Mental Health, Burnout, and Turnover Intention Among Nurses in Conflict-Affected Yemen: A Multicenter Study Across Eight Accessible Governorates.

Abstract

Background: Yemen's long-standing armed conflict has decimated the health system and subjected nurses to unprecedented levels of occupational and conflict-related stress. The role of nurses is pivotal, yet little is known about their mental health in Yemen, limiting the evidence available to inform nursing leadership and workforce protection strategies. Methods: A multicenter cross-sectional study was carried out between January and December 2025, involving 800 registered nurses from 24 health facilities across eight conflict-affected Yemeni governorates using a multistage sampling strategy with probability-based selection of facilities and nurses within accessible governorates. Validated Arabic PHQ-9 and GAD-7 questionnaires (cut-off ≥ 10) were used to assess depression and anxiety. Burnout was assessed using a single-item self-rated measure with pilot validation against the Maslach Burnout Inventory emotional exhaustion subscale (r = 0.82), selected for pragmatic feasibility in a highly stressed population. Mixed-effects logistic regression was used to account for clustering at the facility level. Exploratory supplementary analyses examined associations involving self-rated burnout and reported availability of psychological support. Results: 52.0% (95% CI: 48.5-55.5) of nurses experienced moderate-to-severe depressive symptoms, while 47.0% (95% CI: 43.5-50.5) experienced moderate-to-severe anxiety symptoms. High self-rated burnout was prevalent in 34.0% (95% CI: 30.7-37.4), and 54.8% (95% CI: 51.2-58.3) reported their intention to leave within 12 months. Psychological distress was independently associated with displacement (AOR = 2.31, 95% CI: 1.68-3.17), workplace violence (AOR = 2.84, 95% CI: 2.03-3.97), inadequate income (AOR = 2.53, 95% CI: 1.80-3.56), nurse-to-patient ratios ≥ 1:20 (AOR = 1.68, 95% CI: 1.07-2.63), and frequent night shifts (AOR = 1.26, 95% CI: 1.17-1.36 per additional shift). Not all expected associations were significant; nurse-to-patient ratios of 1:15, facility type, and type of employment showed no consistent associations. Sampling-weighted prevalence estimates were very similar to the unweighted estimates (absolute differences < 1 percentage point), supporting the robustness of the findings against differential selection probabilities across governorates. Conclusions: Armed conflict and structural workforce stressors were associated with a substantial mental health burden among nurses in southern, central, and eastern governorates in Yemen. Because the most heavily conflict-affected northern governorates were inaccessible for security reasons, the findings are generalizable only to accessible areas, and the direction of difference in burden in inaccessible areas cannot be determined from these data. While the cross-sectional design precludes causal inference, the findings identify potential targets for intervention. Mental health support, workplace violence prevention, and safe staffing in nursing leadership and humanitarian workforce strategies may be relevant to workforce resilience strategies in fragile health systems, but these are implications consistent with observed associations rather than evidence of intervention effectiveness. Findings should be interpreted given the cross-sectional design, limited geographical access, and the use of a single-item self-rated burnout measure that does not capture the multidimensional nature of burnout. Future longitudinal studies should include multidimensional burnout instruments and trauma-related assessment.