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Gazzaz, Lamya Asaad (2009) Saudi nurses' perceptions of nursing as an occupational choice: a qualitative interview study. PhD thesis, University of Nottingham.
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Saudi Nurses’ Perceptions of Nursing as an Occupational
Choice: A Qualitative Interview Study
By
Lamya Asaad Gazzaz BSN, MSc
Thesis submitted to the University of Nottingham
for the degree of Doctor of Philosophy
Faculty of Medicine and Allied Health Science
School of Nursing
January 2009
Dedications
To my beloved husband, faithful friend, and soul-mate for his
love, support, and patience throughout the long hard hours spent in
this PhD endeavour. My love, appreciation and gratitude for
exploring with me the realms of life and life’s intricate meanings
by standing next to me, encouraging, listening, entertaining my
arguments and clarifying my thoughts whenever needed.
My ever lasting appreciation to the memory of the departed
soul of my father who has been around for me; this one is for you.
To my caring mother for her love and sincere prayers during the
uncountable difficult times which I faced.
Acknowledgements
I would like to acknowledge the many individuals and groups
who contributed to the development of my thesis. My deep
gratitude and thankfulness to my supervisors Dr. Tony Arthur,
Prof. Mark Avis and Dr. Elizabeth Hart for their continuous
support and guidance throughout the course of my PhD study.
Their advice and feedback were extremely valuable.
My sincere appreciations and thankfulness goes to: my
friends in Jeddah who endured this long process with me; Dr.
Suhair Qurashi, Dean of Dar Al-Hekma College and Dr. Sawsan
Al-Majali, Director of the Nursing Programme for their support
and assistance.
Abstract
Background: Saudi Arabia has always been dependent on non-Saudi nurses. However,
the recruitment of these nurses has been challenged by the consequences of the first Gulf
War of 1991 and the political unrest in the Middle East ever since. Moreover, the annual
supply of Saudi nursing graduates has been insufficient in meeting the demands of the
expanding healthcare services. Indeed, Saudi nurses make less than 30% of the total
nursing workforce Kingdom wide. The Saudi literature links the shortage in Saudi nurses
to socio-cultural factors found to influence the prevailing negative images and perceived
low status of nursing. Hence, I have developed a personal interest to explore the impact
of prevalent images and perceived status of nursing on the Saudi nurses’ perceptions of
nursing as an occupational choice. The reviewed literature guided the development of a
framework for my study using six concepts.
Aim: To gain an understanding of the social, cultural, economic and political influences
on Saudi nurses’ perceptions of nursing and their impact on recruitment of nursing
students and retention of graduates.
Method: Sixty eight semi-structured interviews were conducted in Jeddah, Saudi Arabia
with a sample of student nurses (n = 38), staff nurses (n = 21) and senior nurses (n = 9)
from government and private sectors. A purposive sampling approach increased the
likelihood that the variability within nursing was represented in the data. A focus on the
inclusion of Saudi male nurses is unusual; it allowed this study to explore gender issues
in more depth. The interview guides covered selected concepts derived from the
literature. These include: nursing images; status of nursing; perceptions of nursing as an
occupational choice; nursing education; gendered-nature of nursing and nursing support
systems. Interviews were conducted and transcribed in Arabic and participants were
interviewed once. A socio-demographic checklist was filled at the end of each interview.
Findings: Findings were presented using three explanatory themes. First, perceptions of
nursing suggesting that, against a background of negative gender-related perceptions of
nursing, there is an increasing recognition of nursing as a secure occupational choice in a
shifting labour market. Second, challenges facing professionalism suggesting that
participants acknowledged the importance of achieving a recognised professional status
for nursing. Third, dealing with personal struggle suggesting that participants have been
experiencing a personal struggle as they were learning to cope with the prevalent
negative perceptions of nursing at social and professional levels.
Conclusions: Findings from the study provide evidence of a personal struggle female and
male participants have been experiencing in their attempts to transcend through shifting
gender, social, cultural, economic and global boundaries. A struggle they had to deal with
in order to achieve social and professional recognition. Overlooking causes of struggle
might risk Saudi nurses’ recruitment into and retention within nursing. A new model for
the Saudisation of nursing workforce has been proposed. Policy makers are requested to
divert their strategies from focusing only on graduates from the nursing programmes to
targeting Saudi school children. They are expected to design and implement Saudisation
strategies that aim at changing the prevailing gender-related perceptions of nursing as an
occupation among prospect candidates; and building on the nurses’ efforts to achieve
professional recognition and integrate success in their career with their personal life.
Table of Content
Chapter 1 Nursing in Saudi Arabia Social, Cultural and Economic Contexts ......... 1
Introduction .................................................................................................................. 1
Nursing in Saudi Arabia .............................................................................................. 2
History of nursing education ...................................................................................... 2
Towards professionalism ........................................................................................... 4
University nursing education ..................................................................................... 4
The development of formal nursing bodies ................................................................ 7
The current nursing situation ..................................................................................... 8
Nursing in Islam ......................................................................................................... 10
The country ................................................................................................................. 11
The Saudi culture ..................................................................................................... 11
Social context ........................................................................................................... 13
Urbanisation ............................................................................................................ 13
Social classification ................................................................................................. 14
The Saudi economy .................................................................................................. 16
Education ................................................................................................................. 17
Unemployment.......................................................................................................... 18
The Saudisation Policy ............................................................................................. 19
The role of the private sector ................................................................................... 20
Conclusion................................................................................................................... 22
Chapter 2 Literature Review ....................................................................................... 23 Introduction ................................................................................................................ 23 The Saudi literature ................................................................................................... 24
Images of nursing ..................................................................................................... 24
Status of nursing ....................................................................................................... 26 Saudisation ............................................................................................................... 29
Saudisation of nursing ............................................................................................. 30 Gender challenges .................................................................................................... 32
Gender mixing in nursing ........................................................................................ 32 Work-related issues .................................................................................................. 33 Saudi male nurses .................................................................................................... 35
The western literature ............................................................................................... 37 Images of nursing ..................................................................................................... 38 Entry images ............................................................................................................ 38 Experience-acquired images .................................................................................... 40 Media portrayals ...................................................................................................... 41 Status of nursing ....................................................................................................... 43
Nursing education .................................................................................................... 45 The perception of nursing as an occupational choice .............................................. 48
Job characteristics and values ................................................................................. 49 Age, gender and occupational choices..................................................................... 52
The gendered-nature of nursing ............................................................................... 53 Gender stereotyping ................................................................................................. 55 Gender-role and nursing specialities ....................................................................... 57 Advantages and discrimination ................................................................................ 58
Support systems ....................................................................................................... 60 Support from family and significant others .............................................................. 60 Recognition and appreciation .................................................................................. 61 Job satisfaction ........................................................................................................ 62 Nursing policies and regulations ............................................................................. 64
Magnet hospitals ...................................................................................................... 65
Conclusion................................................................................................................... 67
Chapter 3 The Research Process .................................................................................. 69
Introduction ................................................................................................................ 69
The research question ................................................................................................ 69
The research design ................................................................................................... 70
Why qualitative approach? ....................................................................................... 70
Whose voice to be heard? ........................................................................................ 72
Interviewing as a qualitative technique .................................................................... 72
Setting .......................................................................................................................... 74
Study setting ............................................................................................................. 74
Sampling strategy ....................................................................................................... 75
Selected hospitals and academic institutions ........................................................... 75
The target population ............................................................................................... 76
Nursing students ....................................................................................................... 76
Staff nurses ............................................................................................................... 76
Senior nurses ............................................................................................................ 77
Table 1: Target Sample ............................................................................................ 79
Access and permissions .............................................................................................. 80
Ethical approval ....................................................................................................... 80
Obtaining permissions to access the selected facilities ............................................ 81
Flow Chart 1 ............................................................................................................. 82
Flow Chart 2 ............................................................................................................. 83
Approach and consent ............................................................................................... 84
Preparing and commencing the research interviews .............................................. 87
The interview guides ................................................................................................ 87
Table 2: Actual Sample ............................................................................................ 87
Piloting the interview guides .................................................................................... 88
The data collection phase ......................................................................................... 89
Gender specific ethical considerations ..................................................................... 94
Transcribing and translating .................................................................................... 96
Data analysis ............................................................................................................... 97
Figure 1: Data Analysis Process ............................................................................ 100
Conclusion................................................................................................................. 101
Chapter 4 Perceptions of nursing ............................................................................... 102
Introduction .............................................................................................................. 102
Table 3: Participants’ Socio-demographic Characteristics .................................... 103
The domestic nature of bedside nursing care ........................................................ 104
The bedside care ..................................................................................................... 105
Nursing as domestic work ...................................................................................... 107
Nationalities and tasks............................................................................................ 108
“Nursing is not for the Saudis” .............................................................................. 111
Role of the media ...................................................................................................... 113
Media portrayals..................................................................................................... 113
The cultural values ................................................................................................... 115
Historical images of nurses .................................................................................... 116
Work-related images .............................................................................................. 118
Religious motives ................................................................................................... 120
The social norms....................................................................................................... 124
Socially acceptable jobs ......................................................................................... 126
The changing economy ............................................................................................ 129
A need for money ................................................................................................... 129
Conclusion................................................................................................................. 132
Chapter 5 Challenges facing professionalism ............................................................ 133
Introduction .............................................................................................................. 133
Nursing education .................................................................................................... 133
“Reality-shock” experiences .................................................................................. 133
Gaining competence ............................................................................................... 133
Developing confidence........................................................................................... 145
Nursing policies and regulations ............................................................................. 150
Grades for posts...................................................................................................... 150
Nursing salaries and financial benefits .................................................................. 152
Nursing salaries ..................................................................................................... 152
Financial benefits ................................................................................................... 155
Support systems........................................................................................................ 157
In-service education and training ........................................................................... 158
Appreciation and recognition ................................................................................. 158
Scholarship opportunities ....................................................................................... 160
Saudisation programmes ........................................................................................ 161
Conclusion................................................................................................................. 167
Chapter 6 Dealing with personal struggle ................................................................. 169 Introduction .............................................................................................................. 169
Barriers to choosing nursing as an occupation ..................................................... 169 Nursing awareness ................................................................................................. 170
Lack of interest in nursing...................................................................................... 173 Nursing as an alternative field of study.................................................................. 174 Family support ....................................................................................................... 176
Gender-related struggle ........................................................................................... 178 Issues faced by women........................................................................................... 179 Social challenges .................................................................................................... 180 The 12-hour shift pattern ....................................................................................... 184 Marriage and family issues .................................................................................... 187 Transportation ....................................................................................................... 188
Maternity leave and on-site crèche ........................................................................ 190 Issues faced by men ............................................................................................... 191
Generation-related struggle .................................................................................... 199 The early generation ............................................................................................... 199 The new generation ................................................................................................ 203
Conclusion................................................................................................................. 208
Chapter 7 Discussion .................................................................................................... 209
Introduction ............................................................................................................... 209
Strengths and limitations of the study ..................................................................... 210 Study sample ........................................................................................................... 210
Qualitative data ....................................................................................................... 211 Timeliness ............................................................................................................... 212 Gender as a methodological issue ........................................................................... 213
The interview guides ............................................................................................... 215 The retrospective nature of some data .................................................................... 215
Gender boundaries .................................................................................................... 216 Perceptions of nursing ............................................................................................. 216 The changing role of Saudi women and their participation in the labour market .. 218
Gender-role boundaries in the workplace .............................................................. 221 Challenges facing professionalism .......................................................................... 225 Nursing education ................................................................................................... 226
Nursing policies and regulations ............................................................................ 230 Dealing with personal struggle................................................................................ 232
Cultural values and social norms ........................................................................... 232 Social status of Saudi women .................................................................................. 236
Social, economic and global boundaries ................................................................. 238 Perceptions of nursing ............................................................................................. 238 The impact of socio-economic developments on occupational choices .................. 238
Need for money ....................................................................................................... 241 The media ................................................................................................................ 243 Challenges facing professionalism .......................................................................... 245 The institution of Saudisation to face nursing supply and demand ........................ 247
Education segment .................................................................................................. 248 Service segment ....................................................................................................... 249
Dealing with personal struggle................................................................................ 252 An interest in nursing .............................................................................................. 252 Humanitarian motives ............................................................................................. 254
Conclusion and recommendations ........................................................................... 256
Refrences ........................................................................................................................ 259
List of Abbreviations
AD Associate Degree
ARAMCO Arabian American Oil Company
BSN Bachelor of Science in Nursing
CEO Chief Executive Officer
MoCS Ministry of Civil Services
MoEP Ministry of Economy and Planning
MoH Ministry of Health
MoHE Ministry of Higher Education
MoL Ministry of Labour
MoP Ministry of Planning
RN Registered Nurse
SCFHS The Saudi Council for Health Specialities
List of Appendices
Appendix 1-1 A written approval for the data collection trip issued by
the Saudi Cultural Attaché in London
Appendix 1-2 An acknowledgment issued by the Saudi Cultural
Attaché in London
Appendix 1-3 An ethical approval issued by Dar Al-Hekma College
Council
Appendix 1- 4 to 1-8 Written permissions to access the selected
academic institutions
Appendix 1-9 to 1-12 Written permissions to access the selected
hospitals
Appendix 2 Participants’ Information Sheet
Appendix 3-1 Interview guide for nursing students
Appendix 3-2 Interview guide for staff nurses
Appendix 3-3 Interview guide for senior nurses
Appendix 4 Copy of Consent Form
Appendix 5 A socio-demographic checklist
Appendix 6 Interview Transcript
Appendix 7 Case Summary
Appendix 8 A Table showing Literature-guided Concepts and
Interview Questions
Appendix 9 Grouping of Inductive Codes
Appendix 10-1 Data Analysis (Coding to Themes)
Appendix 10-2 An Example of the Coding and Data Analysis Process
Appendix 11 Brief reviews of 2 Arabic TV dramas on nurses
Appendix 12 Article by Arab News (Saudi nurses face opposition
from kin)
Appendix 13-1 & 13-2 The Jordanian Nursing Campaign 2007
Appendix 13-3 The Nurse Camp at the Mayo Clinic Hospital
Appendix 13-4 The Nursing Shortage Consortium in South Florida
Overview
This thesis is organised into seven chapters;
Chapter one is divided into two sections. The first section presents a review of the
development of nursing education in Saudi Arabia, followed by an appraisal of the
country’s effort to professionalize nursing. Chapter one is divided into two sections. The
first section presents a review of the development of nursing education in Saudi Arabia,
followed by an appraisal of the country’s effort to professionalize nursing. Despite efforts
to professionalize nursing, the number of Saudi nurses has remained small. It has been
estimated that a minimum of 25 years is required to meet 30% of the national needs from
Saudi nurses. The second section provides an overview of the social, cultural and
economic contexts through which the shortage in Saudi nurses could be understood.
Emphasis has been placed on the shift in nursing image from one attaining great respect
during Prophet Mohammed’s time to one that is socially less favourable.
Chapter two provides an overview of the relevant literature. The reviewed literature is
divided into Saudi and western; relevant studies from other Arab and Muslim countries
are used to compare and contrast where applicable and to enrich the overall review. Areas
of similarities and differences are highlighted. The chapter begins by reviewing the
limited Saudi literature concerned with recruitment and retention of Saudi nurses; studies
on image, status and Saudisation of nursing are examined. In contrast, western literature
concerned with the recruitment and retention of nurses are numerous and diverse.
Attention is drawn to areas which have attracted interest and to those which remain
relatively unexplored. A framework of six concepts is proposed to focus the area of
inquiry, refine my research question and guide the research process and methodological
design. Combined, the reviewed literature and the social, cultural and economic contexts
presented in chapter one provide the base for the development of this research.
Chapter three sets out the justification for the use of a qualitative approach as a
methodology of choice. To fill in identified gaps, three methodological decisions were
taken. First, a qualitative design was selected to understand areas of interest and answer
the research question. Second, a semi-structured interview technique was adopted for the
data collection process. Third, a purposive sampling technique to recruit participants
from Saudi nursing students, staff nurses and senior nurses with a focus on male students
and nurses. The chapter covers the sequence of the research process starting from the
development of the research question and the choice of semi-structured interview
technique through to getting permissions, gaining access, piloting the interview guides,
and the data collection phase. Data collection took place between mid November 2005
and end of February 2006; a total of 68 interviews was achieved. The first interview was
conducted on the 20 th
of November 2005 and the last interview was on the 14 th
of
February 2006. Ethical issues are highlighted. The last section of this chapter discusses
the three techniques employed for data analysis.
Chapter four explores the participants’ views on nursing and their perceptions of
prevailing images of nursing held by the people around them. Themes (synthesis and
organising) are used to explore these views and perceptions of nursing and understand
how they influenced the participants’ decisions to pursue nursing and to continue as
nurses. For this purpose, the chapter is divided into five sections: the domestic nature of
bedside nursing care, role of the media, cultural values, social norms, and changing
economy.
Chapter five explores participants’ views on nursing education, nursing policies and
regulations and nursing support systems as selected aspects of professionalism.
Throughout this chapter, themes (organising and synthesis) are used to convey
participants’ views on the importance of achieving a nationally and internally recognised
professional status of nursing. As a supporting national policy and organisational
strategy, the last section of the chapter presents participants’ perceived views and
expectations of the Saudisation Policy highlighting its impact on their decisions to pursue
nursing and to remain as nurses.
Chapter six presents the argument that participants have been experiencing a personal
struggle as they were learning to cope with the prevalent negative images of nursing at
social and professional levels. Throughout the chapter, participants’ accounts are used to
convey individualised efforts invested in coming to terms with pervading and
predominantly negative images at a social and professional level. Three organising
themes are explored: barriers to choosing nursing as an occupation, gender-related
struggle and generation-related struggle. The underlying synthesis themes are used to
illustrate variation in the individual nursing experiences.
Chapter seven is designated to discuss how shifting gender, social, economic and global
boundaries, within a Saudi context, might have impacted on the perceptions of nursing,
challenges facing nursing professionalism and dealing with personal struggle. Hence,
illustrating how these shifting boundaries might have influenced the participants’
decisions to become nurses, pursue nursing and remain as nurses. The chapter is divided
into three sections. In the first section, I present a critical review of the strength and
limitations of the study. In the second section, gender boundaries, I argue that negative
gender-related perceptions of nursing have for many years contributed to its perception as
a professionally less prestigious and socially unappealing occupational option.
Simultaneously, this has hindered and limited the number of men and women who
wanted to become nurses. The third section, social, economic and global boundaries,
argues that Saudi Arabia is experiencing an emerging economic-driven interest in
nursing. It discusses how changing political, economic, social and global boundaries,
combined, have been influencing nursing appeal.
1
Chapter One
Nursing in Saudi Arabia
Social, Cultural and Economic Contexts
Introduction
I am a Saudi nurse with twenty years experience in a variety of nursing jobs within
Saudi Arabia. In 2000, I joined a newly established private academic institution and
became actively involved in the introduction of a baccalaureate nursing programme.
Having been involved in planning the nursing programme and promoting it as a
competitive academic and occupational choice, I started to develop an interest in the
complex nature of recruitment and retention of the Saudi nursing workforce.
Much of the Saudi literature, reviewed in depth in chapter two has cited prevailing
negative images of nursing and perceived low status of nurses as two important factors
in explaining the severe shortage of Saudi nurses. These themes were attributed to work-
related factors such as gender-mixing, long working hours and rotating shifts which
render nursing a socially unacceptable occupational choice. Some authors (Meleis &
Hasan 1980, El-Sanabary 1993, Hamdi & Al-Hyder 1995, El-Sanabary 2003) have
linked the poor image and status to the type and level (diploma) of the early nursing
programmes. In contrast, I have observed an increasing uptake of apparently „less
popular‟ academic programmes such as nursing since the 1990s. This has coincided with
escalating unemployment among graduates of some more „favourable‟ fields of study
(MoEP 2003).
In 2003, I decided to pursue my interest in the recruitment and retention of Saudi nurses
through a research degree in this area. At an institutional level, I hoped that my research
findings would guide my future academic work and management responsibilities. As a
contribution to national nursing workforce planning, it was hoped that the research
2
findings would provide insight into aspects to improve the recruitment and retention of
nurses.
This chapter is divided into two sections. The first section presents a review of the
development of nursing education in Saudi Arabia, followed by an appraisal of the
country‟s effort to professionalize nursing. The second section provides an overview of
the social, cultural and economic contexts within which the prevailing images and
perceived status of nursing are constructed. Saudisation as a national policy is
introduced at the end of this section.
Nursing in Saudi Arabia
Ever since the establishment of the Ministry of Health in the 1950s (Long 2005), Saudi
Arabia has relied on non-Saudi nurses to meet the nursing demands. However, as an
outcome to the Gulf War in 1991, the repeated terrorist activities since 1995 and the
events of September 11 th,
2001, recruitment and retention of international qualified
nurses has become increasingly difficult. Simultaneously, the global nursing shortage
and the political situation in the Middle East continued to pose major challenges for
international recruitment particularly from western countries. Most hospitals have
suffered a severe nursing shortage. However, the shortage is related to national as well
as international factors. The annual rate of Saudi nursing graduates is insufficient to
meet the increasing healthcare demands. For example, in the academic year 2005/2006,
the annual number of BSN graduates (females) from the three government universities
was only 82 (MoH 2006).
History of nursing education
In 1958 and in collaboration with the World Health Organisation (WHO), the Ministry
of Health (MoH) opened the first Health Institute for young men in Riyadh, central
province. Fifteen students who completed six years of elementary education were
enrolled and they graduated after one year as Health Inspectors (Meleis & Hasan 1980,
Al-Osaimi 1994c, Tumulty 2001). The WHO offered technical expertise while the MoH
covered expenses and provided buildings. Two nurse-aide programmes for young
3
women were established in Riyadh and Jeddah in 1962. Incorporated into two
elementary schools, students continued their elementary education while studying a
curriculum for assistant nurses (Meleis & Hasan 1980, Al-Osaimi 1994c).
Challenging the traditional societies, nursing as a proposed programme for young
women was met with strong objections from the Saudi people and government. To
overcome objections, the authorities and families were assured that female students
would remain veiled, would be taught by female instructors, would give nursing care to
female patients, would not work with male physicians and would be exempted from late
and night shifts (Meleis & Hasan 1980, El-Sanabary 1993). Following these assurances
by an Arab Muslim consultant representing the World Health Organisation 1 , the MoH
was determined to promote nursing as a viable educational option for Saudi women.
However, only thirteen Saudi female nurses were reported as graduating in 1963 (Meleis
& Hasan 1980, Al-Osaimi 1994c, El-Sanabary 1993).
Gradually, more MoH institutes were opened in different parts of the Kingdom offering
a range of health specialties to choose from such as pharmacy, x-ray, laboratories,
anaesthesia, physiotherapy and nursing. Teaching was in Arabic and programmes were
two-year in duration with emphasis placed on basic nursing knowledge and skills.
Students were provided with free accommodation, uniforms, transportation and a
monthly allowance of £100. Completing 12 years of education, graduates were issued
with diploma certificates equivalent to that of a high school. They were appointed as
nurse aides at government hospitals or dispensaries with starting salary of £515 (Al-
Osaimi 1994c, El-Sanabary 1993).
By 1993, there were 18 Health Institutes for male students and 26 for females (Al-
Osaimi 1994c, MoH 1999). Three of these institutes were transformed into colleges
accepting students with 12 years of schooling (MoH 1999). The college programme is
1 Dr. Suad Hasan, the first Egyptian nurse with a PhD degree, was appointed by the World Health
Organisation as an consultant in charge of the planning and implementation of the nursing programmes
in Saudi Arabia. She was the first female who used radio programmes to promote nursing. Dr. Hasan
Nasief, the Minister of Health then, supported the project.
4
three years whereby the first is a foundation and the remaining two are allocated to the
selected speciality e.g. nursing or pharmacy. Graduates from this type of nursing
education obtain an associate degree and they are usually employed by MoH services.
With the growing opportunities for university-level education, Saudis perceived the
technical-type and diploma-level nursing education undertaken in colleges as a less
prestigious path for school students with poor educational prospects. This perception
may have further reduced students‟ enrolment to the MoH programmes. Indeed, the
number of male and female nursing graduates remained very small to meet the demands
of the MoH. This shortage was not resolved by the growing pool of school graduates or
the steady increase in the number of Allied Health colleges across the Kingdom. The
1999 MoH statistics showed that the total number of graduates from all MoH institutes
and colleges had reached 22,815. Of these, 7098 were female graduates of which 97%
were nurses, and 15,717 were male graduates of which only 27% were nurses (MoH
1999). The latest MoH statistics for the year 2006 showed that the number of graduates
of all specialities including nursing is 1335 of which 35% are women (MoH 2006).
