The Impact of the Coronavirus Disease (COVID-19) Pandemic on Nurses’ Turnover Intention: An Integrative Review

The COVID-19 pandemic has increased the demand and workload on nurses. In addition, the number of critical cases, the uncertainty about the disease, and the incidence rate of death from the disease impose a psychological stress on nurses. Considering the alarming issues of stress, burnout, and turnover among nurses even before the pandemic, the pandemic might have amplified such issues. Thus, the impact of the COVID-19 pandemic on nurses’ turnover and turnover intention warrants investigation. The aim of this review is to appraise and integrate the current pre- and post-coronavirus disease (COVID-19) literature on nurse turnover, published between 2016 and 2021. Forty-three studies on nurses’ turnover intention were appraised and synthesized. The reviewed literature suggested that nurses’ turnover intention increased significantly after the COVID-19 pandemic. Post-COVID-19-pandemic studies focused more on predicting nurses’ turnover intention through the pandemic’s negative impact on the nurses’ psychological wellbeing. The findings of this review should be considered by nurse managers and leaders in the development of policies and programs to reduce the negative impact of COVID-19 on nurse retention.


Introduction
Nurse turnover has been defined as a global healthcare-system issue [1]. It has been defended as voluntary and early termination of nurses' employment [2]. Nurse turnover could be either organizational or professional, with the latter being the most consequential because of its contribution to the preexisting nurse shortage [3]. In the literature, studies that measured the actual organizational and professional nurse turnover are limited; however, many studies have evaluated nurses' turnover intention. In addition, nurses' turnover intention has been defined in the literature as the most accurate predictor of actual nurse turnover [4].
Many terms have been used in the nursing literature that are synonymous with nurses' turnover intention, such as intention to leave, intention to quit, intention to stay, risk of quitting, and job retention intention [5][6][7]. Although increasing attention has been paid to the difference between organizational and professional turnover intentions, the lack of consistency of the definition and measurement of organizational turnover, professional turnover, organizational turnover intention, and professional turnover intention is still evident in the nursing literature [8]. Nonetheless, nurses' turnover intention has been widely defined as "an individual's perceived probability of permanently leaving the employing organization in the near future" [1].
Turnover intention has been linked to several adverse outcomes such as medication error, falls, and pressure injuries [9]. Moreover, it has been linked to increased healthcare system costs due to its impact on both financial and time resources [10]. Thus, numerous studies have been conducted to identify nurses' turnover intention predictors and provide useful information for the development of remedial programs to lower nurses' turnover intention rates. Among the identified predictors are job satisfaction, job commitment, stress, anxiety, and burnout [11]. Historically, the prementioned predictors were found

Aim
The aim of this review was to appraise and integrate the current turnover literature, published between 2016 and 2021, by using Whittemore and Knafl's integrative review method [17]. The review was aimed at answering the following questions: How is nurse turnover defined and measured? What are the differences in turnover and turnover intention rates before and after the COVID-19 pandemic? What are the predictors of nurse turnover before and after the COVID-19 pandemic?

Methods
The integrative review method was described by Whittemore and Knalfl as the most comprehensive and inclusive review method because it enables reviewers to include varied articles, including empirical qualitative and quantitative studies and theoretical reports. Thus, this method was utilized to minimize the review bias and increase the rigor of the study. Whittemore and Knalfl identified six phases of their review method, namely problem identification, literature search, data evaluation, data analysis, and presentation of conclusions. Since the study is a review of the literature, it did not require IRB approval.

Problem Identification
The problem identification stage is the first phase in the review technique and makes the following phases easier to perform. The goal of this phase is to set the focus and bounds to the otherwise vast, complex, and ambiguous review. This goal is achieved by identifying the target concepts, population, healthcare problem, and sample frame [17]. Indeed, nurse turnover is a problem that has impacted healthcare systems and outcomes worldwide. The impacts of COVID-19 on nurses' physical and psychological wellbeing are evident in the literature [18]. Thus, we hypothesized that COVID-19 will amplify the problem of nurse turnover. The target concepts for this review are nurses' turnover and turnover intention, and the COVID-19 pandemic.

