Chapter One: Introduction
1.0 Background of the Study
The research has taken the case of hospital management and the burning issue of employee turnover in the healthcare system. Hospital management is the discipline or a field that organizes, plans, and leads hospitals and plays a critical role in human resource management there. Nurses and healthcare providers are the primary employees there. Clinicians hea, healthcare experts, and practitioners are experienced (Mengstie, 2020). Research has noted that hospital staff have low retention rates, and they always think about leaving their present hospital or healthcare institution. It is a very concerning issue because the high rate of turnover causes a burden on cost and lowers the revenue of hospitals and healthcare institutions. Research also notes that human resource management practices can play an instrumental role in increasing the level of satisfaction and motivation of employees (Simone et al., 2018). As a result, their turnover intentions can be lower, and in the end, hospitals and healthcare institutions perform well. In this respect, employee engagement strategies are worthwhile as employees draw meaningful practices there (Prasetyo et al., 2021). It also affects the working culture as organizational culture shapes employees’ practices and behavior. The research has addressed the issues of employee turnover in the healthcare system of the Sultanate of Oman through employee engagement and working culture.
1.1 Statement of the Problem
Hospitals face high levels of burnout, fatigue, and stress among their employees. Nurses and healthcare staff face pressure in the hospital setting, and they have high turnover intentions (Martins et al., 2023). Research studies have consistently found that nursing staff think about switching their organization after a few years. It causes a burden on the balance between cost and revenue. Studies have shown that a higher level of employee engagement and favorable organizational culture can prevent their desire to leave the healthcare institution in which they work (Manshadi et al., 2022). Therefore, the research examines whether employee engagement and working culture can stop the rising turnover ratio among employees in a hospital.
1.2 Objectives of the Study
The study aims to improve the retention rate of employees in Oman’s healthcare system. The following research objectives guide the study.
- To investigate reasons for high turnover intention among employees in hospitals in Oman.
- To study the role of employee engagement and working culture in solving the problem of higher turnover intentions among hospital employees and nursing staff
- To recommend how to improve retention rate through employee-centric hospital management practices.
1.3 Research Questions
- What are the reasons for the high turnover ratio among hospital staff and employees?
- What is the effect of employee engagement strategies on turnover intentions in Omani hospitals?
- What is the effect of working culture on turnover intentions in Omani hospitals?
- How can the employee retention rate be improved in hospitals located in Muscat, Oman?
1.4 Scope of the Study
The research has a broad scope to include concepts like hospital management and valuable strategies to make it effective. After the focus on hospital management, the study emphasizes that employees know how their management can improve hospital management. For this purpose, it has chosen employee engagement and working culture concepts to affect hospital management practices favorably. The study has been done in the context of hospitals and the healthcare system of the Sultanate of Oman.
1.5 Significance of the Study
This research has some prominent significant features that make it valuable. The immediate benefit of this research is academic research in the field of hospital management and employee-centric policies. Another significance is its empirical nature in that it helps the healthcare system and sector in Oman to improve employee retention. It helps to understand the reasons for employee turnover intentions and the role of employee engagement and working culture in lowering these intentions (Marufu et al., 2021). Broadly, it contributes to empirical research and practices that support all stakeholders, including private and government institutions.
1.6 Definition of the Keywords/terms
The research used five key terms: hospital management, employee turnover ratio, employee engagement, working culture, and healthcare system. Hospital management is defined as planning, organizing, leading, and controlling operations and processes in a hospital (Manshadi et al., 2022). Employee engagement is defined as the dedication and enthusiasm of an employee towards the organization (Wan et al., 2018). Working culture is the atmosphere and surroundings under which an employee works and performs. A healthcare system is defined as the combination of resources and infrastructure, including hospitals and healthcare providers, and they fulfill the medical needs of clients.
1.7 Chapter Summary
The chapter has set the background of this research and has emphasized the problem of hospitals having a higher employee turnover ratio. The chapter has presented the scope and significance of research that has addressed this issue through employee engagement and working culture perspectives. It has also defined key terms used in this research along with the presentation of objectives and research questions.
Chapter Two: Literature Review
2.0 Introduction
The chapter has reviewed previous studies on variables used in this study and their relationship. Subheadings in this chapter have reviewed the link between employee engagement and working culture with turnover and turnover intentions in the healthcare sector. Theoretical foundations and conceptual model sections completed this chapter before the summary that summarized it together.
