Turnover intention among nurses in Iranian hospitals: a systematic review and meta-analysis

Healthcare systems, particularly hospitals, are critical components of sustainable development, significantly impacting human health. Hospitals, which consume approximately half of healthcare budgets [1] are tasked with delivering high-quality diagnostic, therapeutic, and rehabilitative services. To fulfill this mission, hospitals rely on a skilled and motivated workforce, with nurses constituting the largest professional group [2]. Nurses play a pivotal role in patient care, contributing to approximately 80% of patient interactions [3].

Nurses occupy a central position within healthcare systems, interacting extensively with patients, families, and other healthcare professionals [4]. Effective communication is essential to their role in monitoring patients and fulfilling their professional duties [5]. Given the multifaceted nature of their work, nurses are uniquely positioned to address significant health challenges, including epidemics, chronic diseases, emerging and re-emerging infections, and violence. Their contributions are vital to achieving overall health system goals [6, 7]. Furthermore, nurses are key stakeholders in healthcare system transformations, influencing policymaking, planning, and the implementation of health services. To optimize their impact, it is imperative to provide nurses with the necessary working conditions [8]. Despite their critical role, many nurses experience job stress, fatigue, and burnout, leading to increased turnover rates [9].

Iran, like many other developing countires, faces significant challenges in the healthcare sector, particularly a shortage of nursing staff. This shortage has led to job dissatisfaction and burnout among experienced nurses, hindering the Ministry of Health and Medical Education’s efforts to provide quality care [10]. The shortage of nursing staff is a longstanding human resource issue, with the country falling short of international standards in nursing education. The Coronavirus disease 2019 (COVID-19) pandemic exacerbated this problem, with nurse-to-patient ratios reaching critically low levels, often below one nurse per hospital bed [11]. In a systematic review of systematic reviews, stress and dissatisfaction at the individual level and management style and supportive factors at the organizational level identified as the main factors that cause nurses to leave their jobs [12].

The COVID-19 pandemic exacerbated an existing trend of nurse attrition. For example, a study conducted in Isfahan found that nurses’ intention to leave their job was a moderate to high level, with external factors were more influential than organizational factors in nurses’ intention to leave [13]. Nurse turnover has detrimental consequences for healthcare organizations, impacting service quality, safety, and overall performance. Voluntary turnover incurs direct costs associated with recruitment and training new staff, as well as indirect costs such as reduced productivity, increased dissatisfaction, and the depletion of human capital [14]. Additionally, increased workloads for remaining nurses can lead to reduced morale, job stress, and heightened workplace tension [15].

The national employment association of the United States has reported significant turnover and attrition rates among nurses, reaching 32% and 40%, respectively. These high rates impose substantial costs on the nation’s healthcare system [16]. While case studies conducted in Iran suggest a more moderate turnover rate among hospital employees, it remains a concern that necessitates proactive management strategies to mitigate its impact [17‐19]. With the implementation of the Health Transformation Plan (HTP), shortage of manpower, increased workload and pressure, dissatisfaction with payment methods and financial issues, lack of status and job security have been some of the problems faced by nurses [20]. The results of a study in Tehran hospitals showed that after the implementation of the health system transformation plan, nurses’ job satisfaction decreased, nurses’ intention to leave increased, and nurses’ burnout remained constant [21].

A comprehensive review of domestic and international literature reveals a substantial body of research investigating nurse turnover in Iranian hospitals. However, these studies, often conducted with varying sample sizes, have yielded conflicting results regarding the magnitude of nurse turnover. To synthesize and critically evaluate these results, a systematic review and meta-analysis approach was employed. The current study aims to utilize this rigorous approach to quantify the extent of nurse turnover in Iranian hospitals and provide valuable insights for policymakers, healthcare managers, and researchers.

The present study aimed to perform a systematic review and meta-analysis on turnover intention among nurses in Iranian hospital settings. Overall, 42 studies with a sample size of 12,898 published between 2011 and 2024 were analyzed.

The overall turnover intention of 2.96 out of 5 indicates that the level of intention among Iranian nurses is sensitive level and requires attention. In the health system, nursing has always been one of the careers that has its ups and downs from the time of education to retirement due to its difficulties. They mainly face challenges such as staff shortages, job dissatisfaction, poor social position, the gap between theory and practice, lack of community-based nursing care, lack of an appropriate student recruiting system, improper monitoring and evaluation, weak recruiting and retaining nurses, the aging of the nursing workforce and shortages in the nursing educational curriculums [68‐70].

