1. Background

World health Organization estimated the number of died people due to heart diseases in 2005 as 17.5 millions, which represented 30% of all global deaths.

In Bahrain the heart diseases considers as the forth cause of death [1] . Therefore the Ministry of health in Bahrain increased the number of beds in cardiology wards from twenty beds to forty eight in a short period from 2003 to 2007 [2] . Which means the heart problem is increasing and implying high demands to the cardiac health care delivery department to satisfy the patients' needs.

High turnover can be costly and impact negatively on any unit, particularly in critical care area such as Coronary Care unit (CCU). Hiring and training new nurses, loss of experienced nurse, increase nursing care workload, use of temporary agency's staff who are less familiar with CCU setting than actual employees, and potential adverse patient outcomes. In addition the new nurses need time to improve their skill, education and knowledge in cardiac care [3-5].

Many studies reveal that low job satisfaction would be more likely to intent the nurses to leave their working place or the profession, hence behavioral intention considers a significant predictor for actual turnover in the future [6] .

2. Rationale for a Study

Internationally, the supplement of adequate numbers of nurses to health services has always been a challenge [7] . Bahrain is suffering from the same problem as it is facing severe shortage of nurses, in 2006 an agreement between Bahrain and Philippine was established to import more nurses to overcome this insufficiency [8] .

The nursing shortage in CCU within Salmanya hospital in Bahrain had been notified in a case study written by Salman [9] . The writer identified the main cause of the shortage was corollary of high rate of turnover. The manger of CCU posit a report to the administration of the hospital explained the impact of insufficient number of nurses per shift and how it threatened the quality of care when patient to nurse ratio is increased. Nevertheless the study mentioned the rate of turnover within years (2008) and (2009) was 10 cardiac specialized senior nurses out of 50 had left the unit. Those senior nurses were replaced by both newly graduated and newly recruited registered nurses who had no back ground on caring of cardiac diseased patient. Those changes generated instability in the area, as it was looked most likely as a training center for new nurses. During the training period which usually takes 1-3 months, CCU was experienced severe nurses' shortage because of less qualified nurses. These challenges inherent an environment with mismatched between demand and supply that intensified by turnover.

For all these important resons, it is worthwhile to explore job satisfaction factors that stimulate commitment among critical care area nurses such as CCU and those factors should be considered more significantly to reduce turnover intention then in consequently reduce the actual tunrover [10] .

3. Research Question

Is there a relationship between job satisfaction and intention to turnover among CCU nurses in Bahrain.

4. Aims & Objectives

This study will investigate the relation between job satisfaction components (Personal, organizational, environmental) on intent to turnover among CCU nurses in Bahrain. The dependent variable in this study was intent to leave whereas the independent variables included demographic data and job satisfaction factors.

The knowledge of the study finding gives an idea on the direction and strength of the relationship of research variables. Therefore it might be a fundamental to understand the most significant factor of job satisfaction influence nurses thinking to leave working place in CCU. Moreover the results may draw a direction to develop more effective strategies to improve nurses' shortage as well as add more enhancements in management style to increase nurses' satisfaction and decrease turnover intention. The findings will provide a suggestion of the most influence factors that may influence the nurses' retention.

5. Research Methodology

This study is a cross sectional, quantitative research and it examined the type of relationship between variables. Also, it is non experimental, descriptive with correlational design which expedient to determine if there is a relationship between the job satisfaction and turnover intention and indicates the extent to which one variable is related to another.

The participants of the study were selected according to convenience sampling, which involved the most suitably present people working in specific area such as CCU within the time of study. This way has probably seen the most frequently used sampling method in nursing research, and it fits the quantitative research as well as it saves the time and money for the researcher [11] .

6. Research Instrument

Self administered questionnaire was used to collect data, which contained fixed choice questions assessing. It included three main parts: Demographic data, job satisfaction, and intent to turnover scale.

In order to assess Job satisfaction scale, McCloskey Mueller [12] Satisfaction Scale (MMSS) was used. The MMSS consists of 31 items rated on a 5 point likert scale and grouped by factor analysis into 8 subscales:

1- Satisfaction with extrinsic rewards.
2- Scheduling.
3- Family and work balance.
4- Co workers interaction.
5- Professional opportunities.
6- Praise and recognition.
7- Control and responsibility.

Each item scores from 1-5; 1 is corresponding to very dissatisfied and 5 corresponding to very satisfied. When the mean scores a number toward (1) it indicts respondent has greater satisfaction & vice versa when its' record toward (5).

Nurses were assessed whether they plan to leave their working position in CCU via 12 questions in anticipated turnover scale (ATS) developed by Hinshaw & Atwood [13] . All items of ATS are Likert format with 7 response options ranging from strongly agree (7) to strongly disagree (1). When the mean scores a number toward (7) it indicts respondent has greater intentions to leave their current positions. However when its' scores toward (1) it indicates more intent to stay in a job, and number (4) indicates as neutral respond neither intent to leave nor to stay.

7. Data Collection

Prior to data collection of the study the research instrument was piloting on five nurses in CCU wards according to accessible sampling procedure of total number of CCU nurses. Those five nurses were excluded from the final sample. No modification was done in ATS but minor changes in MMSS and sociodemograhic were kept. Lastly small modification was made in configuration.

