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Editorial verdict
Methodologically transparent but limited evidence base — seven qualitative studies across nine reports is a thin foundation for system-level conclusions; the three core findings on leadership failure, discrimination, and societal pressure are coherent and consistent, but confidence remains moderate-to-low due to acknowledged methodological flaws in three of the seven included studies.
Executive summary
This qualitative evidence synthesis (QES) examines factors driving nurse turnover and turnover intention within the Kingdom of Saudi Arabia (KSA) healthcare system, with particular attention to the distinct experiences of Saudi and non-Saudi nurses. The authors argue that systemic leadership failure, multi-layered workplace discrimination, and culturally-imposed societal pressures collectively undermine nurse retention across both population groups. Drawing on seven primary qualitative studies published between 2016 and 2022, the synthesis employed thematic analysis guided by the RETREAT and SPIDER frameworks and assessed confidence using GRADE-CERQual. Five predominant themes emerged — relationships with supervisors, workplace equity, work assignments and workload, quality of life, and Saudi societal factors — comprising 19 subthemes. Key findings indicate that management and leadership failures pervade the KSA healthcare system at all levels; that salary discrimination by nationality, exclusion from decision-making, and professional disrespect are endemic; and that societal and cultural norms create distinct pressures on both Saudi and expatriate nurses. The authors conclude that systemic leadership reform, operationalised through a nationwide Leadership Development Program, represents the highest-leverage intervention point, with downstream benefits anticipated for discrimination and societal pressure.
Key insights
- 1Leadership and management failures were reported consistently across all seven included studies, manifesting as supervisor abuse, lack of appreciation, poor scheduling practices, and exclusion of nurses from decision-making — suggesting a systemic rather than isolated problem.
- 2Salary discrimination based on nationality and ethnicity was reported: one nurse said nurses from Canada and the US are paid more for the same work, and two nurses expressed an intention to leave because of it.
- 3Both Saudi and non-Saudi nurses experience societal pressure, though differently: non-Saudis face cultural isolation and restrictive norms, while Saudi nurses navigate tensions between workplace demands and conservative societal expectations around gender roles.
Practical takeaways
- Organizations operating within the KSA healthcare context may find that addressing leadership quality and management capability — particularly around fairness in scheduling, recognition, and protection from abuse — has the potential to reduce turnover drivers more broadly than targeted retention incentives alone.
- The distinct needs of Saudi versus non-Saudi nursing workforces (including expatriate support, equitable compensation structures, family access, and social infrastructure) warrant separate workforce planning and retention strategies rather than a uniform approach.
Frameworks mentioned
RETREAT
A Cochrane-recommended framework used to determine the most appropriate type of qualitative evidence synthesis (e.g., thematic synthesis, framework synthesis, or meta-ethnography).
SPIDER
A search tool for qualitative research standing for Sample, Phenomenon of Interest, Design, Evaluation, and Research type, used here to structure the search strategy and selection criteria.
GRADE-CERQual
A framework for assessing confidence in findings from qualitative evidence reviews, evaluating methodological limitations, coherence, adequacy of data, and relevance of included studies.
Critical Appraisal Skills Programme (CASP)
A tool adapted by the authors to assess methodological limitations of included qualitative studies, with reviewers independently rating each study across seven items.
References
- Xu et al. (2023).Pooled prevalence of turnover intention among ICU nurses across 23 countries.
- Drennan and Ross (2019).Nurse migration and global nursing shortage.
- Alsadaan et al. (2021).Nurse turnover in KSA during COVID-19.
- Kingdom of Saudi Arabia (2017).Saudi Vision 2030.
- Cardiff et al. (2023).Realist review of nurse retention interventions.
- Alshahrani (2022).General solutions for nurse turnover in KSA.
- Cozart (2024).Qualitative study of US nurse turnover reduction strategies.
- Yun and Yu (2021).Focus group study of nurse turnover suggestions (South Korea).
Source & Provenance
Not specified
Sarh Almubark, Andrew Booth, Emily Wood
March 14, 2025
Meta-Analysis/Review
Middle East
Original source metadata is preserved. AI analysis is generated separately.
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