However, these statistics do not specify the proportion or actual number of male and
female nursing graduates.
Towards professionalism
To improve the quality of nursing programmes, the MoH nursing curriculum has been
continuously revised and upgraded. Speciality one-year programmes such as midwifery
and paediatrics were initiated in 1988 for the diploma nursing graduates (Al-Osaimi
1994c). Similarly, major teaching hospitals started to offer development programmes
which integrate theoretical and practical knowledge in order to develop the clinical
competence of the Saudi nurses to nursing practice level expected of western staff nurses
(Miller-Rosser et al. 2006).
University nursing education
One of the first steps towards professionalizing nursing education was taken in 1975
when two university level programmes (Bachelor of Science in Nursing - BSN) were
5
launched under the Ministry of Higher Education both in Riyadh and Jeddah. Ten years
later, a third programme was established in the city of Damam, eastern province. While
the MoH diploma programme is service-oriented, the four-year BSN programme has a
focus on education. The MoH diploma is open for male and female students but the BSN
programme is limited to females only. The BSN programme is taught in English and
designed to cover comprehensive nursing theories and practical experiences in addition
to a number of university-required general education courses. Incentives for the BSN
students include free textbooks and uniforms, boarding facilities for those who need
them and a monthly allowance of £150.
To recruit new students, nursing colleges tend to take part in the annual career day
organised by the academic institutions. However, since some schools may not grant their
students approvals, only high school students from some public and private schools
might attend such function. For the purpose of announcement, academic-calendar dates
designated for processing application and running admission tests are usually advertised
in local newspapers. To retain the newly recruited nursing students, Saudi nurses in
senior positions might be invited to talk and share their experiences with junior students.
With the steady increase in the number of high school graduates and the limited college
capacity at baccalaureate level, medical, allied health and science colleges were forced
to maintain strict admission criteria (Al-Faisal 2002). Consequently, these scientific
majors were rejecting applicants who fail the Aptitudes Test or the Admission Tests. If
not accepted into their first choice of medicine or pharmacy, many students may choose
nursing and use the first year as a bridge to other speciality of interest. This carried with
it a potential to exclude students who might have an interest in nursing.
Sixteen years following the establishment of the university nursing programmes, there
were only 117 female BSN graduates from the three universities. Al-Osaimi (1994d)
attributed this small number to the prevailing negative images of nursing, the perceived
low-level nature of nursing work, the 5-year duration of the BSN programme and the
high turn-over rate among first year students. El-Sanabary (1993) argued that declaring
6
an occupation culturally appropriate by government authority is not enough to guarantee
acceptance by the public. To encourage female students to join a career in nursing, a
master‟s programme in nursing was established under King Saud University in 1986
(Al-Osaimi 1994d). In 1994, a joint-supervision PhD programme was initiated by King
Abdul-Aziz University in collaboration with some universities in the United Kingdom
(Abu-Zinadah 2006).
Female diploma students were granted the opportunity to apply for a paid study leave to
get a BSN degree. Not having a baccalaureate programme available for the male
students, male nursing graduates remain deprived of an equal opportunity to pursue a
higher education. Their only chance of pursuing degree education is through external
scholarships to neighbouring countries like Jordan or western countries like the United
Kingdom, United States or Australia. As such, the majority of Saudi male nurses are the
product of the 3-year nursing programmes (Tumulty 2001); this tended to limit their
academic opportunities and career progress. It was only in the academic year 2005 that
King Saud University launched the first baccalaureate programme for the Saudi male
students.
At their clinical placements, students are supervised by clinical instructors; however, the
student-instructor ratio has been low and possibly inadequate for training purposes.
Hospital nurses are expected to teach and supervise individual students assigned to their
patients. Due to nursing shortage and increased workload, hospital nurses may not have
the time or the interest to train students. Thus, nursing students tend to have limited
training opportunities and, subsequently, inadequate practical skills. These students may
find it very difficult to cope with the demands of the internship period.
Internship is a compulsory transitional period between the years of nursing education
and the years of nursing practice. It runs for 52 weeks for BSN students and 24 weeks
for diploma students. Interns work 12 or 8-hour shifts, day or night duties, in male or
female units. Their competency in terms of clinical skills and professional judgment is
7
monitored by the head nurse of the unit although attendance and personal behaviour are
issues for the university.
The development of formal nursing bodies
Since mid 1990, there has been a gradual and steady increase in the number of high
school students who were taking up nursing. For example, the number of registered
students at the nursing programme, King abdul-Aziz University in Jeddah used to
average 7 for the first 15 years of its establishment. By 1995, the average had increased
to 120 (Nagshabandi 2004a&b, pers. comm., 25 April). With such increase in Saudi
graduates (associate degree and baccalaureate), there was a need to form an
administration to monitor the nursing services, support nurses, regulate the work and
represent nursing at senior levels of services and government. A Central Nursing
Committee was established under the MoH in 1987. The committee was initially formed
and managed by male medical doctors then gradually started to extend membership to
nursing-specialists working at the government, other-government and private sectors. By
1990, regional nursing committees were formed to achieve decentralisation of decision
making (Al-Osaimi 1994b).
In 2002, a Scientific Nursing Board (SNB) was formed under the independent regulatory
authority of the Saudi Council for Health Specialities (SCFHS). The SNB main
functions include accrediting nursing education programmes, registering nurses and
providing licensure (MoH 1999). Toward the end of the same year (2002), a General
Directorate of Nursing with Regional Nursing Offices were established under the MoH
to replace the Central Nursing Committee. Nevertheless, to date, Saudi Arabia has no
formal nursing union, council or association to legally represent nurses and nursing
services and to monitor professional licensure, educational accreditation, clinical
practice and nursing research. Tumulty (2001), an American nursing consultant, who
was invited by the United States – Saudi Arabia Joint Economic Commission to evaluate
the nursing service at the MoH, described nursing in Saudi Arabia as a profession in its
infancy. She emphasised the need for Kingdom-wide nursing regulatory system and
subsequent membership in the International Council of Nurses.
8
Based on academic qualifications, there are three occupational classifications: 1) the
nurse aides typically nurses with high-school equivalent nursing-diploma; 2) the nurse
technician typically nurses with an associate degree following high school; and 3) the
nurse specialist, (nurses with a minimum BSN degree). In 2006, three more categories
were approved by the SNB to further differentiate among the various educational levels
(SCFHS 2006a). The approved classifications reflect a variation in the allocated
financial benefits and professional status.
The current nursing situation
Development in nursing education and efforts to professionalize nursing has made only
a small contribution to the number of students enrolled in nursing programmes
throughout the Kingdom. For example, over a period of 30 years, the number of nursing
graduates from King Abdul-Aziz University in Jeddah has not exceeded 550 female
nurses in total (Nagshabandi 2004a&b, pers. comm., 25 April). El-Sanabary (1993)
claimed that the introduction of university-level nursing programmes in the Gulf
countries did not increase the public demand for nursing education. With less than 5%
classified as 4-year BSN graduates (Abu-Zinadah 2006), the majority of the Saudi
workforce has been educated to diploma or associate degree levels and are considered
“technical nurses”. Hence, the discrepancy between nursing supply and demand
persisted.
During the national symposium aimed at planning for the year 2020 and as consultant
from the World Bank, Schieber (2002) presented the following figures as part of his
report on population dynamics and the resulting health transition. Between 2000 and
2020 the population of Saudi Arabia will continue to grow at an average annual rate of
2.8 percent resulting in a 75% larger population. The population under 15 years will
increase from 8 to 12 million. The population will begin to age and those over sixty
years will increase from 4% of the total population in 2000 to 7% by 2020 (Schieber
2002).
9
Schieber (2002) claimed that the next 20 years will pose a major challenge on the Saudi
economy. He advised health policy-makers to be prepared to deal with a situation of
additional economic resources to meet those demands. Based on his review, the number
of hospital beds will need to increase from 45,000 in 1998 to 87,000 in 2020 (93%). The
number of physicians will need to increase from 30,000 to 61,000 (103%) and the
number of nurses from 65,000 to 120,000 (85%).
As a Saudi chairperson of the SNB, Abu-Zinadah (2006) described the Saudi nursing
workforce as having 67% diploma holders (technical level) and 30% associate degree
holders (technical level). She also voiced a concern for having a Saudi nursing
workforce made of only 3% as BSN graduates (professional level). While representing
27% of the total nursing workforce, Saudi nurses constitute around 41.5% of the MoH
nursing workforce, 17.5% of the workforce at the other-government agencies and only
4% at the private sector (MoH 2006). She argued that despite increased enrolment since
2000, nursing colleges are losing 60% of their applicants annually due to limited
colleges‟ capacity. Moreover, Abu-Zinadah claimed that the Kingdom is losing 50% of
its nursing graduates annually due to social and professional factors.
Compared to a neighbouring Gulf country like Qatar where the nurse-population ratio is
1:181 2 , this ratio has reached 1:283 in Saudi Arabia (MoH 2006). Abu-Zinadah (2006)
argued that the estimated figure of 70,000 nurses, proposed by the MoH to meet the
needs of the country, is not accurate because it did not take into consideration the
existing nursing shortage. To resolve the shortage and to compete with Gulf and western
countries, Abu-Zinadah (2006) estimated the Kingdom‟s needs as ranging between
140,000 and 175,000 nurses. Bearing in mind that the annual number of nursing
graduates does not usually exceed 150 nurses from the three main universities and tends
to average around 500 nurses from the 25 MoH colleges, Abu-Zinadah (2006) has
estimated a minimum of 25 years to meet 30% of the national needs from the Saudi
nurses. Despite the ambitious vision of 2020 aimed at training and developing Saudi
2 The nurse-population ratio is reported as 1:120 in Finland, Holland, and Sweden and as 1:350 in Bahrain
and United Arab Emirates (Al-Humedhi 2000).
10
human resources to replace the non-Saudis, nursing will remain dependent on non-
Saudi nurses well after the target date. The 2006 statistics by the MoH reflect that the
non-Saudi represents 73% of the total nursing workforce (MoH 2006). In contrast, Saudi
nurses continue to be a minority group in a non-Saudi dominant occupation.
Nursing in Islam
Recruitment and retention challenges and the associated nursing shortage seem to exist
and operate despite the glorious image and respected status of the early Muslim nurses
who volunteered to provide nursing service during the time of Prophet Mohammed and
with his approval (570 - 632 AD). During the early Islamic era, fourteen hundred years
ago, there was a need to defend the newly formed Muslim community. Later on, there
was a need to expand and to spread Islam to other dominant and competing civilisations
such as the Romans and the Persians. Unlike Arab women of pre-Islamic era whose role
was limited to cheering and encouraging men to fight, Muslim women volunteered as
nurses in the battle fields. They provided first aid, cared for the wounded, gave water to
the thirsty, transferred the martyrs and handed arrows and swords to the fighters (Hasan
1982, Sultan 1990). They were known as (Al-Asiyat) referring to their role in alleviating
the pain and easing the suffering (Mahir 1970). Their participation gave rise to nursing
as a religious duty which later developed into a more organised social health service. In
recognition, Prophet Mohammed granted them the same honour and status as the male
fighters and gave them an equal share of the material gain collected at the end of the war
rounds (Sultan 1990, Al-Osaimi 1994a). He even encouraged his wives and daughters to
take part in such a service.
However, nursing service was not limited to war times. It has been documented that
Rufidah Al-Aslamiah, one of the early Muslim nurses, had a tent within the Prophet's
mosque where she was nursing those who need the service outside the battle field.
Prophet Mohammed used to regularly visit the patients in Rufidah's tent (Mahir 1970,
Sultan 1990). Just like western societies, nursing service in Muslim societies was
initiated for religious causes (Hasan 1982, Sultan 1990). It was encouraged for its
humane motives and was honoured for its moral and spiritual values. However, over the
11
past 14 centuries, nursing image has transformed in most Muslim countries and
particularly in the Gulf Countries into a low-status image.
To help understand the nature of the shortage of Saudi nurses, the section below presents
the cultural, social and economical aspects impacting on the development of nursing as a
profession and its uptake as an occupational choice.
The country
Saudi Arabia is a country unified as a Kingdom in 1932. It has the custody of the
Muslims‟ two holy mosques in Makkah and Madinah and plays an important role in the
politics of the Middle East. The latest population count was around 22,600,000 of which
73% are Saudi citizens (MoP 2005a 3 ). The majority of the Saudi population descend
from Arab origin with some Afro-Asian minority.
Absolute monarchy dominates the Saudi system with the King and the royal family
controlling political power. The Kingdom's national constitution is the Holy Quraan
(words of God as revealed to Prophet Mohammad) and Shariah (Islamic laws) which
serves as the law of the land. Sunnah is a model of life presented by Prophet Mohammad
reflecting his public actions, private behaviour, what he advocated, allowed, or tolerated.
Combined, Quran and Sunnah, provide the foundation for Shariah. The Kingdom has
some degree of cultural homogeneity reflected in a common Arabic language and
adherence to Sunni School of Islam 4 .
The Saudi culture
In Saudi Arabia, Islam is not just a religious ideology; rather, it is a social system
embracing detailed prescriptions regarding every aspect of people's life. Saudis,
3 National/local statistics used throughout this chapter are obtained from the relevant ministry e.g. Central
Department of Statistics-Ministry of Planning, the Ministry of Economy, or the Ministry of Health. The
most recent statistics available at the respective web-site were used.
4 The word Sunni comes from the word Sunnah which means the words and actions or example of the
Prophet of Islam Muhammad. It represents a branch of Muslims who follow Sunnah.
12
however, may vary in their understanding, interpretation and practice of Islam. It has
been observed that the intensity with which men and women of the social subgroups
adhere to the traditional regulatory system and comply with the overall inherited
religious understanding varies enormously. A western author, Parssinen (1980, p. 166)
argued that the socio-cultural diversity which characterises the Saudi population
includes: urban and nomadic, tribal and non-tribal, city-dwellers and villagers, literate
and illiterate, open-minded and conservative.
The veiling of women and gender segregation are cultural mechanisms to ensure
modesty and to keep women‟s behaviour under low profile (Parssinen 1980). In practice,
some families may adopt more conservative standards in defining the extent of veiling
and segregation. Saudis like many Arabs and Muslims believe that the conduct of
women represents a serious source of potential jeopardy to the honour and reputation of
the family (Dodd 1973). Possibly as a way to protect these social values, certain laws
and regulations have the effect of restricting women‟s roles and mobility outside the
household boundary.
Huge oil revenues have brought an influx of wealth to the Kingdom. However, in
addition to gained benefits, affluence has created problems. On one hand, Saudis were
determined to preserve their cultural and religious heritage and on the other, they aimed
at realising all advantages wealth might bring. As a Saudi born and brought up in the
country, I perceive that the dichotomy between tribal and non-tribal groups and between
conservatives and modernizers has always been at the heart of the country's social,
economical and political affairs. The expansion of educational and economical
opportunities may have succeeded to bring these groups into a common ground
concerning highly contentious issues such as women‟s right for education. On other
issues, education and economy seem to have further polarized these groups. For
example, there has been a conflict in the views of these groups regarding women‟s
participation in the labour market particularly in relation to women‟s work within
mixed-gendered settings (refer to Al-Bar 1984, chapter 2, p. 33).
13
Social context
Saudi Arabia has a patriarchal social system which maintains power of men over women
and respect for age and seniority (Long 2003). The traditional extended family form the
basic unit of the society with prevailing gendered-roles whereby men are providers and
protectors and women are house-wives. Members of the extended families live in close
proximity whenever possible; if not, they socialise on a regular basis. Each family
member shares a sense of collective obligation and responsibility for the welfare of the
family. Long (2003) argued that it is to the extended family not the government that a
person first goes to seek help and support. The family is the most important social
institution; for Saudis, family means identity and status. Family members share a sense
of corporate identity and each is expected to live up to socially prescribed ideals of
honour, pride and dignity. Families may form alliances with other families who share
common interests and life-styles.
Urbanisation
During the early stages of the Kingdom's development as a social and political system
(1901 - 1930), two thirds of the population were nomads. The non-nomadic segments of
the population lived in small towns and villages scattered across the Kingdom. During
the 1940s about ten urban areas existed; most of them were located in the western part of
the country with Makkah, Hijaz region, as the largest urban centre of 80,000 inhabitants
(Al-Khalifah 1995).
The emergence of Saudi Arabia as a political system coupled with the discovery of oil in
the 1930s marked the beginning of a major socio-economic change. The government
encouraged the nomadic population to settle down in newly established industrial and
strategic towns, villages and hamlets. These towns and villages grew as a result of
increased internal (from rural areas) and external (from Arab and Asian countries)
migrants seeking job opportunities. The increased rate of urbanisation has transformed
Saudi Arabia from one of the least urbanised countries in the 1950s to a highly urbanised
nation in 1990 (Frisbie 1995). In 1992, 77% of the total population were living in
settlements with more than 2400 inhabitants (Frisbie 1995). By 1995, about 45% of the
14
urban population were living in four cities which share up to 85% of the country's
industrial establishments and contribute up to three-quarter of the total national
employment (Al-Khalifah 1995, Long 2005).
Social classification
Individuals or families of tribal backgrounds, who moved to urban centres, tended to be
more inclined to keep close contact with their tribes. These tribal ties limited their
interaction even with other tribal families within the urban community (Frisbie 1995).
As such, their cultural values and social patterns of living remained predominantly
unchanged. Until twenty years ago, most tribal families were in favour of large family
size, early marriage age, polygamy, marriage within the tribe, minimal education
particularly for women and enforcing women‟s role at home (Long 2003). However, it
has been suggested that with education and exposure to different social norms within
urban cities, successive generations have gradually merged with the new communities
and have slowly lost contact with the original tribe (Long 2005). Nevertheless, tribes and
tribal affiliation formed a major status category based on blood-line (Al-Yassini 1982).
To date, the notion of tribalism in urban areas (tribal versus non-tribal status) is still
observed (Long 2005).
Traditionally, most urban people from western and eastern provinces were working in
trade businesses. Sea trade through the main ports of the Arabian Peninsula and the
trans-Arabian caravan trade 5 were the source of wealth for the people living in these
areas (Long 2005). In contrast to the tribal status, merchants from western and eastern
provinces formed an elite status category based on wealth. By contrast, the Shiaa
minority 6 (10%) continued to be located toward the low end of the social ladder.
However gradual, in contemporary Saudi Arabia, new status categories based on
5 A type of ancient caravan trade which used to run between Yemen in the south and Turkey in the north
and between the Far East and Africa across Hijaz region.
6 A branch of Muslims comprising sects believing in Ali (first cousin of the Prophet ) and 12 other Imams
as the only rightful successors of Prophet Muhammad.
15
education and subsequent economic advantages may have began to undermine the
highly valued tribal affiliations, religious orientation and possession of wealth.
The growing economy and political openness have brought a massive influx of an
international workforce with diverse social and cultural backgrounds. An emerging
foreign (non-Saudi) social group made of professionals, technical experts, students and a
vast corps of workers was formed within the traditional societies of urban cities (Looney
1982). Despite efforts to insulate the Saudi population from the influence of the
increasing foreign community, the inevitable interaction at school, work and
neighbourhood introduced a gradual and visible social change. Cross-marriages among
the different social subgroups produced a new generation of mixed blood Saudis with
modified socio-cultural values, a great degree of tolerance and more flexible attitude
toward the inherited traditions.
In addition to recruiting non-Saudi professionals like doctors and nurses, visas were
issued to non-professional labourers needed to do the unskilled manual work. These
labourers included maids, drivers and guards. Perceived as a sign of wealth and social
prestige, most Saudi families imported labourers from Asia, India and other Arab
countries to do the domestic chores previously expected of the different members of the
family. The Gulf News 7 reported that of the seven million foreign labour-force working
in the Kingdom, two million were domestic helpers (5 April 2007). Even people in rural
areas were gradually getting used to foreign labourers doing the farming and herding
work for them.
Since women are not permitted to drive in Saudi Arabia, most families were increasingly
applying for visas to recruit male drivers from Asian countries. The selection and
preference of non-Arab and non-Saudi family drivers might be attributed to the great
degree of freedom experienced, particularly by women, in the presence of these drivers.
Freedom, in this context, refers to being able to take the veil off while in the car and to
carry out a private conversation without worrying about being understood by the driver.
7 A popular newspaper published in English and cover news from all over the Gulf Countries.
16
Parssinen (1980, p. 147) reported that Saudi men are considered “less appropriate
candidates for such employment”.
With rapid socio-economic development, gaps appeared among various income groups.
Investigating determinants of household residential location, Jenaideb (1993) argued that
there is interdependence between the income status and migration status. His findings
indicated that the average income for Saudi households vary according to area of origin
with people originally from the southern region being more common in the low income
group. Examining urban structure and determinants of residential location, Telmesani
(1995) reported that household income level varied significantly across the capital
Riyadh. His findings revealed that low income group represents people with monthly
income of £470. Low-middle income group include people with monthly income of
£1000. Upper-middle income group represent those with monthly income of £2200. The
high income group include people with monthly income of £3600 and more. Telmesani
(1995) argued that his findings were applicable to Jeddah due to close resemblance of
the two cities. Ten years later, a newspaper article argued that the expanding low income
group will have to face major challenges trying to cope with the increasing cost of living
(Al-Hayat Newspaper 8 , 28 May 2005).
The Saudi economy
The most powerful agent of change for the Saudi economy was the discovery of huge
reserves of oil in 1930. Saudi Arabia has the largest (25%) reserves of petroleum in the
world; hence, it plays a leading role in the Organisation of Petroleum Exporting
Countries (OPEC). Development projects relied heavily on capital generated by
petroleum industry and the country employed foreign labourers to meet the need of its
economic growth. In 1980, the foreign workforce from Arab and Asian countries was
more than one million; a substantial number for a nation whose total population was
around nine million (Looney 1982, Frisbie 1995).
8 Al-Hayat is a popular Arabic newspaper printed in London and distributed world-wide.
17
One of the most prominent initiatives of the Saudi government has been a series of five-
year development plans. These Development Plans began in 1970 aiming at improving
the standard of living and providing for greater equality in the distribution of wealth
(Frisbie 1995). To support the government's economy, lessen the Kingdom‟s
dependence on oil and increase employment opportunities for the growing population,
the country encouraged the economic growth of the private sector and worked on
attracting foreign investment.
Education
Ever since the Kingdom‟s first development plan in 1970, education has been given the
highest priority. Illiteracy rate for the age group ten years and above has gradually
declined from 64% in 1974 to 20% in 2000 (MoEP 2003, p. 57). Students have strictly
gender-segregated educational facilities from the age of seven years. Education at all
levels is free to Saudi citizens. In contrast, the role of the private sector in the provision
of education services has greatly expanded over the past fifteen years. At present, 40%
of the Saudi population is under 15-year of age (MoP 2005a) placing extra demands on
educational services and future labour force plans. Hence, the seventh development plan
(2000 - 2004) suggests that the private sector will account for 10% of total enrolment in
the general education system (MoEP 2003).
Formal public education for Saudi men and women was launched in 1952 and 1959
respectively. A major challenge to women‟s education was a prevailing tradition which
expected women to stay at home; such tradition was strongly associated with family
reputation and honour (Al-Suwaigh 1989). To overcome this challenge, the Saudi
government delegated the responsibility of the sensitive assignment of women‟s
education to a group of religious scholars who formed what was known as the
Administration of Girls‟ Education 9 . Nevertheless, scattered opposition occurred in
some conservative areas of the country. Parssinen (1980, p. 159) reported that "a public
demonstration erupted and government troops were dispatched to restore order".
9 This administration was dissolved in 24/03/2002 following a royal decree number A/2. Women‟s
education is now managed by the Ministry of Education.
18
Women‟s education was perceived as a social revolution encouraging women to leave
their homes to go to school on daily basis; a change which might challenge the
prevailing tradition. Indeed, educated women tended to postpone marriage to a later age.
According to a 2000 demographic survey, 65% of the Saudi females in the age group
20-24 years were not married (MoEP 2003).
Resistance to the concept of modern education for women soon faded and education
programmes for women expanded across the Kingdom. By 1976, almost half of Saudi
women between the ages of six and twelve were attending schools (Parssinen 1980).
Despite gender inequality in the allocation of educational resources, with a smaller
percentage allocated to women' education, gender ratio in enrolment at higher education
institutions has recently shifted in favour of women (1 male to 1.4 females). Statistics
indicate that 45% of all university graduates are women (MoP 2006 in MoH 2006).
