strong relationships with turnover intention, p < 0.05. These were gender, dependent adults, positional tenure and payment per month. How- ever, the model as a whole is still significant. Altogether, the demographic variables explain 11.1% (Adjusted R2 = .111) of the variability in turnover intention, F(4,444) = 14.976, p < 0.001. Table 2 presents the parameter esti- mates for the significant demographic variables on the turnover intention scores.

QWL and turnover intention results A standard multiple regression was performed between turnover intention as the dependent variable and the four dimensions of QWL (work life/home life, work de- sign, work context, and work world). Altogether, 26% of the turnover intention among the PHC nurses was explained by knowing the scores for the four dimensions of QWL. R for regression was significantly different from zero, F(4,491), 43.71, p < 0.001, with R2 = .263 (see Table 3). The largest beta value in this case was -.387, which is

for work context, followed by work design (−.112). This means that the work context variable makes the stron- gest unique contribution to explaining turnover intention, when the variance explained by all other

variables in the model was controlled. The other signifi- cant variable was work design p < 0.05. Its beta value (−.112) was lower than the work context value, indicat- ing that it made less of a contribution. Although the bi- variate correlations between turnover intention and each of the work life/home life and work world dimensions were statistically different from zero (see Table 4), they

Table 2 Parameter estimates of the demographic variables on the turnover intention using the GLM univariate analysis

Parameter Estimates Std. Error t Sig. 95% Confidence Interval

Lower Bound Upper Bound

Intercept 46.069 1.546 29.804 <0.001 43.031 49.107

Gender

1 = Male 4.371 1.286 3.399 0.001 1.844 6.898

2 = Female 0a . . . . .

Dependent adults

1 = Yes 2.238 1.162 1.925 0.055 -.047 4.522

2 = No 0a . . . . .

Positional tenure -.350 .092 −3.792 <0.001 -.532 -.169

Payment per month -.644 .197 −3.261 0.001 −1.032 -.256

a. This parameter is set to zero because it is redundant. Note. Dependent variable: Turnover Intention. Only significant demographic variables and intercepts were presented in this table. R Squared = .133 (Adjusted R Squared = .098).

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did not contribute significantly to the explanation of turnover intention. Apparently, the relationship between turnover intention and each of the work life/home life and work world dimensions are mediated by the rela- tionships between the other independent variables (work design and work context) and turnover intention. Table 5 displays the unstandardised coefficients (B), standard error, standardised coefficients (β), t value and the sig- nificance of model for the standard multiple regression. The hierarchical multiple regression analysis was used

to examine if the QWL dimensions are still useful in predicting turnover intention after controlling for the possible effect of the demographic variables. The demo- graphics were entered at Step 1, explaining 13.2% of the variance in turnover intention. After entry of the four dimensions of QWL (work life/home life, work de- sign, work context and work world) at Step 2, the total variance explained by the model as a whole was 32.1%, F(17.433) = 12.04, p < 0.001. The four QWL dimen- sions explained an additional 19% of the variance in turnover intention, after controlling for demographic variables, R squared change = .19, F change (4, 433) = 30.190, p < 0.001. In the final model, only four variables where statistically significant: work context recording a highest beta (β = −.37, p < 0.001), followed by pos- itional tenure (β = −.30, p < 0.05), payment per month (β = −.23, p < 0.05), and finally, gender (β = −.11, p < 0.05). Table 6 displays the unstandardised coefficients (B),

Table 3 Model summary for standard multiple regression of the QWL dimensions on the turnover intention scores

Model R R2 Adjusted R2 Std. Error of the Estimate

1 .512a .263 .257 10.625

a. Independent Variables: (Constant), Work life/Home life, Work Design, Work Context, Work World. Note. Dependent Variable: Turnover intention.

standard error, standardised coefficients (β), t value and the significance of the model for hierarchical multiple regression.

