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Turnover among Filipino nurses in Ministry of Health hospitals in Saudi Arabia: causes and recommendations for improvement Khalid Abdullah Aljohani,a Omar Alomarib

From the aDepartment of Nursing, Taibah University, Madinah, Saudi Arabia; bDepartment of Nursing, Sultan Qaboos University College of Nursing, Muscat, Oman

Correspondence: Dr. Khalid Abdullah Aljohani ∙ Department of Nursing, Taibah University, Madinah 41311, Saudi Arabia ∙ aljohani. [email protected] ∙ ORCID: http:// orcid.org/0000-0003-3242-082X

Citation: Aljohani KA, Alomari O. Turnover among Filipino nurses in Ministry of Health hospitals in Saudi Arabia: causes and recommenda- tions for improvement. Ann Saudi Med 2018; 38(2): 140-142 DOI: 10.5144/0256-4947.2018.140

Received: December 31, 2017

Accepted: February 7, 2018

Published: April 5, 2018

Copyright: Copyright © 2018, Annals of Saudi Medicine, Saudi Arabia. This is an open access article under the Creative Commons Attribution-NonCommercial- NoDerivatives 4.0 International License (CC BY-NC-ND). The details of which can be accessed at http:// creativecommons. org/licenses/by- nc-nd/4.0/

Funding: None.

BACKGROUND: Nurse turnover is a critical challenge for healthcare organizations as it results in a decreasing nurse/patient ratio and in- creasing costs. AIM: Identify factors influencing the termination of Filipino nurses in Ministry of Health (MOH) hospitals and record nurse recommendations to improve retention. DESIGN: Cross-sectional. METHODS: Data was gathered from a convenience sample of Filipino nurses with previous experience in MOH hospitals in Saudi Arabia who attended recruitment interviews at the Saudi employment office in Manila. RESULTS: The sample included 124 nurses. Major turnover factors in- cluded low salary (18.3%), low nurse/patient ratio (15%), end of con- tract (14.5%), discrimination (13.5%), and bad accommodations (9%). Suggested areas of improvement included financial motivations (34%), administration support (25%), quality of life (25%), and work environ- ment (16%). CONCLUSION: Managing nurse turnover can be implemented on the organizational as well as at MOH levels. The recommendations given by the participants provide direct targets to improve retention. LIMITATIONS: With convenience sampling, the sample is probably not representative of the Filipino nursing population. CONFLICT OF INTEREST: None.

N urses turnover is a critical challenge for healthcare systems.1-3 The turnover rates in the United States, Australia, the United Kingdom,

and Canada are 16.2%, 15%, less than 15%, and 20%, respectively.2,4-7 The estimated turnover in Jordan is higher at 32%.8 Earlier national studies have indicated that the average stay of expatriate nurses is 2.2 years.9

Consequently, the cost of continued replacement of nurses as a result of turnover is affecting all healthcare organizations in Saudi Arabia. This study explores the causes of turnover among Filipino nurses who had worked in the Ministry of Health (MOH) hospitals in Saudi Arabia who re-applied to work in the Saudi MOH. In addition, the study requested participant recommen- dations to minimize turnover.

SUBJECTS AND METHODS A convenience sample of female Filipino nurses with previous experience in the Saudi MOH was obtained from nurses attending Saudi MOH recruitment inter- views at the Saudi Employment Office in Manila in 2015. The participants were given a questionnaire de- veloped by the researchers from earlier questionnaires exploring turnover in the Saudi context.1,2,9 The instru- ment consisted of three sections: demographic data, reasons for turnover/termination, and participant rec- ommendations to improve nurse retention (qualitative short answer).

Data are presented as descriptive statistics (frequen- cy and percentage). Section three of the questionnaire was analyzed by thematic content analysis. The re-

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searcher used nurse retention factors identified in pre- vious studies as a framework to cluster the responses of the participants around the main themes.10,11

Approval to conduct the study was granted by the Saudi Employment Office in Manila and the Philippine Office of Employment. Since no personal data or any identifying information were gathered, verbal consent and acceptance to take part in the study by the partici- pants satisfied the ethical requirement to conduct the study.

RESULTS Of 63 invited, 142 agreed to participate (87%) (Table 1). Low salary and low nurse:patient ratio were the most common reasons for leaving employment (Figure 1). The study participants suggested numerous im- provements that were classified into four dimensions: financial motivations (34%), administration support (25%), quality of life (25%), and work environment (16%) (Table 2).

DISCUSSION The top cause of turnover was low salary (18.3%). Financial incentives are a major driving force for nurses working in international organizations.12 Despite the nurses being aware of their salary before signing the contract with MOH, actual salary may vary due to differ- ences in financial incentives between remote hospitals, general hospitals and medical cities, and overtime in medical cities and tertiary hospitals. Moreover, nurses

Table 1. Demographic characteristic of the study sample (n=124).