Unemployment
In spite of the significant increase in educational facilities and school enrolment, the
Saudi human resources continued to lag behind in terms of productive capabilities
needed to fulfil the requirements of a variety of jobs demanded by the labour market.
According to the 2003 human development report, about two thirds of all higher
education students are in art, humanities and Islamic studies. These fields do not match
the requirement of the labour market (MoEP 2003 p. 11).
Published unemployment rates vary considerably based on the different sources. For
example, the unemployment rate published by the Saudi Ministry of Economy and
Ministry of Planning ranged between 10 and 13% (MoEP 2003, MoP 2005b). The two
ministries highlighted that 46% of the unemployed are in the age group of 20–25 years.
In contrast, an executive summary published through the Saudi-American Forum stated
that the unemployment rates for Saudi males and females between 20-24 years were
around 27% and 33% respectively (Taecker 2003). These rates are high particularly
when the percentage of the total workforce that is made up of non-Saudi workers has
increased from 6% in 1975 to an average of 50% between 2001 and 2004 (MoL 2005).
19
In Saudi Arabia, unemployment might be attributed to the mismatch between
qualifications or training of job seekers (educational output) and the requirements of the
labour market particularly in the private sector. Unemployment is further aggravated
with differences between the conditions tied to the jobs on offer (supply price) and the
conditions acceptable to job applicants (demand price). The types of vacant jobs
available and the terms of employment were found to fall below the expectations of
Saudi job seekers (MoP 2005b). For example, Saudis may be reluctant to work in certain
jobs that require manual work and serving others. Nevertheless, economic inequalities
among Saudis, which have been exacerbated by urbanisation and rapid social
developments, has perhaps contributed to an increased uptake by low income groups of
less socially favoured career opportunities such as nursing. This may have further
reinforced the reputation of nursing as an occupation for the socially and educationally
disadvantaged groups (Meleis & Hasan 1980, El-Sanabary 2003).
The Saudisation Policy
Saudisation is a process aimed at reducing dependence on foreign (non-Saudi) labour in
order to create more jobs for Saudi nationals. Saudisation implies the creation of an
environment conducive to training and development where Saudi individuals can
achieve their full potential and eventually gain employment in the most appropriate
positions demanded by the labour market (MoL 2007). El-Sanabary (1993) argued that
Saudisation is not a matter of national pride; rather, it has major practical implications.
Due to failure of national manpower to meet the increased demand for labour, there was
an increased dependency on expatriate labour. It was estimated that in 2003 there was
1.5 non-Saudi workers to every Saudi worker (MoP 2005b). To enhance participation
and improve employment opportunities for the Saudis, the Saudisation Policy was
launched with the commencement of the fourth national development plan (1985 -
1989). Consequently, the total participation of Saudis in the workforce had increased to
37% between 2000 and 2004; the percentage of Saudi women of the total workforce has
just reached 10% (MoP 2005b). However, budget constraints have left government
agencies unable to sustain the same jobs and benefits. With the declining demands from
20
the government sector (less than 1% annually), the private sector and to some extent the
other-government sector will be the main sources for employment.
Thus, in partnership, government and private sectors have taken some initiatives to
review existing educational components and methods (MoP 2005b). Emphasis has been
placed on developing the analytical skills and innovative capabilities of the Saudi
graduates through on-the-job-training, continuing education and scholarship
opportunities. Moreover, to enhance Saudisation within the private sector, authorities are
in the process of establishing a minimum wage, limiting working hours to eight per day
and creating social insurance or pension plans similar to those available at the
government sector (MoEP 2003). However, according to Al-Hayat Newspaper (28 May
2005), a recent study showed that the private sector generally provides low-income jobs
for the Saudis. These jobs have a monthly salary of £360 which, according to the
newspaper, tends to keep employees close to the poverty line. Examples of these jobs
include security officers, receptionists, cashiers, salesmen, porters, drivers and switch-
board operators.
To further increase the challenge posed on the private sector, the seventh development
plan (2000 - 2004) indicated that only 329, 000 new jobs will be created for the expected
817, 000 Saudis entering the labour market (MoL 2004). This indicates a deficit of
488,000 jobs that has to be resolved through replacing the non-Saudis working in the
private sector with Saudis.
The role of the private sector
The Kingdom has a long-standing policy of providing free and accessible health care to
all citizens. The responsibility for this provision lies primarily with the MoH. As such,
public health expenditure has increased to reach 6.4% of GDP compared to 3.2% for
middle income developing countries (MoEP 2003). With socio-demographic changes
and subsequent increased demand for healthcare services, the role of the private sector in
the provision of health has expanded over the past two decades. Between 1994 and
1998, the number of patients visiting the private health facilities increased by 30%; three
21
quarters were Saudi citizens (MoEP 2003). By 2006, the private healthcare services
represented approximately 23% of the total Kingdom-wide (MoH 2006).
Nevertheless, being profit based, the private sector tends to be in favour of cheap non-
Saudi labour. Applying for jobs at the private healthcare services, Saudi nurses may face
issues related to low pay, long hours and limited developmental or promotional
opportunities. These issues may have caused Saudi nurses to find the terms of
employment at the private hospitals as falling below their expectations (MoP 2005b)
which in turn may have contributed to maintaining Saudisation of the nursing workforce
at the private sector to a minimal. The MoH Annual Statistics Book shows that Saudi
nurses make almost 4% of the total nursing workforce at the private sector (MoH 2006).
This suggests that the private sector remains highly unattractive to Saudi job-seekers in
general.
In contrast, nursing education has always been the responsibility of the Saudi
government and, to some level, the other-government sector; however, over the past ten
years the private sector started to invest in this field. For example, in addition to the two
main government programmes, Jeddah (western province) has seven private nursing
programmes (SCFHS 2006b). Generally, the private healthcare sector is faced with two
types of pressure. An internal pressure to enhance Saudisation rate despite the
inadequate supply of Saudi nurses and an external pressure to recruit qualified expatriate
nurses despite the international shortage. This pressure forced most private hospitals to
individually or collectively consider establishing their own nursing education
programmes. At present, the Kingdom has 60 private health institutes and two private
colleges which offer diploma and BSN nursing programmes (Abu-Zinadah 2006).
The fees for the private diploma and baccalaureate programmes tend to range between
£1,400 and £8000 annually. Limited scholarships (full or partial scholarships) are
awarded to outstanding students. Most private programmes have links with the Human
Resource Development Fund which is committed to promoting Saudisation and
enhancing the gradual replacement of foreign manpower with a Saudi workforce (HRDF
22
2007). The purpose of such government-private fund is to help young Saudis identify
opportunities for education and training which lead to secured employment.
Conclusion
Saudi Arabia has been dependent on a non-Saudi female-majority nursing workforce.
However, as an outcome to the Gulf War in 1991 and the consequences of September
11, 2001, the country has suffered from a severe nursing shortage caused by difficulties
in recruiting qualified non-Saudi nurses and an inadequate supply of Saudi nurses.
Despite efforts to professionalize nursing, the number of Saudi nurses has remained
small and predominantly female. It has been estimated that a minimum of 25 years is
required to build up a national workforce to meet 30% of the nursing needs in Saudi
Arabia. This chapter has provided an overview of the social, cultural and economic
contexts through which the shortage of Saudi nurses might be understood. Emphasis has
been placed on the shift in nursing image from one attaining great respect during
Prophet Mohammed‟s time to one that is socially less favourable.
Urbanisation and education have been highlighted as indicators of the rapid socio-
economic developments experienced by the country. Women‟s education which was
once perceived as a social revolution challenging the prevailing tradition has gradually
transformed in favour of women. However, due to a miss-match between outcomes of
the education systems and the requirements of the labour market, unemployment among
Saudi graduates from favoured academic specialities has been steadily rising.
Compounded by economic pressure, the escalating unemployment over the past ten
years may have channelled many high school graduates to the socially less prestigious
and un-Saudised career opportunities such as nursing. The challenges facing Saudisation
as a national policy launched to replace non-Saudi workforce with qualified Saudis has
been discussed with special emphasis on the role of private sector. With more than 70%
non-Saudi nursing workforce, the government, other-government and private healthcare
sectors have a long way to achieve Saudisation of the nursing workforce.
23
Chapter Two
Literature Review
Introduction
This chapter provides an overview of the relevant literature. The reviewed literature is
divided into Saudi and western; relevant studies from other Arab and Muslim countries
are used to compare and contrast where applicable and to enrich the overall review.
Areas of similarities and differences are highlighted. The chapter begins by reviewing
the limited Saudi literature concerned with recruitment and retention of Saudi nurses;
studies on image, status and Saudisation of nursing are examined. In contrast, western
literature concerned with the recruitment and retention of nurses are numerous and
diverse. Attention is drawn to areas which have attracted interest and to those which
remain relatively unexplored. A framework of six concepts is proposed to focus the area
of inquiry, refine my research question and guide the research process and
methodological design. Combined, the reviewed literature and the social, cultural and
economic contexts presented in chapter one provide the base for the development of this
research project.
The Saudi literature
As discussed in chapter one, the nursing shortage in Saudi Arabia is linked to an
increased demand for international and national nurses and to an inadequate supply of
both. Since the supply part of this equation is my area of interest, the focus of the
literature review is on what might influence recruitment and retention of nurses. There
appears to be a consensus within the Saudi literature in relation to the importance of
image and status as factors influencing the choice of nursing as an occupation and the
decision to continue working as nurses.
24
Images of nursing
For the purpose of this thesis, the following definition of “images of nursing” is used as
a term of reference: “Images of nursing are the sum of beliefs, ideas and impressions
that people have of nurses and nursing” (Kalisch & Kalisch 1987, p. 2). Despite the
positive images attached to Muslim nurses during the early Islamic era, modern history
has documented a negative perception of nursing surfacing since the nineteenth century.
This shift in image might be attributed to the choice of Nubian female slaves and
Egyptian orphans to learn midwifery and nursing skills in 1832 (Hasan 1982, Sultan
1990). In contemporary history, prevailing negative images and perceived low status of
nursing have contributed to the nursing shortage in most Arab and Muslim countries
(Meleis & Hasan 1980, Alawi & Mujahid 1982, Zuraikat & McClosky 1986, Jackson &
Gary 1991, AbuGharbieh & Suliman 1992, Mansour 1992, El-Sanabary 1993, Al-
Kandari & Ajao 1998, Okasha & Ziady 2001, Boyle & Salman 2003, Shukri 2005) and
(Abaan 2000, Akhter et al. 2003, Amarsi 2003, Sarfati 2003, Karaoz 2004) respectively.
These Arab and Muslim authors have drawn similar conclusions in relation to nursing.
Negative images of nursing continue to persist. Nursing is perceived as an unskilled, low
paid women‟s job and is often ranked lower than other healthcare and non-healthcare
professions.
In a small scale survey, Al-Kandari and Ajao (1998) examined perceptions associated
with low enrolment to nursing programmes in Kuwait. Their results suggested that
recruitment and retention were guided by beliefs that nursing is a low status and non-
respected profession. Barriers included: images of nursing, nursing as a powerless
profession and the difficult working conditions. The perception of nursing work as being
similar to that of maids‟ was attributed to the mass employment of Asian workers as
domestic maids and as nurses. This was consistent with Meleis‟s argument (1979) that
nursing in Kuwait is viewed with suspicion; only the educationally and economically
disadvantaged women will consider it as a career choice. For similar social and work-
related reasons, Okasha and Ziady (2001) and El-Haddad (2006) reported a negative
public attitude toward nursing contributing to the limited number of Qatari and Emirati
nurses respectively. Sharing the same socio-cultural beliefs and coming from the same
25
geographical area (Arabian Gulf), I would argue that Saudi people have similar
perceptions of nursing. El-Sanabary (1993) suggested that the lack of interest in nursing
among Saudi nationals is linked to the prevailing stereotypical images of nurses as
subservient uneducated women.
Identifying image, education and practice as the main factors affecting the development
of nursing as a profession in some Arab countries, Shukri (2005) reported that in
Bahrain and Jordan there existed more positive images of nursing. The questionnaire-
based study by Shukri also reported that, despite recent improvements, nursing in
Algeria, Egypt, Oman, Palestine, Qatar, Saudi Arabia and Syria continued to lack the
desired appeal and prestige (Shukri 2005). Gender-mixing and the long working hours
have been identified as important issues influencing the social aspect of the nursing
image (Meleis & Hasan 1980, Alawi & Mujahid 1982, Jackson & Gary 1991, Mansour
1992, El-Sanabary 1993, Hamdi & Al-Hyder 1995, Al-Johari 2001). Similarly, the
perceived low status of nursing was frequently cited as influencing the professional
aspect (Meleis & Hasan 1980, Jackson & Gary 1991, Mansour 1992, El-Sanabary 2003).
Highlighting these issues, Alawi and Mujahid (1982) argued that most Saudi families do
not consider nursing as an honourable occupational choice for their own children. This is
consistent with what was documented in the World Health Organisation report on
Women as Healthcare Providers:
“The public image of the nurse appears to be negative in countries where
strong cultural traditions severely restrict the participation of women in
paid occupations outside the home. As a result, nursing functions in these
countries are performed by women of the lowest social class” (Pizurki et
al. 1987, p. 65)
Status of nursing
In most Arab and Muslim countries, nursing has been perceived as menial and
subservient type of work (Meleis & Hasan 1980, AbuGharbieh & Suliman 1992, El-
Sanabary 1993, Al-Kandari 1998, Okasha & Ziady 2001, Amarsi 2003, Akhter et al.
26
2003). As two pioneering nursing consultants representing the Arab and Muslim worlds,
Meleis and Hasan (1980) reviewed the history of nursing education in the Gulf
Countries and discussed forces that have contributed to the nursing shortage in the
region. These forces include: status of women, image and status of nursing, and control
of nursing. The authors suggested that nursing in the Middle East was generally
considered as menial labour for those who have no hope of doing work that is more
socially acceptable. Marrone (1999) and El-Haddad (2006) attributed the negative
perceptions to the low status accorded to nursing in Saudi Arabia and United Arab
Emirates respectively. Exploring the country‟s dependency on expatriate nurses,
Marrone (1999, p. 9) stated that “despite its long and respected history in post-Islamic
times, nursing in modern Saudi Arabia is not a well-respected profession, particularly
because of the intimate nature of some of the physical care needs of patients”.
In Saudi Arabia, a survey by the Central Nursing Committee (1991) found that the
majority of MoH hospitals did not have: a nursing organisational structure, a written
nursing philosophy, job descriptions for nurses, written clinical nursing procedures, a
nursing education department and a library. By and large, nurses were assigned to non-
nursing jobs and hospitals in general were not involved in any nursing research (Al-
Osaimi 1994b). Professionalism and its underlying set of characteristics was ranked
fourth out of the five factors influencing nurse-students' choice of nursing (Al-Motairy
1998). Most of the students involved in this study were in doubt regarding nursing
identity and status; they believed that nursing lacks professional standards, legislations
and leadership.
Historically, in Saudi (Jackson & Gary 1991, Mansour 1992, El-Sanabary 2003) and
western societies (Hallam 1998, Darbyshire 2000) nurses have been viewed as assistants
to medical doctors and their work was perceived as extension of the physician‟ work.
Compared to the university-level medical programmes, nursing was initially established
as a technical apprenticeship rendering it less favourable particularly among middle
class families who tend to prefer university education for their children. Seventy percent
of the Saudi female high-school students, involved in the study by Hamdi and Al-Hyder
27
(1995), were in favour of a university level education rather than a diploma degree in
nursing. El-Sanabary (2003) argued that in Saudi Arabia, like in many other Muslim
countries, vocational education is unpopular.
“Its stigma and repute as the dump basin for those who cannot succeed in
academic secondary schools has made it virtually out of bounds for middle
class girls” (El-Sanabary 2003, p. 72).
This perception might explain why nursing has been viewed as a less prestigious career
option for most Saudis. Unlike the highly educated medical doctors, nurses are viewed
as under-educated and unskilled hospital staff who carry out orders and perform basic
work. From high school and university sample groups, Jackson and Gary (1991)
reported that nursing was not viewed as an autonomous profession; rather, it was more
of an extension of medicine. Similarly, more than half of Mansour‟s sample (1992)
believed nurses cannot make critical decisions and that they mainly carry out doctors‟
orders. El-Sanabary (1993, 2003) suggested that despite sharing the same working
conditions, medicine has not been stigmatised like nursing. On the contrary, it enjoys a
prestigious status which makes it the most favoured occupational option for Arab and
Muslim women.
Jackson and Gary (1991) found that male and female non-nursing students have rated
teaching, military, pharmacy, engineering and business higher than nursing. Medicine
was intentionally excluded from the list of career options used in the study. Similarly,
female students from the high school programmes and the diploma nursing programmes
have ranked nursing fourth following teaching, medicine and social work (Hamdi &
Hyder 1995). Al-Johari (2001) also reported that out of nine career options, school and
university students rated nursing last. These results were consistent with the claims made
by Meleis and Hasan (1980).
In a large-scale questionnaire-based national study, Hamdi and Al-Hyder (1995) targeted
female high school students and diploma nursing students from the three main cities of
28
Jeddah, Riyadh and Damam. Results showed that female students from both groups have
agreed that nursing is a humane service. This belief, however, did not positively
influence the uptake of nursing. Families of high school students disapproved of the
choice of nursing as an occupation for their daughters. The students themselves
perceived night shifts and weekend duties unfavourably. Students from both groups
agreed that nurses are not similar to domestic maids. The majority of the diploma
nursing students did not agree that working as a nurse will affect their reputation. On the
contrary, they agreed that Saudi nurses should replace the expatriates.
With an interest in factors influencing the choice of nursing, Al-Motairy (1998)
conducted a questionnaires-based study involving female nursing students enrolled in
nine BSN and Diploma nursing programmes across the Kingdom. Results suggested that
the image of nursing as a service which provides opportunities to help people was most
influential. However, the majority of students perceived other professions as more
important to society than nursing. By contrast, Al-Johari (2001) conducted a survey to
identify factors influencing the attitude towards nursing. A mixed sample including male
and female, school and university, nursing and non-nursing groups was selected. Some
female high-school students showed interest in nursing; however, this interest was
associated with disapproval from their families. The disapproval was linked to social and
work-related factors.
Saudisation
Statistics of the Seventh Development Plan showed an increase in total manpower from
7.23 million in 1999 to about 8.27 million in 2003. This resulted in more than one
million new job opportunities during the period, 56.4% of which filled by national
manpower. The rate of female participation is estimated at only 10.25%, compared to
63.64% for men. The limited economic activity of women is largely due to work
opportunities available to them being limited (MoP 2005b).
In her keynote speech at the 5 th
Economic Forum held in Jeddah 2004, Olayan, CEO of
Olayan Financing Company, argued that a growing unemployment rate and the need to
29
create job opportunities for young Saudis are major challenges facing Saudi Arabia.
Olayan (2004) claimed that the 3.5 million foreign labourers working in the Kingdom
are sending around £1,000 Billion annually out of the Saudi economy
10 . For Saudisation purposes, she urged the government and private sectors to work in
partnership to define the required academic specialisations and practical skills needed to
bring the taught curriculum in line with real demands of the labour market.
However, the implementation and subsequent outcome of the Saudisation Policy seem to
vary considerably depending on service sectors. For example, in the city of Jeddah, 80%
of the female staff who work at the segregated school system are Saudis with teachers
representing 72% (Zazoe 2004). In contrast, despite the increased number of nursing
colleges and institutes (government and private), the number of nursing graduates (the
supply) continues to be inadequate for the growing national demand of the country
(Nagshabandi 2004a&b, pers. comm., 25 April, MoH 2006). Abdul-Qader (2003) called
for collaborative efforts to encourage more Saudis to join the healthcare sector which
has 38% of its total workforce as Saudi nationals. In case of nursing, Saudi nurses form
only 27% of the total nursing workforce under the three sectors (MoH 2006).
Saudisation of nursing
In Saudi Arabia, recruitment and retention of nurses appear to be faced with challenges;
it has been reported that the majority of young women do not view nursing as socially-
appropriate career choice (Meleis & Hasan 1980, El-Sanabary 1993, Hamdi & Al-Hyder
1995). Moreover, families tend to disapprove of the choice of nursing as a future career
for their children (Alawi & Mujahid 1982, Jackson & Gary 1991, El-Sanabary 1993,
Hamdi & Al-Hyder 1995, Al-Johari 2001). Saudi male nurses, in contrast, apply for non-
nursing administrative jobs because they cannot cope with the prevailing nursing
stereotypes (Al-Rabiah 1994). Reviewing unpublished MoH-based surveys, Al-Rabiah
(1994) reported that half the working Saudi male nurses request a transfer to
10
The Ministry of Economy and Planning has estimated that between 1975 and 2003 a total of £14 billion
was sent out of the Saudi economy by the foreign labour force (Ministry of Labour 2005).
30
administrative posts outside nursing service. The lack of interest in nursing and the high
turnover were attributed to the negative prevalent images of nursing and the perceived
low status of nurses.
Aboul-Enein (2002) argued that the nursing shortage created during the first Gulf War of
1991 caused policy makers to seriously consider Saudisation. Indeed, nursing being one
of the few services staffed by 70% non-Saudi nationals had severely suffered from the
departure of its nurses particularly those from western countries. Al-Mahmoud (1999)
examined Saudisation of the nursing workforce at the MoH hospitals (government
sector) and compared the financial rewards received by Saudi nurses to those received
by western nurses. The author reported that Saudi nurses working in the MoH receive
25-50% lower salary compared to that given to western nurses. Compared to western
nurses who receive return tickets to their country of origin, free accommodation, free
transportation, free meal tickets, free uniforms and free medical treatment, the Saudis
receive only a small transportation allowance. When promoted to managerial posts, only
western nurses are entitled to a management allowance and other incentives associated
with the post (Al-Mahmoud 1999).
Al-Mahmoud (1999) also explored Saudisation within other-government sectors. Al-
Mahmoud (1999) argued that the medical services at ARAMCO, the Arabian American
Oil Company, has “magnet” characteristics attracting more nursing students. These
characteristics include a commitment to sponsor nursing students, provide training
programmes during the academic year and over the summer holiday, and offer attractive
employment opportunities with individualised professional development plans.
However, elements such as job opportunities, competitive employment packages,
structured training and professional development programmes needed to support
Saudisation of nursing are not necessary available in healthcare facilities under the
various sectors (government, other-government, private). Budget allocated for
Saudisation may vary even among hospitals under the same healthcare sector. The
impact of the variation in organisational resources on Saudisation plans and
interventions has never been examined in previous research.
31
Many Saudi studies have discussed strategies to improve recruitment and retention of
Saudi nurses and hence Saudisation of the nursing workforce. These strategies included
increasing financial benefits, enhancing educational opportunities and improving
working conditions (Alawi & Mujahid 1982, Al-Moaiqel 1991, Jackson & Gary 1991,
Al-Motairy 1998, Al-Mahmoud 1999, El-Gilany & Al-Wehady 2001). Moreover,
Jackson and Gary (1991) reported that segregation of hospitals into males and females
was cited as a recommendation to promote Saudisation of nursing.
Gender challenges
As discussed in chapter one, the nursing workforce in Saudi Arabia remains
predominantly female and foreign. However, due to limited work opportunities (MoP
2005b), an increasing number of Saudi women started to venture into demanding
education and challenging careers such as nursing. El-Sanabary (1993) suggested that,
for these women, having a secured job would justify the sacrifice. This shift might be
linked to an increasing awareness that nursing is one of few academic specialities known
for its job security (Hamdi & Al-Hyder 1995). The challenge is Saudi women applying
for a job in non-traditional mixed work settings may require their mahram‟s (male
guardian‟s) written approval (Article 4, Labour Law, Royal Decree No. M/51). A male
guardian is a close family member such as a husband, a father, a brother or even a son
over the age of 22 years. This approval tends to leave women at the mercy of their
guardians. Alawi and Mujahid (1982) and Hamdi and Al-Hyder (1995) reported that
Saudi female nurses often experience family conflicts associated with night shifts, caring
for male patients, the 12-hour shifts and weekend duties.
Describing the career choice experience of four Saudi female nurse leaders, Lovering
(1996) found that Saudi nurses respond to being part of a minority in a number of ways.
They may work harder to get the same recognition given to the dominant group or they
may seek to be invisible and hide their accomplishments. As an expatriate Director of
Nursing, Lovering suggested that non-Saudi nurses tend to view Saudi nurses as spoiled
or irresponsible because they tend to request day shifts, flexible working hours, paid or
unpaid leaves in order to meet family commitments. She also described discriminatory
32
hiring practices against Saudi nursing graduates particularly in hospitals where such
decisions are made primarily by non-Saudi staff (Lovering 1996).
