The Impact of Human Resource Practices on Nurses’ Turnover Intention: An Empirical Study of Hospitals in North Lebanon

Nurse turnover has become a continuous and increasing challenging problem in the healthcare system worldwide; and this became a priority that needs to be adequately managed. As a matter of fact, nurses are care givers and represent the frontline services that hospitals deliver to their patients, so it is an indispensable necessity to retain this workforce through both job satisfaction and job motivation. Providing the nurse workforce an appropriate treatment will surely lead to retention of talent that is critical to the continuity of the healthcare organizations. This research aims to assess the impact of Human Resource Management (HRM) practices mainly in relation to job satisfaction on nurses’ turnover intention, especially that Lebanon is one of the countries where the healthcare system is suffering from nurses’ shortage. This study uses a descriptive correlational study based on a structured questionnaire administered to 100 nurses within North Lebanon Hospitals. The collected data statistical analysis is carried out via the Statistical Product and Service Solutions SPSS-version 25. Results revealed that the absence of efficient HR practices forces nurses toward turnover decision. Thus, the creation of supported and motivated environment will positively affect the nurses’ decision to stay, and thus minimize the turnover rate.

stress that nurses play a new fundamental role requiring a new mind-set and a new set of competencies. -These shifts require a new or an enhanced set of knowledge, skills, and attitudes around wellness and population care with a renewed focus on patient-centred care, care coordination, data analytics, and quality improvement‖ (p. 12). Consequently, and according to Hejase, Rifai, Tabsh, & Hejase (2012), -HR managers will have to have a holistic view of the organization. As their roles become more strategic, they must be able to define strategic goals, cooperate with employees (nurses or other) to achieve the goals, and be acquainted with the financial aspects of business‖ (p. 28). Therefore, overall, the Human Resources (HR) department responsibility to meet the challenges is not only to regulate the recruitment process but they also manage compensation, benefits, performance management, recognition, promotion and training of employees (Khaliq, Zia-ur-Rehman, & Rashid, 2011). As a matter of fact, Panayotopoulou, Bourantas, & Papalexandris (2003) assert that there is strategic fit between HRM and organizational strategy leading that HRM give -emphasis to quality and innovation, as well as team spirit creation and skills development‖ (p. 692). As a result, the HR department plays an important role in boosting nurses' job satisfaction in order to mitigate turnover intentions (Khaliq et al., 2011). Nowadays, the healthcare industry is facing challenge in term of retaining qualified nurse due to high turnover rate (Wheeler, Halbesleben, & Harris, 2012;Roulin, Mayor, & Bangerter, 2014). Mainly nurses who are dissatisfied with the work environment ultimately leave their workplace; as a result, the efforts of the human resource management to mitigate the nurses' intention to quit continue to receive attention in the recent research.

Nurses' Turnover Intention
The definitions of turnover and its causes are often inconsistent, that is why it is challenging to link or take a much broader view across the different researches (Tai, Bame, & Robinson, 1998;Hayesa, O'Brien-Pallasa, Duffield et al., 2006). However, all starts with employees' intention to leave his/her current jobs. More formally, Vandenberg and Nelson (1999) assert that employees' intention to quit is an individual's estimated probability that they are permanently leaving their organization at some point in the near future. So, turnover intention is defined as the total willingness of a staff to leave his/her job.
Intention is defined as a staff craving to quit the workplace. In fact, intention to leave is a manifestation and predictor of real turnover (Cohen & Golan, 2007), and an immediate antecedent to actual turnover (Halawi, 2014). Moreover, Meler & Toygar (2020) defined ‗turnover intention' as, -The destructive and active action of nurses as a result of voluntary or involuntary relocation in their working position and their dissatisfaction with their working conditions‖ (p. 488). Based on the aforementioned, intention to leave among nurses is really a challenging situation especially when the shortage of nurses has become a serious issue across the globe (Blaauw, Ditlopo, Maseko et al., 2012).

Nursing Turnover Cost Calculation Methodology (NTCCM)
is widely used to distinguish between direct costs (related to the hiring, temporary replacement and hiring of a new employee) and indirect costs (direct time spent managing the dismissal and turnover process as well as the orientation, training and productivity). In fact, O'Brien-Pallas, Griffin, Shamian et al. (2006) suggested that while turnover accounted for 21% of total costs of direct recruitment costs, indirect costs of lost productivity accounted for 79% of total costs.