2.1 Hospital Management and Turnover
Research has noted the link between hospital management and turnover. Good hospital management practices lead employees to stay with the organization. Lack of proper hospital management leads employees to leave the organization or the healthcare institution (Prasetyo et al., 2021). Micro and macro-level factors affect employees and their intention to stay with the organization. Research studies have noted that factors responsible for employee turnover in hospitals relate to managers, medical universities, hospitals, and the country (Prasetyo et al., 2021). Factors related to these heads make up the environment shaping employees to stay with the hospital.
Leadership and management support are crucial parts of hospital management that allow employees to stay with the hospital. It also relates to any organization in which leadership and management support support employees to keep associating with the organization (Rindu et al., 2020). Insufficient support from officials and the management increases employee turnover, and they prefer leaving the hospital in this context. Another research has focused on performance, stating that management must display extraordinary performance to encourage employees (Rindu et al., 2020). Poor managerial performance also increases the employee turnover ratio, and management is responsible for positive intentions to stay with the hospital.
Research studies have indicated the value of managerial and leadership support in decreasing the turnover ratio among employees in the hospital setting (Rindu et al., 2020). Conflict in the workplace or lack of agreement with the management does not make the workplace favorable for workers in the hospital setting. Frequent and unresolved conflicts with managers increase the turnover ratio. The range of conflict can also reach the employees’ level, which also makes the work climate less friendly (Manshadi et al., 2022). Colleagues and employees can raise conflict and differences of opinion that can be unhealthy. Though research has welcomed the difference of opinion, it should be meaningful and constructive. Conflict and fierce arguments indicate the stage of storming, which does not bring adequate results (Manshadi et al., 2022). Thus, research has noted the negative impact of conflict across different levels on employees and their tendency to be with the organization. It increases the turnover ratio in hostels, and hostel management faces a setback.
Hospital managers develop unique reasons for leaving hospitals or other healthcare institutions. Changes in senior managers and regulatory changes at the macro level affect their practice. It brings uncertainty and a lack of uniform practices, which can cause a loss of interest for senior managers. Macro-level factors like regulations and the legal environment also affect senior-level management (Manshadi et al., 2022). Research has shown that employee or manager-level turnover occurs because of a lack of staff engagement and collaborative organizational culture.
Research has emphasized the importance of engagement and working as well as practical culture to affect employees’ stay in the organization. The employee turnover ratio can improve if the organizational culture in a hospital is interactive and engaging. At the same time, research has found a positive impact on healthcare effectiveness and efficient hospital management when there is managerial stability (Jian, et al., 2022). Healthcare organizations and health managers perform the best when senior-level managers work in responsible positions in hospitals. The longevity of work from senior-level management supports the work climate, and it improves the process of working in hospitals (Jian, et al., 2022). At the same time, voluntary turnover of nurses and hospital staff is a concerning sign for hospitals and healthcare institutions. It is a global phenomenon that affects service quality and standards in hospitals. Therefore, prevention of employee turnover also guarantees service quality and improvement in hospital services.
2.2 Employee Engagement and Turnover
Hospital management presents a unique set of challenges, and employees can face challenges related to the workplace. Research has found that employee engagement is directly related to employees’ tendency to stay in the hospital or an organization. As more and more employees feel engaged and connected to the workplace, they have a higher level of satisfaction and contentment (Boakye, et al., 2021). Employee engagement is expressed in different ways that a person is well-integrated and connected to the workplace. Nurses draw meaning and a sense of purpose through employee engagement practices.
Different human resource management practices play their role in enhancing employee engagement. Compensation management and performance appraisal are effective methods to ensure employee engagement. Monetary compensation offers monetary rewards and benefits to let employees meet their needs (Simone et al., 2018). Non-monetary rewards like recognition and exposure to a diverse range of environments provide unique satisfaction for employees. They develop a connection with the workplace, and it leads them to be engaged in the workplace. Research has noted that a more significant level of employee engagement leads to a lower level of voluntary turnover of nurses in hospitals. It brings different benefits and positive effects in service provision that raise the standard of hospital management (Simone et al., 2018).
Turnover ratio and turnover intentions are two related variables. The turnover ratio is the ratio of nurses who leave a hospital or a healthcare institution. Turnover intentions refer to intentions or the beginning of thinking when nurses start thinking or deciding to leave the organization. A research study has found that 35.9 percent of experienced nurses have a higher level of turnover intentions (Wan et al., 2018). It is concerning, especially when experienced nurses provide value and better service provision in hospitals and healthcare organizations. Research studies have identified a positive impact of employee engagement in hospitals to motivate nurses and hospital staff to stay longer.