Discussion The findings of the present study indicated that the respondents were dissatisfied with their work life. These findings are consistent with findings of a number of previous studies where nurses were not satisfied with their work life [10,34,40]. Successful QWL strategies in healthcare settings can improve employees’ morale and organisational effectiveness [41]. Additionally, QWL can improve the quality of care provided as well as recruit- ment and retention of the nursing workforce [36,42]. Using the ATS, about forty percent (40.4%, n = 205) of

the respondent nurses indicated that they intended to leave their current employment. This finding supports the notion that turnover and turnover intention are high among nurses in general [43-46], and among nurses working in Saudi Arabia [47-49]. Saeed [49] conducted a study in Riyadh to determine the variables related to nurses’ intention to leave their hospital. Data were col- lected from three hospitals in Riyadh. Of the 488 respondents, 275 (56.4%) intended to leave their job. Al- Ahmadi [47] collected data from 434 nurses working in nine psychiatric hospitals randomly selected from vari- ous geographic regions of Saudi Arabia. Results showed that 37% of nurses had the intention to leave the institu- tion. Most recently, Zaghloul, et al. [48] studied the intention of 276 nurses to stay at a university hospital in Al-Khobar, Saudi Arabia. Findings revealed that about 17% of the sample (47 nurses) agreed that they had intentions to leave. Additionally, more than half of the respondents were not sure exactly whether they intended to leave or not. Studies on health professionals, other than nurses, in Saudi Arabia reported similar

Table 4 Correlation between QWL variables and turnover intention

Variables Turnover Intention*

Work life/ home life

Work Design

Work Context

Work life/home life -.245**

Work Design -.408** .446**

Work Context -.497** .424** .667**

Work World -.291** .309** .444** .418**

* Dependent variable. ** Correlation is significant at the 0.01 level.

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findings as well. For example, Al-Ahmadi’s [50] study found that approximately 38% of respondents reported an intention to leave their current hospital. However, the present study is the first to address the issue of turnover intention in the PHC sector in Saudi Arabia.

Demographic variables and turnover intention Findings of this study revealed significant associations between turnover intention and demographic variables of gender, age, marital status, dependent children, edu- cation level, nursing tenure, organisational tenure, pos- itional tenure, and payment per month. Younger nurses were more likely to indicate turnover intention compared to older nurses, a finding consistent with prior research [51]. On the other hand, older nurses were reported in several studies to be more satisfied with their work and, in turn, less likely to plan on leaving [44,52-56]. Older nurses may have strong per- sonal ties to the organisation and leaving the organisa- tion (before retainment) would be costly and unworthy for them [57-59]. Male respondents had a higher intention to leave their

current employment. The literature is not consistent in terms of the relationship between gender and each of employees’ satisfaction and turnover intention. A num- ber of nursing studies support the notion that the female nurses are more satisfied in their work and are more likely to stay [60-64]. Other studies found no relation- ship between gender and employees’ satisfaction and their intention to leave [44,47,65]. It can be argued that male nurses were less satisfied with their work life and

Table 5 Summary of coefficients for the standard multiple reg intention scores

Model Unstandardized Coefficients

Variable B Std. Error (SE

1 (Constant) 79.878 3.210

Work life/home life -.018 .107

Work design -.208 .102

Work context -.394 0.055

Work world -.270 .155

Note. Dependent variable is turnover intention. * p < 0.05. ** p < 0.001.

were more intent on leaving their current employment for two reasons: first, male nurses in this study com- prised 32.7% (n = 166/508) and about 99% of them (n = 164) were Saudis. Saudi males are responsible for their families, parents and relatives; thus, they prefer to work in or close to their communities so they can meet their responsibilities. However, contrary to the Saudi female nurses, the Saudi male nurses do not have the opportun- ity to work in their living areas − Saudi female nurses are given this priority [15]. Another possible cause for gen- der difference in terms of turnover intention is the poor public image of nursing in Saudi Arabia. Although 36.4% of the nursing workforce in Saudi Arabia are males, community members do not regard nursing as highly as other health disciplines. Male nurses are particularly not well regarded by the community. ‘Hidden turnover’ among Saudi male nurses is a challenge for public healthcare organisations where male nurses work in management or other non-nursing or non-clinical departments and yet are officially counted in the nursing workforce. This kind of ‘turnover’ appears in the public health facilities due to lack of accountability for em- ployee and management departments. In this case, or- ganisational turnover and professional turnover are associated. Nurses who have never married were more likely to

indicate turnover intention. This finding is consistent with the literature [66]. A possible explanation for this finding is that the nurses who have never married were younger compared to the other groups so they may not have the required clinical and life skills to cope with their working environment when it differed from their expectation. Additionally, nurses who have never mar- ried may have less family responsibilities so they do not have to consider moving family members when transfer- ring to another organisation [67]. Respondents with children were less likely to indicate

an intention to leave than those who had no children. This could be attributed to the responsibilities of parent- nurses ‘as breadwinners’ towards their family members, including children. According to Phillipson and Smit [68], financial commitments to children such as pressure

ression of the QWL dimensions on the turnover

Standardized Coefficients t Sig.