Similar to our study, a 2024 meta-analysis on the turnover intention among Ethiopian nurses found that the pooled proportion was 53.35%, posing a significant challenge to healthcare managers in this country [24]. Also, the meta-analysis results showed that the pooled proportion of nurses’ intention to leave their jobs in sub-Saharan Africa was 50.74%, with the highest pooled proportion of intention to leave in East Africa and the lowest pooled estimate in South Africa [71]. Unlike Iran, turnover intention rates among hospital nurses have been reported at much lower rates in Israel (9%) [72], Brazil (21.1%) [73], and 12 European countries (33%) [74]. Furthermore, rates of intention to leave can also vary across nursing settings, with the results of a meta-analysis showed that intensive care nurses from 23 countries had intention rates ranging from 3.0 to 75.0%, with a pooled prevalence of intention to leave of 27.7% [75]. These discrepancies between our study’s results and previous studies, might be the consequence of variations in organizational factors such as management/ leadership styles, workload, infrastructure in the health institutions, organizational climate, organizational policies and cultural issues in healthcare systems.

A pressing issue for nurse and human resource managers in developed economies is to introduce interventions which are effective in addressing those determinants, reducing nurses turnover and increasing nurses retention [76]. A series of policy initiatives and strategies are recommended in the literature to prevent or minimize the nurses’ turnover intention [77‐79]. A systematic review identified some interventions including preceptorship, internships, residencies, and structured orientation programs and mentorship for new graduates; transformational or relational leadership; clinical sabbaticals; and teamwork [78]. Likewise, a meta analysis carried out by Nei et al. (2015) revealed that supportive and communicative leadership, network centrality, organizational commitment, job strain, role tension, work-family conflict, job control, job complexity, rewards/ recognition, and team cohesion were the predictors of nurses turnover intentions [79].

This meta-analysis also showed that despite all the efforts and costs made to reduce nurses’ turnover intentions, especially after the health transformation plan in Iran, the results of these policies have not led to improved retention. Based on subgroup analysis the turnover intention among Iranian nurses was 2.95 ± 0.123 and 2.96 ± 0.064 before and after of implementing of health transformation plan. The HTP in 2014, as the latest reform of Iran’s health system, has been implemented gradually in several phases to facilitate the achievement of universal health coverage, financial protection of households, ensure justice in access to health services for the society members and efficiency of the health system [80, 81]. Despite the achievements of this plan, discrimination in payments between physicians and nurses, job dissatisfaction among nurses, declining moral values, and increasing expectations of nurses are the main challenges of this plan [82]. In addition, the number of patients referred to the emergency department increased following the implementation of the health transformation plan [83, 84] which led to a high workload for nurses in hospitals [85]. Such reforms put more pressure on health workers, especially nurses [55, 86]. In such situations the likelihood of a turnover intention in the profession [87].

The results of a study conducted during the COVID-19 pandemic in Iran showed that there was a statistically significant relationship between the variables of fear of COVID-19 and job stress, job stress and intention to leave, and resilience and job stress. Also, in low resilience and high job stress with a probability of 100%, the variable of intention to leave increased by 20%, while in high resilience and low job stress with a probability of 100%, the intention to leave decreased by 32% [67]. In a study among nurses in Iran (2022), 79.4% had a moderate to low tendency and 20.6% had a high tendency to leave the service during COVID-19 pandemic [19]. This increase was not unique to Iran, as the rate of turnover intention was also higher among Qatari nurses compared to pre-COVID-19 pandemic, and nurse characteristics and stress levels played an important role in nurses’ turnover intentions during COVID-19 pandemic. Also, the previous literature showed that nurses’ turnover intention increased significantly after the COVID-19 pandemic, which researches after the COVID-19 pandemic mostly focusing on predicting nurses’ turnover intention through the negative impact of the pandemic on nurses’ psychological wellbeing [88].

The challenging conditions of caring for COVID-19 patients and the physical and mental stress imposed on nurses during the pandemic may cause them to quit their jobs. This was also evident in the present meta-analysis, as 65% of the included studies in Iran were conducted after the COVID-19 pandemic [89]. In the past 5 years and after the COVID-19 pandemic, the Iranian government’s efforts to solve the problem of hospital nurses’ turnover intention have focused mostly on resolving problems related to the welfare of nurses, including increasing salaries, implementing nursing service tariffs, and establishing other financial options. Analysis conducted based on the COVID-19 pandemic subgroup showed that after this pandemic, the turnover intention among Iranian nurses has increased. Through a variety of policies, understanding the environmental, relational, and individual factors that influence nurse satisfaction and commitment can help prevent nurses’ turnover intention and enhance their retention in clinical settings [90].

The present meta-analysis attempted to provide a clear image of turnover intention among nurses in Iran by systematically reviewing and collecting studies conducted in recent years. Based on the analysis, nurses’ turnover intention in Iran is at a moderate level, in general, before and after implementing the HTP and the COVID-19 pandemic. This study has good and bad news for health policymakers and nurse managers in Iran. The good news is that overall the level of turnover intention among nurses is moderate. Still, the bad news is that in recent years turnover intentions have increased, especially after the COVID-19 pandemic and societal problems. Hence, due to the negative consequences of turnover intention on patients, nurses and organizations, health policymakers and managers should intervene to prevent and reduce turnover intention among nurses in Iran. Policy attention should focus on developing effective interventions to prevent and minimize the prevalence of turnover intention among nurses in Iran.