Job satisfaction and turnover intention among public sector nurses: Is workload and burnout the issue?

The growing rate of nurse turnover is unavoidable and inevitable. Nursing considered one of the most stressful occupations in the health industry. Unfortunately, there are limited studies published in Indonesia that explain this phenomenon among clinical nurses. This study aims to describe the nurse job satisfaction and turnover intention at public hospitals from workloads and burnout perspective. The design used in this study was quantitative with the survey approach. The data were collected by using simple random sampling from the hospital (cluster B) nurses with the total participant was 190 nurses. The result of this study shows that workload and burnout affect job satisfaction directly. The mediator role of job satisfaction in the effect of workload and burnout on turnover intention is significantly proved. Interestingly, this study failed to prove the effect of workload on turnover intention which means that although many nurses experienced a heavy workload, the majority of nurses in this study feel that the workloads are still reachable or even low due to their young aged. They tend to keep the job since it’s difficult to find any other opportunities. They will intend to leave their job only if they experienced a greater level of burnout and disenchantment.


Introduction
Nurse turnover becoming a global issue in the healthcare industry. The growing rate of nurse turnover across the world is undeniable high, ranged from 13-37% (Roche et al., 2015).
A similar finding was also reported by (Dewanto & Wardhani, 2018) who found that there are 13-35% of the nurse turnover rate in Indonesia. Kovner et al. (2014) added that about 17.5% of new nurses tend to leave their job after gained a year of experience. The need to understand the nurse turnover contributors remains essential especially since the costs associated with nurse turnover are significantly higher.
Several factors can influence nurse turnover. Seo et al. (2004), Sveinsdóttir et al. (2006), Zeytinoglu et al. (2007) stated that workload is one of the crucial factors that can affect job satisfaction. Yin & Yang (2002) added that work stress due to heavy workload considered one of the most frequent reasons for nurses to leave their job. Therefore, it can be concluded that the heavy workload perceived by nurses, the lower the job satisfaction will be. Thus, the lower the job satisfaction resulting in the greater the nurse's intention to leave (Utami & Bonussyeani, 2009) Burnout also considered a significant predictive aspect for job satisfaction (Kalliath & Morris, 2002;Oliveira et al., 2018). Chen et al. (2013) describe burnout through various dimensions like long working hours and mental depression, the evaluation assessment system, hospital culture, patient relationships, and the environment. Piko (2006), Weng et al. (2011), Khamisa et al. (2016. stated that there is a negative relationship between burnout and job satisfaction which means that the higher the level of burnout will lead to the less satisfaction. Also, a greater level of burnout will lead to a high turnover intention (Scanlan & Still, 2013). In other words, a higher level of burnout associated with lower job satisfaction and high turnover intention.
Job satisfaction and turnover intention among healthcare nurses is an extraordinarily important issue that healthcare management needs to deal with. Not only it will affect the turnover cost including separation costs, temporary replacement costs, recruitment costs, and induction costs (Hayes et al., 2012), but it also will reduce patient satisfaction (De Simone et al., 2018). While the majority of prior related studies have mainly focused on exploring the dimension of satisfaction and turnover intention from various perspectives, there are limited studies published in Indonesia that explain this phenomenon among clinical nurses.
Accordingly, the purpose of this study is to describe the relationship between workloads, burnout, satisfaction, and turnover intention at Indonesia public hospitals. Long &Thean (2011) andDysvik &Kuvaas (2010) defined turnover intention as an employee consciousness and deliberate wilfulness to leaving the organization permanently soon. Turnover intention is the final stage in the decision-making process before individual leaves the organization (Bothma & Roodt, 2013;Adhikara et al., 2017). Scanlan et al. (2010) classified turnover intention predictor into two conceptualization model which is the internal and external push/pull factors. Scanlan & Still (2013) added that internal pull is job-related factors that encourage individuals to stay while internal push is job-related factors that encourage individuals to leave the organization. External pull can be described as various factors that attract a person to another job while external push is non job-related factors that can encourage a person to leave a position such as individual commitment (Pardiman, 2018) .

Workload
The workload can be described as a degree to which work role demands are excessive (Seo et al., 2004). Yuyu Zhang & Kumada (2017) added that there are three ways of measurements of mental workload, which is self-reported, performance, and physiological measures. In the present study, we use self-reported measures in which individuals respond to a question set that summarizes the influences of many factors after a task is completed.
H1a: There is a significant relationship between workload and job satisfaction.
H1b: There is a significant relationship between workload and turnover intention.

Burnout
Schaufeli & Greenglass (2001)  there is a relationship between burnout, job satisfaction, and turnover intention. The higher the level of burnout the lower the job satisfaction and the high the turnover intention will be.
H2b: There is a significant relationship between burnout and turnover intention.

