3026  |  wileyonlinelibrary.com/journal/jan J Adv Nurs. 2020;76:3026–3038.© 2020 John Wiley & Sons Ltd

Received: 30 April 2020  |  Revised: 27 June 2020  |  Accepted: 29 July 2020

DOI: 10.1111/jan.14512

O R I G I N A L R E S E A R C H : E M P I R I C A L R E S E A R C H – Q U A N T I T A T I V E

The relationships between nurses’ work environments and emotional exhaustion, job satisfaction, and intent to leave among nurses in Saudi Arabia

Amal A. Alharbi1,2  | V. Susan Dahinten1 | Maura MacPhee1

1School of Nursing, The University of British Columbia, Vancouver, BC, Canada2Department of Nursing, University of Tabuk, Tabuk, Saudi Arabia

CorrespondenceAmal A. Alharbi, School of Nursing, The University of British Columbia, Vancouver, BC, Canada.Email: amal.alharbi@alumni.ubc.ca

Funding informationFunding for this study was received from the University of British Columbia, School of Nursing Katherine McMillan Director's Discretionary Research Fund. Amal Alharbi was supported by a scholarship from the University of Tabuk, represented by the Saudi Arabian Cultural Bureau in Ottawa.

AbstractAims: To examine relationships between components of nurses’ work environments and emotional exhaustion, job satisfaction and intent to leave among nurses in Saudi Arabia.Design: A descriptive correlational study with cross-sectional data.Methods: Data were collected in 2017 from 497 Registered Nurses working in a large tertiary hospital in Riyadh, Saudi Arabia. Participants completed an online survey like that used in RN4Cast studies to measure nurses’ perceptions of their work environ-ments and nurse outcomes. Hierarchical linear regression and logistic regression were conducted to examine the relationships between components of nurses’ work envi-ronments and nurse outcomes after controlling for nurse and patient characteristics.Results: Nurse participation in hospital affairs was uniquely associated with all three nurse outcomes, whereas staffing and resource adequacy was associated with emo-tional exhaustion and job satisfaction, but not intent to leave. These two variables were also the components of the nursing practice environment that received the lowest ratings. Nurse manager ability, leadership and support of nurses, and nurse–physician relationships were associated with job satisfaction only. A nursing founda-tion for quality of care was not uniquely associated with any of the three outcomes. Finally, nurse emotional exhaustion and job satisfaction fully mediated the relation-ship between nurse participation in hospital affairs and intent to leave.Conclusion: Magnet-like work environments in Saudi Arabia are critical to recruiting and retaining nurses in a country with critical nursing shortages.Impact: This study addresses a gap in the literature regarding which components of the nurses’ work environment are uniquely associated with emotional exhaustion, job satisfaction and intent to leave among nurses in Saudi Arabia. Study results will assist Saudi hospital administrators and nurse leaders to develop recruitment and retention strategies by focusing on those work environment components most associated with nurse outcomes: participation in hospital affairs and staffing and resource adequacy.

K E Y W O R D S

burnout, emotional exhaustion, intention to leave, job satisfaction, nurses’ work environments, retention, Saudi Arabia

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1  | INTRODUC TION

The current nursing shortage jeopardizes the quality and safety of patient care globally. In Saudi Arabia, there are insufficient numbers of Saudi nurses to support the healthcare system and Saudi hospitals rely heavily on expatriate nurses to meet staffing demands (Aboshaiqah, 2016). Thus, the recruitment of more Saudi nurses and the retention of all nurses (Saudi and expatriate) are essential for the provision of quality care. Some of the factors that deter Saudi nationals from choosing nursing as a profession (Alotaibi, Paliadelis, & Valenzuela, 2016) and contribute to rapid turnover rates among expatriate nurses (Alyami & Watson, 2014) are the low status, negative perceptions of nursing, and unfavor-able working conditions such as long hours and heavy workloads. However, an increasing body of evidence shows that there are as-pects of nurses’ work environments (NWEs) that are also import-ant to nurses’ job satisfaction, emotional exhaustion and nurse retention. Most of this research has been conducted in the United States and Europe, with very little emanating from Saudi Arabia or other Middle Eastern countries. Therefore, the purpose of this study was to identify aspects of Saudi NWEs that are associated with these nurse outcomes.

1.1 | Background

The terms NWE and nursing practice environment are used inter-changeably to refer to organizational characteristics that facilitate professional nursing practice (Lake, 2002; Lee & Scott, 2016). Lake (2002) developed a model of the professional nursing practice en-vironment and measurement scale, based on characteristics of hospitals that were successful in attracting and retaining nurses during the nursing shortage crisis in the United States in the early 1980s. Lake's Practice Environment Scale of the Nursing Work Index (PES-NWI) includes five components or subscales: nurse participation in hospital affairs (e.g., shared governance); nursing foundations for quality of care (hospital support for a professional nursing practice model); nurse manager ability, leadership and support of nurses; staffing and resource adequacy; and collegial nurse–physician relations. The PES-NWI has become a key meas-ure in RN4CAST studies which have been conducted globally to investigate relationships between organizational characteristics and nurse and patient outcomes (Heinen et al., 2013; Sermeus et al., 2011).