Literature Search
In accordance with Whittemore and Knafl's method, the objective of the literature search phase is to incorporate as many suitable primary sources as possible within a predefined frame [17]. The use of various search techniques is recommended, and purposive sampling may be used if necessary. Transparency and explanation of each sample decision are critical components of this phase [17].
For this review, the literature search was conducted using a preformulated search strategy to identify current articles on pre-and post-COVID-19 pandemic nurses' turnover. Initially, the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Medline databases were searched, followed by a supplemental search on Google Scholar. The databases were accessed using the Saudi Digital Library. The keywords used included "nurse*," "turnover," "turnover intention," "intention to leave," and "intention to quit." The steps of the literature search are presented in Figure 1.  The initial database search yielded 346 articles. Limiting the search to the years between 2016 and 2021 to focus the review on the most recent literature pre-and post-COVID-19 resulted in 176 articles. When the search was additionally limited to academic journals only, the number of articles became 174. Finally, 140 articles remained when the search was limited to English-only articles. The author reviewed the titles of the 140 articles and identified 55 suitable articles that met the inclusion criteria (Table 1). After reviewing the abstract of these articles based on the inclusion criteria, 38 were selected. After obtaining the sample, an independent expert was consulted about the inclusion criteria, the search strategy, and the included articles. She suggested a supplemental Google Scholar search and five more articles were included in the review after the supplemental search. A total of 43 articles were included in this review. Only primary peer reviewed articles were included in this review and all the grey literature items were excluded. Articles that were discussing turnover in other professions and not including nursing were excluded. For example, articles that were examining turnover among physicians were excluded, however articles that were examining turnover among physicians and nurses were included.

Criteria
Primary reports of studies that utilized any research method (qualitative, quantitative, or mixed method) Articles published between 2016 and May, 2021 Articles published in academic journals "peer reviewee process" Articles published in English language The articles' full text available through the reviewed databases Examine or discuss turnover or turnover intention among nurses

Data Evaluation
Owing to the different research methods of the primary sources, evaluating the quality of the primary sources for an integrated review may be difficult. As a result, the data evaluation step in an integrative review is determined by the sample frame used [17]. For example, if the reviewed article includes qualitative and quantitative studies, two different appraisal tools must be used to evaluate the studies. All the studies included in this review used a quantitative research method, and most were cross-sectional studies. Thus, a modified Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool was used to evaluate the reviewed studies. As all the studies did not include a control group, the items used to evaluate the use of a control group were eliminated, and 12 questions were used to appraise the studies. A one-point score was assigned to each of the 12 appraisal items, and the quality score ranged from 12 to 0. The score was divided into three levels as follows: from 12 to 9, high quality; from 8 to 5, good quality; and from 4 to 0, low quality. The quality assessment is summarized in Table 2.
Most of the studies rated as high quality in the quality assessment obtained 11 points (n = 16), followed by those who obtained 12 points (n = 10), 10 points (n = 8); and 9 points (n = 7). Only two articles obtained 8 points and were rated as good quality. More than half of the reviewed articles (n = 24) scored 0 in the item related to the use of current literature, as more than half of the used sources in these articles were published >5 years from the year of publication. Instrument validity was not discussed on 18 of the reviewed articles. Moreover, turnover instrument reliability was not reported in seven of the reviewed articles. Similarly, the survey response rate was not reported in seven of the reviewed articles. Overall quality rating High 41 Good 2 Low 0 From 12 to 9 high quality; from 8 to 5 good quality; from 4 to 0 low quality.

Data Analysis
The goal of the data analysis phase is to provide an answer to the preidentified problem while facilitating a thorough understanding of the review topic. Data analysis involves organizing, classifying, categorizing, and summarizing information from primary sources to arrive at a methodical and creative conclusion. The steps of the data analysis in the integrative review technique include data reduction, data display, data comparison, conclusion drafting, and validation [17].

