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 . Additionally, QWL can improve the quality of care provided as well as recruitment 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  conducted a study in Riyadh to determine the variables related to nurses’ intention to leave their hospital. Data were collected from three hospitals in Riyadh. Of the 488 respondents, 275 (56.4%) intended to leave their job. Al-Ahmadi  collected data from 434 nurses working in nine psychiatric hospitals randomly selected from various geographic regions of Saudi Arabia. Results showed that 37% of nurses had the intention to leave the institution. Most recently, Zaghloul, et al.  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 findings as well. For example, Al-Ahmadi’s  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, education level, nursing tenure, organisational tenure, positional tenure, and payment per month. Younger nurses were more likely to indicate turnover intention compared to older nurses, a finding consistent with prior research . 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 personal ties to the organisation and leaving the organisation (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 number 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 relationship 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 were more intent on leaving their current employment for two reasons: first, male nurses in this study comprised 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 opportunity to work in their living areas − Saudi female nurses are given this priority . Another possible cause for gender 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 employee and management departments. In this case, organisational 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 . 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 married may have less family responsibilities so they do not have to consider moving family members when transferring to another organisation .
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 , financial commitments to children such as pressure to fund them through university may increase the likelihood 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 significant relationship between education status of nurses and their turnover or turnover intention [47, 74, 75].
In the current study, it could be argued that Associate 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 Associate 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 . All these factors may negatively influence their commitment to their organisations and profession and push them to leave.
Negative relationships were revealed between turnover 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 salary employees. This indicates that salary is important for the satisfaction and retention of the PHC nurses. According to Gardulf et al. , 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. However, the model as a whole (demographics and QWL dimensions) explained 32.1% of variance in nurse’s turnover intention. These findings are similar to the models tested by Tourangeau and Cranley , Shader, et al. , Gregory, Way, LeFort, Barrett and Parfre , Sourdif  and Larrabee, et al. , 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 supervision, co-workers, professional opportunities and work environment. These variables were found in prior research to be associated with turnover intention [54, 79].
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 contributors 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 . For example, a model tested by Boyle, Bott, Hansen, Woods and Taunton  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 , the regression model of the current study explained about 32% of variance in nurses’ turnover intention, meaning that approximately 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 .
This study has a number of limitations. First, it used a convenience 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 interpretation 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. However, no such case reports were received by the researchers. 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 observation 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 attrition to be monitored against turnover intention.
It would be valuable to conduct an intervention study to improve QWL and retention of PHC nurses considering 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 payment and professional opportunities on the improving the QWL and retention of nurses. This would help in assessing the impact of such strategies on reducing turnover 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 produce different determinants of QWL and turnover intention of nursing personnel.