Numerous studies have demonstrated strong relationships be-tween NWEs and nurses’ job satisfaction, work-related burnout, and intent to leave (e.g., Coetzee, Klopper, Ellis, & Aiken, 2013; Kutney-Lee, Wu, Sloane, & Aiken, 2013; Wei, Sewell, Woody, & Rose, 2018). Most of these studies have been conducted in Western contexts such as the United States (Kutney-Lee et al., 2013, 2015) and Europe (Aiken et al., 2012; Estryn-Be´har et al., 2007; Sermeus et al., 2011). Less research has been conducted in Middle Eastern countries and in Saudi Arabia, in particular.

Studies that have been conducted in the Middle Eastern re-gion have generally not measured NWEs as conceptualized by Lake (2002) or have not examined the effect of the various components of NWEs. Two recent studies in Jordan found that more favorable work environments were associated with greater job satisfaction and intent to stay but, in each study, work environment was mea-sured only as a total aggregated score. AbuAlRub, El-Jardali, Jamal, and Al-Rub (2016) used the Nursing Work Index-Revised (NWI-R, Aiken & Patrician, 2000) and Al-Hamdan, Manojlovich, and Tanima (2017) used the PES-NWI. An earlier study of 1,793 nurses working in Lebanese hospitals (El-Jardali et al., 2011) examined the effect of six components of NWEs, measured with the NWI-R, on intent to leave and found that only one of the subscales, nurse participation in decision making, was uniquely significant.

We were able to identify only three published studies have ex-amined relationships between NWEs and nurse outcomes in Saudi Arabia. None of these studies used Lake’s (2002) conceptual model of nursing practice environment and each study used a different conceptualization and measure of work environment, thereby com-plicating a comparison of findings. Al-Ahmadi’s (2014) study found that pay equity and job satisfaction (conceptualized as work envi-ronment) and leadership and recognition (conceptualized as organi-zational factors) were associated with lower intent to leave. Almalki, FitzGerald, and Clark (2012) also found that work context was asso-ciated with turnover intention in the expected direction, but the re-gression analysis did not examine the explanatory strength of the 19 individual components of work context. In contrast, a more recent study of 364 nurses in Riyadh City (Kaddourah, Abu-Shaheen, & Al-Tannir, 2018) found no significant association between an aggre-gated measure of quality of work life and nurses’ turnover intentions.

Another feature of studies investigating the influence of NWEs on nurse outcomes is that they have tended to focus on the direct effects of work environment (Al Sabei et al., 2020). Exceptions are studies from Brazil (Panunto & Guirardello, 2013) and Belgium (Van Bogaert, Clarke, Willems, & Mondelaers, 2013; Van Bogaert, Meulemans, Clarke, Vermeyen, & Van de Heyning, 2009) that ex-amined the direct and indirect effects of NWI-R subscales on nurse outcomes.

2  | THE STUDY

2.1 | Aims

The purpose of this study was to identify the aspects of the NWE that are associated with nurses’ emotional exhaustion, job satisfac-tion, and intent to leave among registered nurses (RNs) working in Saudi Arabia. The study aimed to answer the following research questions (hypotheses are presented in Table 1):

1. What are the relationships between components of the NWE and emotional exhaustion after controlling for nurse and patient characteristics?

3028  |     ALHARBI et AL.

2. What are the relationships between components of the NWE and job satisfaction after controlling for nurse and patient characteristics?

3. What are the relationships between components of the NWE and intent to leave after controlling for nurse and patient characteristics?

4. Do emotional exhaustion or job satisfaction mediate the effects of components of the NWE on intent to leave after controlling for nurse and patient characteristics?

2.2 | Design

A descriptive correlational study design was employed to explore the relationships between NWEs and nurse outcome variables (Figure 1). This study was informed by prior research based on Lake's conceptual model of NWEs, particularly, the RN4CAST studies (Aiken et al., 2012; Coetzee et al., 2013; You et al., 2013).

2.3 | Sample and setting

The study used a convenience sample of RNs who were providing direct patient care in inpatient or outpatient nursing units and had at least one year of nursing experience. Our sample was selected from

one large tertiary hospital in Riyadh, Saudi Arabia. The hospital has an 860-bed capacity and is accredited by several accrediting bodies for international healthcare organizations. It employs approximately 2,200 RNs, 95% of which are expatriate RNs and is similar to other government hospitals in Saudi Arabia in terms of services provided and nursing workforce (L. Bell, personal communication, November 19, 2016). English is the primary language in healthcare education and services across Saudi Arabia.

The study was advertised through paper and electronic recruit-ment posters that were posted on nursing units and advertisement screens throughout the hospital. Invitation emails with a secure link to the online questionnaire were sent to all RNs by the Nursing Director through the hospital email service, on behalf of the research team. Two reminder e-mails were sent out 4 and 8 weeks after the first invitation. Participants who completed the online survey were invited to enter a raffle to win one of 10 gift cards worth S100 as a mean of appreciation.

Our final sample consisted of 496 RNs; this was a response rate of 32% of nurses who received the invitations (although many of the nurses who received invitations would not have met the in-clusion criteria of 1-year nursing experience). The required sample size for multiple regression was estimated to be 212 to detect a small to medium effect (f2 = 0.08) with a power of 0.80, at α = 0.05 (Soper, n.d.). The required sample size for logistic regression was es-timated to be 371 based on the formula recommended by Peduzzi, Concato, Kemper, Holford, and Feinstein (1996): N = (10 * number of explanatory variables) ÷ (expected proportion of positive cases). N = (10 * 13) ÷ 35% = 371.