Data Reduction and Display
In this phase, the articles are divided into subgroups according to, for example, demographics or countries, or historical events. The data are then taken from primary sources and organized into a comprehensible structure such as a matrix or spreadsheet. The data are then compiled into a presentation based on certain factors or categories [17]. This review aimed to evaluate the impact of the COVID-19 pandemic on nurse turnover. Thus, the reviewed studies were divided into two subgroups, pre-and post-COVID-19 studies. Data, including author and year, purpose, time (pre-or post-COVID-19), method, variable, turnover prevalence, turnover predictors, and turnover outcomes, were extracted using a spreadsheet ( Table 3). The outcome column was eliminated from the displayed table because no data were found in any of the articles related to the outcomes of nurse turnover.

Data Comparison
Data comparison is an interactive technique that involves reviewing the data presentation to discover similar themes, patterns, and/or correlations among the primary resources [17]. While the design of most studies was identified as cross-sectional, two of the studies had a longitudinal design [38,42]. No explicit definition of turnover intention was provided in 28 of the reviewed studies. While two of the reviewed studies did not explicitly discuss how turnover intention was measured [6,35], eight studies used a single item ( Table 3).
The purposes of the 32 pre-COVID-19 articles can be viewed in Table 3. The purposes included assessing nurses' turnover intention rates [24,29,38], identifying nurses' turnover intention factors [10,14,44], and examining the association of turnover intention with variables such as job satisfaction, leadership style, burnout, and work climate [11,23,39,40]. In summary, we can conclude that most post-COVID-19 studies aimed to examine the psychological impacts of the pandemic on nurses' turnover and turnover intention. By contrast, the pre-COVID-19 studies aimed to examine the association between nurse turnover and varied staff-, profession-, patient-, and organization-related factors.
Two of the 10 post-COVID-19 studies assessed nurses' intention to stay and retention intention [5,7], which were 2.00 and 3.91, respectively. The rest of the post-COVID-19 studies measured nurses' turnover intention, and the mean ranged from 2.23 to 3.42 [15,18]. Two of the post-COVID-19 studies measured professional turnover intention and obtained mean values of 1.86 and 2.87 [15,29]. Nashwan and others found a significant increase in turnover intention from a mean of 13.24 to 15.54 [20]. Similarly, a comparative study conducted in Egypt by Said & El-Shafei on 210 nurses from the Zagazig Fever Hospital (ZFH), a COVID-19 triage hospital and 210 nurses from the Zagazig General Hospital (ZGH), which is neither a triage nor an isolation hospital, found significant differences in intention to leave current position (ZFH = 40.0%; ZGH = 30.5%), intention to leave current organization (ZFH = 45.2%; ZGH = 34.3%), and intention to leave the field of nursing (ZFH = 24.8%; ZGH = 10.0%) [12].
The predictor of job turnover intention post-COVID-19 was dependent on the nurses' age and work experience. In terms of the factors related to COVID-19, the group with experience in nursing care for patients with COVID-19 infection and those working in COVID-19 divisions had high rates of job turnover intention. Lastly, job engagement and turnover intention appeared to differ depending on the category and type of social support available for the nurses [7]. The identified predictors of turnover intention after the COVID-19 pandemic were; frequency of providing care to patients in the workplace, having taken a course on providing care related to pandemic prevention after starting work, willingness to provide services, and clinical stress [5]. In addition, nurses' fear of contracting COVID-19 was significantly associated with increased turnover intention [15,18,21]. The factors perceived to increase nurses fear of COVID-19 include lack of experience in nursing care for patients with COVID-19 infection and working in COVID-19 divisions (Kim et al., 2020), deployment in COVID-19 departments [12,20], and age, wherein younger nurses had higher turnover intention [22]. Liaqat and others conducted a study from September 2019 to April 2020 to examine the association between workplace bullying and nurses' intention to leave the job [19]. They found that most study participants affirmed that work-related bullying was the reason behind their intention to quit their job (59.5%). Many of the study participants affirmed that person-related bullying was present in their workplace and was the reason behind their intention to quit their job (39.7%). Physically intimidating bullying was affirmed by 40.9% of the nurses and was the reason behind their intention to quit their job.