) Beta (β)

24.888 <0.001

-.007 -.169 0.866

-.112* −2.041 0.042

-.387** −7.209 <0.001

-.077 −1.740 0.082

Table 6 Summary of coefficients for hierarchical multiple regression of the QWL dimensions on the turnover intention scores after controlling for demographic variables

Model Unstandardized Coefficients Standardized Coefficients t Sig.

Variable B Std. Error (SE) Beta (β)

Step 1 (Constant) 59.524 6.135 9.702 <0.001

Gender −4.405 1.394 -.168* −3.159 0.002

Positional tenure -.543 .229 -.301* −2.368 0.018

Payment per month −1.310 .393 -.361** −3.336 0.001

Step 2 (Constant) 87.826 6.169 14.235 <0.001

Gender −2.907 1.253 -.111* −2.319 0.021

Positional tenure -.532 .204 -.295* −2.602 0.010

Payment per month -.840 .353 -.231* −2.381 0.018

Work life/home life -.047 .127 -.019 -.366 0.715

Work design -.128 .109 -.069 −1.174 0.241

Work context -.380 0.058 -.374** −6.507 <0.001

Work world -.225 .162 -.064 −1.386 0.166

Note. R2 = .132 (Adjusted R2 = .106) for Step 1, R2 = .321 (Adjusted R2 = .294) for Step 2 (p < 0.001). Only significant coefficients and QWL dimensions are presented in this table. * p < 0.05. ** p < 0.001.

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to fund them through university may increase the likeli- hood for people to remain in their workplace. This was supported in previous research [69,70]. Respondents with an Associate Degree were more

likely to indicate turnover intention compared to other groups. While a number of studies found higher status of education to be more related to nurses’ turnover intention [49,64,71-73], others revealed the opposite [4,44]. Moreover, a number of studies found no signifi- cant relationship between education status of nurses and their turnover or turnover intention [47,74,75]. In the current study, it could be argued that Asso-

ciate Degree holders were intending to leave in order to pursue their studies. While they usually study for about three and a half years to graduate with an As- sociate Degree in nursing, in practice they perform the same tasks as Diploma or Institute graduates. However, when they decide to pursue further study inside the country, they receive no recognition of prior learning and thus must start their studies from scratch [76]. All these factors may negatively influ- ence their commitment to their organisations and profession and push them to leave. Negative relationships were revealed between turn-

over intention and years of experience in nursing, with the organisation and in the current position. Turnover intention decreased as the years of experience increased. This finding is consistent with prior research [61,64,77]. It could be argued that nurses with longer years in their jobs may have become used to their work, duties, co-workers, general working environment and the organisation’s system; as a result, they have developed a high level of commitment to their work, position and

organisation. Thus, they do not intend to leave their organisation. Level of salary was significantly associated with the

scores of turnover intention. Nurses with lower salary demonstrated higher intent of turnover than higher sal- ary employees. This indicates that salary is important for the satisfaction and retention of the PHC nurses. According to Gardulf et al. [43], salary alone may not be the only factor encouraging nurses to leave, as not being offered an opportunity to discuss the salary and related criteria may also be a contributing factor. For example, nurses may not know why they receive the salary that they do and what to do to improve it.

Relationship of QWL and turnover intention The findings indicated that the QWL dimensions explained 19% of the variance in turnover intention. How- ever, the model as a whole (demographics and QWL dimensions) explained 32.1% of variance in nurse’s turn- over intention. These findings are similar to the models tested by Tourangeau and Cranley [64], Shader, et al. [54], Gregory, Way, LeFort, Barrett and Parfre [78], Sourdif [73] and Larrabee, et al. [75], which explained 34%, 31%, 31%, 26% and 25.5% of variance in turnover intention. The work context dimension makes the strongest

unique contribution to explaining turnover intention, followed by the work design dimension, β = −.387 and β = −.112, respectively. The ‘work context’ dimension includes a number of variables: management and super- vision, co-workers, professional opportunities and work environment. These variables were found in prior research to be associated with turnover intention [54,79].