Gender mixing in nursing
For socio-cultural reasons, the participation of Saudi women in nursing has been
restricted because of mixed-gender work settings (Meleis & Hasan 1980, Alawi &
Mujahid 1982, Jackson & Gary 1991, El-Sanabary 1993, Hamdi & Al-Hyder 1995, Al-
Johari 2001). Unlike teaching which is strictly gender-segregated, nursing implies
working with doctors, patients and other health professionals of the opposite sex. This
has contributed to a perception of nursing as an unacceptable occupational choice among
many Saudi families who tend to direct their children to socially and professionally
recognised career options such as teaching and medicine. Mansour (1992), Hamdi and
Al-Hyder (1995) and Al-Johari (2001) argued that school students (females), who may
be interested in the humanitarian aspect of nursing and may acknowledge the need to
replace the non-Saudi nurses, are most likely unwilling to risk their reputation and
jeopardise the family name by choosing a career in nursing. Investigating Saudi people's
attitudes toward Saudi women working with men in hospitals, Al-Rashidi (2000)
conducted a survey in three main cities. Results showed that respondents held the least
favorable attitudes toward Saudi women working in hospitals particularly administrative
staff and nurses.
Gender mixing is further aggravated with published written opinions of religious
scholars and modern Muslim writers. Al-Bar (1984), a Saudi conservative writer and an
internist who received his specialised medical training in England, claimed that the role
of women is primarily that of mothers and wives taking care of their families and homes.
In his book, he argued that the breakdown of family values is linked to women‟s
employment and to their paid work outside the home. He warned against the collapse of
the family unit as a result of women's employment. He also voiced his concern about the
moral corruption which may result from the mixing and intermingling of men and
women at work places. Despite referring to the important role played by the early
33
Muslim women in the battlefields, the author believes that nursing for women is
permitted only in highly segregated settings and during time of war or crises.
Work-related issues
The long hours and rotating shifts which characterise a career in nursing were frequently
cited as major deterrents to the uptake of nursing by Saudi female school students
(Meleis & Hasan 1980, Mansour 1992, Hamdi & Al-Hyder 1995, Al-Johari 2001).
Gender mixing and rotating shifts are work-related conditions which conflict with deep
rooted traditions particularly in relation to women.
Strongly associated with the socially unacceptable long rotating shift work expected of
nurses is a prevailing social belief that a career in nursing would reduce women‟s
chances of getting married. This issue was investigated in the Saudi literature showing
that Saudi female nurses are perceived as unsuitable marriage partners and prospective
mothers. More than half the sample of male high-school and university students
involved in the study by Jackson and Gary (1991) was against marrying a nurse. Ten
years later, Al-Johari (2001) reported that more than half the Saudi male university
students would look for a working wife but tend to avoid nurses. Compared to the
sample in the former study, those involved in the latter study appear to have
acknowledged the need for a working wife to support a satisfactory standard of living.
However, they (males) would not choose a nurse (female).
Bearing in mind that Saudi women are not permitted to drive, transportation to and from
their work place was reported as problematic for Saudi female nurses (Al-Rabiah 1994,
El-Gilany & Al-Wehady 2001, El-Sanabary 2003). Even in Arab and Muslim countries
where women can drive, means and cost of transportation were found to influence
nurses‟ satisfaction (Zuraikat & McClosky 1986, Amarsi 2003, Demir 2003).
Furthermore, as working mothers, nurses are struggling to find safe, accessible and
affordable child-care facilities for their young children (Al-Rabiah 1994, El-Gilany &
Al-Wehady 2001). This is not unique to Saudi Arabia; nurses from other Arab (Egypt
and Jordan), Muslim (Turkey) and western countries (Canada and United Kingdom)
34
have cited similar concern (Moores et al. 1983, Zuraikat & McClosky 1986, Price
Waterhouse 1988, Ghazi et al. 1994, Stewart & Arklie 1994, Whittock et al. 2002,
Demir 2003). Problems with transportation and child care further stir family conflicts
placing Saudi female nurses under heavy family-work pressure.
Subject to family and work pressure, Saudi female nurses often request day-shift areas
that can easily integrate with their family responsibilities (Alawi & Mujahid 1982,
Tumulty 2001). Their male guardians may demand such a request as a condition to
continue a career in nursing. Alawi and Mujahid (1982) suggested that many qualified
Saudi female nurses prefer either to stay at home or take administrative jobs that are
more convenient, family friendly and rewarding in their own right. Similarly, Al-Rabiah
(1994) highlighted that the MoH is constantly losing married Saudi female nurses for the
same social and work-related reasons that cause low enrolment to nursing programmes.
This was consistent with the finding reported by Al-Kandari and Ajao (1998) which
highlighted that, despite the exemptions made for the female nurses with special social
needs or family problems, Kuwaiti nurses continued to prefer outpatient clinics. This
trend tends to leave the in-patient units highly dependent on non-Saudi nurses.
Evaluating the nursing service at the MoH, Tumulty (2001) reported that Saudi female
nurses find working in primary healthcare or ambulatory clinics more compatible with
their families' expectations than the 24-hour responsibility at the hospitals. She argued
that reducing the weekly 48 working hours should maintain the highly valued child-
bearing and family-relation norms and would promote nursing as an attractive career
option for women. The above suggest that retention of Saudi female nurses within the
highly un-Saudised in-patient units continues to be a challenge for policy makers and
poses an important and relatively un-explored topic for future nursing research.
Saudi male nurses
It appears that patriarchal societies such as Saudi Arabia, which may exert strict codes
on women, have minimal constraints imposed on men. Al-Rabiah (1994) suggested that
Saudi male nurses may not be burdened by social pressure experienced by their female
35
counterparts. Moreover, they do not have to compete with a high number of non-Saudi
male nurses. Nevertheless, Saudi male nurses continue to represent a minority within the
Saudi nursing-workforce. Al-Osimy (1994c) emphasised that nursing, at the MoH
Health Institutes and Colleges, should be made more appealing to Saudi male applicants
who tend to prefer other health disciplines over nursing.
As highlighted in chapter one, prior to 2005 Saudi men had no BSN programme
available for those interested in such level of education. The first organised attempt to
prepare a cadre of professionally-prepared Saudi male nurses took place in 1995
whereby a panel of experts from King Faisal Specialist Hospital and Research Centre
selected 14 male applicants for scholarships in nursing (GMU 2002). The group was
filtered out of 51 applicants with science majors and was sent for an accelerated 15-
month BSN programme at to George Mason University in the United States. This may
suggest that increased unemployment among Saudi graduates of some favoured
academic specialities such as natural sciences coupled with the underlying economic
pressures might change the social perception and stereotyping of nursing as an
occupational choice. AbuGharbieh and Suliman (1992) suggested that increasing
unemployment among Jordanians graduating from popular professions such as
medicine, engineering and law should provide nursing with the advantage to recruit
students with high academic abilities.
Indeed, the male to female ratio of practicing nurses has increased in some Arab
neighbouring countries which share similar socio-cultural traditions to reach 1:1 in
Palestine and 2:3 in Jordan (Shukri 2005). By contrast, male nurses in Saudi Arabia do
not constitute more than 25% of the Saudi nursing workforce with a majority holding a
3-year nursing diploma (Tumulty 2001, Abu-Zinadah 2006). Tumulty (2001) argued
that, in societies where power and control rest with men, these male nurses are greatly
hampered by their lack of educational credentials. Moreover, Al-Rabiah (1994) reported
that 53% of the Saudi male nurses working at the MoH tend to request a transfer to
administrative posts outside the nursing service. Consequently, male in-patient units
remain highly dependent on non-Saudi nurses. Nevertheless, Al-Rabiah (1994) and
36
Lovering (1996) suggested that having more educated and highly qualified Saudi male
nurses will improve the power and status of nursing in Saudi Arabia.
In summary, the Saudi literature on recruitment and retention of nurses have
predominantly employed questionnaire-based quantitative designs covering areas such
as workforce planning, factors influencing the decision of choosing nursing as a career
and nurses‟ job satisfaction. Many of the Saudi studies recruited one group of the
nursing population such as staff nurses or made comparisons between a nursing group
(nursing students) and non-nursing groups (high school students). Almost all have
excluded male Saudi nursing students and nurses. To my knowledge, only one study was
qualitative; it aimed at examining the career choice experiences of four Saudi female
nurse-leaders (Lovering 1996). Results reported by the reviewed Saudi studies were
mainly concerned with the impact of negative social images and low professional status
of nursing on its choice as an occupation and with recommending Saudisation as a plan
to nationalise the nursing workforce. This has created a personal interest to examine how
prevailing negative images of nursing and perceived low status of nurses have been
influencing Saudi nurses‟ perceptions of nursing (males and females) and their decisions
to pursue such occupational choice.
With reference to the existing literature on Saudisation, it seems that there is a need to
examine the implementation of Saudisation national policy at organisational level and to
explore its impact on nurses' recruitment and retention. There is also a need to examine
the effect of variation in budget allocation and organisational resources on Saudisation
plans and interventions and subsequently on nurses‟ recruitment and retention. To
predict needs and plan strategies for the Saudisation of the nursing workforce, Saudi
male nurses need to be involved in future research.
The western literature
Over the past two decades, an international nursing shortage has been of increasing
concern. In Britain, the loss of nurses from either the educational programmes or service
sectors seems to have contributed to the nursing shortage (Alderman et al. 1996, Shields
37
& Ward 2001, Arnold et al. 2003, Deary et al. 2003). The shortage has been attributed to
an increase in healthcare demands and to supply difficulties such as the aging nursing
workforce and the declined enrolment to nursing programmes (Buchan & Edwards
2000). In the United States similar causes have been identified, however, nurses'
dissatisfaction with working conditions and their lack of professional autonomy were
found to contribute to the persisting shortage (Ma et al. 2003).
Buerhaus et al. (2000) estimated that the future shortage of registered nurses that began
in the US in 1998 would double in size reaching to 800,000 by 2020. However, in 2004,
they observed a substantial growth in RN employment (300,000 from 2000 to 2005). In
2007, the same authors forecasted a comparatively smaller shortage of 340,000
developing over the next decade (Auerbach et al. 2007). The American Association of
the Colleges of Nursing argued that the slight increase in enrolment at the nursing
colleges and universities earlier this century is still insufficient to meet the projected
future workforce demands (AACN 2001). Hence, the association suggested that nursing
is no longer a prominent career choice for women (AACN 2001).
Images of nursing
For decades, the prevailing images of nursing and the perceived status of nurses have
been major concerns for an emerging profession. Numerous studies have addressed
these concerns (Kalisch & Kalisch 1982, Kalisch & Kalisch 1987, Austin & Champion
1985, Waterhouse 1988, Grossman et al. 1989, Mendez & Louis 1991, Kiger 1993, Day
et al. 1995, Spouse 2000, Coombs et al. 2003, Ward et al. 2003). In the western
literature, terms such as perception of, beliefs about, attitudes toward and views
regarding were frequently used to refer to images of nursing. Stereotypes, attributes,
aspects of attractiveness and media portrayal were also used to describe the prevailing
images of nursing.
Fletcher (2007) claimed that what is known about the images of nursing from the
literature is almost all from the perspective of the media, the public, or other health
professionals and not from the perspective of nurses. Her review of the literature
38
suggested that nurses do not have a very positive self-image nor do they think highly of
themselves. Unlike the Saudi studies which focused mainly on the social images and
professional status of nursing, western studies have further examined the social and
professional images and differentiated them as entry images, experience-acquired
images and media images.
Entry images
The literature highlights that students tend to enter nursing with initial images, some
preconceived views and perceived values (Kiger 1993, Day et al. 1995, Spouse 2000).
These images, views and values are formed either through personal experiences with
nurses and nursing or through the influence of the media. They might be reinforced or
modified depending on the nature of socialisation during education and practice
experiences and the level of support students receive from their nurse teachers and
clinical staff.
The two studies from the UK recruited new nursing students and employed a qualitative
approach with interviews as the main method of data collection (Kiger 1993, Spouse
2000). The aim of Kiger‟s work (1993) was to explore and understand processes through
which students‟ images develop from its initial form into experience-mediated form.
Seventy-one interviews were conducted with twenty four Scottish students from the four
types of basic nursing training leading to registration. Kiger‟s findings suggested that
entrants to nursing programmes use examples taken from the media to describe what
they are expected to do as nurses. "Working with people" and "helping others" were
central characteristics of nursing that emerged from the data. In contrast, Spouse (2000)
adopted a naturalistic longitudinal study employing mixed qualitative methods on a
small sample of nursing students from a single educational setting. She claimed that
students entered the programme with images and values of how they like to practice as
nurses some, however, seem to hold their beliefs stronger than others. Students‟ images
informed their attitudes, their relationships with patients and the way in which they tried
to nurse.
39
Kiger's 24 students had some disparities between their initial images and their
experience-mediated images; they were less willing to alter their images in order to
accommodate staff behaviours and attitudes they considered inappropriate. Similarly, on
some occasions, the students in Spouse‟s study resisted being engulfed by experiences
they found disruptive to their images. However, in courses where students were
employees, they were compelled to get on with their nursing colleagues otherwise their
progress reports might have reflected their social dislocation. This is consistent with
Melia‟s findings (1984). Through informal interviews, Melia (1984) attempted to
understand what it is that nursing students learn during their course of study. Scottish
participants spoke of learning to accept that there are “education” and “service” versions
of nursing, with each having its own rationality. Melia argued that with this
segmentation within nursing, students have two sets of expectations to meet and two
groups of powerful people to satisfy (Melia 1984, p. 137).
The Canadian study by Day et al. (1995) which combined quantitative and qualitative
methods argued that students move from a lay to a professional image of nursing over
the course of their 4-year programme. Students adopted more humanitarians than
religious values; help, care and concern for people were central values held by new
entrants. Unlike the sample in Melia‟s study (1984), the students in Day et al‟s study
(1995) tried to “fit in”, but were determined not to “give in”. For some of these students,
nursing had always been a career goal. Others had simply drifted into nursing with no
clear view of nursing initially; however, by their second year interviews they seemed to
have assimilated values and developed similar views as their classmates.
Entry images and nursing socialisation have been found to influence students‟ decisions
to continue or leave their educational programme. In a Delphi study using focus groups,
semi-structured interviews and a questionnaire, Last and Fulbrook (2003) attempted to
establish a consensus view of the reasons why student nurses leave their pre-registration
education programme. Issues of concern for students included communication and
operational factors between the university and clinical areas, feelings of not being
valued, unmet expectations and stress. The authors suggested that first year students
40
need a more supportive and task-oriented approach to meet their learning needs. Formal
detailed exit interview processes were recommended to generate accurate information of
the reasons students give for leaving.
Experience-acquired images
This type of images refers to values, perceptions and impressions acquired by nurses
during their course of practice. Combined with other social and work-related factors,
these images may contribute to the motivation to pursue a career in nursing. In the UK,
several studies have attempted to explore reasons behind nurses‟ decisions to join, stay
or leave the National Health Service (NHS) (Price Waterhouse 1988, Coombs et al.
2003). Findings from both studies suggested that the NHS is still a moderately attractive
employer identifying job security, job variety and patient contact as benefits of working
for the NHS. However, workload and poor pay undermined the attractiveness of nursing
as a career choice.
Coombs et al. (2003) explored nursing within the NHS and images held by potential
nursing recruits and returnees. Findings from semi-structured individual and group
interviews with six-sample groups suggested that learning opportunities and the chance
to be part of a professional team were aspects reported to attract more recruits to nursing
in the NHS. In contrast, a quarter of the responses obtained from nurses with 5-6 years
work experience indicated a possible departure from NHS nursing into teaching (Park et
al. 2007). Nevertheless, the authors reported that the sample of BN nurses were
confident and motivated in their nursing careers.
The imbalance between effort and reward (money and career opportunities) and the lack
of social support were major influences on Canadian nurses‟ intention to quit their
present jobs for another in nursing (Lavoie-Tremblay et al. 2008). Their main reasons
for changing jobs included a lack of challenge, dissatisfaction with work conditions and
other career opportunities. Identifying several passage points in establishing professional
identity, Deppoliti (2008) argued that American hospital nurses were challenged by
stress, a sense of responsibility and the need for continuous education.
41
Media portrayals
Audio-visual and written work on nursing and nurses has been of interest to researchers
particularly in North America and were found to impact on people‟s perception of
nursing as a career choice (Kalisch & Kalisch 1982, Kalisch & Kalisch 1987). After
studying attributes and characteristics of nurses portrayed in randomly selected
American television programmes, Kalisch and Kalisch (1982) suggested that young men
and women will not consider nursing as a desirable career choice as long as the
profession continues to be devalued and ridiculed in the media. They recommended a
concerted effort to upgrade the quality of the nursing image being projected on the
media so that the true role and healthcare contributions of nurses can be communicated
to the public and policy makers. The authors also encouraged nursing pressure groups to
lobby for media portrayal of professional nursing images to counteract this. In 1987, the
study of nurse images in the mass media guided the same authors to five dominant
image-types that were fundamentally characteristics of five successive periods of time:
between 1854 and 1919, the Angel of Mercy; between 1920 and 1929, the Girl Friday;
between 1930 and 1945, the Heroine; between 1946 and 1965, the Mother; between
1966 and 1982, the Sex Object (Kalisch & Kalisch 1987).
Grossman et al. (1989) argued that the media favour “poor and downtrodden” images of
nurses who are overworked and underpaid. News stories, the authors maintain, are
largely pessimistic focusing on problems and failures of nursing and nurses rather than
successes and rewards. Reviewing the literature, Fletcher (2007) suggested that nurses
are portrayed in the media as female, single, childless, white and under 35 years of age.
Stereotypical images (nurses are women and physicians are men), she maintains, have
been identified in advertisements in nursing and medical journals.
Advancing the claim that television viewers are exposed to highly stereotypical and
generally negative portrayals of nurses and nursing, Lippman and Ponton (1989) found
that academic staff, selected from 19 north-eastern states universities, held more positive
views of nursing than the one presented by the media and perceived nurses as educated,
autonomous and compassionate. The authors attributed this positive perception to the
42
high degree of personal contact with nurses. This finding is consistent with that of
Begany (1994) who claimed that the views and ideas about nurses for less than 10% of
the respondents from a major American public opinion survey were influenced by
television shows, newspapers or magazines.
In a Turkish study, Abaan (2000) collected data from a popular daily newspaper
(Hurriyat). Every newspaper was screened for “thank you” acknowledgments from
patients and families. Page area, print size and words were examined. The findings
indicated that, compared to medicine, nursing ranked low as an acknowledged
profession. To my knowledge, the Arab world has no available literature examining or
reviewing the media portrayals of nursing and its impact on the prevalent perceptions.
Status of nursing
Nursing status has been frequently linked to job characteristics, career opportunities,
working conditions and educational qualifications (May et al. 1991, Mendez & Louis
1991, Stevens & Walker 1993, While & Blackman 1998, Hemsley-Brown and Foskett
1999, Al-Omer 2004, Karaoz 2004, Seago 2006, Nasrabadi & Emami 2006).
Some researchers were interested in the differences between perceptions of a career in
nursing and perceptions of an ideal career (May et al. 1991, Mendez & Louis 1991).
Results from these studies indicated that the different American sample groups did not
consider nursing an ideal career. Respondents described an ideal career as having
knowledge, power, technical skills, respect and independence in decision making.
Nursing, however, scored high on attributes such as activity, working hard, being busy
and caring for people. Respondents felt that making money was important for an ideal
career, but nursing scored low for this item; moreover, nurses were rated significantly
low on being respected and appreciated (May et al. 1991). Even nursing students had a
discrepancy between their views of nursing and their perceptions of an ideal career (May
et al. 1991). May et al. (1991) sent questionnaires to school students, parents, school
nurses, teachers and counsellors, and college students. In the study by Mendez and Louis
43
(1991) questionnaires were distributed to nursing and non-nursing college students. In
both studies the response rate was low (12%) and (23%) respectively.
A sample of pre-18 English students viewed nursing as having limited career
opportunities with a ceiling to seniority and autonomy (Hemsley-Brown and Foskett
1999). Many described nursing as unattractive and nursing tasks were described as
domestic rather than clinical. Similarly, Al-Omer (2004) compared perceptions of
nursing as an occupational choice among Saudi high school students to that of medicine,
computer science, teaching and business administration. Only 5% of the surveyed male
and female students from the capital Riyadh have selected nursing as their preferred
future profession. The author suggested that the competitive nature of the preferred
professions has resulted in a lack of interest in nursing.
Examining desired job characteristics and nursing characteristics, Stevens and Walker
(1993) Found that many respondents did not perceive nursing as having the
characteristics they preferred in a career. Their survey involved college-bound American
high school seniors. Despite indicating that nurses made their own decisions, a majority
believed that nurses follow doctors‟ orders. The preferred career characteristics
included: doing important work, being respected, being helpful to others and using
scientific information. Results from Seago (2006) suggested that science and math
American college students perceived nursing as financially rewarding career;
nevertheless, nursing has been less attractive on other occupational characteristics such
as job independence. Similarly, nursing in Saudi Arabia has been ranked low compared
to other healthcare specialities (Jackson & Gary 1991, Mansour 1992, Hamdi & Al-
Hyder 1995, Al-Johari 2001).
In relation to professional status, nearly one third of the forty undergraduate nursing
students who took part in While and Blackman‟s exploratory study (1998) referred to a
conflict experienced within the clinical settings. This conflict was attributed to the low
status accorded to nurses and the power struggles that exist between healthcare
professionals. In contrast, the Australian nursing students surveyed by Ward et al. (2003)
44
viewed doctors and nurses to be closely aligned in status as healthcare professionals;
however, nurses were ranked lower in status within the general community. The eighty
drawings produced by the students indicated that stereotypical images of nursing
continue to persist (Ward et al. 2003). Improved working conditions and the importance
of career opportunities within the NHS were cited as factors to improve the status of
nurses.
From a Turkish perspective, Karaoz (2004) argued that the educational differences
between doctors and nurses threaten the development of nursing autonomy and that
university education increases the collaboration between these two professional groups.
Karaoz‟s study (2004) was undertaken to examine the changes in students‟ perception of
nursing after completing an introductory course on nursing. An initial negative response
regarding nurses‟ independence was identified; this was attributed to the prevailing
perception of nurses as assistants to the doctors. Similarly, Nasrabadi and Emami (2006)
attributed nursing stereotypes to the hierarchical structure between Iranian doctors and
nurses. A hierarchy that originate from the differences in educational backgrounds and
the historical role of nurses and physicians. Nurses were unhappy with performing
menial tasks below their level of education.
Nursing education
Internationally, nursing education continues to produce diploma and associate degree-
prepared nurses. Some researchers have argued that this pattern of education has
restricted the process of nursing professionalism (Letvak 2001, Whittock et al. 2002,
Karaoz 2004). Highlighting a gender difference, Whittock et al. (2002) argued that more
men will participate in the female-dominated profession of nursing in countries where
higher nursing qualifications are required. This argument may suggest a correlation
between the level of education, the societal image of nursing and the numbers of men
entering the profession. However, in a Saudi context where research involving male
nursing students and staff nurses is scarce, it is female school-students who were found
to be discouraged by the diploma level and technical-nature of nursing programmes
(Hamdi & Al-Hyder (1995). Furthermore, many of the 17-year-old female students
45
involved in the study by Hemsley-Brown and Foskett (1999) had questioned why
anyone would enter nursing not medicine for a university level education. This is
consistent with what Al-Rabiah (1994) raised on behalf of the Saudi female high-school
graduates.
Degree education, higher education and specialisation were frequently linked to
professionalism and have been reported as a priority for many nursing students in
western countries. With an interest in BSN graduates‟ career progression, aspirations
and satisfaction, Park et al. (2007) reported that a sample of nurses, graduating between
1994 and 2000, have focused their career priorities on promotion, gaining experience
and further specialisation or study. In contrast, Rognstad and Aasland (2007) analysed
questionnaire data from a cohort of Norwegian BSN students at three time points.
Initially, 92% had a wish for further education; this proportion dropped to 74% in 2001.
Students‟ preference was for specialties such as midwifery, public heath and high-tech
nursing. Results from 2003 indicated that only 16% had started or finished further
education at the end of their third year following graduation. Male nurses were more
likely than the females to have undertaken an opportunity for further education.
As part of “The RN Job Analysis and Retention Study”, Rambur et al. (2005) argued
that BSN nurses have high degree of professionalism than those with associate degree
education and suggested that BSN education was associated with social return on
educational investment. Arguing why nursing is not considered a profession, Watson
(2006) suggested three reasons. Nurses are trained rather than educated; nurses are
largely controlled by medicine; nurses, ultimately, are not accountable for what they do.