Turnover rate
= Number of employees who left * 100/the average number of employees during the period. The average number of personnel means the average of the total number of staff at the beginning of the term and the number of staff at the end of the term. 4-12% nurse turnover rate is low; 12-22% are considered medium, and 22-44% high turnover Heinen et al. (2013) found that nurses' turnover intention in European countries affects the costs of the institution between 5-17%. Dawson, Stasa, Roche, Homer, & Duffield (2014) found that the cost of changing a nurse can range from $ 22,000.00 to $ 64,000.00 Garnett et al. (2008) reported that the Northern Territory (Australia) show a 38% turnover rate per nurse and an average turnover cost of $ 10,734 (Australian dollars). Shaffer & Curtin (2020) asserted that the -Nursing Solutions, Inc., found out in 2019, that each 1% change in nurse turnover will cost (or save) the average hospital an additional $328,400. The turnover rate for hospitals' bedside nurses grew to 17.2%. The average turnover costs result in hospitals losing $4.4 million to $6.9 million each year. The report also found that the average time it takes to fill a staff nursing position is 85 days and costing about $82,000‖ (para 3).

Turnover Consequences
It is a common sense to associate nurses with patients. Their day to day tasks is closely linked with patients. Therefore, nurse's performance affects greatly the institution resources. According to Valizadeh, Zamanzadeh, Habibzadeh et al. (2016), -Shortages of nurses affect health care continuity and have negative effects on patient outcomes. Also, health work force crises seriously impair the ability of many countries in fighting disease and improving health. In fact, turnover is causing problems for nursing and health care in the areas of cost, ability to take care of patients and the quality of care delivered‖ (p. 169). Moreover, Antwi & Bowblis (2018, p. 131) report that turnover leads to lower quality of healthcare and higher mortality. In addition, the University of New Mexico reports that, -When nurses leave a healthcare organization, they create a vacancy that can affect the cost of operation. The vacancy is also costly to other nurses, who may have to work overtime and can experience burnout due to long hours and a high patient load‖ (RN to BSN Online, 2016, para 5).
continuous increase in turnover rate among nurses within the healthcare domain with more and more shortage with this powerful source. Also, turnover creates a disruptive and unstable work environment especially that new employee will be hired continuously. This instability in the quality of service delivered to patient have a major influence on the patients' perception and can be negatively associated with bad image toward hospital as whole (O'Brien-Pallas, 2010). In addition, Perry, Richter, & Beauvais (2018) assert that turnover is the result of the lack of five workplace factors (dissatisfaction factors) that align with fulfillment of nurses' needs and are -priorities in the health care context: supportive leadership, staffing adequacy, nurse-physician teamwork, nursing care practice, and advancement opportunities. Moreover, the authors add to the aforementioned the psychological needs of autonomy, competence, and relatedness‖ (p. 4945).

Impact on Patient Satisfaction
Several studies stressed on the correlation between nurse job and patient's quality of service received.
The quality service provided by nurses is critical as it is associated with human lives, thus recruiting capable and enough nurses is essential in this field of work (Clarke & Aiken, 2003). Moreover, the same factors that lead to nurses' satisfaction especially those factors mentioned by Perry et al. (2018, p. 4945), -supportive leadership, staffing adequacy, nurse-physician teamwork, nursing care practice, and advancement opportunities, autonomy, competence, and relatedness‖ lead to better quality of care, lower mortality, lower feelings of burn-out to other remaining nurses improving their services, and higher patient comfort. Therefore, energizing and motivating nurses to perform will definitely increase the positive affect on their patients increasing patients' satisfaction and faster recovery (Houston et al., 2012;McHugh et al., 2013). Dussault & Dubois (2003) complain that -current approaches in human resources suggest a number of weaknesses including being reactive, using an ad-hoc attitude towards problems of HR, having a trend to dispersal of accountability within Human Resources Management (HRM), capitalizing on a limited notion of personnel administration that fails to encompass all aspects of HRM, and finally depending on a short-term perspective of HRM‖ (p. 1). On the other hand, based on WHO's report (2000), the performance and the benefits the health care system can deliver depend largely upon the knowledge, skills and motivation of those individuals responsible for delivering health services. Nevertheless, though health care administrators now a day have an adequate knowledge of resource management, resources utilization and budgeting, which is a good improvement, but according to Khaliq et al. (2011), -it needs serious strategic human resource planning and organization to be implemented properly. The dilemma is that hospitals try to recruit and retain the best nurses, whereas nurses look for good employers, handsome salary and benefits, flexible schedules, stability recognition and better work/life balance‖ (p. 975). Healthcare institutions are compound and energetic. Therefore, Kabene, Orchard, Howard, Soriano, & Leduc (2006) assert that there should be -a balance between the human and physical resources. Due to their obvious and important differences, it is imperative that human capital is handled and managed very differently from physical capital‖ (p. 2). In fact, Dieleman & Harnmeijer (2006) report that, -HR strategies are based on interventions that can take place at two levels, the first at the macro or health-system level, such as HR policy and planning, rural recruitment and training and bonding; and the second at the micro or facility level, aimed at improving job satisfaction by addressing working conditions, improve the living conditions, providing incentives and offering professional development‖ (p. 1). Moreover, HR strategies need to address, at various levels, staff members' performance which is determined by productivity, responsiveness and competence. However, www.scholink.org/ojs/index.php/jbtp Journal of Business Theory and Practice Vol. 9, No. 4, 2021 Published by SCHOLINK INC.