Almalki et al. BMC Health Services Research 2012, 12:314 Page 9 of 11 http://www.biomedcentral.com/1472-6963/12/314

Evidence was found to support the impact of the ‘work design’ variables on the PHC nurses’ turnover intention. These variables include job satisfaction level, workload, lack of workforce, lack of autonomy, non-nursing tasks, interruptions, limited time to do jobs and patient care [54,80,81]. Although the bivariate correlations between turnover

intention and each of the work life/home life and work world dimensions were statistically different from zero, they were not found to be statistically significant contri- butors to turnover intention among the PHC nurses using multiple regression analysis. However, the impact of these two dimensions on the nurse’s turnover intention cannot be omitted. Factors such as family needs, working hours, salary and public image of nursing were reported in prior research as important predictors of the nurses’ turnover intention [44,46,79,82]. It could be argued that the questionnaire items

regarding home life/work life and work world did not cover all the variables of these dimensions. Including additional variables to the scale may explain more variance in nurses intention to leave or stay [64]. For example, a model tested by Boyle, Bott, Hansen, Woods and Taunton [83] explained 52% of variance in ICU nurse intention to stay, because they used a large number of independent variables. As argued by Tourangeau and Cranley [64], the regression model of the current study explained about 32% of variance in nurses’ turnover intention, meaning that approxi- mately 68% of variance remained unexplained. This indicates that there are other important predictor variables to turnover intention of PHC nurses not captured by the model [64].

Limitations This study has a number of limitations. First, it used a con- venience sampling method that may limit generalization of the findings to PHC nurses in Saudi Arabia. However, it is noted that all of the PHC centres in the Jazan region were included in the study. In addition, the study used a self- reporting survey to collect the data, leaving the interpret- ation to the participants. Finally, the questionnaires were distributed to the participants through the managers of the PHC centres. These managers may have pressured the nurses to complete the survey in a particular way. How- ever, no such case reports were received by the research- ers. Despite these limitations, the study has provided important findings and contributed significantly to the body of research knowledge regarding QWL and turnover intention of PHC nurses. The findings could assist Nurse Managers and policy makers to understand the impact of work life experience on the retention challenges of PHC health professionals, particularly nurses.

Suggestions for further research Using a cross-sectional survey design limits the observa- tion of change over time. Further longitudinal study is required to look at changes in QWL and turnover intention of PHC nurses at various points in time. Ideally, participants would be linked at different time points. Such a methodology would enable actual attri- tion to be monitored against turnover intention. It would be valuable to conduct an intervention study

to improve QWL and retention of PHC nurses consider- ing the findings of the present study. For example, a PHC centre or a small group of PHC centres could be chosen for a longitudinal intervention study to assess the impact of providing supportive facilities for nurses, clearly identifying roles and tasks, offering better pay- ment and professional opportunities on the improving the QWL and retention of nurses. This would help in assessing the impact of such strategies on reducing turn- over of PHC nurses. There is a need to conduct a series of comparative

studies focusing on QWL and turnover intention of nurses. These studies may compare nurses to other health professionals in PHC centres and PHC nurses to hospital nurses as well as nurses in public sector to nurses working in private health organisations. Variety in health systems and working environments may pro- duce different determinants of QWL and turnover intention of nursing personnel.

Conclusions Nurse turnover is a major challenge for many healthcare services and it interacts with the employees’ QWL. The PHC nurses in this study indicated low satisfaction with their QWL and a high turnover intention. There is a sig- nificant association between QWL and turnover intention of PHC nurses. This information could be used to develop appropriate strategies to improve QWL and to reduce the turnover of PHC nurses. Sustaining a healthy work life for PHC nurses is crucial to improve their QWL, increase retention, enhance performance and productivity and promote safe nursing care.

Competing interests The authors declare that they have no competing interests.

Authors' contributions All of the authors have contributed significantly in the development of this work. M. J. Almalki contributed to the design, collected and synthesized the data used in this paper and wrote the main text. G. FitzGerald and M. Clark contributed to the design, editing and revisions of the manuscript. All authors read and approved the final manuscript.

Acknowledgements The authors are grateful to the PHC nurses in the Jazan region, Saudi Arabia for their participation. This study was funded and supported by the Saudi Government.

Almalki et al. BMC Health Services Research 2012, 12:314 Page 10 of 11 http://www.biomedcentral.com/1472-6963/12/314

Received: 11 January 2012 Accepted: 4 September 2012 Published: 12 September 2012

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doi:10.1186/1472-6963-12-314 Cite this article as: Almalki et al.: The relationship between quality of work life and turnover intention of primary health care nurses in Saudi Arabia. BMC Health Services Research 2012 12:314.

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