Ethical Climate, Not Pay or Age, Predicts Whether Nurses Plan to Quit

Nurses who believe their hospital does the right thing are far less likely to walk away from their jobs, according to a new cross-sectional study of frontline nurses in Saudi Arabia. The research, published in BMC Nursing by Essa Hakamy and Ali Alharbi of King Saud University, examined how the ethical climate of hospitals shapes turnover intention among nurses working in three of the most demanding areas of acute care: intensive care units, oncology wards, and emergency departments. These are the settings where moral distress tends to run highest, where end-of-life decisions, aggressive treatment limits, and split-second triage choices confront clinicians daily. The study’s central finding is striking in its simplicity: of all the factors tested, the perceived ethical climate of the hospital was the only significant predictor of whether a nurse intended to leave.

The researchers recruited 143 nurses working in governmental and private healthcare organizations across 13 regions of Saudi Arabia. This geographic spread matters, because it captures the diversity of a health system that has been expanding rapidly under national transformation programs aimed at improving care quality and workforce stability. Participants completed two validated instruments: the Hospital Ethical Climate Survey, known as the HECS, which measures how nurses perceive the ethical environment of their organizations, and the Turnover Intention Scale, which quantifies the strength of a nurse’s thoughts about quitting. A cross-sectional, correlational design means the data capture a single moment in time, revealing associations rather than proving cause and effect, but the statistical relationships uncovered are robust enough to carry real weight for hospital administrators.

The statistical core of the study rests on a moderate negative correlation between ethical climate scores and turnover intention. The Pearson correlation coefficient was −0.483, with a p-value below 0.001, indicating that as nurses’ perceptions of their hospital’s ethical environment improved, their intention to leave declined in a statistically reliable way. In practical terms, a correlation of this magnitude suggests that roughly a quarter of the variability in turnover intention moves in tandem with how ethically sound nurses judge their workplaces to be. That is a substantial effect in organizational research, where many psychological and structural factors compete to explain why employees consider resignation.

When the researchers built a regression model combining ethical climate scores with sociodemographic variables, the result sharpened the message further. Hospital ethical climate emerged as the only significant predictor of turnover intention, with a standardized beta coefficient of −0.490 and a p-value below 0.001. The full model explained 25.5 percent of the variance in turnover intention, with an adjusted R-squared of 0.216. In plain language, more than a fifth of the differences in nurses’ desire to quit could be traced to measurable factors in this study, and the ethical environment outweighed every demographic characteristic tested. Age, experience, and other personal variables did not reach statistical significance once the ethical climate was accounted for.

Not all units were equal, however. Nurses working in oncology reported significantly higher turnover intention than their colleagues in intensive care and emergency departments, with a one-way analysis of variance yielding F = 3.34 and p = 0.038. This finding deserves attention from anyone who has spent time on an oncology ward. Oncology nurses manage prolonged relationships with patients whose trajectories often bend toward decline, navigate frequent end-of-life conversations, and shoulder the emotional labor of balancing hope with honesty. The study’s authors note that a positive ethical environment has previously been associated with improved job satisfaction and reduced turnover intention, and their new data suggest oncology settings may be where that protective effect is most needed.

The concept of ethical climate refers to the shared perception among staff about how their organization typically handles moral questions: whether managers model integrity, whether nurses feel safe raising concerns, whether conflicts between patient welfare and institutional pressures are resolved fairly. Researchers generally treat it as an organizational property rather than an individual trait, which is precisely why it is actionable. Unlike personality or personal circumstances, an ethical climate can be deliberately cultivated through leadership behavior, ethics committees, open reporting channels, and training. The study’s conclusion points in exactly this direction, recommending that healthcare organizations implement strategic interventions, including ethics training, to promote positive ethical climates that support effective retention of the nursing workforce.

The global context makes these findings resonate far beyond Saudi Arabia. Health systems worldwide have been grappling with nursing shortages intensified by pandemic-era burnout, and turnover intention is widely used in the literature as an early warning signal, because stated intent to leave often precedes actual resignation. Every departure of an experienced intensive care, oncology, or emergency nurse removes institutional memory, disrupts team cohesion, and imposes recruitment and orientation costs that can take months to recover. If a quarter of the variation in that intention traces back to something as tractable as the ethical environment, the economics of investing in ethics become compelling for hospital boards.

The methodological choices of the study strengthen confidence in its measurements. The Hospital Ethical Climate Survey is an established instrument designed specifically for nursing populations, and pairing it with the Turnover Intention Scale allows direct comparison with a broad body of prior research. The anonymity safeguards were rigorous: the online survey platform collected no identifying information, including names or hospital affiliations, and informed consent was obtained before participation. Institutional review board approval came from the Ethics Committee of King Saud University under reference KSU-HE-25-1405, and the study was conducted in accordance with the Declaration of Helsinki. Data were stored on a password-protected computer accessible only to the primary investigator and destroyed when the study concluded.

As with any cross-sectional design, some caveats apply. Because perceptions and intentions were measured at the same moment, the study cannot definitively establish that a poor ethical climate causes nurses to consider leaving; it is theoretically possible that nurses already inclined to leave rate their workplaces more harshly. The sample of 143 nurses, while drawn from 13 regions and both public and private sectors, is modest relative to the national nursing workforce, and the three specialty units studied, though high-acuity, do not represent all nursing roles. Longitudinal follow-up would help confirm the direction of the relationship and test whether improvements in ethical climate actually produce measurable drops in resignation over time.

Even with those limitations, the practical implications are clear and immediate. Hospital leaders who want to retain nurses in their most demanding units should look first at the moral fabric of the organization rather than assuming that demographics or unit assignment seal a nurse’s fate. Structured ethics training, visible support for nurses who raise moral concerns, fair handling of end-of-life conflicts, and leadership that models ethical behavior are concrete levers suggested by this evidence. The study, funded through the Ongoing Research Funding Program at King Saud University, adds to a growing consensus in nursing science: nurses stay where they feel their hospital stands for something. In an era when every retained nurse matters, ethical climate is not a soft abstraction but a measurable, manageable determinant of workforce survival.

Subject of Research: The relationship between hospital ethical climate and turnover intention among acute care nurses

Article Title: The impact of hospital ethical climate on turnover intention among nurses working in intensive care, oncology, and emergency department units: a cross sectional study

Article References: Hakamy, E., & Alharbi, A. (2026). The impact of hospital ethical climate on turnover intention among nurses working in intensive care, oncology, and emergency department units: a cross sectional study. BMC Nursing. https://doi.org/10.1186/s12912-026-05397-y

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05397-y

Keywords: nursing, ethical climate, turnover intention, hospital ethics, intensive care, oncology, emergency department, nurse retention, cross-sectional study, Saudi Arabia, job satisfaction, moral distress