Analysis of Burnout and Job Satisfaction with Intention to Leave among Indonesian Nurses in post Pandemic in Saudi Arabia

: The Covid pandemic has ended, but health workers, especially nurses in Saudi Arabia, are still experiencing burnout due to high workloads. This study aims to analyze burnout and job satisfaction related to intention to leave among Indonesian nurses in health services in Saudi Arabia. This research used a qualitative method with a case-study approach. The research subjects used purposive sampling with a typical case of 12 Indonesian nurses who worked in health services and terminated their work contracts in Saudi Arabia. This research used data triangulation, source triangulation, and peer debriefing. In-depth interviews conducted at a predetermined place, data analysis follows 7 steps of Colaizzi's analysis. The results showed that burnout was closely related to emotional exhaustion, depersonalization, and low appreciation for one's abilities. Indonesian nurses who worked in health services in Saudi Arabia were happy and did not experience burnout. Meanwhile, job satisfaction or nurse satisfaction in dealing with work situations and environments is related to internal factors such as salary and rights to work facilities, while externally, it is related to self-development and professionalism.


INTRODUCTION
The COVID-19 pandemic significantly impacted health workers, especially nurses, by increasing the number of patients, increasing the workload, and using new procedures related to COVID-19 (Tomaszewska, 2022).At the same time, nurses also work with feelings of anxiety, fear, fatigue, physical and emotional stress and put themselves in a work environment full of risk of contracting Covid-19.This causes nurses severe stress and burnout syndrome (Lorente, 2021).
Burnout syndrome is defined in ICD 11th as an occupational phenomenon consisting of three dimensions: fatigue, negative feelings related to work, and decreased professional efficacy at work.Burnout causes a decrease in work productivity and increases errors at work.It can also reduce the quality of health services and job satisfaction (Willard-Grace et al., 2019).The COVID-19 pandemic in Saudi Arabia was declared over on June 13, 2022, which was marked by the lifting of the obligation to wear indoor and outdoor masks by the Ministry of Interior of Saudi Arabia (Govsa, 2022).However, expatriate nurses or those outside Saudi Arabia still face serious burnout challenges (Fahruddin et al., 2022).One of the reasons for this is the reasonably high workload.The ratio of nurses to the population is 55/10,000 (WHO, 2020), with more than 60% expatriate nurses (Aldossary, 2018).
The significant impact of burnout can reduce nurses' job satisfaction.Job satisfaction is defined as positive feelings or emotions relating to their work role.A worker gets job satisfaction through job stability, development, career growth, balance, and comfort at work (Maslach and Leiter, 2016).Job satisfaction for health workers is a significant issue that influences work effectiveness and efficiency.Job dissatisfaction worsens mental and physical health, reducing work effectiveness and productivity (Osman & Abdlrheem, 2019).The result of job dissatisfaction among nurses also causes a desire to leave their place of work because they feel that their work and efforts are not appreciated enough (Palazoğlu & Koç, 2019).
Indonesian nurses in Saudi Arabia experience the same conditions as other nurses, namely a high workload that becomes heavier when faced with COVID-19.The researcher also has experience working as a nurse in Saudi Arabia for 5 years and worked during the Covid-19 pandemic.While working during the COVID-19 pandemic, researchers experienced various challenges, such as increasing workload due to the increasing number of patients and a reduction in nursing staff due to being infected with COVID-19, strict health protocols, and stress due to the risk of being exposed to the coronavirus.Apart from that, the Curfew Time imposed by the Saudi Arabian government to limit the spread of COVID-19 adds to the psychological impact of being required to stay at home or in a designated area.These challenges caused prolonged stress during the COVID-19 pandemic, resulting in many nurses terminating their work contracts in Saudi Arabia.Data from the PPNI (Indonesian National Nurses Association) in Saudi Arabia states that 206 nurses are officially registered and licensed in Saudi Arabia.During the pandemic, more than 15 nurses chose not to continue their contracts and returned to Indonesia.This is caused by changes in working hours during the pandemic, increased workload, and fatigue at work (Fahruddin et al., 2023).
The results of research conducted by Alqarni et al. (2022) show that 23.4% of health workers said they were satisfied working in Saudi Arabia, 69.2% said they were doubtful, and 7.5% said they were not satisfied working in Saudi Arabia.The research conducted by Wali et al. (2023) at the King Abdul Aziz Medical City Saudi Arabia primary health service showed results that 42% of nurses expressed dissatisfaction with a response rate of 89.5% with dissatisfaction with the salary of 49%, dissatisfaction with working hours 47%, dissatisfaction with promotions 44%, dissatisfaction due to lack of nursing staff was 51%, and 44% of nurses were dissatisfied with workload.
Post-pandemic research conducted by Fahruddin et al. (2023) explained that Indonesian nurses working in Saudi Arabia face serious challenges, especially burnout, support systems, and job satisfaction.Some nurses face job challenges that leave them feeling physically and psychologically exhausted.A support system that has not implemented the rules properly and job satisfaction means they have to live in Saudi Arabia and cannot meet their families because the holiday rules have been abolished.
Job uncertainty has made Indonesian nurses feel the impact of the Covid-19 pandemic.The research also concluded the importance of a support system from hospital management, nursing managers, and leaders that can reduce the psychological impact faced by nurses.Their role in creating a comfortable working atmosphere is essential for the continuity of nurses' work.
The entry and exit of nursing staff are indicators of the quality of the workplace environment for health workers (Kim et al., 2021).A nurse's desire to leave her workplace can be explained by her desire to leave a particular place, department, or nursing professional organization (Brook et al., 2019).In Saudi Arabia, according to research data, the prevalence of nurse turnover in primary health services is 40% (Almaliki et al., 2021), while the results of research conducted by Kaddourah et al. (2018) on nurses working in tertiary hospitals showed that 94% of nurses wanted to leave their workplace.