Discussion
This is the first integrative review study that aimed to examine the prevalence and predictors of nurses' turnover and turnover intention before and after the COVID-19 pandemic. As in previous studies and reviews, no consensus was reached regarding the definition and measurement of nurses' turnover and turnover intention [27]. This lack of congruency might be the cause of the observed variation in nurses' turnover and turnover intention rates. Nonetheless, nurses' turnover intention is considered high compared with those of other professions [10], and COVID-19 appeared to have increased the mean nurses' turnover intention rate. This result has been forecasted by many studies and is reported to be due to the social and psychological impacts of COVID-19 [7,18].
The findings of this review have confirmed that post-COVID-19, the most reported nurses' turnover intentions predictors included fear of the disease, stress, and anxiety. This predictor differs from the pre-COVID-19 turnover intention predictors, which included satisfaction, commitment, and leadership style. This expectation was confirmed in a few studies that supported the evidence of the significant impacts of the COVID-19 pandemic on nurses' turnover and turnover intention. Hence, more studies are needed to enhance the understanding of the impacts of COVID-19 on nurses' outcomes, including turnover intention.

Implication
As per the findings of this review, future research in nursing turnover should be based on clear and explicit theoretical and operational definition of nurses' turnover and turnover intention. This will improve the consistency across the nurses' turnover-related literature and provide a more accurate estimation of the proviolence of the problem. Additionally, future research on nurses' turnover should utilize experimental design to examine the impact of interventions based on the uncovered significant predictors.
In management, nurse leaders and policy makers should build polices and regulation based on the evidence found in the literature to decrease nurses' turnover. These include reconsidering aspects such as nurses' workload, pay and benefits, and educational reimbursement. At the front-line management level, nursing mangers should strive to improve staff nurses' satisfaction through their inclusion in decision making and give them autonomy of their clinical practice. Additionally, during pandemics and crises, nursing mangers should ensure that their staff have adequate social and psychological support systems. Lastly, providing nurses with appreciation and acknowledgment might play an important role in decreasing nurses' turnover and turnover intention during unpresented crises.

Limitation
Although this study utilized an integrative review method that enabled the inclusion of studies with varied designs, the lack of a statistical method, which is utilized in metaanalyses and would confirm the statistical significance of the pre-and post-COVID-19 differences in nurses' turnover, could be considered a limitation. Thus, future reviews in this area should implement meta-analysis review methods that enable the use of statistical methods. Nonetheless, the finding of this review provides a wide appraisal and integration of the current literature on pre-and post-COVID-19 nurses' turnover intentions.
Another limitation is that this review was conducted by single reviewer, which might impact the rigor of the review. To mitigate this limitation, the author consulted a nursingmanagement research expert several times during the review.

Conclusions
The unpresented COVID-19 pandemic has impacted many aspects of people's lives, of which healthcare services are one of the most impacted. Nurses, being the largest group of healthcare providers who spend the longest time with patients, are among the healthcare groups that are highly impacted by the pandemic. Before the pandemic, nursing was one of the professions with the highest turnover intention rates. Owing to the psychological impact of COVID-19, this review was aimed at examining the pre-and post-COVID-19 turnover and turnover intention rates and their predictors. In this review, we used Whittemore and Knafl's integrative review method, and evaluated the primary resources by using a modified Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool. On the basis of the review of 43 studies, we can conclude that the COVID-19 pandemic has impacted both the rates and predictors of nurses' turnover intention.
This review emphasized the alarming rates of nurses' turnover intention, both before and after the COVID-19 pandemic. Most of the reviewed studies identified the predictors of nurses' turnover intention. Nursing managers and leaders should utilize this knowledge and develop policies and programs to reduce the impacts of the predictors that increase nurses' turnover intention and enhance the predictors that increase nurses' retention. For example, many studies have identified leadership style as one of the predictors of turnover. Thus, new orientation and development programs for managers and leaders must be mandated to reduce staff turnover intention.
Owing to the COVID-19 pandemic, nursing staff have been experiencing increased stress, anxiety, and fear of contracting the infection. Improving nurses' competencies in caring for patients with COVID-19 might reduce these psychological factors, thereby reducing turnover intention. Moreover, ensuring the availability of personal protective equipment might reassure nurses and reduce their fear of the disease. Nursing managers and leaders should also provide psychological support and counseling to nursing staff during the COVID-19 pandemic to reduce their turnover intention.

Conflicts of Interest:
The authors declare no conflict of interest.