The role of the work environment is crucial in providing better work engagement for employees. Work environment relates to a working culture that provides an environment in which nurses and hospital staff perform efficiently and productively (Li et al., 2019). An improved work environment leads to an increased level of work engagement that lowers turnover intentions of nursing staff and hospital employees (Li et al., 2019). Work engagement is the mediating variable that lowers turnover intentions and turnover ratio in hospitals when there is a suitable work culture. It leads to a focus on factors responsible for work engagement so that the turnover ratio can be lowered.
This is the reason why research studies have focused on increasing work engagement. The role of job characteristics is vital in this regard, and favorable job attributes should improve the workplace culture and environment in the workplace. The research finds that the job demands-resources model can be adapted to affect work engagement through extrinsic and intrinsic motivators. Motivation plays a crucial role here, and job characteristics support them (Lee & Jang, 2020). It is the job of hospital managers and HR managers in the healthcare sector to improve motivation levels and the level of employee engagement as part of employee retention.
However, focus on employee engagement must relate to employee satisfaction. Research has noted that the purpose of any activity or action for employees should be to make their views and perspectives better. Employee motivation and satisfaction strategies aim to improve employees’ perspectives on remaining in the organization. In a hospital setting, nurses and healthcare practitioners spend time in continuous uncertainty (Li et al., 2019). Improvement in their satisfaction is possible through engagement strategies so that they remain connected and aligned with the work setting. It also relates working culture to their performance and productivity.
2.3 Working Culture and Turnover
Research has found that the turnover ratio of nurses in hospitals is higher. According to research, this ratio is between 12 and 34 percent (Dewanto & Wardhani, 2018). This considerable variability of turnover ratio is due to different factors. Among them, a study has informed that a nurse of thirty years old, single, and working experience of up to three years in a hospital increases the chances of turnover. The most important reason is that nurses and hospital staff do not remain with the hospital for long. Three main factors are there, which are personal reasons, attraction from the external environment, and unfavorable and unsuitable working conditions and culture in the hospital (Dewanto & Wardhani, 2018). Hospital management finds the opportunity to know why nurses and hospital staff choose to leave the hospital because nurse and hospital staff turnover affects the operations of a hospital badly. It also affects the revenue and costs of a hospital (Dewanto & Wardhani, 2018). Working culture and management strategies in this respect are instrumental to reversing the turnover ratio in hospitals and healthcare institutions.
Organizational climate and culture are crucial to defining the retention of employees in hospitals. The role of employee perceptions of training is vital as research positively relates it to organizational commitment. Research studies have shown that organizational commitment leads to lower turnover intention as an employee prefers staying with the organization. Hospital management takes serious measures for employee retention, and like motivation, increasing organizational commitment is a priority. However, research studies have reached mixed results on the role of training and corporate commitment that affects turnover intention in hospital settings (Rawashdeh & Tamimi, 2020). It implies that there needs to be a comprehensive strategy or plan to affect employees and the level of their commitment. It requires investing in the whole working climate and organizational culture to motivate them to stay in the hospital. Stress, fatigue, and burnout in hospital settings play their role in the high turnover ratio of employees.
Justice and equality are essential attributes of organizational culture that shape the working culture where employees work and perform their activities. Hospitals and healthcare workers face fatigue and burnout due to the hectic work environment. They also face issues with justice and equality. Research studies on justice show that justice and its various forms shape their perceptions and views about how hospital staff decide to stay or not. A research study has demonstrated that perceived distributive, interpersonal, procedural, and informational justice plays a crucial role in the working and organizational culture of a hospital (Mengstie, 2020). A comparison of justice between private and public hospitals has revealed a better perception of justice in private hospitals. Overall, turnover intentions are high in both public and private sector hospitals (Mengstie, 2020). As far as fairness in interpersonal and informational justice is concerned, these dimensions are higher in private-sector hospitals. All sizes of justice, including distributive, interpersonal, procedural, and informational justice, affect turnover intentions, while distributive justice is the most influential predictor (Mengstie, 2020). Justice decides important orientation in an organizational setting, including hospitals, as perceptions of employees decide if there is just treatment of employees.