2.4 | Data collection

Data were collected using an English-only online survey hosted by the Saudi hospital. Participants were able to access the online survey for 7 weeks starting from 1 August 2017. Participation in the survey was considered indicative of informed consent.

TA B L E 1   Study hypotheses

1. Nurses’ supportive work environments are negatively associated with their emotional exhaustion.

2. Nurses’ supportive work environments are positively associated with their job satisfaction.

3. Nurses’ supportive work environments are negatively associated with their intent to leave.

4. The relationship between nurses’ work environment and intent to leave is mediated by job satisfaction and emotional exhaustion.

F I G U R E 1   Conceptual model and hypotheses

–

–+

+–

Nurses’ Work Environment

Intent to Leave

Emotional Exhaustion

Job Satisfaction

     |  3029ALHARBI et AL.

2.5 | Measures

The study questionnaire was comprised of standardized scales used in the global RN4CAST survey which has received rigorous psychometric testing (Sermeus et al., 2011) and other questions developed for the BC Nurses’ Workload Impact Study (MacPhee, Rodney, Havaei, Musto, & Carino, 2015). Some questions were slightly reworded to meet the local context of the nursing work-force in Saudi Arabia, based on recommendations from the Director of Nursing.

Nurses’ Work Environment was measured using the PES-NWI - re-vised (Lake, 2002), that asks nurses to rate their perceptions of their current work environment on a 4-point response scale ranging from 1 = strongly disagree - 4 = strongly agree. The PES-NWI is a 31-item scale that measures five dimensions of nurse practice environment: nurse participation in hospital affairs (9 items); nursing foundations for quality of care (10 items); nurse manager ability, leadership and support of nurses (5 items); staffing and resource adequacy (4 items); and collegial nurse–physician relationships (3 items). Mean subscale scores were computed with higher scores indicating a more support-ive work environments (Lake, 2002).

Emotional Exhaustion was measured using the 9-item Emotional Exhaustion subscale of the Maslach Burnout Inventory – Human Service Scale (MBI-HSS; Maslach, Jackson, & Leiter, 1996). The scale asks nurses to report how often they experience work-re-lated feelings of psychological depletion using a 6-point response scale (never to every day), with total possible scores ranging from 9-54.

Job Satisfaction was measured with a single item asking nurses to identify their overall satisfaction with their current job, using a 6-point response scale (very dissatisfied to very satisfied). Scores were dichotomized as very dissatisfied to slightly satisfied (0) ver-sus moderately or very satisfied (1). A single item was used to avoid conflation between the explanatory and outcome variables as many established measures of nurses’ job satisfaction have items that overlap with concepts and items of the PES-NWI.

Nurses’ Intent to Leave their position was measured using a single item asking nurses to report how likely they are to leave their current job in the hospital within the next year, using a 4-point response scale (very unlikely to very likely). Scores were dichotomized to (0) very un-likely to somewhat unlikely versus (1) somewhat likely or very likely.

Nurses’ Demographic Characteristics were measured with re-searcher-developed questions about age, years of nursing expe-rience, gender, nationality, marital status, country where nursing education where received, highest educational qualification, cur-rent professional designation (i.e., nurse specialist or technician), and area of nursing practice. Nurse technician refers to nurses with a diploma or degree education less than 4 years long. Nurse special-ist refers to nurses with a 4-year bachelor's degree program plus an internship or 1-year of nursing experience (Saudi Commission for Health Specialties, 2014).

Patient Characteristics were measured using two questions asking about patient acuity and dependency levels, as these

factors contribute to nursing workload (MacPhee et al., 2015) and have been found to be associated with nurse outcomes (MacPhee, Dahinten, & Havaei, 2017). Acuity refers to amount of skilled nursing care required. Nurses were asked to rate their pa-tients’ average acuity level during the last month, using a 5-point scale ranging from 1 = not at all acute -5 = very acute. Scores were dichotomized as (0) less than moderately acute versus (1) moderately or very acute. Dependency refers to the amount of support required for activities of daily living. Nurses were asked to rate their patients’ average dependency level during the last month, using a 5-point scale ranging from 1 = very independent - 5 = very dependent. Scores were then dichotomized as (0) less than moderately dependent versus (1) moderately or very dependent.

2.6 | Validity and reliability

The PES-NWI is the most universally used tool to assess nurses’ perceptions of their practice environment (Zangaro & Jones, 2019). Cronbach's alpha scores for the PES-NWI subscales ranged from 0.71-0.84 with U.S. nurses (Lake, 2002). Predictive validity has been established in multiple international nursing settings in relation to nurse outcomes (Aiken et al., 2012; Warshawsky & Havens, 2011), workforce stability and hospitals’ quality of care (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Bruyneel, Heede, Diya, Aiken, & Sermeus, 2009). In the present study, Cronbach's alpha for the five subscales ranged from 0.76-0.90 indicating satisfactory internal consistency.