METHOD Research Design
This research used qualitative research with a case study design.A qualitative research design with a case study explores burnout and job satisfaction on intention to leave in Indonesian nurses postpandemic of COVID-019 in Saudi Arabia.

Setting and Samples
The sampling technique used was purposive sampling by grouping participants among the existing population according to selected criteria.The population was 206 nurses based on the data from The Indonesian National Nurses Association (INNA) in Saudi Arabia.The selection questionnaire of 12 nurses was selected from this research.There were 46 nurses filled out the form, and 18 nurses were selected.The data was filtered according to the inclusion criteria, and 12 nurses agreed to participate.
The inclusion criteria were Indonesian nurses who worked in hospitals and clinics and were willing to become informants in this research, have an SCFHS (Saudi Commission for Health Specialties) license in Saudi Arabia, registered nurses based on a Member Registration Identification Number (MRIN), and had work experience more than 5 years.Exclusion criteria were nurses who recently worked, had no license, and were unwilling to become informants in the study.

Study Procedure
Primary data were obtained from in-depth interviews and observation of secondary data.Interviewed guidelines were created to evaluate all research information.Instruments in the form of laptop, zoom app, and stationery.Interviews were conducted individually, and the audio transcript was conducted during interviews above 30-40 minutes for each respondent.Coding was used to make differences for each respondent, e.g., Informant 1, Informant 2, Informant 3, etc.

Data analysis
The data were carefully analyzed after transcription following Colaizzi's seven steps, which include 1).Read and re-read all transcripts and find the goals from the participants' expressions.2).Identifying significant statements about burnout, job satisfaction, and intention to leave.3).Formulating meaning from the significant statement.4).Identified meaning in themes.5) Developing an exhaustive description.6).Producing the fundamental structure.7).Seeking verification of the fundamental structure (Morrow et al., 2015).To analyze this study, researcher 1).Prepare the data that has been obtained, including informed consent, and then save it on Google Drive to minimize data loss.2).Transcript the interview audio and read the results carefully.The interviews are combined with a voice recorder that has been prepared and then made in one file for each informant.2).Saved the file in the internal folder for data transcripts.3).Arrange codes for each interviewer to differentiate the person being interviewed.4).Identify and interpret data to look for important relevant themes with research questions from textual interview results. 5. Create a report on the results of data analysis based on processed data from the device used.