The Nature of HRM on Healthcare Organization
the aforementioned -elements are influenced by absenteeism, motivation and job satisfaction, obtaining knowledge, skills and attitudes, accountability systems and working conditions, which in turn are all interrelated‖ (Dieleman & Harnmeijer, 2006, p. 1). Consequently, HR managers' responsibility lies to monitor, coordinate and take the lead at healthcare system aspects. They need to supervise and guarantee that all tasks are performed properly, using the institution resources in the best way to achieve targets and goals. This can be achieved by allowing authority-sharing and power to create decisions that address the quality of service provided as well as the performance of the staff In fact, dissatisfaction with HR practices has regularly been referred to as a main cause for high nurses' turnover intention (Gebregziabher et al., 2000). The research is continuous to discover the real cause of nurse turnover in the context of HR. For example, the Jordanian researchers Amarneh, Raza, Matloob, Alharbi, & Abbasi (2021) contend that the existing Human Resource for Health (HRH) challenges include retention and continuous training. The Iranian researcher Mosadeghrad (2013), in his literature review, quoted several researchers' results stating HR-related factors influencing turnover including, -Less quality of work life, job satisfaction and organizational commitment, organizational culture, job stress, burnout, long shifts, and work-family conflict. In addition, socio-demographic characteristics such as age, marital status, tenure, and education‖ (p. 169). On the other hand, Mosadeghrad (2013) found that hospital managers must apply appropriate policies to decrease nurses' occupational stressors.

Research Methodology
This study is based on a positivism philosophy (Saunders, Philip, Thornhill, & Bristow, 2019), which according to Hejase & Hejase (2013), -the researchers act as objective analysts, independent, and neither affect nor are affected by the subject of the research‖ (p. 77). Moreover, this research is quantitative following a deductive approach that -is useful if the general aim was to test a previous theory in a different situation or to compare categories at different time periods‖ (Elo & Helvi, 2008, p. 107). In the process to find answers to the research questions addressed in our study, a structured survey questionnaire was administered to 150 nurses in order to assess their satisfaction level with HR practices in the hospitals.

Sampling and Sample Size
The questionnaire was distributed to 140 Lebanese nurses chosen conveniently working in private hospitals in Tripoli, North Lebanon, who willingly provided their consent to participate. According to the Order of Nurses in Lebanon (2020) Where, Z = 1.96 (95% Confidence level), P = 79% female nurses, Q = 21% male nurses, and e = 8% error (due to the lack of precise numbers in Lebanese statistics, we opted for less than 10%). Therefore the sample size -n‖ is 99.58 nurses or 100 nurses to be specific.
Participants were selected from different departments and different hospitals in Tripoli, North Lebanon.
Questionnaires were distributed by personnel from the human resource departments and the other by the researchers. 110 questionnaires were collected back. But 10 questionnaires were not filled adequately therefore the researchers discarded them and only 100 questionnaire were analyzed with a response rate of 71.43%.

Questionnaire Design
The questionnaire is divided into three sections. (2 statements). The third section includes four (4) statements about nurses' intention to turnover.

Reliability Analysis
The Internal Reliability of the 24-item scale is assessed using the Cronbach's Alpha technique. Table 1 shows

Data Analysis
The collected primary data were analyzed using the Statistical Product and Service Solutions, SPSS-version 25.0 IBM program. Descriptive analysis is used first followed by factor analysis and regression.

Research Framework
Figure 1 depicts the proposed research framework consisting of seven hypotheses which help the assessment of the research questions and at the same time lead to a final inferential model relating the hospitals' human resources practices to nurses' turnover intention.
Next, the hypotheses are as follows:

H1. Recruitment & Selection
H1 o : There is no relationship between nurses' satisfaction due to recruitment & selection process and nurses' turnover intention.