Watson also argued that a university is for training people, formation of character and
preparation for accountability.
Literature from Saudi Arabia (El-Sanabary 1993, Hamdi & Al-Hyder 1995, Tumulty
2001), Arab (Meleis & Hasan 1980, AbuGharbieh & Suliman 1992, Boyle & Salman
2003) and Muslim countries (Amarsi 2003, Akhter et al. 2003, Herberg 2003, Karaoz
2004, Nasrabadi 2004) suggested that the relatively low level education required to
46
study nursing has influenced its perception as an occupational choice and as an emerging
profession. To my knowledge, the Saudi literature does not have studies that particularly
examined Saudi nurses‟ aspiration for higher education or evaluated returns on investing
in BSN education.
With a predominant perception that diploma level education is technical and low level
(Meleis & Hasan 1980, Hamdi & Al-Hyder 1995, El-Sanabary 2003), one might argue
for gradual upgrade of all levels of nursing education to a minimum of BSN. However,
as presented in chapter one, nursing education in Saudi Arabia has, for a number of
years, been either diploma and associate degree programmes managed by the MoH; or
BSN programmes managed by MoHE. Considering either an upgrade or integration of
the former programmes with the latter would require careful and long-term planning that
takes into account experiences from other countries. Exploring the process of integration
of schools and colleges of nursing into higher education using qualitative design of
policy analysis and interview methods, Burke (2006) highlighted a number of key
lessons. The need for clarity of aims; the value of sensitivity to the context and culture;
the importance of empowering key individuals with the needed skills; and the need to
share good practice.
Nevertheless, the 4-year BSN programmes, other nursing degree courses,
prequalification and pre-registration diplomas are not without their own challenges.
Some authors have highlighted a theory-practice gap and inadequate preparation for
future qualified nurses‟ role as areas of concern in relation to these programmes
(Landers 2000, Watkins 2000, Maslin-Prothero & Owen 2001, Maben et al. 2007).
Reviewing the literature, Landers (2000) explored reasons cited for a theory-practice
gap. Of those related to clinical areas, Landers highlighted four: a rapidly changing
environment; diversity of environments; the „busyness‟ of the clinical environment; and
a tension between learning and service needs. The importance of clinical learning and
the role of nurse teachers in supporting nursing students have been frequently
emphasised (DoH 1999, UKCC 1999, Maslin-Prothero & Owen 2001). A major
challenge facing nursing education is the increasing shortage of nurse teachers (Walrath
47
& Belcher 2006, AACN 2006, Allan & McClellan 2007, Nettleton 2008). According to
the AACN 2006 report:
“U.S. nursing schools turned away 41,683 qualified applicants from
baccalaureate and graduate nursing programmes in 2005 due to primarily
an insufficient number of faculty” (AACN 2006, p. 2)
Watkins (2000) highlighted some problems associated with the Project 2000 model of
nursing education. The project was launched in the early 1980s suggesting that, in
preparation for practice, nursing students should have a higher education experience.
Perceived benefits of a university-based education were that students will benefit from
working alongside others on different courses (multi-professional education) and that
nursing practice will focus on evidence-based research (research-based education). With
the increase in the number of graduate nurses, there was a widely reported theory-
practice gap in nursing. The author argued that staff employed by the NHS and by
Institutions for Higher Education needed to work in partnership to further refine the way
practice-based competencies are incorporated into the nursing curricula and to achieve
“fitness for purpose” and “competence for practice” emphasised by the UKCC.
Nevertheless, the Australian nurses who took part in the longitudinal study by Cowin
(2002) talked about facing difficulties during the transition from students to registered
nurses. Findings by Maben et al. (2007) suggested that, due to organizational constraints
and inadequate preparation for the actual roles undertaken by qualified nurses, newly
qualified UK nurses experienced frustration when attempting to implement ideals and
values in practice. The lack of preparation during prequalification nursing courses is
related to a disconnection between the education segment of nursing and the pressing
realities registered nurses face in practice. The authors concluded that this disconnection
leads to disillusionment and, for some, a desire to leave nursing. Maben et al. (2007)
conducted a longitudinal interpretive study with 26 final-year students undertaking
„typical‟ prequalification programmes to gain an understanding of their experiences and
trajectories at two time points post qualification.
48
The perception of nursing as an occupational choice
More and varied occupational alternatives have become increasingly available for young
men and women to consider. The changes in the labour market coupled with the
increased participation of women in the labour force has motivated more young women
to choose from a wider range of potential occupations including those formally
designated as male-dominated jobs characterised by high income and high status.
Making a choice implies deciding between competing possibilities or options. To
examine the impact of nursing images on its attractiveness and uptake, the popularity of
nursing as a career choice was frequently investigated in the western literature. Many
studies focused on examining the influences of factors such as job characteristics, job
values, age and gender. Studies from the UK (Firby 1990, Hemsley-Brown & Foskett
1999) and USA (Grossman et al. 1989, Kohler & Edwards 1990, Stevens & Walker
1993, Staiger et al. 2000, Seago et al. 2006) reported similar findings. There is a decline
in the numbers of school students who are considering nursing as an occupational choice
which may suggest a decline in interest. Issues related to image, status and working
conditions were the main factors influencing such decision.
In contrast, Auerbach et al. (2007) suggested that nursing is drawing entrants from a
potentially larger pool than earlier years. Compared to the career-minded late teens who
aim for the few professions available to them, these entrants are undecided and looking
for a fresh start. Auerbach, Buerhaus and Staiger conducted several studies to examine
the American RN workforce and project future supply (Staiger et al. 2000, Buerhaus et
al. 2000, Buerhaus et al. 2004). The authors claimed that, although the number of people
entering nursing in their early to mid-twenties remain very low, large numbers of people
are entering the profession in their late twenties and early thirties (Auerbach et al. 2007).
Using focus groups and individual interviews, Hemsley-Brown and Foskett (1999)
reported that many British school students expressed their admiration for the work of
nurses; however, this was rarely matched by envy or a desire to become a nurse.
Hemsley-Brown (1996) suggested that school children are likely to exaggerate negative
49
factors and reinforce inaccurate perceptions. From an Australian perspective, Ward et al.
(2003) highlighted three main influences on the choice of nursing: information from
schools, the role of relatives and the impact of the media. Experiences with nursing,
exposure to nurses and having a nurse role model in the family were found to influence
the uptake of nursing as a career (Grossman et al. 1989, Mendez & Louis 1991, Stevens
& Walker 1993, Richardson 1996, Mooney et al. 2008).
Job characteristics and values
Western literature focusing on occupational choices has highlighted a number of job
characteristics that would either attract or discourage people from choosing a particular
career. These characteristics include professional autonomy, independent decision-
making, power, authority, social prestige and high income.
Marini et al. (1996) examined gender differences in relation to job values of American
high school seniors. Results suggested that students make a choice of work based on
multiple criteria. There was a high degree of similarity in the values male and female
students attach to jobs. Whereas previous research indicated that young men valued
more than young women, The study also suggested that both sexes valued extrinsic
rewards and influence equally. Both sexes attached importance to the intrinsic rewards,
however, young women valued them more. Both sexes equally valued participation in
decision making and the challenging type of work; The findings also refuted the
argument that greater demands of family roles cause women to choose jobs that require
less effort or shorter hours.
With reference to job values and characteristics, it is unclear whether intrinsic factors are
more important than extrinsic. Marini et al. (1996) argued that neither male nor female
students seek to maximise status or earnings irrespective of other work attributes. In
contrast, May et al. (1991) and Stevens and Walker (1993) argued that school children
are reviewing their options and considering their career based on income, status and
working conditions. Firby (1990) claimed that girls are likely to find the intrinsic nature
of work more important than salary and boys are more likely to have chosen an
50
occupation based on anticipated salary. However, Hemsley-Brown and Foskett (1999)
reported that young people make their career choices based on interest or enjoyment and
without regard for financial rewards.
The desire to help others and to work with people was highlighted by the literature as the
most popular reasons for choosing nursing as an occupation (Moores et al. 1983,
Grossman et al. 1989, Murray & Chambers 1990, Stevens & Walker 1993, Kiger 1993,
Day et al. 1995, Williams et al. 1997, While & Blackman 1998, Hemsley-Brown &
Foskett 1999, Boughn 2001, Jensen & Aamodt 2002, Nasrabadi & Emami 2006,
Rognstad & Aasland 2007, Mooney et al. 2008). Half the nursing students involved in
the interview survey by While and Blackman (1998) indicated that the satisfaction of
working with and caring for people was a reason for entering nursing. Similarly, the few
school children who have chosen nursing in the study by Hemsley-Brown and Foskett
(1999) did so based on a desire to help people.
Presenting data from a large scale project on moral motivation of four groups of
Norwegian university nursing students, Jensen and Aamodt (2002) argued that despite
the dominance of self-directed motives, results do not support the claim of a decline in
other-directed motives. Statements related to the desire to “do something useful” and
“help people” were high among nursing and social work students. Similarly, Al-Motairy
(1998) reported that Saudi nursing students have listed personal interest, a desire to help
others and perceived job satisfaction as reasons for choosing a career in nursing. In
contrast, Rognstad and Aasland (2007) reported that motives such as human contact and
helping others were initially important among Norwegian BSN students. Towards the
end of the baccalaureate programme (2001), there was more ambiguity in the helping
motives. On one hand, the students wanted to be altruistic but on the other, they wanted
gratitude in return. Appraising future job challenges in 2001 and 2003, there was a
decrease in emphasis on human contact.
Results from Jensen and Aamodt (2002) showed that students considered job security
and balanced work-social life as motivation factors of high importance; however, scores
51
on “high income” and “promotion chances” were relatively weak compared to those on
human contact. In contrast, the students in Rognstad and Aasland‟s study (2007) had
more emphasis on the high salary and job security particularly toward the end of their
programme and after two years of graduation. Job security was cited as one of the
factors influencing the career choice for undergraduate Irish nursing students (Mooney
et al. 2008). From a Saudi perspective, Hamdi and Al-Hyder (1995) reported that an
interest in nursing and the availability of work opportunities immediately after
graduation were the main reasons for choosing nursing by the diploma nursing students.
For these Saudi female students, nursing was an occupational choice which provides job
satisfaction, a competitive income and an opportunity to replace expatriate nurses.
Age, gender and occupational choices
Unlike western developed countries, Saudi Arabia does not have a declining number of
young college-age groups (Firby 1990, Auerbach et al. 2007). Almost 40% of the Saudi
population fall under the age of 15-year (MoP 2005a). This percentage guarantees
enough influx of high school graduates who will be looking for career opportunities and
secured jobs. Some western studies highlighted the difference between nurses who make
their career choice early in age and those who choose nursing later in life (Moores et al.
1983, Kohler & Edwards 1990, Murray & Chambers 1990, Soothill & Bradby 1993,
Barriball & While 1996, Staiger et al. 2000, Auerbach et al. 2007). On the basis of a
large interview survey, Ginzberg et al. (1951) argued that young people progressively
make choices and gradually build up a picture of their chosen occupation which tends to
be irreversible.
Moores et al. (1983) found that the majority of English qualified female nurses have
decided to enter nursing before they left school; 53% had no help or information through
their schools. In contrast, Murray and Chambers (1990) claimed that students entering
undergraduate nurse-training differ in a variety of aspects from those who undergo
traditional college nurse training. Their survey showed that college nursing students
were females who came from nursing families, had decided to become nurses at an early
age and had wanted to become nurses to help people. The undergraduate students were
52
mostly males with strong interest in medicine and biology and who decided to become
nurses later in life. Survey results‟ of nine British cohorts doing conventional diploma
and degree nursing courses by Soothill and Bradby (1993) suggested that prospective
nurses choose nursing at varying ages. The early decision-makers (11-16 years) are
mostly women who are more likely to see nursing as requiring a special person. Over
half of those who chose nursing at the age of 16 had either negative or mixed feelings
about their school experience.
In an interview survey examining similarities and differences between qualified and
unqualified British nurses with different career-choice profiles, a quarter reported that
they had always wanted to be nurses and that nursing had been an early choice (Barriball
& While 1996). Only one male participant indicated that nursing had been a childhood
occupational choice. Of the group for whom nursing was not a childhood choice, slightly
less than a third had academic records and potential which would have placed other
career options at their disposal. Although nursing was not the first career choice for the
23 undergraduate Irish nursing students interviewed by Mooney et al. (2008), all
participants had initially sought a career which involved caring.
Some western studies suggested that members of younger female cohorts are less likely
to consider nursing as a career; others argued that an increasing number of women is
opting for medicine, law, journalism, acting and singing (Firby 1990, Hemsley-Brown &
Foskett 1999, Staiger et al. 2000). Staiger et al. (2000) had three claims. Women's
movements over the last three decades of the 20 th
century provide the best explanation
for their declined interest in nursing. An increasing numbers of young women with high
academic achievement are choosing traditionally male-dominated occupations available
for them. Job-interest is driven by continuous shifts in the labour market.
Exploring the various factors affecting the choice of nursing as a career among
American women, Staiger et al. (2000) argued that traditional female nurses and
teachers were moving into managerial and professional occupations with higher pay and
prestige. While almost all male students in Boughn's qualitative study (2001) were clear
53
about the importance of salary and earning power attached to a career in nursing, only a
few female students made reference to salary, benefits, job security and working
conditions. The influence of gender on occupational choices and the difference between
nurses who make their career choice early in age and those who choose nursing later in
life have not been covered by Saudi research.
The gendered-nature of nursing
Historically, social expectations associated with family structure and functions have
differed for women and men. This has played a significant role in their educational and
occupational attainment. Ever since the 19 th
century, Florence Nightingale had a
significant role in the designation of nursing as an occupation for women. For
Nightingale, nurses were doing what came naturally to them as women (Nightingale
1980; first published in 1859). So, it should not come as a surprise to find that 99% of
the images of nurses in the novels examined by Kalisch and Kalisch (1982) were of
women reflecting its gendered-nature. Moreover, the belief that nursing is an extension
of the women‟s domestic roles was instrumental in the perception of nursing as unskilled
and of low value (AbuGharbieh & Suliman 1992, El-Sanabary 1993, Davies 1995,
Evans 2004). However, Firby (1990) argued that traditional British female applicants
with five GCSEs are no longer looking to teaching and nursing but have widened their
horizons to incorporate many occupations which in the past have been considered part of
the domain of men‟s work e.g. law, social work, police and management.
Conveying the perspective of patriarchal societies, AbuGharbieh and Suliman (1992)
critically evaluated the nursing programme at the University of Jordan. The authors
argued that early socialisation experienced by Jordanian women may interfere with their
socialisation into nursing. These women are socialised to serve, obey and defer to the
judgement of male family members; hence, they usually experience incongruity between
the traditional roles of a wife, a mother, a daughter and some of the professional roles
ascribed to the professional nurse. Just like their Jordanian counterparts, Saudi women
are orientated to gender-specific roles characterised by dependence upon and
subordination to their male family members. In their study of the factors influencing the
54
choice of nursing as a career for Saudi women Hamdi and Al-Hyder (1995) reported that
33% of the female high school students agreed that nursing is an appropriate career for
Saudi women; however, almost 25% believed that working as a nurse will conflict with
the prevailing traditions.
In her literature review, Mackintosh (1997) claimed that men as well as women have an
equally valid historical role within the occupation. As early as1095, men nursed the
mentally ill and cared for people with leprosy. In the UK, formal records trace men in
nursing back to the 1791 where they worked in sex segregated wards of the Manchester
Infirmary. Between 1861 and 1894, men worked at workhouses, asylums and in some
private nursing sectors. In 1907, 800 male nurses formed the Navy and Army Male
Nurses Association. To compare and contrast why women and men choose nursing,
Boughn (2001) interviewed American male and female BSN students. Participants had
equal intensity of a motivation and a desire to care for others. Female participants
expressed an interest in empowering patients, while males were more inclined to
empower the profession and themselves. All but one of the twelve male participants
reported that they chose nursing because they expected a good salary and earning power.
In contrast, only four of the sixteen females made reference to practical motivations such
as salary, benefits and job security. Boughn (2001) suggested that nursing needs both
sets of values and that nursing education should encourage men and women to
incorporate the other‟s way of thinking into their professional value system.
As a sociologist interested in nursing, Davies' book (1995) on gender and nursing
provides a feminist analysis of nursing. Davies explained that “gender codes” are
embedded in the social worlds which nurses inhabit and need to be comprehended in the
context of “nurses as women”. In her analysis of gender, she singled out three elements.
First, the notion that masculinity and femininity could be expressed as two different
developmental trajectories. One towards separation and autonomy and the other towards
connection and attachment. Second, the suggestion that masculinity gains its coherence
by denying and repressing feminine qualities. Third, the proposition that masculinity
could inform action in the public sphere (Davies 1995, p. 36). In her opinion,
55
“masculinity of organisational life” empowers men and undermines the women. Davies
(1995) also described women in patriarchal societies as silenced, neglected and
misunderstood trying to articulate values that do not fit with masculine world.
Gender stereotyping
With an increasing number of male nurses, several western authors are debating whether
nursing should continue to be viewed as a female occupation. Some of these authors
have raised the argument that caring and having a desire to work with and help people
are not exclusively female qualities (Bush 1976, Galbraith 1991, Haywood 1994,
Foskett & Hemsley-Brown 1998, Muldoon & Reilly 2003, Jinks & Bradley 2004).
Just like women in traditional-male jobs, some men might seek a female-dominated
occupation to fulfil certain aspects of their characters and ambitions. For instance, it
might be quite natural for some men to choose nursing for a desire to help people, an
interest to work within humanity or social services and a high value for opportunities
that build relationships, and maintain contact and interaction with people. Haywood
(1994) argued that caring is embedded in the person‟s soul rather than being designated
a gendered-based quality. In an American survey, Galbraith (1991) compared the views
and characteristics of male nurses with their female peers, with men in a non-traditional
early education occupation and with men in the traditional engineering male occupation.
Results suggested that men in non-traditional jobs retain components of their
masculinity such as their value for money, power and prestige while adding other
components they find important and personally rewarding such as human contact and
relationship.
In contrast, Muldoon and Reilly (2003) argued that it is more difficult and stigmatising
for men to behave in a “feminine” way than it is for women in a “masculine” way. The
authors argued that female-dominated professions such as nursing have failed to attract
male recruits not only due to issues such as status and pay but also as an outcome of
gender-role stereotyping of the profession. Comparing newly recruited Project 2000
students in 1992 with pre-registration students in 2002, Jinks and Bradley (2004)
56
reported a significant shift of opinion about nursing stereotypes and gender. Around
70% of the students in 1992 agreed that nursing was female-dominated compared to
51% in 2002. Less students in 2002 agreed with the statement that “women are more
affectionate and caring than men”. More students in 2002 agreed with the statement that
“male nurses are effeminate”.
Eight Canadian male nurses indicated that they used touch less than their female
colleagues (Evans 2002); interview finding suggested they were aware of their
vulnerability as caregivers. For these male nurses and regardless of purpose, touching
patients particularly the females is potentially dangerous leading to accusations of
inappropriate behaviour or sexual molestation. Nevertheless, the majority talked about
male patients enjoying the freedom of joking and sharing things with them that female
nurses might find inappropriate or offensive. These findings from western societies
might explain why male nurses are not allowed to work with female patients in a country
like Saudi Arabia where gender-segregation is a highly observed tradition.
Gender-role and nursing specialities
A number of western studies examined the role and work preference of male nurses and
reported similar findings in relation to male nurses‟ choice of specialities (Bush 1976,
Egeland & Brown 1989, Williams 1995, Mackintosh 1997, Muldoon & Reilly 2003,
Evans 2002, Stott 2004). These nursing specialities require less association with the
feminine traits of intimate touch and bedside care; hence, tend to reinforce the male
identity and masculinity (Evans 1997, Evans 2002, Mooney et al. 2008). Despite gender-
related issues, AbuGharbieh and Suliman (1992) reported that increasing numbers of
Jordanian men have been applying to the nursing programmes for the job security and
prospect of administrative positions.
Some authors have highlighted the gender-appropriateness of the nursing careers and its
impact on confirming gender-role and reducing role-strain (Muldoon & Reilly 2003,
Stott 2004). Muldoon and Reilly (2003) reported that irrespective of gender,
psychologically feminine nursing students were most interested in highly female gender-
57
typed nursing careers such as midwifery and health visiting. Psychologically masculine
students were most interested in gender-neutral careers such as mental health and
accidents and emergency. Regardless of gender role orientation, male and female
students had rigid views on the gender appropriateness of various nursing careers. The
majority of nursing careers were rated as more appropriate work for women than men.
Just like their western counterparts, Saudi male nurses tend to prefer highly-technical
nursing areas. However, due to a lack of research involving Saudi male nurses, these
work trends remain unverified 11
. As the number of Saudi male nurses is very small, their
contribution has hitherto been unexamined. With the persisting current shortage in
nursing, Saudi Arabia might need to invest on research into influences on choice of
nursing as an occupation among men and women. An area that was not investigated
extensively in the Saudi and Arabic literature.
Negative sanctions, sexuality and labelling were claimed to influence male nursing
students during the socialisation process of learning (Stott 2004). To cope with social
labelling and minority status, the author argued that male nurses opt to work in
specialities that confirm their gender role, strengthen their status and reduce role-strain.
These specialities include administration, anaesthesiology, accident and emergency,
intensive care and psychiatry. However, results from an American survey on male
registered nurses revealed that respondents did not experience significantly less role
strain while working in a field congruent with the male gender-role (Egeland & Brown
1989). Bush (1976) argued that men would cross the gender boundary in occupations
such as nursing only if they have a personal contact which convinces them that the gains
will compensate for any negative sanction they may incur. Pressure experienced came
from parents, particularly fathers. Bush (1976) argued that the masculine role of men
may conflict with the affective and sympathetic roles that characterises nursing as
woman‟s occupation. With a third of the participants questioned about being “gay”,
Bush claimed that a major factor which contributes to keeping men out of nursing is the
attribution to homosexuality.
11
Eighteen years ago, the MoH in collaboration with Dr. Suliman Al-Sukait‟s private institute conducted a
study examining the occupational contribution of male graduates from all-specialities under the Health
Institutes (Al-Rabiah 1994).
58
Advantages and discrimination
It is claimed that gender stereotyping and gender discrimination are still observed in the
education and service segments of nursing (Williams 1995, Evans 1997, Jinks &
Bradley 2004, Stott 2004). In her literature review, Evans (1997, p. 227) argued that, in
nursing, power and prestige are becoming increasingly associated with the small
numbers of men occupying a disproportionate number of administrative positions.
Similarly, Stott (2004) claimed that male nursing students have high status and more
power than their female counterparts. Exploring the hidden advantages for men in
nursing, Williams (1995) carried out in-depth interviews with American male nurses.
Several participants reported experiencing a preference for hiring men in nursing for
their physical strength, technical competence, dedication, employment stability and
leadership abilities. However, two nursing professors felt their chances of promotion to
deanships were poor because the position was reserved for female colleagues. There was
a consensus among male participants that physicians treat male nurses more favourably
than female nurses.
In a cross-sectional study adopting a multi-method technique, Whittock et al. (2002)
examined the effects of gender and family-friendly policies on the career advancement
of NHS nurses. Interviews were conducted with managers, directors and CEO. Findings
highlighted different work patterns for men and women. The study indicated that male
nurses were more likely to be involved in tasks and responsibilities that enhanced
experiential learning, role development and thereby career opportunities and increased
salaries. Nevertheless, male nurses were more likely to express an intention of leaving
the profession in three years time. The authors suggested that it was often the male
managers‟ perceptions of men‟ and women‟ performance and capabilities which was
responsible for the female nurses‟ deteriorating career profiles. Davies (1995) called for
a profound change if the NHS is to demonstrate that it really values its “womanpower”
suggesting that progress may be judged by how successfully the NHS provides for the
lifetime participation of its nurses. In her book, Davies (1995) discussed reasons for and
consequences of a poor understanding of the gendered character of the NHS in the UK
59
context. She criticised the inadequacies of “womanpower” planning arguing that, unlike
doctors, nurses in the NHS have been viewed as disposable assets.
Reviewing the literature on male nurses in Canada, Britain and the United States
between 1900 and 2003, Evans (2004) argued that men‟s participation in nursing has
been shaped by social and political factors. The literature indicated that, for centuries,
men played an important but rather invisible role as nurses. Nevertheless, men have been
channelled into the prestigious and highly paid areas of specialisation and leadership
viewed as congruent with their masculine traits. Examining the Saudi male nurses‟
perceptions of nursing as an occupational choice and their status in man-controlled
societies and organisations appear to be areas that have never been explored in the Saudi
literature.