Rigor and Trustworthiness
According to Lincoln and Guba, there are four criteria for assessing and improving the results of the qualitative study, which refer to the principles of credibility, transferability, dependability, and confirmability.The research began when the ethics clearance process was completed by The Medical and Health Research Committee FK-KMK Gadjah Mada University and research approval from the Indonesian National Nurses Association (INNA) in Saudi Arabia.The process of implementing the research begins with informed consent from the researcher to the participants as a form of information and explanation related to the flow, aims, and time of the research.After the participant knows as a whole, it is agreed upon through a consent sheet.

Ethical Considerations
This study was approved by The Medical and Health Research Ethics Committee of the Faculty of Medicine, Public Health and Nursing Gadjah Mada University with number KE-FK-1492-EC-2023

RESULTS
This research was conducted in Saudi Arabia on 12 Indonesian nurses who work in health services; including hospitals and clinics.Those informants work in emergency departments, ward departments, hemodialysis departments, and nursing management.A total of 12 nurses agreed to become informants for interviews with semi-structured questions, and electronic recording was used to perform the interview, see

Burnout
Burnout has three categories: emotional exhaustion, depersonalization, and low self-efficacy.Herbert explains that burnout is a condition of extraordinary stress and fatigue experienced by professionals who provide services, such as police, doctors, and nurses (Batayneh et al., 2019).The fatigue experienced by nurses is also influenced by the number of patients and the difficulty level of the cases they face.Indonesian nurses in Saudi Arabia have to face cultural differences that can cause conflict, for example, the stubborn nature of patients who are challenging to work with.This can cause emotional exhaustion in nurses, and if it continues, it can result in burnout.With this patient's background and condition, Indonesian nurses must have the appropriate cognitive abilities and perception to solve various health problems patients face.This is peer research conducted by Schaufeli et al. (2017) that the uncertainty and dynamics of work cause stress in nurses a nurse faces in various patient statuses and circumstances.So, nurses must have appropriate perceptions or good cognitive abilities to complete their duties and responsibilities in providing nursing care to patients and avoid the risk of emotional exhaustion, which can cause burnout.
The results of qualitative research conducted on 12 informants showed that 10 nurses stated they were happy, enthusiastic, and enjoyed their work experience in Saudi Arabia.This explains that this research is not in line with previous research that shows that Indonesian nurses who work in health services in Saudi Arabia face burnout challenges (Fahruddin et al., 2023).Nurses feel more appreciated when working in Saudi Arabia, so nurses can be more enthusiastic about their work, even though they have to face various challenges at work, such as the behavior of patients who have a strong character or the number of patients that exceeds the capacity of the number of nurses.Still, Indonesian nurses have good cognitive abilities to complete their duties and responsibilities as nurses.This is the result of research conducted by Ayalew et al. (2019), who found that the reward system for nurses is an intrinsic factor that strongly increases nurses' motivation to work.Besides, working in Saudi Arabia for Muslim nurses certainly provides valuable experience.Apart from working, you can also worship in the holy cities of Mecca and Medina.Previous research stated that 80% of Muslim research participants want to work in Saudi Arabia for reasons of Hajj or Umrah (Almansour et al., 2023).
Furthermore, 2 informants stated that they were tired of working in Saudi Arabia, especially after the end of the pandemic; this was because, after the pandemic, the government no longer enforced regulations limiting medical treatment for the public, as was the case during the COVID-19 pandemic which resulted in the number of patients increasing sharply, and also appointment patients who were postponed during the pandemic.This can cause an imbalance in the ratio of nurses and patients which can further increase emotional exhaustion in nurses and can cause burnout.This aligns with research conducted by Huang (2018), which states that a high ratio of patients and nurses can cause emotional exhaustion, which can trigger burnout.
Furthermore, 12 Indonesian nurses showed that they did not experience depersonalization, meaning that Indonesian nurses felt emotionally connected to patients or their work as nurses.Even though Indonesian nurses in Saudi Arabia experience boredom due to the same daily activities with varying levels of boredom, Indonesian nurses can overcome boredom by doing activities with colleagues on their holidays or worshiping in the holy cities of Mecca and Medina.By carrying out this activity, nurses can refresh themselves from boredom and return to work, carrying out their duties well in providing nursing care.This is based on research by Yuan & Xu (2020), who found that management needs a supportive program to overcome this burnout and improve nurses' quality of life.One of the management programs that must be implemented is having nurses' holidays to take a break from the same activities and avoid risks of burnout.This research also aligns with Cleary et al. ( 2016), who state that providing nurses vacation time can reduce workplace boredom.
