Our meta-analysis highlighted the moderate negative correlation between organizational support and turnover intention. Moreover, two studies found a negative association between organizational support and turnover intention after eliminating confounding. Nurses’ turnover intention has a significant impact on the functioning of healthcare organizations. This impact includes the understaffing of nursing departments from which nurses leave, the negative impact on nurses' mental health, the deterioration of patient safety (falls and medical errors) and patients’ dissatisfaction with the healthcare services provided (Bae, 2022). The impact also includes the waste of financial and other resources in recruiting new staff and training them to fully assume their duties (Bae, 2022; Roche et al., 2015). As there are already serious safety problems in the provision of healthcare (Makary & Daniel, 2016) and issues with the mental health of nurses (Cranage & Foster, 2022), the nurses' turnover intention seems to exacerbate the existing situation.
The decision of nurses to leave the profession is not a sudden decision but a process that goes through three stages (Takase, 2010). In the first stage, the psychological, the employee through turnover intention psychological responses to negative aspects of organization or job. He/she begins to feel dissatisfaction with his/her job, showing reduced commitment and attachment to his/her organization. In the second stage, the cognitive, turnover intention is defined as the final cognitive step leading to actual turnover. In the third stage, the behavioral, the employee now changes his/her behavior, as besides expressing his/her desire to leave, he/she loses enthusiasm, is late to work or even absent. A recent study showed that nurses who opt for quiet quitting, in which they reduce their performance at work, are more likely to have high levels of turnover intention (Galanis, Moisoglou, Katsiroumpa, Vraka, Siskou, Konstantakopoulou, & Kaitelidou, 2023). Therefore, the factor that triggers turnover intention is the working environment of nurses and the management of healthcare organizations should focus on improving it.
Even if nurses are dissatisfied with their work or experience burnout and report their turnover intention, organizational support can mitigate the effect of the two factors mentioned above on their turnover intention. Four studies showed the indirect, mediating role of organizational support on turnover intention through job satisfaction (Brunetto et al., 2016; Galletta et al., 2011; Liu et al., 2018; Shacklock et al., 2014) and two studies showed the similar role through burnout (Bobbio & Manganelli, 2015; Liu et al., 2018). Nurses report moderate levels of job satisfaction in primary healthcare settings and high levels of dissatisfaction in secondary ones (Dilig-Ruiz et al., 2018; Moisoglou, Meimeti, et al., 2021). Even now, in the post COVID-19 era, as workload has been reduced and the functioning of healthcare organizations has been normalized, nurses continue to show dissatisfaction at a higher rate than other health care professionals (Galanis, Moisoglou, Katsiroumpa, Vraka, Siskou, Konstantakopoulou, Meimeti, et al., 2023). When nurses report increased satisfaction with their work, the likelihood of turnover intention is reduced (De Simone et al., 2018). The main organizational factors associated with increased job satisfaction are a good working environment, characterized by well-staffed nurses, adequate resources, reduced workload, satisfactory salary and rewards, opportunities for development and promotion, recognition of the role of nurses and effective supervision (Al Maqbali, 2015; Yasin et al., 2020). The aforementioned factors constitute the conceptual framework of perceived organizational support (Kurtessis et al., 2015; Rhoades & Eisenberger, 2002). Therefore, ensuring and improving these factors constitutes a strong organizational support for nurses, which is directly linked to increasing their job satisfaction, and will indirectly reduce their turnover intention. In addition to job dissatisfaction, nurses also experience high rates of burnout. Before the COVID-19 pandemic, it is estimated that one out of three nurses reported being exhausted (Gómez-Urquiza et al., 2017), and this rate increased to a very high levels after the pandemic and its impact (Galanis, Moisoglou, Katsiroumpa, Vraka, Siskou, Konstantakopoulou, Meimeti, et al., 2023). Burnout appears to be a strong predictor of nurses' turnover intention (Ran et al., 2020; Shah et al., 2021). The effect of the way that nurses' work environment is organized and operated is also related to their burnout, in addition to their dissatisfaction. Factors such as low/inadequate nurse staffing levels, ≥ 12-h shifts, low autonomy, poor nurse-physician relationship, poor supervisor/leader support, job insecurity and reduced opportunities for nurses to participate in hospital affairs make up the organizational factors that lead nurses to burnout (Dall’Ora et al., 2020; Moisoglou, Yfantis, et al., 2021). During the COVID-19 pandemic, the extremely difficult and demanding working conditions combined with the organizational inefficiencies of the past resulted in a large proportion of nurses becoming burnt out (Galanis et al., 2021). Recognition of nurses' work, opportunities for development and ensuring good working conditions through ongoing organizational support reduce nurses' burnout (Bobbio et al., 2012), increase trust in the organization (Bobbio et al., 2012; Bobbio & Manganelli, 2015) and ultimately reduce the chances of nurses' turnover intention (Bobbio & Manganelli, 2015).