The Emotional Exhaustion subscale is the most widely used measure of job-related burnout (Coetzee et al., 2013; Kutney-Lee et al., 2013, 2015; MacPhee et al., 2015). Factorial validity based on repeated confirmatory factor analyses and evidence of con-vergent and discriminate validity has been established (Maslach et al., 1996). Poghosyan, Aiken, and Sloane (2009) validated the three-factor structure of the MBI in a large multi-country study of direct care nurses (N = 54,738), demonstrating that it can be employed with confidence to measure nurses’ burnout interna-tionally. In the present study, internal consistency was satisfac-tory with a Cronbach's alpha of 0.79. Job satisfaction and intent to leave were each measured with a single-item question. Several prior studies have used a single item to assess overall nurse job satisfaction (e.g., Aiken et al., 2012; Aiken, Sloane, Bruyneel, Van den Heede, & Sermeus, 2013; Kutney-Lee et al., 2013) and intent to leave their current position (Coetzee et al., 2013; Kutney-Lee et al., 2013, 2015).

2.7 | Ethical considerations

Ethics approvals were obtained from the Behavioral Research Ethics Board of the University of British Columbia and Institutional Research Board at the Saudi hospital prior to data collection.

3030  |     ALHARBI et AL.

2.8 | Data analysis

Data were provided to the researchers as an Excel spread sheet and imported into IBM SPSS Statistics (Version 25) for all analyses. Hierarchical linear regression was used to answer research ques-tion 1 and hierarchical logistic regression was used to answer re-search questions 2, 3 and 4. The same set of control variables was used in all regression analyses, based on the bivariate test results. Nurse characteristics included marital status, years of nursing ex-perience and country where nursing education was received. Age was excluded from regression analyses due to its high correlation with years of nursing experience (rs = 0.86, p < .01) and non-signif-icance in preliminary regression results. The significance level was set at α = 0.05.

The regression analyses for emotional exhaustion, job satisfac-tion and intent to leave (to answer research questions 1, 2, and 3, respectively) included a series of three models with variables en-tered as follows: nurse and patient characteristics were entered in the first and second blocks, respectively; followed by the five PES-NWI subscales in the third block. A fourth block was added to test the hypothesized mediating effects of emotional exhaustion and job satisfaction (question 4), described in detail in the Results section.

3  | RESULTS

Table 2 presents the demographic characteristics of the final sample of 496 RNs. Most notably, almost all participants (99.2%) were expatriates: 60.8% had received their basic nursing educa-tion in the Philippines and 33.5% had been educated in India. The nurses worked in various practice areas, with 43.4% working in medical and/or surgical units and 31.9% in critical care, intensive care or emergency. Others (24.7%) worked in ambulatory care, the operating room or recovery, oncology and women's health, and pediatrics.

Descriptive characteristics for key study variables are shown in Table 3. On average, each of the five components of nurses’ work en-vironment measured by the PES-NWI were scored positively by the study participants. The two subscales that received the highest mean scores were nursing foundation for quality of care (mean = 3.33, SD 0.51) and collegial nurse–physician relationships (mean = 3.12, SD 0.59). Staffing and resource adequacy (mean = 2.85, SD 0.67) and nurse participation in hospital affairs (mean = 2.83, SD 0.63) received the lowest mean scores. With respect to nurse outcomes, 64.4% of participants reported being moderately or very satisfied with their jobs, although the mean score for emotional exhaustion was 25 (SD 13.28) which is suggestive of moderate levels of burnout (Maslach et al., 1996) and 56.1% reported being somewhat to very likely to leave their current jobs within the next year. Inter-correlations between key study variables are presented in Table 4. Not shown on the table, are the correlations between education (degree/non-degree) and profes-sional classification (nurse technician/specialist) with the three out-come variables, all of which were non-significant (p > .05).

3.1 | Multiple regression results for emotional exhaustion (research question 1)

Table 5 presents results for the final model (Model 3) of the linear regression for emotional exhaustion. After controlling for nurse and patient characteristics, only two components of the PES-NWI were uniquely associated with emotional exhaustion: nurse participation in hospital affairs (B = −5.61, p < .01, 95% CI [−8.90, −2.32]) and staffing/resource adequacy (B = −6.06, p < .001, 95% CI [−8.38, −3.74]). Years of nursing experience (B = −0.21, p < .05, 95% CI [−0.42, −0.00]) and patient dependency (B = 2.55, p < .05, 95% CI [0.20, 4.89]) were also associated with emotional exhaustion. Only the results of Model 3 are shown as there was little change in the regression coefficients across models, although there were

TA B L E 2   Demographic characteristics of participants

Characteristics Mean (SD)

Frequency

N %

Age 34.0 (7.5)

Years of nursing experience 10.9 (6.4)

Gender

Male 52 10.7

Female 436 89.3

Marital status

Married 282 57.9

Single 205 42.1

Nationality

Saudi 4 0.8

Non-Saudi 491 99.2

Country where nursing education received

Saudi Arabia 3 0.6

Other Middle Eastern Countries

3 0.6

Philippines 299 60.8

India 165 33.5

Other 22 4.5

Professional classification

Nurse techniciana  462 94.1

Nurse specialistb  29 5.9

Educational qualification

Diploma in nursing (2 years) 2 0.4

High-diploma in nursing (3 years)

158 32.0

Baccalaureate degree in nursing (BSN-RN)

324 65.7

Master's degree 9 1.8

Note: N = 496.aNurses with 2 or 3-year diploma, or non-Saudi nurse with BSN less than 4 years. bNurses with 4-year BSN and 1-year internship or nurses with higher education.

     |  3031ALHARBI et AL.

statistically significant changes in the R2. The R2 for Models 1, 2, and 3 were 5.3%, 6.8%, and 21%, respectively.