In the category of low self-esteem, 6 out of 12 Indonesian nurses who work in health services in Saudi Arabia stated that they had experienced frustration when working in Saudi Arabia.Still, this situation only occurred at certain times, such as during the Covid-19 pandemic, at the start of working in Saudi Arabia, when the number of patients exceeds the capacity of the number of nurses, or when faced with impolite and stubborn patient behavior, the remaining nurses can adapt to the work environment and enjoy the experience of working as nurses in Saudi Arabia.This is in accordance with Schaufeli et al. (2017), who state that good cognitive abilities can prevent oneself from the risk of stress and burnout.
This category also discusses the motivation to work for Indonesian nurses in Saudi Arabia, including experience working abroad with greater benefit than working in Indonesia, because of the desire to perform the Hajj and Umrah pilgrimages.By becoming a nurse in Saudi Arabia, the opportunity for Hajj and Umrah is greater than in Indonesia.All informants expressed that being able to work in Saudi Arabia was something to be grateful for.Some informants even stated that becoming a nurse was not their dream, but they had no regrets and were grateful to be nurses in Saudi Arabia.This is in accordance with research conducted by Magliveras & Al Qurtuby (2023) that one of the motivations for Indonesian Muslim nurses who work in Saudi Arabia is to be able to worship in the two holy cities of Islam, namely Mecca and Medina.

Job Satisfaction
Job satisfaction is influenced by three factors: intrinsic factors (work conditions, type of clients faced, and coworkers), organizational factors (including supervision, job demands, financial abilities, and development opportunities), and salary and promotions (Dall'Ora et al., 2020).
Indonesian nurses who work in health services in Saudi Arabia understand that there are differences in the habits and behavior of patients in Saudi Arabia, so they can adapt to their work environment, carry out their duties and responsibilities well, and enjoy the experience of working in Saudi Arabia.This is in accordance with research conducted by (Baroudi et al., 2022), that intrinsic factors play a more important role in determining the relationship with job satisfaction.Indonesian nurses' job satisfaction is also reflected in statements of happiness after helping patients overcome their problems, as revealed through in-depth interviews.This happiness affects all professions, especially nurses, because nurses are directly related to patients in various conditions experienced by patients, so happiness is needed to support nurses in carrying out their duties confidently, creatively, and in a friendly and energetic way (Alegre & Fernández, 2016).
Furthermore, the factor that influences the job satisfaction of Indonesian nurses in Saudi Arabia is the appreciation from their colleagues and superiors.This award is included in the organizational factors that can increase the work motivation of Indonesian nurses in Saudi Arabia so that nurses can maintain the quality of their nursing care services and increase job satisfaction.This aligns with research results, which found that superiors with transformational leadership characteristics will increase their motivation and simultaneously feel satisfied with their work (Jalagat, 2016).
Then, 10 of the 12 informants interviewed were satisfied with the salary given at their workplace.This can explained by the fact that salary positively influences job satisfaction.Nurses can be motivated to improve the quality of nursing services in the workplace with an appropriate salary.This is in accordance with research conducted by Akinwale & George (2020), who found that salary is a fundamental factor influencing nurses' job satisfaction.Meanwhile, 2 informants stated they were not satisfied with their salaries; they explained that the reason was not because the salaries were less but because salaries were unfairly distributed between new nurses and nurses who had been working for a long time.New nurses get relatively higher salaries than nurses who have worked longer at their place of work.This is in accordance with Zahednezhad et al. (2021) that salary equality is in accordance with work experience or what is also called fair interaction and can positively influence job satisfaction.
Lastly, job satisfaction is influenced by the suitability between position and skills and the ability of nurses to carry out their work.This was expressed by all informants that their position was in accordance with their abilities and skills; even 2 informants stated that they were offered managerial or head nursing positions but did not take them because they did not receive incentives and wanted to have more time with their family.This is in accordance with research conducted by Nurhasnawati & Subhan (2018), who found that job satisfaction is felt when there is a match between the abilities and skills and the job at hand.