Among studies in our review, Sheng et al. found that high organizational support plays a mediating role between nurses' practice environment and their well-being, which in turn is correlated to turnover intention (Sheng et al., 2023). The working environment and the demanding nature of nurses' work negatively affect their well-being (Chung et al., 2020), resulting in high rates of anxiety, depression, psychological stress and posttraumatic stress disorder (Maharaj et al., 2018; Shen et al., 2020; Tan et al., 2020). The more the well-being of nurses deteriorates, the higher the likelihood of turnover intention (Mirzaei et al., 2021; Pang et al., 2020). Nurses often feel both weak and defenseless in the face of difficult situations, as in the case of the COVID-19 pandemic (Miller et al., 2023). In these challenging and difficult times, the support they receive, either at departmental level from their supervisor or at organizational level, helps them to cope with these difficulties and mitigates their impact on their well-being (Jung et al., 2020; Miller et al., 2023) .
Additionally, Liu et al. found that violence in the nurses' workplace is a factor associated with an increase in turnover intention, while organizational support mediates the effect of violence on turnover intention (Liu et al., 2018). Incidents of violence, both physical and verbal, have a high impact on nursing staff, with nurses in emergency departments almost all reporting being victims of violence (Byon et al., 2021; Li et al., 2019). Nurses are dissatisfied with their organization in terms of prevention and management of violent incidents, as well as the lack of their training in dealing with such incidents (Ayasreh & Hayajneh, 2021). The consequences of violent incidents affect the quality of care, employee performance, nurses’ mental health and the willingness to leave their jobs (Li et al., 2019; Vento et al., 2020). The consequences of violence, which even can lead to serious physical injury and death, make it imperative to protect nurses, who feel defenseless and vulnerable. When nurses receive organizational support and feel less invulnerability, their desire to leave their jobs is mitigated (Cakal et al., 2021).
Moreover, Filipova found that increased nurses’ commitment mediates the relationship between perceived organizational support and their intent to leave job (Filipova, 2010). High commitment is an important factor influencing the quality of care and hospital performance (Baird et al., 2019). A significant number of factors have been found to affect nurses' commitment, e.g., well-being, satisfaction, leadership and management style and behavior and working environment (Vagharseyyedin, 2016). When organizational support is low and nurses wish to leave their jobs, then through organizational commitment the negative effect of support on turnover intention is mitigated (Albalawi et al., 2019).
4.1. Limitations
Our study has several limitations. First, the number of studies included in our review and meta-analysis is small. Moreover, the number of studies for subgroup analyses is even smaller. For example, there is only one study in the USA and one study in Africa. Thus, the representativeness of our results is limited. Further studies in different countries, cultures, and settings should be conducted to get more valid results. Second, only two studies assessed the independent effect of organizational support on turnover intention in nurses by applying multivariable models. All studies estimated the correlation between organizational support and turnover intention. Thus, future studies should employ multivariable models to eliminate confounding in the relationship between organizational support and turnover intention. Moreover, we suggest scholars to explore the role of mediating or/and moderating variables since the structural equation modeling enable us to perform mediation/moderation analysis in a valid way. Third, all studies included in our review were cross-sectional and a causal relationship between organizational support and turnover intention cannot be established. Measuring organizational support and turnover intention at the same time may produce a spurious correlation. Thus, there is a need for longitudinal studies, which can further explain the relationship between organizational support and turnover intention. Fourth, seven studies used convenience samples and only one study used a purposive sample. For example, nurses in all studies were mainly females. Therefore, selection bias is potential in our review. Further studies with more representative and stratified samples can add valuable evidence. Finally, we searched six major databases applying the guidelines for systematic reviews but it is still possible to miss studies in our evaluation. For example, we did not include studies in non-English languages and grey literature.