3.2 | Logistic regression results for job satisfaction (research question 2)

Table 6 shows results for the final model of the logistic regression for job satisfaction. Four components of the PES-NWI were sta-tistically significant after accounting for nurse and patient charac-teristics. Nurse participation in hospital affairs (OR = 2.27, p < .05, 95% CI [1.18, 4.38]), nurse manager ability and leadership support for nurses (OR = 1.80, p < .05, 95% CI [1.07, 3.01]) and staffing and resource adequacy (OR = 1.92, p < .01, 95% CI [1.23, 2.99]) were positively associated with job satisfaction. Collegial nurse-physi-cian relations were also uniquely associated with job satisfaction,

but unexpectedly, more positive nurse-physician relations were found to be associated with decreased job satisfaction (OR = 0.42, p < .01, 95% CI [0.23, 0.75]). The inverse relationship for this com-ponent of the PES-NWI contradicts results of our bivariate cor-relations, which showed a positive correlation between scores on the collegial nurse-physician relationships scale and job satisfac-tion (ρ = 0.23, p < .01), suggesting a suppression effect. Years of nursing experience and receiving basic nursing education in India were also significantly associated with higher job satisfaction. The Nagelkerke R2 was 30.4% and the model correctly classified 87.8% of the cases who were moderately or very satisfied with their job and 73.3% of cases overall.

3.3 | Logistic regression results for intent to leave (research question 3)

Logistic regression results for intent to leave, also shown in Table 6, indicates that nurse participation in hospital affairs (OR = 0.52, p < .05, 95% CI [0.28, 0.95]) was the only component of the PES-NWQ associated with intent to leave after controlling for nurse and patient characteristics (see Model 3). There was only one other sig-nificant predictor in Model 3; nurses who were educated in India (OR = 0.42, p < .01, 95% CI [0.24, 0.73]) were much less likely to intend to leave within the next year compared with nurses who were educated in other countries.

3.4 | Mediation effects (research question 4)

We followed the causal steps approach for investigating media-tion, as represented in Figure 2 (Baron & Kenny, 1986; MacKinnon, Cheong, & Pirlott, 2012). Our prior regression results reported in Tables 5 and 6 showed that nurse participation in hospital affairs was associated with each of the two hypothesized mediators, emotional exhaustion and job satisfaction (path a) and the outcome variable, intent to leave (path c). We then tested paths b and c' by running two other logistic regressions, each of which included one of the mediators (and all other explanatory variables). The same results were obtained for each mediator: Path b was statistically significant and path c' became non-significant. Together these findings indicate that emotional exhaustion and job satisfaction fully mediated the ef-fects of nurse participation in hospital affairs on intent to leave after controlling for nurse and patient characteristics, thus supporting Hypothesis 4. We then ran another logistic regression that included both mediators in the same model (reported as Model 4 in Table 6). Both emotional exhaustion (OR = 1.03, p < .01, 95% CI [1.01, 1.05]) and job satisfaction (OR = 0.57, p < .01, 95% CI [0.34, 0.93]) were significantly associated with intent to leave. As the results indicated full rather than partial mediation of nurse participation in hospital af-fairs, no further mediation analysis was conducted. The final model, Model 4, correctly classified 73.4% of nurses who intend to leave and 66.1% of cases overall.

TA B L E 3   Descriptive statistics for key study variables

Mean (SD)

Frequency

N %

Explanatory variables

Nurse participation in hospital affairs

2.83 (0.63)

Nursing foundation for quality of care

3.33 (0.51)

Nurse manager ability, leadership and support of nurses

2.93 (0.67)

Staffing and resource adequacy 2.85 (0.67)

Collegial nurse–physician relationships

3.12 (0.59)

Patient acuity

Less than moderately acute 202 41.7

Moderately or very acute 282 58.3

Patient dependency

Less than moderately dependent

233 48.0

Moderately or very dependent

252 52.0

Outcome variables

Emotional exhaustion 25.07 (13.28)

Job satisfaction

Very dissatisfied to slightly satisfied

174 35.6

Moderately or very satisfied 315 64.4

Intent to leave

Very unlikely to somewhat unlikely

214 43.9

Somewhat likely or very likely

274 56.1

Note: N = 496.

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4  | DISCUSSION

Our regression results showed significant variation in terms of which PES-NWI components were uniquely associated with each of the three nurse outcomes. Nurse participation in hospital affairs was strongly associated with all three outcomes, whereas staffing and resource adequacy was associated with nurse emotional ex-haustion and job satisfaction, but not intent to leave. These two explanatory variables were also the domains of the NWE that re-ceived the lowest ratings. Nurse manager ability, leadership and support of nurses and nurse–physician relationships were related to job satisfaction only. A nursing foundation for quality of care was not uniquely associated with any of the three outcomes. Finally, nurse emotional exhaustion and job satisfaction mediated the relationship between nurse participation in hospital affairs and intent to leave. The demographic characteristic of most im-portance was country where nursing education was received, with nurses educated in India reporting higher job satisfaction and less intent to leave.