Intention to leave.
Many factors cause a nurse to want to leave her workplace.These include a lack of functioning nursing management, a lack of recognition and promotion, a lack of self-development programs, personal factors, and an unsupportive work environment (Marufu et al., 2017).The research results revealed that 5 out of 7 nurses still working in Saudi Arabia explained that they wanted to stop working and change their place of work.Family factors and self-development are the main reasons for nurses to end contracts.This aligns with research conducted by Moloney et al. (2018) that found that work-life and family-life balance in health workers is related to the desire to leave the workplace.This also shows that self-development factors play a direct role in determining someone to stay in the organization.
Other research also reveals that family support greatly influences the desire to leave or stay at work (Al Zamel et al., 2020).Family factors influence a person's decision to stick with what they want or vice versa to look for another job ideal for themselves and their family.The results of interviews with 5 nurses who had stopped working in health services in Saudi Arabia revealed that 4 nurses specifically explained the reason for stopping work was that they wanted to be close to their families.Another reason is the increasing workload not accompanied by equal pay and work experience for nurses.Equal pay according to work experience is also called fair interaction, which can influence job satisfaction and nurses' stay in their workplace.Research from Zahednezhad et al. (2021) explains that fair interaction in health service management positively relates to job satisfaction and the desire to stay in the workplace.This research is in line with research by Phillips (2020) that shows that several factors, including workplace management, influence the desire to leave the workplace.
The research limitations were that participants had no more time to explore their work experience in Saudi Arabia, those nurses had limitations to participate in this research, and the participants were only Indonesian nurses in Saudi Arabia.

CONCLUSION
Based on interviews, this research found several factors Indonesian nurses face in Saudi Arabia: burnout, job satisfaction, and intention to leave.Burnout is closely related to emotional exhaustion, depersonalization, and low appreciation for one's abilities.Indonesian nurses who work in health services in Saudi Arabia work happily and do not experience burnout because they can work and worship in the two holy cities of Islam.Meanwhile, job satisfaction or nurse satisfaction in dealing with work situations and environments is closely related to internal factors such as salary and rights to work facilities, while externally, it is related to self-development and professionality.The final meaning is the intention to leave, related to the nurse's desire to leave or stop at work.On average, nurses want to quit for various reasons, namely family reasons and fair salary.
Table. 1.There are 11 nurses who have bachelor's degrees in nursing, and 1 has a diploma III in nursing.A total of 5 nurses work in the emergency department, 2 nurses work in the hemodialysis department, and 5 nurses work in the ward department.The average age of informants is 39 years old, and the average work experience is 12 years.All nurses have a Saudi Commission for Health Specialties (SCFHS) license.