Research has consistently referred to burnout and fatigue among hospital employees and nurses. It also affects the quality of care in a hospital. It calls for a favorable working environment, and it is associated with less turnover intention. However, research has reached this finding if there is high job satisfaction (Al Sabei et al., 2020). Nurses’ perceptions of the work environment play a central role in defining whether they stay in a hospital. In another research study, a culture-work-health model that considers fatigue, job stress, and organizational culture in connection with turnover intentions has been presented. According to this research, the model based on culture, work, and health is a good fit. Nurse turnover intentions are influenced by factors such as organizational culture, fatigue, and job stress (Lee & Jang, 2020). It explains how theory-driven interventions can improve the work culture for nurses and how they can overcome stress and fatigue.
The above literature has revealed the adverse impact of unfavorable organizational culture on employee retention that implies turnover intentions and turnover increase when the work environment is not favorable. It has connected variables of employee engagement and working culture in the healthcare system with employee turnover intentions (Lee & Jang, 2020). The following heading presents strategies to address turnover in the healthcare system and hospital management.
2.4 Strategies to Address Turnover in Hospital Management
Hospitals and healthcare institutions face serious challenges related to their staff and employees. Nurses and healthcare providers in hospitals face burnout, fatigue, and stress that prevents them from performing their duties effectively. The above literature has indicated strategies that address turnover in hospitals and healthcare institutions.
Nurses and employee turnover in hospitals is due to burnout and fatigue. Research has found that clinicians and staff consider burnout, low engagement, and turnover intentions to be high in hospitals and their management. Only 35 percent of staff has reported high engagement, while turnover is very high. From the total number of staff, 41 percent will be working in a different primary care system two to three years later. The reason for high turnover is a higher level of burnout (Willard-Grace et al., 2019). Therefore, research calls for improving the level of employee engagement in hospital settings to lower the turnover ratio.
Research has called for a fit between the health and education sectors for the workforce to be purposeful and objectives oriented. Collaboration across industries provides purpose and vital objectives for the workforce to stay in a hospital or healthcare organization. Support and funding certainty are also reasons for motivating employees to stay in the hospital. A safe work environment and working culture are also crucial for improving employee engagement and increasing retention. Above all, an employment policy and the way employment conditions and strategies are implemented decide how the health workforce can be retained by lowering their turnover ratio (Wakerman et al., 2019).
Hospital management deals with healthcare staff retention by lowering their turnover intentions. A research study has shown that teamwork and supervisory leadership support are crucial factors in lowering turnover intentions and increasing the level of retention. There has not been a direct association between supervisory leadership support and work organization with turnover intentions, as the relationship has been found to be insignificant (Zaheer et al., 2019). However, frontline health workers have a positive effect of supervisory leadership on turnover intentions when they have lower levels of mindful organization (Zaheer et al., 2019). It implies that considerations of factors can decide how to make supervisory leadership significant for lowering turnover intentions.
Retention of nursing hospital nurses has been a priority of hospital management, and it employs a range of strategies and policies to make things in its favor. A systematic review has found that nine domains influence staff turnover and lead them to stay with the hospital or the healthcare system. These domains include leadership and management in nursing, career advancement and education opportunities, work environment and solving professional issues, support at work, and financial rewards and compensation, among some other factors and dimensions (Marufu et al., 2021).
2.5 Theoretical Framework
Literature has noted that practices have directed the role of employee engagement and working culture as crucial factors for the improvement and betterment of the healthcare system. Hospital management and employee turnover are closely related factors, and employee engagement policies and supportive work culture, along with leadership support, can stop the trend of lower turnover ratios. Theories of employee engagement, leadership support, and healthy being indicate how the environment for employees can improve and how a supportive culture in hospitals can be ensured.
Work culture and leadership policies are very crucial factors for changing the work culture. Hospital management continuously deals with increasing burnout, fatigue, and stress that affect performance and the level of employee satisfaction and motivation. Theories that underpin this research relate to employee engagement and satisfaction. At the same time, theories focus on hospital management settings and the healthcare system. It is worth noting that the healthcare setting and hospital environment have plenty of concerns about employee engagement and satisfaction. Burnout and fatigue are typical and must be resolved. This context increases the turnover rate and ratio, which affects employee retention rates in hospitals.
Therefore, work-life balance, support from leadership, and supportive human resource management policies make up the theoretical foundation and context that have been the focus of this research, and these theoretical foundations have guided this research work.
2.6 Conceptual Framework
The conceptual framework for this research is as follows. It links three variables where hospital management and healthcare systems focus on employee-oriented strategies to lower the turnover ratio.