The distribution of the questionnaires was facilitated via the cooperation of nurse managers of two CCU wards and the researcher. Two boxes were kept in the nurses' stations of each ward to collect the answered questionnaires. Subsequent the nurses were asked to complete the questionnaire individually which takes approximately 10 to 12 minutes then to keep it in the boxes. In order to appreciate the accomplishment of the questionnaire by the participant, sweets were kept inside the envelopes.

Initiation of the study, ethical approval for this study was obtained from the RCSI University research committee as well as the hospital which selected for the study.

8. Data Analysis

After completing data collection, all statistical analyses were exported by the Statistical Package for Social Science (SPSS) for Windows (version 18).

Univariate descriptive statistics were conducted to summarize the demographic characteristics of the sample including age, gender, nationality, marital status, number of children, educational level, years of experience and working shits. At the second stage, bivariate associations between job satisfaction scale of MMSS and demographic characteristics were tested using Kruskal Wallis test and Mann Whitney test.

9. Presentation of Findings

Accessible sample consisted of 40 nurses who had received the questionnaires, but 42 nurses returned the questionnaires with a response rate of 70%. According to Aiken et al., [14] , this percentage is a favorable for recently published studies involving surveys of health professionals.

Only 21.4% of CCU nurses were satisfied with their working in CCU. The remaining which is 64.3% uncertain with their satisfaction and 14.3% of nurses expressed definitely unsatisfied.

The results of this study showed that a high percentage (92.8%) of nurses were suspicious with their staying in CCU or thinking to leave. Only 7.1% of CCU nurses were intent to stay, the remaining which were 57.1 uncertain with their decision wither to stay or to leave and 35.7% of nurses expressed definitely they are thinking to leave. This high percentage of uncertain with their decsion to work in CCU is alarming of losing experienced nurses.

The finding clearly indicates that the variables of demographic data and job satisfaction jointly predict substantial variance in the turnover intentions as following:

1. Youngest & junior nurses in CCU have the lowest rate in MMSS but the highest in ATS. The characters of age and experience factors were forming a U shape; both factors started with the peck of lowest rate propensity of satisfaction and highest tendency to leave the working sitting, and then gradually the satisfaction increased and the leaving intention decrease. With the progression of time again the trends repeated same tendency.
2. Evening shift was the most interesting shift for team workers, contradictory night duty but morning nurses were intent to leave more than others.
3. High education had a positive relation with turnover intention and negative with job satisfaction.
4. Bahraini and female nurses were more dissatisfied but at the same time more intent to leave CCU.
5. Married staff with less than two children were more pleased with their current position and less thinking to leave.

To conclude, the present study found a negative and highly significant moderated correlated relationship between job satisfaction and turnover intentions, which mean nurses who were less satisfied are more thinking to leave CCU.

10. Relevance of Research in Nursing Practice

This study established background knowledge since limited information is available on the health workforce in the Gulf area [15] . Interpreting these findings would be important for nurses' managers and leaders to enhance nurses' retention particularly new graduated nurses because they need more support and regular communication. Also, constructive feedback from supervisors and coworkers is important.

The findings showed CCU nurses were moderately satisfied with their ability to control over their work responsibilities which may lead to adverse patient outcomes and quality of nursing care. Thus the hospital administration should consider adequate number of clerical and other supportive staff to carry out non nursing workload tasks. In addition to introducing other level of nursing personnel such as licensed practical nurses and assistant nurses is another option to offer more opportunity of registered nurses to demonstrate high quality professional nursing care.

Pay rates and work condition particularly for national workers (Bahraini) need to be competitive to reduce nurse intent to leave and turnover.

Incentive packages could be improved by including more encouragement benefits such as health insurance, conference leave, preceptor allowances, and increases in annual leave days, post graduate education scholarship and adequate paid time to study; childcare subsidies [16] .

11. Relevance of Research in Education

1. For nurse educators, whether in the basic educational settings or within the hospital structures, the results of this study suggested increasing and updating clinical skills are important for nurses to feel more prepared for their area of practice.
2. Consideration should also be given in teaching skills that promote working relationships including communication, group interaction and leadership.
3. Research committee in CCU could be established with cooperation of research coordinators of the hospital to influence nurses' education and implement positive changes in the area.
4. Health care organizations leaders could encourage formal recognition programs such as awarding special act, staff appreciation events and scholarships that promote praise and recognition of nurses work contribution.

12. Relevance of Research in Management Practice

1. This study finding recommended that the areas concerning scheduling and rewards would be more beneficial, particularly with new staff, thus the manager needs to concentrate more on those areas.
2. Socialization was found critical for nurses' growth and satisfaction in the workplace, thus promoting teamwork sprite environment is a key to hospital success and helping new staff feel confident in their performance particularly in early period of employment.
The key to motivate CCU nurses is to explore what motivates them and to design a motivation program based on those needs to minimize their intention to leave, such as providing monetary compensation raise or stipend to nurses who accept more responsibilities.
3. The hospital management could provide supervisors training on motivation and leadership strategies and teamwork effectiveness. In addition to create a supportive and an enabling work environment via enhance the autonomy, continuance education and training.
4. Nursing directors should address the special needs of nurses with a high risk of leaving such as junior, Bahraini, BSN degrees and single. Then adopt various strategies that can have great impact on their satisfaction which may include financial and non financial.

13. Dissemination of Findings Through Reports and Posters

The study finding would be distributed inform of report and presentation to hospital administration, research and educational committees in addition to an article to academic press of RCSI university as well as internal medical journals can be considered as a highly valuable process in the future.

Competing Interests

The authors declare that they have no competing interests.