Job Satisfaction
Job satisfaction has been defined in many ways. Amponsah-Tawiah et al. (2016) defined job satisfaction as an employee's feelings and thoughts about the overall aspect of the job. Job satisfaction also referred to the collection of feelings and beliefs that employees have about their assigned tasks or job experience (Rezaiean et al., 2010). Job satisfaction playing an important role in health care service. Ylitörmänen et al. (2019) added that job satisfaction in nursing can be classified into three attributes which are an interpersonal relationship, autonomy, and patient care. Unfortunately, job satisfaction among health care is lower compared to other organizations. Moreover, low levels of nurse job satisfaction are related to high turnover (Murray, 2002).

H3:
There is a significant relationship between job satisfaction and turnover intention.
Research from (Yimin Zhang & Feng, 2011) has been conceptualized the relationship between burnout, job satisfaction, and turnover intention. Job satisfaction has a negative relationship on turnover intention but positively related to burnout syndrome subscales. (Richardson & Lanis, 2007) indicated that there is a relationship between heavy workload, job satisfaction, and turnover intention.
H4a: There is a significant relationship between workload and turnover intention with job satisfaction as a mediation role.
H4b: There is a significant relationship between burnout and turnover intention with job satisfaction as a mediation role.

Methods
This research can be classified as quantitative research with the survey questionnaire used as the data collection strategy. The questionnaires assessed workload, burnout, turnover intention, and job satisfaction playing as mediating roles. A cross-sectional survey was carried out by using simple random sampling from the hospital (cluster B) nurses in Jakarta, Indonesia, with total participants were 190 nurses. For data analyses, correlational statistical procedures with mediation variables were applied for generating plausible and explanations for relationships between variables. Measurements of all the items were achieved by using a 5-point Likert Scale (ranging from 1="Strongly Disagree" to 5="Strongly Agree").
Based on our literature review, we build the research model to visualize the effect of workload and burnout to turnover intention with job satisfaction as a mediation role. The visualization of the research model can be described as follows.  et al., 2015). Table 1 shows that all items measured in this study were valid and reliable. This study supports previous studies by Seo et al. (2004), Sveinsdóttir et al. (2006), Piko (2016) that stated there was significant relationship between workload, burnout, and job satisfaction also burnout on turnover intention. The significant values of those relationships (0.000, 0.004, 0.031) were lower than 0.050 which means that H1a, H2a, H2b are accepted.
Interestingly, unlike the previous studies which claim that there is a negative correlation between workload, burnout on job satisfaction and turnover intention which means that the higher the level of workload and burnout perceived by nurses the lower the level of satisfaction, this study found the opposite. Nurses who have worked two years or less with age under 30 years have the largest total proportion in this study. Bunce & Sisa (2002) concluded that at the same relative workloads, a young individual tends to rate their workloads level lower than older individuals. Therefore, it's clear that although the level of workloads in this study classified in a high level, the majority of respondent feels that the workloads are still reachable or even low due to their young aged and perhaps to their lack of awareness of task demands (Dommes, 2019). Lavigne et al., 2012) added that an individual with a harmonious passion for works would lead to low levels of burnout. It means that although from an outside perspective the level of burnout can be defined as the highest, the majority of the respondent in this study feels the opposite. They are enjoying work as a nurse, commit to doing the tasks passionately, and don't feel any burnout feelings. They will intend to leave their job only if they experienced a greater level of burnout and disenchantment.
This study also proved that there was a significant relationship between job satisfaction and turnover intention (H2b) due to the significant values of the job satisfaction and turnover intention relationship (0.002) were lower than 0.050. Unfortunately, this study failed to prove the proposed hypothesis that stated there was a significant relationship between workload and turnover intention. The significant values of the workload and turnover intention relationship (0.082) were higher than 0.050 which means that H1b is rejected. The nurse respondent in this study respondent feels that the workloads are still reachable or even low. Therefore, they found no reason why they should leave their job.  Table 3 shows that the role of job satisfaction as a mediator relationship between workload, burnout, and turnover intention was significantly proved. The significant value of the Sobel test which lower than 0.050 means that H4a, H4b are accepted. This finding supports previous research from Zeytinoglu et al. (2007) and Yimin Zhang & Feng (2011) that concluded there was a significant relationship between workload, burnout, and turnover intention with job satisfaction as a mediation role.

Conclusion and Suggestion
The result of this study shows that workload and burnout affect job satisfaction directly.
The mediator role of job satisfaction in the effect of workload and burnout on turnover intention is significantly proved. Interestingly, this study failed to prove the effect of workload on turnover intention which means that although from an outside perspective the level of workload and burnout can be defined as the highest, the majority of the respondent in this study feels the opposite. They are enjoying work as a nurse, feels that the workloads are still reachable or even low, commit to doing the tasks passionately, and don't feel any burnout feelings. They found no reason why they should leave their job especially since it's difficult to find any other opportunities. They will intend to leave their job only if they experienced the greater level of burnout and disenchantment. Further research should focus on the exploration of the maximum point level of workload and burnout to determine the likelihood of job satisfaction and turnover intention behavior.