Turnover among Filipino nurses in Ministry of Health hospitals in Saudi Arabia: causes and recommendations for improvement.

BACKGROUND: Nurse turnover is a critical challenge for healthcare organizations as it results in a decreasing nurse/patient ratio and increasing 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 included low salary (18.3%), low nurse/patient ratio (15%), end of contract (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 environment (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.

Nurses 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 recommendations 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 interviews at the Saudi Employment Office in Manila in 2015. The participants were given a questionnaire developed by the researchers from earlier questionnaires exploring turnover in the Saudi context.1,2,9 The instrument consisted of three sections: demographic data, reasons for turnover/termination, and participant recommendations to improve nurse retention (qualitative short answer).

Data are presented as descriptive statistics (frequency and percentage). Section three of the questionnaire was analyzed by thematic content analysis. The researcher used nurse retention factors identified in previous 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 participants 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 improvements that were classified into four dimensions: financial motivations (34%), administration support (25%), quality of life (25%), and work environment (16%) (Table 2).

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

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 differences in financial incentives between remote hospitals, general hospitals and medical cities, and overtime in medical cities and tertiary hospitals. Moreover, nurses 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 wages and financial benefits. Due to a shortage of staff, increased workload, and emergency situations, hospitals have to ask nurses to work for extra hours. The accredited 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 mentioned three recommendations: minimize understaffing, decrease paperwork, and use temporary staff. Other recommendations could be attained by adopting a mixed approach to nursing skills where simple nursing skills are delegated to nurse assistants and 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 organizations within the health sectors.

In conclusion, the Saudi healthcare systems especially 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 workforce stability, which is crucial to healthcare system transformation. The primary limitation of the study was the convenience sample, which limits generalizability.