Support systems
Types of support systems discussed in the literature ranged from encouragement and
motivation offered by the family to appreciation, recognition and supportive policies
practiced by the employing institutions. Sources of support were found to reduce stress
and burnout and enhance satisfaction and retention (Moores et al. 1983, Mendez &
Louis 1991, Hamdi & Al-Hyder 1995, Alderman et al. 1996, Al-Johari 2001, Bradley &
Cartwright 2002, Mabel 2002, Callaghan 2003, Shelton 2003, Ward et al. 2003).
Support from family and significant others
Moores et al. (1983) found that the qualified female nurses involved in their study were
encouraged by their family and friends. Similarly, Ward et al. (2003) reported that
family members played a significant role in supporting and encouraging first year
nursing students to take up nursing as a career. Positive reinforcement from family,
friends and counsellors was also found to influence the choice of nursing as a career
(Mendez & Louis 1991). From a Saudi perspective, Hamdi and Al-Hyder (1995) argued
that encouragement and support from families have a positive influence on the uptake of
nursing as a career. Some Saudi high school female students had interest in nursing;
however, for work-related reasons this interest was opposed by their families (Al-Johari
60
2001). Similarly, high school students (males and females) have scored very low on the
intention of becoming a nurse (Al-Omar 2004). These students believed that their
families would not encourage such a decision.
Moreover, Day et al. (1995) argued that dissonance occurs when family and friends
maintain a lay nursing image which conflict with the students‟ new professional values.
It has been argued that the quality and nature of support offered by academic and clinical
staff to nursing students during their professional development is vital in modifying or
reinforcing nursing values and in alleviating dissonance (Day et al. 1995, Spouse 2000).
In reference to the support offered by academic and clinical staff, results from an
American survey showed that students who reported greater perceived support were
more likely to persist throughout the programme than students who withdrew either
voluntarily or because of academic failure (Shelton 2003). Examining the relationship
between perceived support and retention, the author suggested that students who are
struggling academically may not pursue means of support available to them.
Bradley and Cartwright (2002) examined the relationship between perceived social
support, job stress, health and job satisfaction among UK nurses. Survey results showed
that excessive stress, in relation to work-load and meeting deadlines, adversely affected
nurses‟ health and their job satisfaction. Support from different sources has different
outcomes; however, perceived organisational support was the only predictor of nurses‟
health and job satisfaction. Support from managers and co-workers was not necessarily
effective in reducing the negative impact of job stress. The author suggested that in
larger hierarchical organisations such as the NHS, first-line managers may have limited
control over resources. Consequently, nurses may perceive that these managers are not
in a position to address major sources of stress.
Recognition and appreciation
Western and Arabic literature has frequently reported that nurses continue to demand an
appreciation for working within a severe nursing shortage and for their contribution to
patient care. Lack of recognition may render nurses highly stressed and demoralised.
61
Alderman, Seccombe and Buchan (1996) discussed the responses obtained from a third
of the nurses who took part in a journal survey. A majority of the respondents disagreed
with the statement that nurses' morale was high. Problems with recruiting qualified
nurses, an increased work pressure, unpaid overtime and low pay were major issues
causing low morale and loss of nurses. The authors argued that challenges and problems
associated with nursing recruitment have an impact on nurses' morale and patient care.
Seccombe acknowledged that staffing levels have an adverse impact on the working
lives of the nurses and on their ability to provide quality care. Simultaneously, Buchan
emphasised that the survey results highlight worrying opinions of several hundred nurses
and reinforce the need for objective scrutiny of the factors influencing the nursing labour
market within the UK.
Findings from in-depth interviews with 58 nurses working in an NHS hospital ward
suggested that morale was very low (Callaghan 2003). A majority was considering
leaving the profession indicating they would discourage others from becoming a nurse.
A number of themes emerged in relation to low morale: low pay, a lack of support for
education, limited opportunities for promotion, lack of resources and job insecurity.
Similarly, Mabel (2002) and Mabel (2003) found that lack of support and appreciation
from employer, low inequitable pay, high job demands and extra shift work, poor
communication and lack of professional growth were all identified as affecting
motivation and retention among NHS staff nurses.
Job satisfaction
Job satisfaction is often identified as the most important factor contributing to improved
retention of qualified nurses. Low staffing level, increased work-load, uncompetitive
salaries, lack of autonomy and managerial support in relation to advancement
opportunities, decision-making and participation in scheduling were frequently cited as
having major impact on nurses‟ job satisfaction (Shields & Ward 2001, Laschinger et al.
2001, Aiken et al. 2001, Cowin 2002, Ma et al. 2003, Hoffman & Scott 2003). These
issues were consistent with the ones reported by Arab authors (Zuraikat & McClosky
1986, Ghazi et al. 1994). In contrast, continuing education, flexible scheduling and
62
working hours were frequently cited by Saudi female nurses to improve their working
conditions (El-Gilany & Al-Wehady 2001). Nevertheless, the majority of the female
nurses involved in the latter study was satisfied with their place of work (government
sector) and assigned unit (female and paediatric wards or clinics). Recognition, technical
aspects of supervision, work conditions, utilization of skills, pay, and job advancement
were determinants of job satisfaction cited by 500 Saudi hospital nurses (Al-Ahmadi
2002). Recruiting a multi-national sample of nurses working at the government hospitals
in Riyadh, Al-Aameri (2000) found that old nurses are more satisfied and committed to
their hospitals than the young ones. Arab nurses including Saudis were found to be the
most committed group.
Work environment issues particularly those of un-preferred shift pattern, unpaid
overtime and unfair grading were found to reduce job satisfaction (Shields & Ward
2001). The authors suggested that job satisfaction is the most important determinant of
the intention to quit among NHS nurses. Results indicated that dissatisfaction with work
was significantly greater for young, male, ethnic minority and highly educated nurses.
Arguing that nurses are not a homogenous group, Tovey and Adams (1999) suggested a
need to develop different job satisfaction measures for the different nursing grades, and
a need for future research to examine the changing nature of nurses' job satisfaction over
time. Professional opportunities, recognition, autonomy and remuneration were career
issues of great concern for nurses particularly the newly qualified (Cowin 2002,
Hoffman & Scott 2003, Ma et al. 2003). Cowin‟s multi-group longitudinal design
indicated that job satisfaction remained stable with time for the experienced nurses; their
comments reflected issues of burnout, excessive stress and a perception of poor public
images (Cowin 2002). Many participants also commented on the difficulties they faced
during the transition from students to registered nurses.
A wealth of North American literature has examined nurses' job satisfaction (Laschinger
et al. 2001, Aiken et al. 2001, Ma et al. 2003, Hoffman & Scott 2003). A sample of
Canadian nurses indicated that structural empowerment in their work place (access to
information, resources, support and opportunities) resulted in higher levels of
63
psychological empowerment (Laschinger et al. 2001). Psychological empowerment
(confidence and autonomy) had an impact on their work, reduced work strain and
influenced job satisfaction. The job satisfaction of 60% of American RNs remained the
same or had decreased over the past two years (Ma et al. 2003). Those with more years
of experience were less satisfied. Results indicated that satisfaction is influenced by job
position associated with long working hours, stressful workload and lower
compensation. Nurses whose job positions were other than staff nurse, charge nurse,
clinical nurse specialist and nurse manager had the highest levels of job satisfaction.
Similarly, Hoffman and Scott (2003) found that the registered nurses working 12-hour
shifts were younger, less experienced and more stressed than the nurses working 8-hour
shifts.
The nursing shortage and increased dissatisfaction among hospital-nurses have not been
unique to the USA. Similar reports were obtained from 43,000 nurses in the USA,
Canada, England, Scotland and Germany (Aiken et al. 2001). High proportions of
registered nurses in all countries under study, with the exception of Germany, were
dissatisfied with their jobs. However, the percentage was much higher among American
nurses. Many nurses across the five countries were experiencing considerable job-related
strain. More than three in ten nurses in England and Scotland and more than two in ten
in USA were planning to leave their jobs within the next year.
Nursing policies and regulations
The influence of family support and job satisfaction on the recruitment and retention of
nurses have been covered in the Saudi literature. In contrast, examining the impact of
support systems such as organisational characteristics and nursing policies continue to
represent areas which need to be further explored by future Saudi research.
Qualified nurses may leave for different reasons including increased stress, low morale,
and lack of job satisfaction. They may also leave for family reasons such as pregnancy
and child care. National regulations and organisational policies addressing nurses‟
concerns were highlighted in several Arabic and western studies as important factors to
64
overcome challenges facing nursing recruitment and retention (DoH 2006, ICN 2007).
Addressing nurses‟ perceptions of the deficiencies in hospital organisation, work design
and patient care, Aiken et al. (2001, p. 51) argued that in order “to retain qualified nurses
in a competitive labour market, hospitals need to develop personnel policies and benefits
comparable to those in other lines of work and businesses”. These policies and benefits
should include: life-long professional development, opportunities for career
advancement, flexible scheduling, competitive salaries and improved work design, work
climate and workforce management. Similarly, Al-Moaiqel (1991) suggested that Saudi
hospitals need to adopt flexible scheduling options, establish efficient support services
and offer wage differentials for evenings, nights and weekends.
Nurses from the agency and independent sectors indicated that returning to work in the
NHS is quite unlikely (Coombs et al. 2003). Greater level of recognition, improved pay
and more flexible working hours appeared necessary before the leavers consider
returning to the NHS. These findings suggest that nursing was perceived as hard work
involving high levels of pressure and stress. Pregnancy and child care may be the main
reasons for leaving the NHS reflecting that nursing is largely a female profession.
Leavers have cited lack of child care facilities as their main reason for not returning to
the NHS (Moores et al. 1983, Price Waterhouse 1988, Whittock et al. 2002). Qualified
female nurses cited having a young child as the primary reason for their inactivity
(Moores et al. 1983). However, a large pool of these English nurses was keen to resume
work provided there was flexibility in working hours to allow for family commitments.
Nurses working in hospitals with a retirement system plan have indicated a higher level
of satisfaction; however, 84% of the hospitals in the United States were reported to be
taking part in such a plan (Ma et al. 2003).
Magnet hospitals
In North America, hospitals that have organisational features known to attract new
graduate nurses and retain the qualified ones are designated as magnet hospitals
referring to their reputation for attracting and retaining nurses (Huerta 2003).
Characteristics attributed to magnet hospitals are: an interactive management style,
65
decentralised organisational structure, competitive personnel policies, professional
practice and professional development. Aiken et al. (2000) reported that the magnet
designation was originally granted by the American Academy of Nursing to a group of
hospitals that were able to successfully recruit and retain highly qualified nurses in a
competitive market of a national nursing shortage in the early 1980s. The positive
effects attributes such as effective leadership, autonomy and collaborative professional
relationship have on nurse retention and satisfaction were consistent in all research
concerned with magnet hospitals (Scott et al. 1999). However, the lack of information
on non-magnet hospitals, authors maintain, has made it difficult to claim that these
positive characteristics are not also present in other hospitals.
Interview findings with Iranian RNs suggested that the workplace and working
conditions are important variables for the improvement of professional identity in
nursing (Nasrabadi & Emami 2006). A more supportive and encouraging environment
was believed to improve work conditions, enhance retention within and subsequently
recruitment into nursing. Magnet characteristics and designation are not used to monitor,
evaluate or accredit Saudi hospitals. With less than 5% of its nursing workforce as
Saudis (MoH 2006), there is no record that hospitals under the private sector have
attempted to examine its Saudisation policies and magnet reputation.
In summary, compared to the Saudi literature, the western literature on recruitment and
retention of nurses was more diverse and comprehensive. It covered a range of factors
which were grouped under the following concepts: demographic changes; nursing
images; status of nursing; nursing education; gendered-nature of nursing; nursing
support systems; the changing labour market; and nursing as an occupational choice.
Examining these concepts require more than one research study. Thus, to best serve my
research inquiry, six key concepts were selected to be used as a guiding framework.
These are: nursing images, status of nursing, perceptions of nursing as an occupational
choice, nursing education, gendered-nature of nursing and nursing support systems
(including Saudisation).
66
The literature provided evidence that the problem of recruitment and retention is
multifactorial. Since my research interest is to understand influences on recruitment and
retention which are, consequently, causing a shortage of Saudi nurses, I decided to use
the above concepts to gain a comprehensive understanding of how they might influence
Saudi nurses‟ perceptions of nursing as an occupational choice. A focus on involving
male as well as female nurses, obtaining their views and drawing on their experiences is
one of the identified gaps in the Saudi literature.
To date, nursing images and status of nursing have been frequently identified as major
factors influencing the recruitment and retention of nurses. In spite of the well-respected
images of early Muslim nurses who were recognised by Prophet Mohammed, negative
images such as nursing being an occupation for the educationally and economically
disadvantaged women continue to persist in Saudi Arabia. In terms of status, nursing has
been perceived as subservient, menial and similar to domestic service. Moreover, nurses
have been viewed as assistants to medical doctors. An interrelation between prevailing
negative images and the low status of nursing has been documented wherein one is
influencing the other.
The emergence of nursing education as technical rather than academic and diploma level
rather than BSN influenced its perception as unskilled and less professional type of
occupation; this has further contributed to its perceived low status. Combined, the
technical type of education, negative images and low status accorded to nursing, have
influenced its attractiveness, appeal and popularity as an occupational choice. In spite of
being perceived as an occupation that does not meet the criteria for an ideal or socially
acceptable career, the literature highlighted humanitarian and religious motives such as
a desire to help and work with people as the most popular reasons for choosing nursing.
Furthermore, nursing support systems, such as the family and teaching staff;
organisational characteristics; nursing regulations; and personnel policies, were found to
influence the choice of nursing and the subsequent decisions to continue as nurses and to
pursue a career in nursing. At a time of severe nursing shortage, a support system such
67
as the implementation of Saudisation policy has been seriously considered to increase
the participation of Saudis in a foreign-majority nursing workforce. Gender issues
including nursing stereotypes, gender-roles, advantages and discrimination and career
aspirations, have influenced women and men‟s occupational choice. Examining the
gendered nature of nursing from the perspective of Saudi men and women is one of the
identified gaps in knowledge.
Conclusion
The purpose of this literature review was to identify the main factors impacting on the
recruitment and retention of nurses. The prevailing images and perceived status of
nursing as an occupational choice in Saudi Arabia formed the basis for a personal
interest to explore what might encourage Saudi men and women to join nursing and
what might keep those who graduate within nursing particularly at the in-patient units.
Throughout, attention has been drawn to areas which have attracted considerable
research efforts and to those where little attention has been paid. Six concepts were
selected to serve as a guiding framework for the study in hand and to assist in
understanding influences on recruitment and retention. They included: images of
nursing, status of nursing, nursing education, perceptions of nursing as an occupational
choice, gendered-nature of nursing and nursing support systems.
The Saudi literature yielded a variety of studies which looked at the impact of prevalent
images of nursing and perceived status of nurses on the uptake of nursing as an
occupational choice. However, there is a need to examine the impact of these factors on
Saudi nurses‟ perceptions and on their decisions to become nurses and to continue
working as nurses. A topic that has been fairly well covered in the western literature.
Despite involving nursing and non-nursing groups, the Saudi studies focused mainly on
the factors contributing to social images and professional status of nursing. In contrast,
the western studies have further examined the social and professional images and
differentiated them as entry images, experience-acquired images and media images.
Some western studies also explored and discussed nursing students‟ occupational
socialisation. These areas need further attention in future Saudi nursing research.
68
In studying the perceptions associated with the choice of nursing as an occupational
choice, the western literature examined factors such as job characteristics, job values,
age and gender highlighting the various influences on the occupational choices of the
individuals. For instance, some western studies highlighted the difference between
nurses who make their career choice early in age and those who choose nursing later in
life. Whether in relation to nursing or to any other occupational option, the Saudi
literature lacks this type of research. With more men deciding to join nursing, there was
a growing interest among western researchers to compare and contrast the influences on
why men and women choose nursing. They also examined gender stereotyping and
nursing specialities; and gender-related advantages and discrimination. These areas were
not investigated in the Saudi literature and seem to be overlooked by the Saudi and
Arabic authors concerned with recruitment and retention of nurses. Family support and
job satisfaction were addressed as major factors influencing the recruitment into and
retention within nursing; these issues were fairly covered by the Saudi studies. However,
examining the impact of support systems such as organisational characteristics and
nursing policies on the recruitment and retention of nurses appeared as areas which need
to be further explored by future Saudi research.
This chapter had also highlighted gaps in Saudi nursing research and provided a base
from which this research project was developed. The reviewed literature provided
evidence that there is a need for a qualitative design to draw upon the views, opinions
and experiences of different groups of the Saudi nursing population. There is a need to
involve Saudi male nurses; an important group who had hitherto been excluded from
previous nursing studies. There is also a need to examine the implementation of
Saudisation national policy at organisational level and to explore its impact on nurses'
recruitment and retention.
69
Chapter Three
The Research Process
Introduction This chapter sets out the justification for the use of a qualitative design as a
methodological framework for the study. The chapter covers detailed description of the
sequence of the research process starting from the development of the research question
and the choice of semi-structured interview technique through to getting permissions,
gaining access, piloting the interview guides, and the data collection phase. Ethical
issues are highlighted. The last section of this chapter discusses the three techniques
employed for data analysis.
The research question
The process of thinking about an interesting research problem started with the
application for a PhD programme in the United Kingdom. Recruitment and retention of
Saudi female students to the new nursing programme at Dar Al-Hekma College was one
of the responsibilities assigned to me as acting Vice Dean for Students Affairs. I had
been involved in planning and designing the nursing programme as well as promoting
nursing as a viable career option.
After arriving at the University of Nottingham and attending several meetings with my
supervisors, I came to realise the wide scope of an area of interest such as recruitment
and retention. As an initial attempt, my first report had eight broad research questions all
concerned with the recruitment and retention of Saudi nurses. The processes of
conducting a literature review and discussion during supervision were instrumental in
focusing and narrowing down my research inquiry. Eventually the five initial broad
questions were reduced to one:
70
Q. what are the Saudi nurses‟ perceptions of the social, cultural, economic and political
influences on nursing as their occupational choice?
To meet the purpose of the research inquiry, a qualitative design adopting semi-
structured interviews was employed; the research design attempted to achieve the
following objectives:
1. To access participants‟ views and opinions of social and employment factors that
shaped their experiences of becoming and being a nurse.
2. To compare and contrast the participants‟ accounts on what brought them into
nursing and what is encouraging them to or discouraging them from pursuing a
career in nursing.
3. Where applicable, to examine the participants' views regarding the impact of
Saudisation Policy on their nursing education, training, employment and career
advancement.
The research design
Why qualitative approach?
Miles and Huberman (1994) argued that building a conceptual framework “forces you to
be selective – to decide which variables are most important, which relationships are
likely to be most meaningful, and, as a consequence, what information should be
collected and analysed”. They also suggested that “frameworks can be rudimentary or
elaborate, theory-driven or commonsensical, descriptive or causal”. However, using a
conceptual framework is not about importing a methodological theories wholesale into
the proposed research. Rather, a robust and defensible conceptual framework requires an
engagement with the theories deployed by other researchers in the field and a process of
synthesising their theoretical perspectives into working assumptions through a process
of critical reflection (Silverman 2007).
71
Indeed, reviewing the literature was instrumental in guiding the selection of concepts
found to influence recruitment and retention of Saudi nurses. The literature also
suggested a need for a qualitative approach that provide the Saudi nurses with
opportunities to talk about their experiences and express their views instead of being
asked to select from predetermined responses. An approach that generates qualitative
data, in the form of individual accounts and personal views, necessary to supplement and
explain previously reported quantitative data. Pope et al. (2006) and Miles and
Huberman (1994) argued that findings of qualitative studies are useful to complement
and validate previous quantitative work.
The decision to adopt a qualitative approach posed challenges. Permissions and
approvals for research proposals in Saudi Arabia lie mainly in the hands of professionals
not trained in qualitative research methods. Nevertheless, I decided to explore qualitative
research and employ a qualitative method to answer my research question. The social
change in terms of advancement in education and healthcare services has given me
assurance that it was the right time to undertake nursing research using what might be
considered „non-traditional‟ methodology. For example, talk-show programmes have
become very popular among Saudi people; these programmes cover varieties of topics
that invite audience participation. Moreover, Saudi women have been receiving more
attention from the mass media. They are invited to take part in television and radio
programmes and they are encouraged to write in local and regional newspapers about
their expanded roles. School and college students especially from the private sector have
been increasingly interviewed for journals or newspaper articles or even for television
youth programmes.
An interpretivist approach was employed. Interpretation of meanings was made by both
the participants and myself as a researcher. In presenting the interpretivists‟ position,
Miles and Huberman (1994) highlighted that interpretivists are not “detached” from their
context of study. They continue that for interpretivists “researchers have their own
understandings, their own convictions, their own conceptual orientations; they are
members of a particular culture”.
72
Whose voice to be heard?
The target population was Saudi nurses; nevertheless, there is a need to recruit more than
one sample group from the Saudi nursing population; a sample that involves nurses with
a variety of backgrounds in terms of education, work experience, place of study or work,
and tribal/non-tribal affiliation. There is also a need to invite the participation of Saudi
male nurses; a group who had hitherto been excluded from previous nursing studies. As
such, the following three groups were selected: nursing students, staff nurses and senior
nurses. Nurses from these groups represented „the insiders‟; those who studied or were
still studying nursing, and those who were working or pursuing a career in nursing.
Their voices, views and experiences were believed necessary in answering the research
question and enriching the study.
To fill in the above gaps in knowledge, three methodological decisions were taken. First,
a qualitative design was selected to understand areas of interest and answer the research
question. Second, a semi-structured interview technique was adopted for the data
collection process. Third, a purposive sampling technique to recruit participants from the
groups identified above.
Interviewing as a qualitative technique
In order to achieve the set objectives for the study, my plan was to select a sample of
Saudi nurses with a variety of backgrounds, provide them with opportunities to talk and
get their views on literature-guided concepts. Views and opinions are best expressed
through participants‟ own words; words are one form of qualitative data that can best be
collected using qualitative interview. The time and freedom made available for the
participants to talk and express their views in words highly depend on the choice of the
interview technique. Murphy and Dingwall (2003) described the range of qualitative
interviews as a continuum where at one extreme, the researcher may introduce a broad
topic and invite participants to contribute without any attempt to constrain or direct the
talk. While at the other end, the researcher has a clear set of issues or list of questions to
be covered during the course of the interview.
73
With reference to the above continuum, semi-structured interviews covering concepts
derived from the literature were considered to be the most appropriate type of interview
techniques. It has been employed in previous research into nursing morale (Callaghan
2003), perception of nursing in the NHS (Coombs et al. 2003) and nursing images
(Kiger 1993), and has proved effective particularly when the aim is to explore,
understand and describe. Barriball and While (1994) emphasised that semi-structured
interviews are “well suited for the exploration of perceptions and opinions”. Emphasis
of the qualitative interview is on what participants say or raise when responding to
questions informed by the literature. Britten (1996) suggested that all interviews have a
structure of some kind to guarantee that the data gathered would answer the research
question. She also emphasised that “the researcher needs to remain open to the
possibility that the concepts and variables that emerge may be very different from those
that might have been predicted at the outset” (Britten 1996, p.29). Participants had also
the freedom to respond and were encouraged to clarify issues raised during the
interviews that were not anticipated at the outset of the research.
Moreover, Morse and Field (1996, p. 76) argued that “the semi-structured interview is
used when the researcher knows most of the questions to ask but cannot predict the
answers”. Indeed, the designed semi-structured format ensured that the information
required was obtained. The focus was on obtaining qualitative data in the form of
nurses‟ views, opinions, perception and individual accounts. Such data was necessary to
assist and enhance my understanding of what might bring Saudi men and women into
nursing and what might keep them working at hospital-based in-patient units. Moreover,
personal views and individual accounts were necessary to explain the impact of selected
concepts on the recruitment and retention experiences of the participants. However, the
accounts recorded during the interviews represented the views of the participating
students, staff nurses and senior nurses as drawn from their own experiences within the
settings under study and at the time of the interview.
Furthermore, one of my research objectives was to compare and contrast responses
obtained from a sample of nurses with different characteristics. The choice of semi-
74
structured interviews was therefore guided by the multiple-case nature of the study. This
interview technique was proposed for cross-case comparability (Bryman 2001).
Huberman and Miles (1994, p. 431) suggested that a tighter design is indicated when the
researcher “takes more explanatory and/or confirmatory stance involving multiple,
comparable cases”.