Nurse participation in hospital affairs and staffing and re-source adequacy seem to be universal concerns for nurses. Nurse participation in hospital affairs represents an organizational-level phenomenon that provides frontline nurses with opportunities to participate in hospital internal governance and decisions related to policy and practice (Lake, 2002). In this study, nurses who perceived their work environments to be encouraging of nurses’ contributions to organizational decisions were less emotionally exhausted, more satisfied in their jobs and less inclined to leave their jobs within the next year. Notably, nurse participation in hospital affairs was the only component of NWEs associated with intent to leave. Studies in Canada (Havaei, Dahinten, & MacPhee, 2019) and Oman (Al Sabei, 2020) also found that participation in hospital affairs was protective against emotional exhaustion. An earlier study in Belgium by Van Bogaert et al. (2014) did not use the PES-NWI but did find that de-cision latitude was associated with job satisfaction, but not intent to leave. These findings are particularly interesting given that the PES-NWI was developed in the U.S. context where shared gover-nance is a more familiar concept in healthcare organizations and

TA B L E 4   Spearman correlations between key study variables

Study variables 1 2 3 4 5 6 7 8 9 10 11

1. Marital statusa  —

2. Years of nursing experience

0.56**,b —

3. Patient acuityb  0.16**,b 0.18**,b —

4. Patient dependencyc 

0.10*,a 0.02 0.25**,b —

5. Nurse participation in hospital affairs

0.12**,b −0.01 0.01 0.01 —

6. Nursing foundation for quality of care

0.34**,b 0.22**,b 0.16**,b 0.12**,b 0.62**,b —

7. Nurse manager ability, leadership and support of nurses

0.14**,b 0.06 0.06 0.03 0.75**,b 0.54**,b —

8. Staffing and resource adequacy

0.22**,b 0.05 0.06 0.01 0.66**,b 0.55**,b 0.57**,b —

9. Collegial nurse-physician relationships

0.19**,b 0.15**,b 0.12**,b 0.03 0.59**,b 0.66**,b 0.57**,b 0.51**,b —

10. Emotional exhaustion

−0.19**,b −0.15**,b −0.10*,a 0.09 −0.34**,b −0.25**,b −0.23**,b −0.40**,b −0.23**,b —

11. Job satisfactiond  0.21**,b 0.18**,b 0.08 −0.01 0.37**,b 0.35**,b 0.38**,b 0.36**,b 0.23**,b −0.39**,b —

12. Intent to leavee  −0.10*,a −0.12**,b - 0.07 −0.00 −0.19**,b −0.23 −0.13**,b −0.18**,b −0.13**,b 0.28**,b −0.27**,b

a0 = Single, 1 = Married. b0 = Less than moderately acute, 1 = Moderately or very acute. c0 = Less than moderately dependent, 1 = Moderately or very dependent. d0 = Very dissatisfied to slightly satisfied, 1 = Moderately or very Satisfied. e0 = Very unlikely to somewhat Unlikely, 1 = Somewhat likely or very likely. *p < .05. **p < .01.

     |  3033ALHARBI et AL.

they suggest that nurses around the world are aware of the value of professional nursing practice and importance of participating in internal governance.

Consistent with our findings, studies in Belgium (Bruyneel et al., 2009), Hong Kong (Choi, Cheung, & Pang, 2013) and Canada (Havaei et al., 2019) have found that more positive perceptions of staffing and resource adequacy are associated with greater job satisfaction and less emotional exhaustion. Choi et al. (2013) and Cho et al. (2009) also showed an association between staffing adequacy and job satisfaction among nurses in Hong Kong and Korea, respectively. Staffing and resource adequacy are often identified as one component of structural empowerment with links to improved nurse and patient outcomes (Laschinger, 2008; Laschinger, Leiter, Day, & Gilin, 2009). Structural empowerment is the degree to which nurses have access to resources in their nursing units that empower them to meet their job demand s (Kanter, 1993).

Nurse's perceptions of manager ability and leadership support were uniquely associated with job satisfaction, but not emotional exhaustion or intent to leave. To date, research findings on the im-portance of leadership and support have been mixed. For example, studies in Hong Kong (Choi et al., 2013) and Belgium (Van Bogaert et al., 2013) and a systematic review of 17 studies from around the world (Hayes, Bonner, & Pryor, 2010) found that this aspect of the work environment was associated with hospital nurses’ job satisfaction. However, two prior studies that used the PES-NWI, Bruyneel et al. (2009) in Belgium and Al Sabei et al. (2020) in Oman, failed to find that nurse manager ability, leadership and support of nurses was uniquely associated with emotional exhaus-tion or intent to leave. Bruyneel et al. also failed to find an associ-ation with job satisfaction.

Of most surprise and contrary to prior research, our regression results failed to show significant, unique relationships between a nursing foundation for quality care and any of the three outcomes.