Demographic characteristic n %

Age (years)

<30 65 52.4

30-40 52 41.9

>40 7 5.6

Length of service in Saudi Arabia (years)

1-3 62 50

4-6 39 31.4

>6 23 18.5

Work settings

Hospitals 100 80.6

Primary health care

24 19.4

Figure 1. Reasons for turnover.

Table 2. Recommendations to improve the turnover rate.

n %

Financial 81 34%

Increase salary 59 24.6

Add financial benefits

22 9.2

Administration support 60 25%

Stop discrimination 26 10.8

Transparency in policy

11 4.6

Standard appraisal/ credentialing

9 3.7

Improve professional growth

6 2.5

Stick to contract 5 2.0

Flexibility to change workplace

3 1.2

Quality of life 60 25%

Improve accommodations

37 15.4

Increase holidays and day-off

15 6.2

Appreciation 5 2.0

Assure safety 3 1.2

Work environment 38 16%

Minimize understaffing

35 14.6

Decrease paperwork

1 0.4

Utilize temporary staff

2 0.8

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who work in small and remote hospitals or primary healthcare are affected by low staff numbers, and are consequently susceptible to low nurse/patient ratio (15%). Financial motivations include an increase in wag- es and financial benefits. Due to a shortage of staff, in- creased workload, and emergency situations, hospitals have to ask nurses to work for extra hours. The accred- ited hours are accumulated as extra-offs, but the nurses are rarely allowed to use their extra-off days during a shortage crisis. If nurses are unable to enjoy their extra- off days either financially or by having more holidays, they may experience job dissatisfaction and burnout,11 which may result in turnover.

Improving the work environment is an applicable strategy on the organizational level. Participants men- tioned three recommendations: minimize understaff- ing, decrease paperwork, and use temporary staff. Other recommendations could be attained by adopt- ing a mixed approach to nursing skills where simple nursing skills are delegated to nurse assistants and

1. Battistelli A, Portoghese I, Galletta M, Pohl S. Beyond the tradition: test of an integrative conceptual model on nurse turnover. International Nursing Review. 2013;60(1):103-111. 2. Rondeau KV, Wagar TH. Human re- source management practices and nurs- ing turnover. Journal of Nursing Educa- tion and Practice. 2016;6(10):101. 3. Li Y, Jones CB. A literature review of nursing turnover costs. Journal of nursing management. 2013;21(3):405-418. 4. Colosi B. 2017 National Health Care Retention & RN Staffing Report: NSI Nurs- ing Solutions, Inc.;2017. 5. Roche MA, Duffield CM, Homer C, Buchan J, Dimitrelis S. The rate and cost

of nurse turnover in Australia. Collegian. 2015;22(4):353-358. 6. NHS Confederation. NHS registered nurse supply and demand survey: NHS Confederation;2015. 7. O’brien?Pallas L, Murphy GT, Shamian J, Li X, Hayes LJ. Impact and determi- nants of nurse turnover: a pan?Canadian study. Journal of nursing management. 2010;18(8):1073-1086. 8. Al-Maaitah R, Shokeh D. The nursing workforce in Jordan: A policy oriented approach. Amman: Jordanian Nursing Council. 2009. 9. Alonazi NA, Omar MA. Factors affect- ing the retention of nurses. Saudi medical journal. 2013;34(3):288-294.

10. Combs J, Liu Y, Hall A, Ketchen D. How much do high?performance work practices matter? A meta?analysis of their effects on organizational performance. Personnel psychology. 2006;59(3):501- 528. 11. Al-Turki HA, Al-Turki RA, Al-Dardas HA, Al-Gazal MR, Al-Maghrabi GH, Al- Enizi NH, Ghareeb BA. Burnout syndrome among multinational nurses working in SaudiArabia. Ann Afr Med. 2010 Oct- Dec;9(4):226-9. doi: 10.4103/1596- 3519.70960. PubMed PMID: 20935422. 12. Baptiste M. Workplace discrimination: An additional stressor for internationally educated nurses. Online journal of issues in nursing. 2015;20(3).

REFERENCES

allied health professionals. Evidence-based human resource management has been reported to have positive organizational outcomes.12 More important, is support of nurse transfers between healthcare orga- nizations within the health sectors.

In conclusion, the Saudi healthcare systems es- pecially MOH, are facing significant challenges and transformations. These challenges can be navigated by addressing the needs of the nurses who represent the majority of the entire healthcare workforce in the country. The study identified the causes of turnover and recommendations to improve retention by the affected segment of nursing personnel. Approaches to manage these challenges are applicable on the organizational and MOH levels. Health planners may utilize further approaches to predict the nursing work- force stability, which is crucial to healthcare system transformation. The primary limitation of the study was the convenience sample, which limits generaliz- ability.