Interviewing, transcribing and analysing are time consuming processes; Despite being,
often, questioned with regard to subjectivity and bias, qualitative data obtained from
participants who represent different backgrounds and diverse experiences was expected
to add confidence to findings (Miles & Huberman 1994). Moreover; the semi-structured
interviews, which covered literature-guided concepts identified as influencing
recruitment and retention of nurses, were instrumental in generating a range of views
expressed by the participants. This was expected to be a strength that outweighed some
of the weakness of the technique.
Setting
Study setting
The study was carried out in Jeddah the second largest city after Riyadh the capital and
where I reside and work. It serves as the main sea-port and air-gate for the two holy
cities of Makkah and Maddinah. Jeddah has a population of three million people who
come from different ethnic and cultural backgrounds.
Jeddah has one of the eight main universities in the Kingdom and the second oldest of
four university-level nursing programmes. In terms of nursing education, Jeddah has
four baccalaureate nursing programmes (BSN) for female students (government and
private) and nine Associate Degree and diploma programmes for female and male
students (government and private). Jeddah also has a wide range of government, other-
government and private hospitals providing healthcare for its population. While
government sector included MoH and university-linked teaching hospitals, the other-
government sector included hospitals under the Armed Forces, National Guard,
ARAMCO oil company and King Faisal Specialist and Research Centres.
75
Sampling strategy
Selected hospitals and academic institutions
Sampling in qualitative research tends to be purposive rather than random (Miles &
Huberman 1994). These latter authors made two emphasis: 1) the need to set boundaries
which define aspects of the cases to be studied within the limits of time and means; and
2) the need to create a frame to uncover, confirm, or qualify the constructs within the
study. The MoH Annual Statistic Book for 2006 reported that the proportion of Saudi
nurses at the MoH, other-government and private sectors were reported as 41.5%, 17.5%
and 4% respectively. Purposive sampling of hospitals has, therefore, ensured the
recruitment of educational and training facilities with variable resources allocated for
Saudisation purposes and a magnet reputation which placed them on the preference list
for the Saudi nursing students and graduates. Private hospitals were, therefore, excluded
from this study because with only 4% Saudi nursing workforce they do not meet the
above criteria. Moreover, Saudi nurses from the MoH and other-government sectors
represented the majority I was seeking to inform the study and answer the research
question. Selected hospitals included: 1) the University Hospital (government), 2) King
Fahad General Hospital (government), 3) King Faisal Specialist and Research Centre
(other-government), and 4) the National Guard Medical Centre (other-government).
Similarly, the selection of academic institutions was made to ensure the following
factors were represented in the final sample: a well established nursing programme; a
nursing programme ratified by the MoHE and/or Saudi Council for Health Specialties;
running either 4-year BSN or 2/3-year diploma and/or associate degree programmes; and
for the diploma and associate degree programmes to have both male and female students
enrolled. In the light of this, the following institutions were recruited: 1) King Abdul-
Aziz University (BSN programme for females, government), 2) Dar Al-Hekma College
(BSN programme for females, private), 3) Allied Health College for female students
(associate degree programme, government), 4) Allied Health College for male students
(associate degree programme, government), and 5) Saudi German Nursing Institute for
female and male students (diploma programme, private). Up until the designated time
for data collection, the other-government sector had no nursing programme in Jeddah;
76
this sector was, therefore, excluded from the sampling strategy. However, by September
2006 a baccalaureate programme for women was launched.
The target population
Miles and Huberman (1994) and Bryman (2001) argued that generalisation in qualitative
research is not “sample-to-population”. Rather, it is proposed that the themes generated
and insights gained from this study, when established through consistency with the
concepts derived from the literature, will provide a basis for application to a wider
context of nursing recruitment and retention in Saudi Arabia. Thus, my sampling
approach was purposive. I decided to seek out different individuals at various settings
where nursing is experienced in its taught and practiced forms. Selection was made to
ensure that the final sample represented different settings and a wide range of
experiences and views. As such, the target population was Saudi nurses with a variety of
backgrounds in terms of education, work experience and place of study or work. The
following three groups were selected: nursing students, staff nurses and senior nurses.
Nurses from these groups represented “the insiders”; those who studied or were still
studying nursing, and those who were working or pursuing a career in nursing.
Nursing students
This group included nursing students from the 4-year BSN and 2/3-year diploma or
associate degree programmes representing government and private sectors. A sample of
fresh recruits, halfway through students and those who were undertaking their internship
period was recruited for the study. Since the first year of the government and private
diploma programmes is a foundation year for all students registered under any health
specialities, a sample from the second and third year students was recruited. Being
recently established, the private sector did not have all levels of nursing education;
sampling therefore included students from the different available levels. For example
both private programmes did not have nurse interns as yet.
Staff nurses
Members of this group represent those who studied nursing, graduated from one of the
selected nursing programmes and were working as staff nurses during the time of data
77
collection. Recruitment from this group was made based on the following criteria: 1)
being Saudi nationals; 2) having a baccalaureate or an associate degree in nursing; 3)
having a staff nurse post at an in-patient unit in one of the selected hospitals; 4) having a
minimum of three years working experience; and 5) residing and working in Jeddah.
Staff nurses were purposively recruited from in-patient units not out-patients because
that where the shortage is. Alawi and Mujahid (1982) and Tumulty (2001) have both
reported that most married female Saudi nurses opt to work at out-patient units and
primary care centres. According to MoH latest statistic, compared to 33% at hospitals
settings (including outpatient departments), more than 60% of the nursing workforce at
the primary care centres is made of Saudis (MoH 2006). The minimum three years
experience in the current nursing post was necessary to ensure post-related experience
and stability of employment. Since the number of Saudi male nurses working at the in-
patient units is smaller than that of the females, it was anticipated that male participants
in the staff nurses‟ group would be less than the females.
Senior nurses
This group included the small number of nurses with advanced qualifications and
longest years of experience. Selection of participants was made based on the following
criteria: 1) being Saudi nationals; 2) having minimum Master Degree in Nursing; 3)
having a minimum of three years experience as an academic or manager at one of the
selected academic institution; 4) having a minimum of three years experience in a
managerial position at one of the selected hospitals; and 5) residing and working in
Jeddah. The minimum three years experience in the current nursing post was necessary
to ensure post-related experience and stability of employment. With a small number of
Saudi nurses holding senior status within a female dominated occupation, it was
anticipated that male participants in the senior nurses‟ group would be significantly less
than the females. Up and until the pilot study, I was not aware of any Saudi nurse
working at the private academic institutions invited for the study. However, by the time
of data collection, I came across a female nurse who meet the criteria of the senior
nurses‟ group and who had recently moved from a government hospital to one of the
private academic institutions. With a working experience at two different sectors, a
78
decision was made to invite her to take part. Members of this group were, once, school
graduates looking for academic programmes and career opportunities. They had worked
as nurses and progressed up the career ladder. They were involved in the promotion of
nursing and the recruitment as well as retention of nursing students and graduates.
Bearing in mind that the students‟ group is the largest within the Saudi nursing
population, I planned to recruit a minimum of five students from the five selected
academic institutions which represent government and private sectors (table 1). Taking
into consideration that the number of senior nurses is very small (Lovering 1996), I
planned to recruit a sample of staff nurses and senior nurses with a ratio of 2 to 1 (table
1). As such, the anticipated target sample ranged between a minimum of 25 students, 16
staff nurses and 8 senior nurses and a maximum of 35, 23 and 12 respectively.
79
Table 1: Target Sample
Sampling
Groups
Government
Other-Government
Private
Anticipated
Minimum
Total
Students
5 students each
from 3
institutions = 15
(including a
minimum of 3
male students)
No students
within this sector
5 students each
from 2
institutions = 10
(including a
minimum of 2
male students)
25
Staff
nurses
4 nurses each from
2 Hospitals = 8
(including a
minimum of 2
male nurses)
4 nurses each from
2 hospitals = 8
(including a
minimum of 2
male nurses)
Not sampled
due to group
making up less
than 5% of
Saudi Nursing
Workforce
16
Senior
nurses
1 senior nurse
each from 2
hospitals
And
1 senior nurse
each from 2
Academic
institutions = 4
(including a
minimum of 1
male senior nurse)
1 senior nurse
each from 2
hospitals
And
1 senior nurse
each from 2
Academic
institutions = 4
Unaware of
senior nurses
employed in this
sector
8
Indeed the final mixed sample allowed me to view nursing recruitment and retention
through different eyes, collect a wide range of accounts and come to an understanding of
reasons for the variation or similarities in perspectives. Morse and Field (1996) have
suggested two principles for the selection of a sample for qualitative studies. First, the
identification of participants who can best inform the research; and second, the
recruitment of sufficient participants to develop a full and rich description of the
phenomenon. Variation was intended to bring about an insight into what might impact
80
on the recruitment of new Saudi nurses and the retention of graduates particularly at the
in-patient units. Maykut and Morehouse (1994) emphasised that the variability common
in any social phenomenon should be represented in the data. Multiple- case sampling
helped in reducing potential bias which one group of nurses or one sector may have
created (Patton 1990, Maykut & Morehouse 1994). It was anticipated that such a broad
selection of sample would “strengthen the precision, the validity, and the stability of the
findings”; hence, adding confidence to findings (Miles & Huberman 1994).
Access and permissions
Before commencing the main work of data collection, there was a need to go to Jeddah
for an introductory visit. This visit, (first phase of the field work), was necessary to
obtain ethical approval and pilot the interview guides. It took place between mid April
and end of May 2005. The time was also used to initiate the long processes of obtaining
permission, gaining access and making arrangement with the selected hospitals and
academic institutions. As my formal sponsor, the Ministry of Higher Education sent me
a written approval to go for the field work trip (Appendix 1 – 1). On behalf of my
sponsor, the Saudi Cultural Attaché in London provided me with introductory letters
addressed to the selected hospitals and academic institutions to facilitate access,
recruitment of participants and the advanced preparation for the main data collection
phase (Appendix 1 - 2).
Ethical approval
Upon arrival to Jeddah on the 15 th
of April 2005, I visited Dar Al-Hekma College and
enquired about the meeting schedule for the College Council. Accordingly, the research
proposal was submitted for review by Dar Al-Hekma College Council on the 20 th
of
April 2005. Signed and dated ethical approval is attached (Appendix 1 - 3). Within a
Saudi context, such approval is equivalent to those granted by any Ethical Committee at
any United Kingdom based academic institution.
Since the field work and data collection phase of the proposed study was to take place in
Jeddah - Saudi Arabia, the policy of the Nursing School – University of Nottingham,
81
then, was to obtain Ethical Approval wherever possible local to where participants
would be recruited provided such a system was in place. This was done and I obtained
ethical approval from Dar Al-Hekma College Council which was accepted by the other
academic institutions and government hospitals.
Obtaining permissions to access the selected facilities
Anticipating the bureaucratic processes involved in granting an outside researcher a
permission to access a facility for research purposes, I had to implement a different
strategy for the different hospitals and academic institutions. Strategies used to gain
access to nursing students, staff nurses and senior nurses acknowledged the hierarchies
of power and consent. Examples for the steps involved in obtaining permissions to two
different facilities are illustrated in the enclosed flow charts. Written permission to
access the five academic institutions are attached in Appendix 1 - 4 to 1 - 8. Obtaining
these permissions took four to eight weeks. With reference to the selected hospitals, the
two government facilities (the University Hospital and King Fahad General Hospital)
accepted Dar Al-Hekma Ethical Approval. However, the policy at the two other-
government hospitals required that my research proposal be reviewed by their Ethical
committee before approval is granted. Written permissions to access the four hospitals
are attached in Appendix 1 - 9 to 1 - 12. Obtaining these permissions took four to eight
weeks.
82
Flow Chart 1
Illustrating the Process Involved in Obtaining Permission to Access Other-Government Hospital
Written Permission
(after 8 weeks)
Introductory Letter from Saudi Cultural Attaché (London)
Ethical Approval
Dean of Applied Medical Sciences (Female Division)
All Documents
Ready?
Dean (Male Division)
Yes
Yes
Proposal
reviewed by Dar Al-Hekma
College Council (Jeddah)
Prepared &
Hand-delivered Research Proposal
Received an Approval for Field Work from Ministry of Higher Education (Riyadh)
83
Flow Chart 2 Illustrating the Process involved in
Obtaining Permission to Access Other-Government Hospital
Director of Nursing at the selected
Other-Government Hospital
Hospital Director
Ethical
committee to review Research
Proposal
Written Permission
(after 8 weeks)
Introductory Letter from Saudi Cultural Attaché
(London)
Ethical Approval
All Documents
Ready?
Yes
Yes
Proposal reviewed by Dar
Al-Hekma College Council
(Jeddah)
Prepared & Hand-delivered
Research Proposal
Received an Approval for Field Work from Ministry of Higher
Education
(Riyadh)
Ethical
Approval
84
Approach and consent
With the written permissions to access facilities and to recruit participants, I arranged
visits to every hospital and academic institution where I met with Directors of Nursing,
Programme Directors and even Deans for the Schools of nursing. They were welcoming
and supportive; they assigned a coordinator to facilitate the process of recruiting
participants and conducting interviews. At the academic institutions, the coordinators
had lists of students who met the criteria; however, I chose not to look at them so that I
did not get influenced by particular family names or tribes. Selection of participants was
made by choosing the desired number of students from the registry list where every
student has a serial number. The coordinator maintained a record of the names, year of
study and contact numbers. Two backup candidates from each level of study at every
institution were initially selected in case of refusal or cancellation. With a minimum of
25 nursing students from the five selected academic institutions, more students were
recruited from the large and well established institutions. Taking in consideration that
there is no available baccalaureate programme for male students, more male students
were recruited from the diploma programmes. For example, being the oldest and largest
institution, twelve female students were recruited from the available 500 at the
baccalaureate government programme. In contrast, three male students were recruited
from the private diploma programme compared to two females. Nine male students were
recruited from the government diploma programme compared to six females.
At the selected hospitals, coordinators provided me with a list of the Saudi nursing staff,
their date of hire, their current post and number of years on the current post. For ethical
consideration, names were kept hidden. According to the set criteria, the coordinator and
myself identified the number of nurses who fell into either the senior nurses‟ or staff
nurses‟ group. For convenience, staff nurses working day shifts were recruited for the
study. Since Saudi nurses at the in-patient units used to work day and night shifts, such
selection did not exclude those who work nights. Moreover, interviewing nurses during
the day shift facilitated convenient coverage for the participants during the time of
interviews.
85
When the available number of nurses was more than that required by the study, which
was sometimes the case for staff nurses, I tended to select potential candidates from the
list where every nurse has a serial number. Two more nurses were selected as backups in
case of refusal or cancellation. For example, the total number of Saudi nurses at one of
the government hospital was 56 female nurses of which one was working as a
Saudisation and Training Coordinator. Out of the 15 staff nurses working at the in-
patient units, only nine had three or more years of experience. The Saudisation and
Training Coordinator was invited to represent the senior nurses‟ group and four staff
nurses were finally selected to represent the hospital‟s share of this group in the study.
To give potential participants the freedom to accept or refuse participation, the
coordinators at the different facilities initiated contact with them, provided information
about the visiting researcher and distributed the Participants‟ Information Sheets
(Appendix 2). Students were encouraged to share the information sheets with their
parents before deciding to take part in the study. Meetings were then arranged with
potential participants who agreed to take part. During the meetings, I introduced myself,
made sure they had read the information sheet and discussed the nature of the study, the
interview technique and the use of a tape recorder. Furthermore, I emphasized the
voluntarily nature of participation and the participants‟ right for privacy and
confidentiality.
Approaching and talking with potential participants had helped in creating interest in the
study, building trust and stimulating confidence. Hence, potential recruits who might
have been hesitant about participating initially were able to think and consider.
Nevertheless, two male students from the potential candidates at the private academic
institution expressed no interest in taking part in the study. Both were in their first
semester of the nursing programme; they did not want to be interviewed and preferred
filling a questionnaire. The reason they gave was that they had difficulty in expressing
themselves verbally. Barriball and While (1994) have argued that face-to-face contact
with potential participants has three positive outcomes. First, it will increase interest and
confidence in the research as familiarity with the researcher grows. Second, potential
86
recruits who were hesitant about taking part initially were able to ask questions and
think about the research project. Third, the researcher will be able to discuss reasons for
not participating with those who wish not to take part.
As requested by the General Directorate in Riyadh, my husband as a male guardian was
the one who initiated contact and planned initial visits with the director of the nursing
programme at the Ministry of Health Allied Health College for male students. Although
I had a plan with few alternatives, unexpectedly, the director offered that I meet the male
students at the college facility as long as I was accompanied by my husband. My first
visit to the directors‟ office was to select potential participants for the study. The director
assigned one of his clerical assistants to contact the selected students, explain about the
research, distribute the participants‟ information sheet and encourage potential
participants to call me if they needed any further clarifications. Five days later, the
director called to arrange times and dates for the interviews. The six students were
spread over two mornings and interviews were conducted in an office located just few
steps from the college entrance. Meeting and interviewing the male interns were
arranged through the Nursing Education department at the hospital where the three
participating student-interns were undertaking their internship period.
87
Preparing and commencing the research interviews
The interview guides
As presented in table 2, the final sample was made of: 38 nursing students (26 F + 12
M), 21 staff nurses (16 F + 5 M) and 9 senior nurses (8 F + 1 M).
Table 2: Actual Sample
Sampling
Groups
Government
Other-
Government
Private
Total
Students
18 Females +
9 Males = 27
-
8 Females + 3
Males = 11
26 Females + 12
Males = 38
Staff nurses
8 Females +
3 Males = 11
8 Females +
2 Males = 10
-
16 Females + 5
Males = 21
Senior nurses
6 Females
1 Female +
1 Male = 2
1 Female
8 Females + 1
Male = 9
Each group had a different interview guide with some general questions and others that
are group specific. Interview guides were developed by drawing on the concepts
identified and discussed in the literature review chapter. The final semi-structured
interview guides consisted of a series of questions designed to explore the participants‟
views on interest in nursing, nursing as an occupational choice, role of family, image
and status of nursing, role and contribution of Saudi male nurses, nursing education,
support systems, and the Saudisation Policy. Additional prompts were used to encourage
participants to talk and to elicit further explanation. Questions were arranged in the most
logical order and were asked using almost the same wording. The interview guides were
adjusted to suit the particular experiences of the participants. Thus, all participants were
prompted for their views in eight general areas. Members of a group were then further
asked about other issues relevant to their experience. Interview guides were designed in
88
Arabic using simple words and terms that suit all levels of participants; copies of the
three interview guides are attached (Appendix 3).
Piloting the interview guides
The purpose of the pilot project was two fold. On one hand, interview guides were pre-
tested for appropriateness of wording and responses. On the other, the data analysis
project which followed was an excellent exercise that guided the management and
analysis of the data collected during the main study. A convenience sample representing
the three sectors was invited for the pilot project and nine participants were interviewed
(6 students + 2 staff nurses + 1 senior nurse). Participants were informed about the
voluntarily nature of the pilot project, were assured of confidentiality, and were
reminded of their right to refuse to answer any question. Based on the participants‟
convenience, interviews were conducted at their respective facility.
Before commencing the pilot project, I requested that my supervisors review translated
final versions of the interview guides to discuss ambiguities and identify any leading
questions. Final drafts were then taken to the field. Pilot interviews were transcribed and
responses were checked to ensure that information obtained provided interesting data
needed to answers the research questions. This pilot project enabled me to make
informed adjustments to the interview guides before the main study. Questions and
prompts were revised, rephrased and rearranged so that they were likely to be better
understood by the participants. For example, as they yielded similar responses, the two
original questions on how to improve the image of nursing and how to empower nurses
were replaced by one. Nevertheless, despite good responses during the pilot project, four
participants out of the 38 students in the main study did not know what to say in
answering the question about their views on things that can help to change the image of
nursing and support nursing. These students were still in their first semester of nursing
study. Thus, I decided not to ask this particular question to any first or second year
student involved in the main study.
89
Moreover, the pilot project enabled me to make informed adjustments to the set criteria
for selecting participants. For example, I found that the minimum five years experience
originally designated as a criterion for the staff nurses and senior nurses had limited the
number of Saudi nurses available under these two groups. Taking into consideration the
flexibility that characterises qualitative research, I decided to modify the criteria to a
minimum of three years of experience. Furthermore, the pilot project provided me with
opportunities to practice the interviewing technique and to build confidence before the
main study.
The data collection phase
The main data collection phase took place between mid November 2005 and end of
February 2006. During this second phase of the field work, a total of 68 interviews was
achieved. The first interview was conducted on the 20 th
of November 2005 and the last
interview was on the 14 th
of February 2006.
To ensure privacy and minimise opportunity for interruptions, all hospitals and academic
institutions provided me with either an office or a meeting room to conduct the
scheduled interviews. Appointments for interviews were planned with the students‟
group according to their: 1) class timetable, 2) practical training days, and 3) scheduled
quizzes or exams. Two interviews were planned per day and they were conducted at the
assigned office within the nursing college. Intern students were interviewed at the
hospitals hosting their internship period (the main hospitals for internship training were
included in the study). There were times when I had one student and a staff nurse or a
senior nurse scheduled to be interviewed on the same day.
For the staff nurses, the participant‟s preference to be interviewed during or outside the
working hours was taken into considerations. If she/he chose to be interviewed during
their working hours, interviews were then arranged during the units‟ quiet time. For
socio-cultural reasons, only female nurses were given the choice of being interviewed
outside their work place. Hospital nursing staff who chose to be interviewed during
90
working hours were released by their seniors for the time of the interview 12
. One staff
nurse chose to be interviewed during her off day at a hotel coffee shop; another two
wanted to be interviewed at their hospital but during their off days. One senior nurse was
interviewed at my place after her working hours and another one was interviewed at her
place on a weekend. The remaining seven senior nurses preferred to be interviewed
during working hours at their respective colleges or hospitals.
As a researcher conducting interviews, it was necessary to make the participants
(interviewees) feel as comfortable as possible. Conscious attempts were made to stick to
a number of measures if feasible. Conducting the interview in a familiar place; ensuring
privacy, maintaining informality and establishing a rapport. Whether in an office or a
conference room, to ensure informality and generate a rapport, the seating arrangement
was in such away that there was no desk or high table between the participants and
myself during the course of the interview. Participants were encouraged to bring hot or
cold drinks and were asked if they were ready before starting the interview. Participants
were welcomed and thanked for agreeing to meet with me; all, males and females,
seemed animated during the interviews, showed a keen interest in the topics under
discussion, and were generally cooperative and informative.
Before beginning the interview, they were requested to sign and date the consent form
(Appendix 4). Three participants had only their first name, in addition to their mobile
numbers and signatures. Participants were always reminded that they could ask for
clarifications if the questions were not clear enough and that they can simply say they
have no answer if they feel so. At the beginning of every interview, I recorded the
participant‟s code, the date of the interview and the starting time. As a common
Muslims‟ practice, I began each interview by citing a Verse from the holy Quraan which
is “In the Name of God; the most Gracious; the most Merciful”.
12
Directors of Nursing at respective hospitals have communicated information about the study to
concerned head nurses, supervisors and unit managers.
91
During the main study I tried to systematically follow the designed guide within the
allocated time for the interviews. The wording of the questions was the same when
interviewing participants of the same group; nevertheless, the sequence of the questions
was maintained fairly flexible in order to pursue interesting leads raised by the
participants‟ responses. A conversational tone was maintained to encourage participants
to continue talking. Prompts such as “tell me more about”, “please explain”, and “in
what way” were used to encourage participants to elaborate on particular issues of
interest. This systematic approach was needed to facilitate comparability within the
sample group and across the three groups (Barriball & While 1994, Bryman 2001,
Silverman 2001).
Most interviews lasted 60 minutes on average with students taking around 30 minutes
and senior nurses taking around 90 minutes. This might be due to a tendency to
elaborate more on issues when there was more personal experience to draw on. For
example, the first question regarding the participants‟ nursing story had encouraged
those who worked in nursing for more than five years to recall their experiences over the
years. At the end of the interview, participants were thanked for taking part and the
ending time was recorded.
Anonymity was an issue of concern particularly for participants from senior nurses;
members of this group are very few and well known within the nursing community.
Despite their awareness that they might be recognised, the selected participants were
willing to take part. Nevertheless, all participants were assured that their anonymity
would be protected as far as possible and that illustrative quotes would be used without
reference to any particular facility. Similar issues were discussed in the qualitative study
by Burke (2006).