H1 a :
There is a relationship between nurses' satisfaction due to recruitment & selection process and nurses' turnover intention.

H2. Training Program
H2 o : There is no relationship between nurses' satisfaction due training programs and nurses' turnover intention.
H2 a : There is a relationship between nurses' satisfaction due training programs and nurses' turnover intention.

Demographics
Results show that nurses are 30% males, and 70% females. Their average age is 30 years with 50% of the sample's age ranging between 21 and 40. Also, 57% are single (37.5% female & 20% male), 34% are married with children (27.5% female & 7.5% male), and 9% divided evenly between married without children, separated and widowed, respectively (see Table 2). Furthermore, results show that 42% of the nurses have an experience of 5 years or less, 28% have between 6 and 10 years, and 30% have more than 10 years of experience.  Table 3 shows the correlation between nurses' ages and their feeling of belongingness to the hospital that they are working with. Most of the nurses who are below 21 years old feel that they are not part of the hospital (25%). Similarly, for those who are between 21 and 30 (20%) and between 31 to 40 (10%) feel that they don't belong to the hospital, only 2.5% and 10% of each age range, respectively feels such belongingness. While nurses who are above 40 years old most of them feel that they are part of the hospital (17.5%).  Table 3 shows that 55% of nurses are of young age (less than 40 years old) and they agree that they feel that they are not part of the hospital they are in. Thus this may increase the probability of having high turnover rate among this group of nurses. This result is congruent with the findings by Flinkman,

Descriptive Statistics: Likert Scale Statements
The 5-level Likert scale was used to measure the respondents' choices to the questionnaire sections pertaining to HR practices analysis. Table 4 shows the details. This study adopted the following limits to help analyze the arithmetic mean of the terms and assessing Thus, the modified scores are distributed as shown in Table 5. Next, Table 6 presents all the results generated by grouping -Strongly Agree and Agree‖ as well as -Strongly Disagree and Disagree‖ in order to have an easier interpretation of the nurses' attitude (extent of satisfaction) towards the different HR practices. Results show that the grand majority of the statements received a mean average in the Neutral zone (2.61-3.40). Moreover, the respondent nurses showed less than moderate agreement with the HR practices scoring 35 to 50% (16 out of 20 statements), moderate agreement scoring 51 to 65% (3 out of 20) and only one statement scored 86%.
As a matter of fact, the respondent nurses scored a general agreement average of 44.45% in the seven sections representing organizational HR practices. These results lead to the expectation that nurses' intention to leave is actually a fact. On the other hand, reviewing the results for the questionnaire section on turnover intention, the overall average of the nurses' agreement on the four statements is 63%. This result confirms the fact that nurses are actually intending to leave their hospitals sooner or later (see Table 7).  Following the descriptive analysis, it is important next to explore the actual HR factors influencing the nurses' intention to leave using Factor Analysis. Then, after having the actual factors, inferential analysis is conducted using regression analysis.

Common Method Bias (CMB)
This research uses a survey questionnaire, therefore it is necessary to test for -the risk of common method bias‖ (Jakobsen & Jensen, 2015, p. 3;Farhat, 2020). Hence, data are inspected for CMB risk using Harman Single Factor Test (Younis, Hejase, Abdallah, Haddad, & Hejase, 2021a). Consequently, the next step is to extract the valid constructs for this research using Factor Analysis.

Factor Analysis
An initial testing of the data is performed using the Principle Component Analysis (PCA) with subsequent rotation (starting with Varimax and followed by Direct Oblimin). The analysis was carried out using 24-item 5-level Likert scale statements. Results from the resultant pattern matrix showed that www.scholink.org/ojs/index.php/jbtp Journal of Business Theory and Practice Vol. 9, No. 4, 2021 Published by SCHOLINK INC.

Main Factor Analysis Run
The initial run resulted in defining 6 factors only out of the 7 questionnaire constructs and decreasing the 24 items scale to 19 items scale with satisfactory results and improvement in the total variance explained results to 62.879% as well as the weights of all the other items. Consequently, the main run herein is completed.