Explanatory variables B SE B 95% CI β

Marital status*,a −1.56 1.49 [−4.49, 1.37] −0.06

Years of nursing experience

−0.21 0.11 [−0.42, −0.00] −0.10*,c

Country where nursing education received**,b (India)

−1.51 1.15 [−3.77, 0.76] −0.93

Country where nursing education received**,b (Saudi or others)

1.55 1.15 [−0.71, 3.81] 0.96

Patient acuityc  −2.19 1.24 [−4.61, 0.24] −0.08

Patient dependencyd 

2.55 1.19 [ 0.20, 4.89] 0.10*,c

Nurse participation in hospital affairs

−5.61 1.67 [−8.90, −2.32] −0.26**,d

Nursing foundation for quality of care

3.13 1.78 [−0.37, 6.63] 0.12

Nurse manager ability, leadership, and support of nurses

2.05 1.35 [−0.59, 4.70] 0.10

Staffing and resource adequacy

−6.06 1.18 [−8.38, −3.74] −0.31***,e

Collegial nurse-physician relationships

0.26 1.43 [−2.54, 3.07] 0.01

Model R2 21.2%

Note: N = 438.a0 = Single, 1 = Married. bReference = Philippines. c0 = Not at all acute to slightly acute, 1 = Moderately or very acute. d0 = Very independent to somewhat dependent, 1 = Moderately or very dependent. F [11] = 10.38***. *p < .05. **p < .01. ***p < .001.

TA B L E 5   Multiple linear regression for emotional exhaustion (Model 3 results)

3034  |     ALHARBI et AL.

Other studies around the world have found associations with job satisfaction (e.g., Havaei et al., 2019; Laschinger, 2008) and measures of burnout such as emotional exhaustion (e.g., Al Sabei et al., 2020; Leiter & Laschinger, 2006). This result may have oc-curred because nursing foundation for quality care received the highest mean score of the five components, with the least vari-ance. It is also possible that, for the expatriate nurses working in Saudi Arabia, other components of the work environment are more important influences on job satisfaction, emotional exhaus-tion, and intent to leave.

Most nurses in this study were Asian (94.2%), primarily from India (33.5%) and the Philippines (60.8%). India and the Philippines are the two largest ‘exporters’ of nursing care (Oda,

Tsujita, & Irudaya Rajan, 2018). Expatriate nurses from these two countries migrate to wealthier countries, such as Saudi Arabia, for better work conditions, pay and educational opportunities (Moyce, Lash, & de Leon Siantz, 2016). In this study, therefore, perceptions of the work environment may have been influenced by their motivation to seek out better work conditions and ca-reer opportunities. Other findings from this study found that Indian and Saudi/Other nurses were less likely to report intent to leave within the next year compared with Filipino nurses. Filipino nurses typically seek out employment on short-term contracts with the intention of sending remittances to support their fam-ilies back home. Compared with nurses from other countries, therefore, they may view themselves as temporary migrants with

TA B L E 6   Results of hierarchical logistic regressions for job satisfactiona and intent to leaveb

Explanatory variables

Job satisfactiona  Intent to leaveb 

Model 3 Model 3 Model 4

OR 95% CI OR 95% CI OR 95% CI

Marital status*,c 0.87 [0.49, 1.56] 1.33 [0.78, 2.29] 1.37 [0.78, 2.39]

Years of nursing experience

1.05* [1.00, 1.10] 0.97 [0.93, 1.01] 0.98 [0.94, 1.02]

Country where nursing education received**,d

India 2.09* [1.10, 3.96] 0.42** [0.24, 0.73] 0.47** [0.26, 0.83]

Saudi or other 2.69 [0.71, 9.07] 0.34* [0.12, 0.91] 0.37 [0.13, 1.03]

Patient acuity***,e 1.22 [0.76, 1.99] 0.89 [0.57, 1.40] 0.96 [0.61, 1.52]

Patient dependencyf  0.93 [0.59, 1.48] 0.98 [0.64, 1.50] 0.90 [0.58, 1.39]

Nurse participation in hospital affairs

2.27* [1.18, 4.38] 0.52* [0.28, 0.95] 0.64 [0.34, 1.20]

Nursing foundation for quality of care

1.58 [0.77, 3.25] 0.96 [0.50, 1.81] 0.90 [0.47, 1.74]

Nurse manager ability, leadership, and support of nurses

1.80* [1.07, 3.01] 1.08 [0.67, 1.75] 1.10 [0.67, 1.81]

Staffing and resource adequacy

1.92** [1.23, 2.99] 0.81 [0.53, 1.23] 1.02 [0.65, 1.60]

Collegial nurse-physician relationships

0.42** [0.23, 0.75] 1.35 [0.81, 2.25] 1.21 [0.72, 2.05]

Emotional exhaustion 1.03** [1.01, 1.05]

Job satisfactiona  0.57** [0.34, 0.93]

Nagelkerke R2 30.4% 12.8% 17.9%

Correct classification 73.3% 63.6% 66.1%

Specificity 46.2% 48.7% 57.1%

Sensitivity 87.8% 75.5% 73.4%

Note: N = 496.a0 = Very dissatisfied to slightly satisfied, 1 = Moderately or very satisfied. b0 = Very unlikely to somewhat unlikely, 1 = Somewhat likely or very likely. c0 = Single, 1 = Married. d1 = Philippines = Referent group. e0 = Not at all acute to slightly acute, 1 = Moderately or very acute. f0 = Very independent to somewhat dependent, 1 = Moderately or very dependent. Job satisfaction χ2[11] = 113.06***. Intent to leave χ2[13] = 61.38***. *p < .05. **p < .01.

     |  3035ALHARBI et AL.

a finite timeline for working abroad (Alonso-Garboyo & Maben, 2009).

In this study, emotional exhaustion and job satisfaction were each found to mediate the relationship between nurse participa-tion in hospital affairs and intent to leave. This result is consistent with previous research showing that autonomy and control over work environment had an indirect impact on nurses’ intention to leave through emotional exhaustion (Panunto & Guirardello, 2013).