2.7 Chapter Summary
The chapter has reviewed studies on employee turnover in hospital management and the healthcare system. The turnover ratio is higher in hospitals, and nursing staff and clinicians have high turnover intentions. The only way to avoid it is through employee-centric strategies and policies. This chapter has got help from employee engagement and working culture theoretical foundations to lower employee turnover in hospitals. It calls for considering employee-centric policies to get things on the right track, and employee-centric strategies should focus on their issues and concerns.
Chapter Three: Methodology
3.0 Introduction
The chapter describes and explains the methodology employed in this research. The primary intention of this chapter is to justify the decisions and strategies for data analysis and interpretation. It is primary research that enhances the consideration of ethics so that it remains credible and sound.
3.1 Research Paradigm and Research Approach
The research has adopted the deductive research paradigm that is in line with the quantitative research methods. It is in line with positivism, which is an objective method of analyzing a problem. The research is primarily conducted in the Sultanate of Oman and has asked participants working in Omani hospitals. Quantitative research methods are always valuable and helpful as they enable analyzing a problem statement objectively (Basias & Pollalis, 2018). This is the objective set for this research in its first chapter. As far as research design is concerned, this research has chosen an explanatory research design that investigates the impact of employee engagement and working culture on the turnover ratio and intentions of employees in hospitals. The main issue there relates to aiding hospital management so that it can formulate policies for employee retention in hospitals.
3.2 Population and Sampling Procedure and Sample Size
Hospitals face high levels of employee turnover as employees tend to leave hospitals and healthcare organizations due to fatigue and burnout. This research has taken hospital management as a broad field. Indeed, there should be a focus on who can respond to find the relationship between employee engagement, work culture, and employee turnover ratio. Employees and staff working in hospitals can be the best study population for this purpose (Basias & Pollalis, 2018). The research has adopted a convenient non-random sampling strategy to reach employees working in hospitals located in Muscat. The sample size for this research is one hundred, which is suitable to meet the requirements of the research problem and the needed actions for its solution.
3.3 Instruments
For this research, the chosen data collection instrument is the questionnaire. It is an effective and convenient data collection instrument that takes less time to collect responses. It is also in line with primary and quantitative research, which uses closed-ended questions in the questionnaire to collect data conveniently and effectively. The questionnaire contained two types of questions (Rahi, 2017). The first section presents demographic information questions, and the second section asks about variables. Each statement has five options along the Likert scale. The data collection instrument is designed with the help of the literature review.
3.4 Ethical Considerations
It is the primary research and is subject to ethical considerations. One hundred participants have taken part in this research process, and the research has collected data through ethical and responsible means. The first ethical consideration was that all participants participated in this research voluntarily, and the researcher informed them about the research objectives. Informed consent was the first ethical consideration for this research. Then, it has made sure privacy and confidentiality are observed. Data collected for this research was used only for the stated purpose of this research and will be wasted once this research is completed (Rahi, 2017). Along with these considerations, the research has met all ethical considerations and obligations set by the university.
3.5 Data Collection Methods with Timeline
This research has collected data through the chosen data collection instrument, i.e., a questionnaire (Basias & Pollalis, 2018). The questionnaire contained a statement designed considering the literature review. The data collection strategy has adopted online methods using Google Forms in which all statements have been entered. It has generated the link that was conveniently set to prospects. As soon as one hundred participants filled in the questionnaire, the link was disabled. The data collection method has adopted the following timeline of events.
The above timeline includes only the data collection process that started from questionnaire development and covered the data collection process.
3.6 Data Analysis Methods
The research has analyzed responses collected during the data collection process. Each statement generated responses, which were entered into the SPSS, which was the chosen data collection software. Different statistical tests were applied, including descriptive statistics, correlation, and regression. The dependent variable was the employee turnover in the healthcare system, while employee engagement and working culture were independent variables. The data analysis method for this research has considered the study objectives. There are two types of variables, which include the dependent variable and the independent variable. Their relationship has been found through correlation, and the regression analysis has helped to know how both variables will interplay. Then, the analysis section has aligned findings with the previous studies to see if they are aligned with them. The research has found that results are in line with earlier research studies conducted on these variables and their relationship.
3.7 Conclusion and Summary
The chapter has explained the applied research methods and analysis techniques. It is quantitative research and has adopted an explanatory research design. Primary responses have been collected from nurses and staff working in hospitals in Muscat, and the sample size is one hundred. The application of descriptive statistics, correlation, and regression tests have revealed that employee engagement and working culture strategies are practical and productive in lowering the turnover rate of employees in hospitals and the healthcare system of the Sultanate of Oman.
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