PCA using Varimax Rotation
The correlation matrix suitable for factoring consists of all correlations exceeding 0.4 and are statistically significant (less 5%). Table 9 shows that the Bartlett test of Sphericity is statistically significant (χ 2 = 512.542, Sig. =.000) and the Kaiser-Meyer-Olkin measure of sampling adequacy is equal to 0.655 (above .60). This means that variables are correlated to each other, and grouping of variables is possible (Coakes, 2013;Burns & Burns, 2008). Moreover, the anti-image correlation matrix reveals that -all measures of sampling adequacy (MSA) are above the acceptable level of 0.5‖ (Coakes, 2013, p. 133). Sig. .000 Communalities reported in Table 10  Open‖ is accounted for, while only 47.4% of the variance in -Sex‖ is accounted for. Next, Table 11 displays the cumulative percentages and the total variance explained. Moreover, Figure 2 shows the Scree plot and that six factors can be extracted because they have eigenvalues greater than one (1), that is, six factors extracted means that 62.879% of the variance would be explained. According to Burns & Burns (2008, p. 456), the aforementioned is consistent with Kaiser's Rule.  a. When components are correlated, sums of squared loadings cannot be added to obtain a total variance.

Figure 2. Scree Plot
Initially Varimax rotation is carried out, where -the factor axes are kept at right angles to each other.
This rotation is regularly chosen. Ordinarily, rotation reduces the number of complex variables and improves interpretation‖ (Hejase et al., 2014(Hejase et al., , p. 1573. However, the rotated solution still included several complex variables. These items must be interpreted with caution and to lessen the intensity of the observed ambiguous structure, oblique rotation (Direct Oblimin) is chosen (Coakes, 2013, p. 137).

PCA using Oblimin Rotation
Oblimin rotation leads to more interpretable solution. Two matrices result. The first is the -Pattern‖ matrix (Table 12) and the second is the -Structure‖ matrix (Table 13). Loadings differences are clearly seen and separated in the pattern matrix, a fact that leads to choose this matrix for interpretation.
Actually the loadings represent the unique relationship between the factor and the variable. In addition, the Pattern matrix has fewer complex variables and simpler structure. The Factor correlation matrix indicates the relationship between factors. All factors are goodly related.     The final research model (see Figure 4) actually represents the influence of internal (nurses' convictions) as well as the external factors (organizational HR policies and leadership) (Zhang & Goel, 2011;Hammarlund, Nilsson, & Gummesson, 2015) on nurses' satisfaction leading to intention to leave which actually shows if the HR experience has achieved its objectives in the nurses' retention process.
However, this final model stresses the statistical significance of selected items all which have particular significance for this research. Figure   H7 a : There is a relationship between nurses' satisfaction due to career advancement opportunities at hospital & nurses' turnover intention.

Rejected
Semi-Verified

Conclusion
Findings of this research assure the fact that planned and strategized HR activities are fundamental to foment and strengthen the bonds with nurses in Lebanese hospitals. Results have shown that nurses' convincement that their place of work does not offer any prospects for the future coupled with their burnout, exhaustion and stress are very strong motivational forces to strengthen their intention to leave and therefore causing hospital turnover rates increase. Moreover, this paper found that nurses are sensitive, conscientious and highly determined to leave when fundamental HR pillars are not adequately applied namely recruitment and selection policies which are transparent and clear; well-developed training which fit the nurses' goals and expectations beside the job relevance; salaries that are commensurate with their efforts and heavy schedules; opportunities to grow and progress in their careers as nurses; a fair, unbiased and relevant performance appraisal system, and finally an Published by SCHOLINK INC.
-The hospital should diversify its programs that are concerned with its responsibilities towards its local community and try to develop them permanently. That is, job opportunities, internships, and training & development in terms of creating awareness about hospital-related jobs especially nursing in order to foster more interest among the young students looking forward for healthcare service careers (Younis et al., 2021b).
-The administration must be more empathetic to the nurses' needs. According to Drucker (1986), -Work implies not only that somebody is supposed to do the job, but also accountability, a deadline and, finally, the measurement of results-that is, feedback from results on the work and on the planning process itself.‖ Moreover, Hejase (2020b) contends that -one must include the measurement of all aspects of an organization's resources being physical and human in order to accurately and thoroughly assist the control of its activities‖ (p. 1). Actually, Zak (2013) stressed the human side of management of any institution by repeating Drucker's words, -It is the relationship with people, the development of mutual confidence, the identification of people, and the creation of a community‖.
-The administration need to offer several immediate improvements to boost nurses' motivation level and thus minimizing turnover rate:  Allocate appropriate time and resources to select the right person for the right position.
 Align the nurses' purposes with that of the hospital especially that clear expectations promote longer periods of sustained effort to achieve desired outcomes.  Create positive environment where nurses feel that they are valued members of the hospital.