PES-NWI subscales represent magnet-like characteristics of NWEs that draw in and retain nurses and these measures are used by healthcare organizations worldwide as a proxy for healthy work environments (Stimpfel, Rosen, & McHugh, 2014; Zangaro & Jones, 2019). In Saudi Arabia, only two hospitals are designated as magnet hospitals (Alghamdi & Urden, 2016). However, hospi-tals in Saudi Arabia should consider using validated tools, such as the PES-NWI, to diagnose their work environments and strive for magnet-like qualities of importance to nurses and patients.

Magnet-like work environments have effective nurse leaders at all organizational levels (Kelly, McHugh, & Aiken, 2011; Stimpfel et al., 2014) whose role is pivotal in creating and sustaining sup-portive work environments that facilitate professional nursing practice (Germain & Cummings, 2010). However, despite efforts of hospitals in Saudi Arabia to adopt decentralized management models, decision-making in healthcare services, for the most part, is restricted to top-level management. Unit-level nurse leaders have limited authority, hindering their capacity to influence the quality of NWEs (Alghamdi & Urden, 2016). However, although nurse leaders in Saudi hospitals may lack formal authority, there are leadership styles and strategies they could hone over time that are associated with positive nurse and patient outcomes (Cummings et al., 2010; Wong, Cummings, & Ducharme, 2013). For example,

a recent systematic review of eight studies found that transfor-mational leadership is associated with job satisfaction (Alzahrani & Hasan, 2019). Saudi Arabia currently lacks formal leadership development programs for nurse leaders—but this is a human re-source investment well worth considering (Galuska, 2014).

4.1 | Limitations

Findings of this study should be interpreted with caution due to re-liance on cross-sectional data. This study was also subject to mon-omethod and self-report bias as all measures were nurse-reported and collected via an online survey; however, similar methods and measures have been used in the widely conducted RN4CAST stud-ies (e.g., Aiken et al., 2012; Coetzee et al., 2013). Another limita-tion was the use of nested data (i.e., data collected from several nurses working in the same units in the hospital) without the use of multilevel modelling, which may increase the risk of type I error (Woltman, Feldstain, MacKay, & Rocchi, 2012). However, as the data were collected from only one hospital in Riyadh, Saudi Arabia, asking participants to identify their particular units might have hin-dered recruitment resulting in a decreased response rate. Finally, the generalizability of the findings across Saudi Arabia and beyond may also be limited due to the use of a single hospital.

5  | CONCLUSION

To improve nurse outcomes in Saudi Arabia, which in turn has been shown to facilitate better quality and safer care delivery, hospitals and nurse leaders should take actions to improve the

F I G U R E 2   Diagram of mediation models. Path a represents the effect of Nurse Participation in Hospital Affairs on each mediator. Path b represents the effect of each mediator on the outcome variable, Intent to Leave. Path c indicates the direct effect of Nurse Participation in Hospital Affairs on the outcome variable without the mediator in the model. Path c' indicates the effect of Nurse Participation in Hospital Affairs on Intent to Leave after controlling for the mediator. All other explanatory variables were controlled for in each model

Path c

Path bPath a

Path bPath a

Nurse Participation in

Hospital Affairs

Job Satisfaction

(mediator)

Path c '

Path c

Path c '

Emotional Exhaustion

(mediator)

Intentto

Leave

Nurse Participation in

Hospital Affairs

Intent to

Leave

3036  |     ALHARBI et AL.

quality of NWEs, particularly with respect to nurse participation in hospital affairs, staffing and resource adequacy and to a lesser extent nurse manager ability and leadership support. However, it is important that there be further studies in other Saudi hospitals. Three of the five PES-NWI subscales were originally developed to be used at the unit level (nurse manager ability, leadership and support of nurses; staffing and resource adequacy; and collegial relationships), whereas nurse participation in hospital affairs and nurse foundations for quality of care were intended to be used at the hospital level (Lake, 2002). Therefore, there should be multi-hospital studies using a three-level multilevel model-ling approach, with nurses nested in units, nested in hospitals, using the appropriate PES-NWI subscales at the unit and hospital levels. This study also shows the importance of accounting for expatriate status. Ninety-nine percent of the samples were non-Saudis, but country of origin for expatriate nurses should also be controlled, as we found that nurses educated in India versus the Philippines or other countries were more satisfied with their jobs and less likely to intend to leave within the next year.

ACKNOWLEDG MENTSWe extend our gratitude to our nursing colleagues who participated in this study.

CONFLIC T OF INTERE S TThe authors have no conflict of interest to declare.

AUTHOR CONTRIBUTIONSThis study is part of AA's master's thesis, which was supervised by SD and MM. All authors read, provided feedback, and approved the final manuscript. All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recom menda tions/)]:

• substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;

• drafting the article or revising it critically for important intellec-tual content.

PEER RE VIE WThe peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.14512.

ORCIDAmal A. Alharbi https://orcid.org/0000-0003-3347-1143

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How to cite this article: Alharbi AA, Dahinten VS, MacPhee M. The relationships between nurses’ work environments and emotional exhaustion, job satisfaction, and intent to leave among nurses in Saudi Arabia. J Adv Nurs. 2020;76:3026–3038. https://doi.org/10.1111/jan.14512

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