Except for the male unit manager, the remaining eight participants from the senior
nurses‟ group were well known to me. Despite professional seniority and position in the
nursing hierarchy, as early BSN graduates, we were all members of an informal nursing
network. Indeed, all senior nurses were interested in and supportive of the study. By
92
contrast, only four of the 21 staff nurses who took part in the study have heard of me
through their circle of friends. Nevertheless, all were interested and willing to
participate. Three of the six participating students from Dar Al-Hekma College were my
students when I used to work as an academic staff. However, I did not feel that they
were inhibited by the power or authority invested in my original position or title.
Instead, they viewed themselves as experienced informants who have the information
and experience I need for my research. This might be attributed to a prevailing
perception that the research study is academic in nature with findings that might
contribute to the future of nursing in Saudi Arabia. It could also be attributed to the
argument raised by Morse (1989) that people agree to participate in research studies for
various reasons other than just being interested in the research topic. For example,
emotional and intellectual satisfaction may influence the participant‟s decision to take
part in a study. In contrast, Barriball and While (1994) reported that participants‟ feeling
of altruism towards the interviewer may influence their decision to participate.
Fontana and Frey (1994, p. 369) suggested that “in typical interviews there exists a
hierarchical relation, with the respondent being in the subordinate position”. To put the
participant at ease and to encourage him/her to talk freely “the interviewer is instructed
to be courteous, friendly and pleasant”. Such awareness guided the steps involved in
recruiting participants. The initial contact with the students was made through a co-
ordinator from their institution to check their willingness to participate. Moreover, the
following points were made clear to potential participants: 1) the voluntarily nature of
taking part in the study; 2) the need to think about taking part and consulting parents;
and 3) the emphasis made by the researcher that participants are free to choose not to
answer a particular question or withdraw from the interview. Before each interview I
used to: 1) remind the participant of the above points; 2) look for signs of unease,
nervousness and hesitation; and finally 3) if the participant expressed verbal agreement
to take part in a tape-recorded interview, he/she would be asked to sign the consent
form. In spite of all measures, participants from the students‟ group may have felt that
they were in a subordinate position which may well have made them feel uncomfortable.
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Despite advising participants to turn their mobiles to the silent mode, mobile phones
were occasionally ringing causing interruption to the interviews. Similarly, regardless of
a large sign on the door, unexpected knocking was another form of interruption.
However, by and large, interruptions were minimal. Taking notes was difficult during
the course of the interview. I noticed that most participants became distracted when I
started recording notes. I, therefore, decided to keep note-taking to a minimum. After
every interview I wrote brief notes on the context, the individual responses, the
significant pauses and any changes in voice tone.
Interviews were conducted and transcribed in Arabic, the mother tongue for the
interviewee and interviewer. All participants were interviewed once; interviews were
tape recorded using a digital recorder. The information sheet made it clear that the
interviews would be audio recorded for participants to think and ask about before
agreeing to take part in the study. None of the participants expressed any concern about
the recording equipment. Non-verbal cue, such as glancing at the recorder, or a
reluctance to speak freely were looked for but not noted. The only reported disadvantage
for using a tape-recorder is that it might inhibit the participant‟s ability to talk
comfortably; however, I did not feel that the participants were put off by the use of a
tape recorder. Participants spoke freely ignoring the recorder and, despite reminders, they
sometimes used to mention names which were not included while transcribing.
The digital recorder was tested for quality recording before the scheduled interviews. On
one hand, tape-recording reduced the potential for interviewer error and permitted
complete and accurate transcription of the interviews. On the other, it gave me more
freedom to concentrate and interact with participants without being busy with note-
taking. All recorded interviews were downloaded to my personal lap-top as voice files;
three folders were maintained for voice files of participants from the three groups. A
backup copy was saved on a separate USB kept in a safe and secured place. A socio-
demographic checklist was used at the end of every individual interview (Appendix 5).
The checklist provided information which was useful for contextualising participants‟
answers.
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At the end of my data collection phase, thank you letters were sent to all Nursing
Directors, Programme Directors and the assigned Coordinators who facilitated the data
collection process. These letters were signed by the Dean of Dar Al-Hekma College who
represents my employing institution.
Gender specific ethical considerations
In my role as an interviewer, I was aware of the influence of gender on interviews
(gender as a methodological limitation) particularly in sex-segregated societies such as
Saudi Arabia. The arrangement, mandated by the MoH administration, of having my
husband as a chaperone proved worthy as it helped some of the male participants to be at
ease. Before the interviews, my husband used to introduce himself and helped in
breaking the ice especially with the participants who were reserved as a result of their
religious beliefs. Then, in an attempt to be semi-visible, he used to have his laptop out,
head phones on and tended to sit quietly at a distance. For consistency, I decided to
include my husband in all interviews with male participants.
Due to the highly segregated educational system at the MoH colleges, unlike their
female counterparts, the male students were deprived of the opportunity to meet with me
prior to the day set for the interview. Despite having my mobile number on the
information sheets, none of the male students used the contact number to gain further
information. As such, my first encounter with the participating male students was during
their scheduled interview. I tried to be pleasant and courteous; I introduced my study,
explained the interview technique, reminded them of the voluntarily nature of
participation and emphasised that they could skip a question if they had no answer to
that particular question. All students showed interest and agreed to carry on. One of the
six was very shy, his voice was low and trembling and he avoided making eye contact.
Nevertheless, during the last ten minutes of his 25 minutes interview, he was more
relaxed, his voice tone was normal and he was making eye contact. I could argue that
this second-year student from a highly sex-segregated tribal family, was simply shy and
the interview experience with a female researcher was new to him. Moreover, male
nursing students at this level of study are not sent on hospital assignments where they
95
are usually exposed to mixed-gender work setting. This argument is supported by two
personal observations. First, the participant was avoiding eye contact when talking to my
husband prior to the interview and his voice was low and trembling. Second, his
answers, although brief, have covered similar issues raised by other male participants at
the same level of study.
To maintain socially decent and culturally acceptable appearance (social sensitivity), I
decided to go for all interviews wearing the traditional outdoor black gown and head
scarf “Abaya and Tarha”. The traditional outdoor dress ensured that my hair and whole
body were covered in long black type of dress keeping my face and hands exposed.
Compared to the specially designed culturally-sensitive white uniform used by Saudi
nurses in hospital settings, this dress code did not carry any professional significance in
terms of status or hierarchy. Not wearing make-up was just appropriate for maintaining a
low profile and a modest appearance especially in the presence of men. Although I
usually shake hands with men I deal with, I opted not to do so during the course of the
study unless the male participant initiated it. Such practice minimised embarrassment on
the participants‟ part. I tried to speak clearly and confidently but without raising my
voice or laughing unnecessarily. Barriball and While (1994) argued that self presentation
of the interviewer in terms of dress, etiquette and manner would put the interviewee at
ease and could overcome the characteristic effects of gender difference. Aside from
these social precautions, I consistently had a smile on my face and maintained eye
contact with men and women equally.
This particular experience raised an important methodological consideration regarding
the impact of gender on interviewing as a technique. Would the above male student, or
any other male student for that matter, have answered differently if the interviewer was
male. Future studies carried by male/female researchers and involving female/male
students should provide further methodological insight/ clarification on the impact of
gender on interviewing. Denzin claimed that “gender filters knowledge” (1989, p. 116
cited by Fontana & Frey 1994 in Denzin & Lincoln 1994). Gender difference was
96
acknowledged and discussed by western researchers who conducted interviews in
societies that have less rigid gender codes.
“the sex of the interviewer and of the respondent does make a difference
as the interview takes place within the cultural boundaries of a
paternalistic social system in which masculine identities are differentiated
from feminine ones” (Fontana & Frey 1994, p. 369)
Transcribing and translating
I started transcribing some of the early interviews during the quiet days of the data
collection phase; however, the majority of the interviews were transcribed after the
completion of the data collection phase. Transcribing took almost eleven weeks with an
average of six hours six days per week. Each voice file (interview) was transcribed using
the transcribing tool that came with the Digital Recorder Programme.
For each transcribed interview, the following information was typed at the top of the
document: the participant‟s interview code e.g. Int.7 G3, referring to interview number
seven from the students‟ group; the sector e.g. government, other-government and
private; the date; the starting and ending time of the interview. Significant pauses and
changes in voice tone indicating that the participant was emotionally charged were
maintained for reference. The transcribed interviews were checked against the voice
files for accuracy and were then backed up.
The body of every interview which included answers to the interview questions was
transcribed. To keep track of stories reported by some participants, a timed brief
summary was kept for easy reference. Due to religious orientation and/or as a social
habit, participants tended to often use phrases such as “thank God”, “God almighty”,
“glory to God”, “praises to God” or “God willing”. These phrases were not transcribed.
Repeated statements and speech habits such as “you know”, “well”, or “told you” were
not also transcribed.
97
Five interviews were conducted in English (senior nurse, staff nurse and three students).
These participants opted to talk in English because they felt more comfortable doing the
whole interview in English. These five interviewees were the products of an English-
based school education and felt confident expressing themselves in English; appendix 6
has an example of an English transcript. In contrast, the task of translating Arabic
interviews was not straightforward. Arabic is a rich language; it has different words or
terms referring to one English equivalent. With translation, there is a risk of losing what
the participant was saying by not using her/his own words. However, having good
command of both languages, I invested effort to convey the exact meaning of the
participants accounts; in other words I traded exact words for exact meanings.
Data analysis
In order to achieve familiarality and comprehension, I read the transcribed documents
thoroughly and repeatedly. Repeatedly listening to the recorded interviews and re-
reading the transcribed texts were necessary for the data analysis process. I then made a
decision to summarise the transcribed text and produce a reduced script with socio-
demographic data and points from the field notes for every participant (Individual Case
Summary ICS). An example of ICS is attached in the appendices (Appendix 7). This
technique enabled me to capture the individual accounts and personal meanings of the
participants‟ nursing experience in relation to gender, marital status, tribal affiliation,
employing hospital, academic institution, service sector, educational background,
income and having a nurse in the family. Re-visiting the recorded tapes and listening to
the voice tone and the way participants were answering the interview questions had
assisted in getting the feeling and the meanings behind the transcribed texts.
The original plan was to use the NVivo software for data management utilizing its
improved functions to aid in data analysis. Despite several reassuring e-mails from QSR
international that the upcoming version of NVivo 7 software is sensitive to languages
and can cater for the Arabic script, the software failed to deal with purpose-prepared
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Arabic documents 13
. Thus, the decision to follow code-based manual analysis of the data
using Microsoft Word was approved by my supervisors.
Coding is a technique of data reduction and a way of interacting with and thinking about
the data. Combined, a well defined research question, clearly stated research objectives
and semi-structured interview technique covering topics informed by the literature have
facilitated the data reduction phase of the analysis. Huberman and Miles (1994)
emphasised that data reduction is an essential component of data analysis. As an initial
plan, I attempted to reduce and code the collected data using the question-generated
codes. Morse and Field (1996) proposed question analysis technique for research
projects employing focused semi-structured interviews. This technique implies that all
answers to question one are sorted under one topic-category. This initial sorting
facilitated further reduction and analysis of transcribed data Using transcription-
generated inductive codes and thematic approach to analysis.
The coding framework implicit in the design of semi-structured interview questions with
concepts guided by the literature made it possible to divide the textual data of every
transcript into twelve question-generated codes segments. These segments included:
interest in nursing, role of family, nursing as an occupational choice, Saudi male nurses,
status of nursing, image of nursing, strategies to empower and support nursing, strategies
to attract new students or to keep the graduates at the in-patient units, Saudisation,
nursing education, education-related or work-related support systems and personal
perception of nursing. Appendix 8 shows a table of the questions within the interview
guides and the concepts from the literature that guided the development of the questions.
Morse and Field (1996) argued that topic categories should be kept to a minimum of 10
to 15 per study because if they are too specialised very small amount of data will fit
under each category. These coding segments were further dissected into meaningful and
manageable chunks of text using the inductive codes generated and maintained during
the transcription process. These codes were recurrent textual units representing views,
13
Questions were typed as uniformed Heading-style in order to facilitate section coding (topic-category). This is known as auto-coding of structured data.
99
opinions and ideas expressed by the participants during the course of the interview
(Appendix 9). Consequently, similar coded passages or paragraphs from all interviews
were compiled together under the main question-generated codes and work sheets were
eventually created (coding process - figure 1). Worksheets refer to piles of printed word
documents compiled during the process of coding (data reduction) and thematic data
analysis.
Rereading through the coded segments within the context of the question-generated
codes allowed me to extract salient and common themes within the relevant segments
(synthesis themes). Some synthesis themes were repetitive and some were meaningless
when viewed alone; as such, there was a need to re-arrange them further into broader
(organising) themes summarising and making sense of the main ideas proposed by a
group of synthesis themes. The organising themes were necessary for the identification
of overarching themes needed to explain the research findings (thematic analysis –
figure 1). Explanatory themes encompassed the underlying organising themes that
together presented an argument abstracted from and supported by the data. The
techniques employed for data analysis have guided my thoughts, feelings and
comprehension processes; combined, they enabled me to depict and structure three
explanatory themes. Thematic analysis “seeks to unearth the themes salient in a text at
different levels” (Attride-Stirling 2001, p. 387). It “involves the search for and
identification of common threads that extends throughout an entire interview or set of
interviews” (Morse & Field 1996, p. 114). An example of the coding process and
thematic analysis is attached in the appendices (Appendix 10).
100
Figure 1: Data Analysis Process (Adopted from Attride-Stirling 2001)
Question-generated
Codes (n = 12)
Synthesis Organising Explanatory
Themes Themes Themes
(n = 28) (n = 11) (n = 3)
Inductive Codes
(n = 115)
Coding Process Thematic Analysis
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The summary provided by these emergent themes needed verification; thus, the original
text was read in the light of synthesis, organising and explanatory themes (Huberman &
Miles 1994, Attride-Stirling 2001). The verification process aimed at ensuring that: first,
themes were specific enough to identify and illustrate patterns; describe and explain
relationships; and are linked together to reveal what the textual data is saying
(meaningful). Second, themes were broad enough to present ideas, issues, views,
opinions and experiences contained in the textual data and to explain the main
arguments posed by the data (comprehensive). Third, themes reflect the different text
segments of the data and are supported by the data (plausibility); their recurrence,
frequency and representation confirmed their credibility. Fourth, themes would display
findings in the most logical presentation that answers the research question and produces
a plausible and coherent explanation of the challenges encountered in the recruitment
and retention of Saudi nurses (coherent). Fifth, themes would allow a fair examination of
the different “deviant” cases and thorough explanation for the variation. The data
analysis process and the identification of emergent themes was monitored by and
discussed with my supervisors on monthly basis over a period of eight months.
Furthermore, there was enough evidence that similar themes were documented in
previous research which to a great extent indicates their confirmability and coherence with
existing knowledge (Mays & Pope 1996).
Conclusion
This chapter has set out the arguments to support the selection of qualitative design as a
methodological frame work for this research. Links were made to the literature reviewed
in chapter two. The chapter covered detailed description of the sequence of the research
process starting from the development of the research question and the choice of semi-
structured interview technique to getting permissions, gaining access, piloting the
interview guides and ending with the data collection phase and the ethical
considerations. The three techniques employed for data analysis were discussed.
102
Chapter Four
Perceptions of nursing
Introduction
The findings reported in chapters four, five and six are based on 68 semi-structured
interviews with Saudi nursing students, staff nurses and senior nurses recruited from
government, other-government and private sectors. The socio-demographic
characteristics of these participants are listed in table 3. Three explanatory themes were
used to link together all lower-level themes generated during the process of data
analysis. These three emergent themes were: perception of nursing; a challenge to
achieve professionalism; and dealing with personal struggle. These themes provided
explanation for the recruitment and retention experiences of Saudi participants within a
rapidly changing socio-economic Saudi context.
For the sake of complete and accurate presentation of findings, the three themes are
explored in three separate chapters. This chapter explores the first theme - perceptions of
nursing. Findings under this theme suggest that participants recognised the importance
of prevalent nursing images and appreciated the value of nursing as a competitively
emerging occupational choice. Chapter five describes theme two - challenges facing
professionalism. Findings under this theme suggest that participants acknowledged the
importance of a professional status still to be achieved by nursing and the national and
organisational challenges associated with achieving the desired national and
international professional recognition. Chapter six presents theme three – dealing with
personal struggle which suggests that, in their efforts to live and cope with nursing as an
occupational choice, the participants were experiencing individual struggle.
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Table 3: Participants’ Socio-demographic Characteristics
Characteristics
Senior Nurses
(n = 9)
Staff Nurses
(n = 21)
Nursing
Students
(n = 38)
Gender:
Female
Male
8
1
16
5
26
12
Age:
17-24
25-32
33+
0
2
7
1
18
2
36
2
0
Educational
Qualifications:
Diploma
Baccalaureate
Master
Doctorate
0
0
6
3
8
11
2
0
20
18
0
0
Marital Status:
Single
Married
2
7
8
13
35
3
Service Sector:
Government
Other-Gov.
Private
6
2
1
11
10
0
27
0
11
Role Model:
Yes
No
2
7
2
19
8
30
Tribal Origin:
Yes
No
2
7
9
12
17
21
Family Income:
≤ £570
£715-£1429
£1571-£2286
≥ £2430
0
0
1
8
0
7
10
4
5
15
9
8
Experience/yrs:
3-5
9+
NA
1
8
0
18
3
0
0
0
38
Family
Members:
≤ 2 members
3-8 members
≥ 9 members
0
8
1
6
11
4
2
26
10
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Comparisons were made between accounts from the three groups, and also according to
the participants‟ socio-demographic characteristics. Illustrative quotes from the
transcribed interviews are used where needed in order to support the overall presentation
and explanation of findings. Quotes convey the participants‟ voice through the text and
across to the reader. Morse and Field (1996, p. 147) emphasised that quotes will
"supplement the text and provide human insight and dimension to the analysis". The
translation of these quotes reflects my best personal effort to accurately convey the
views of the participants. Another Arabic speaking person might translate the same
quote slightly different; however, the underlying meaning or main message should not
change.
This chapter explores the participants‟ views on nursing and their perceptions of
prevailing images of nursing. Themes (synthesis and organising) are used to explore
these views and perceptions of nursing and understand how they influenced the
participants‟ decisions to pursue nursing and to continue as nurses. For this purpose, the
chapter is divided into five sections: the domestic nature of bedside nursing care, role of
the media, cultural values, social norms, and changing economy.
The domestic nature of bedside nursing care
The Saudi literature suggested that the prevailing poor images of nursing and perceived
low status of nurses are associated with social and work-related aspects of nursing
(Meleis & Hasan 1980, Alawi & Mujahid 1982, Jackson & Gary 1991, Mansour 1992,
Hamdi & Al-Hyder 1995, Al-Johari 2001, El-Sanabary 2003). In my study, most
participants described the domestic nature of bedside nursing care as menial and
degrading causing a range of mixed feelings. The following group of underlying
synthesis themes: bedside care, nursing as domestic work, nationalities and tasks, and
“nursing is not for Saudis” are used to illustrate how they influence and enforce the
prevalent negative images of nursing and nurses.
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The bedside care
Tasks linked to housekeeping and caring were traditionally designated to women who
were expected to carry out such tasks within the privacy of their homes. As an outcome
to economic prosperity and social affluence, Saudis became increasingly dependent on a
foreign labour force (chapter 1, page 15). Work perceived as menial e.g. housekeeping
and jobs classified as socially unacceptable e.g. nursing were delegated to the non-Saudi
workforce. Many Saudi families had at least one maid to help in domestic chores and
house wives eventually delegated tasks related to cleaning and serving to these non-
Saudi (foreign) maids. Over the years new social norms evolved and certain jobs became
(taboos) for the average middle class Saudis (El-Sanabary 2003). Many of the Saudi
generation born and brought up after 1970 were more likely used to maids fixing their
beds, changing their beddings, cleaning their house, washing and ironing their cloths,
preparing and serving their meals.
“I registered in nursing by mere chance. The first module was
fundamentals of nursing; I did not like the bed making and bed bath part
of it. At that time, I was seriously considering a transfer” Int.9, male
senior nurse
Participants‟ accounts suggested negative perceptions of nursing particularly in relation
to the bedside tasks of nursing care. This type of care was described by many
participants from the three different groups as unskilled and menial. There was a
consensus that bedside nursing tasks were low-level domestic duties which require basic
skills and minimal knowledge far below the participants‟ acquired nursing degrees.
Many participants indicated that certain Saudi generations (including themselves) are
finding it very difficult trying to accept and get used to providing bed-side tasks as part
of their future work. Participants had a range of mixed feelings towards these bedside
tasks. Some were shocked, some were embarrassed and some had even considered a
transfer to other majors. The intensity and degree of these negative feelings varied
considerably depending on their coping strategies and the support they received from
family and faculty.
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“… I cannot think of anyone in the college who has been through the bed
making class and did not have the shock of her life. We are used to the
luxury of our homes, we have house keepers doing this type of work”
Int.18, female nurse intern
“Practicing at the nursing lab is really nice. Providing bed-bath is an
exception… many students changed their minds (in disappointment) as
they started the practical sessions in the second year” Int.7, female
student
The bedside care was perceived by most participants (females and males) as low-level
tasks to be performed by nurse aides requiring minimal nursing training and education.
However, due to the severe shortage and in the absence of nurse aides, participants from
the staff nurses‟ group have found that they are expected to provide this level of care.
Most participants (diploma, associate or baccalaureate degree) indicated that providing
the bedside care is acceptable as long as they have a career-path planned for them.
Participants from the staff nurses‟ group who were providing bedside care for five or
more years expressed feelings of disappointment and frustration. These negative feelings
were reported by participants as major reasons for considering a transfer from the in-
patient units or a change of employing hospital.
“Nursing is hard work. Nurses can only be productive for four or a
maximum of ten years, after that they have to find an alternative, like
taking an administrative job. Only few may continue as bedside nurses”
Int.11, male staff nurse
Some participants, particularly male students and staff nurses from tribal origins, pointed
out that there is a tendency to classify jobs like medicine and teaching as “clean” while
others like nursing are considered “unclean”. For these participants, the unclean
classification attached to nursing is linked to the basic bedside tasks such as: giving bed
bath, handling bed pans, changing beds and feeding patients. Interviews suggested that
107
bedside tasks are socially classified as serving-type of work and, hence, perceived as
bringing shame and humiliation to the individual and his or her family.
“People should be made aware. For them nursing is not a good job; It is
not clean. They do not know that you [as nurses] are educated and you
have knowledge” Int.27, male nurse intern
“Unfortunately people think it is shameful to work as a nurse. Nurse,
what do you do! You feed patients, clean them and change their beds.
People underestimate nursing and look down at the nurses” Int.21, male
staff nurse
Nursing as domestic work
Many participants perceived the bedside tasks of nursing as a domestic type of work.
The delegation of the “unclean” domestic tasks to the maids may have enhanced the
perception of bedside tasks as domestic in nature. Half the participants indicated that
people in general view nurses as similar to domestic maids and hence perceive nursing
as equivalent to domestic services. They linked this perception to the very nature of
nursing work which encompassed bed-making and bed-baths, turning and positioning of
patients, feeding them, and assisting them while getting dressed.
“My father is against nursing. He says it‟s a dirty work which involve
serving people, just like a first class maid” Int.5, female staff nurse
“People look down at the nurse and view her as a maid. Nurses do bed
making and bed bath; domestic maids do the same things” Int.33, female
student
Participants often drew attention to a wide range of views expressed by their family
members in relation to the perceived similarity between nurses and maids. Examples
included: “have not sent you to college to become a maid” and “if this is what you do,
108
then do it at home”, or “why go out just do the same work at home”. Nevertheless, it is
usually these intimate and caring tasks that are highly appreciated by the patients and
their families.
“My father had a cerebral vascular accident and I used to take care of him
at home. My sister used to say that my work is just like the maid‟s work.
I asked her to stay around while I provide the morning care… When the
care was over, my father held my hand and kissed it. My sister cried, she
realised that whatever I did helped our father feel good and had
comforted him” Int.27, male nurse intern
The sister of the above participant used to have stereotypical images of nurses. In an
attempt to change her perceptions, the participant, who comes from a tribal origin, asked
his sister to watch him while providing the needed care for his bed-ridden father. At the
end of the bedside care, the participant placed his father in a comfortable position.
Unexpectedly, the father held his son‟s hand and kissed it. The sister was touched.
Regardless of their nature, she realised that these tasks are humane and are highly valued
by those who need them. Those in need of such care might be parents, loved ones,
relatives or simply another human being. This story suggests that people might need
exposure to nursing services before they understand and appreciate the role of the
nurses.
Nationalities and tasks
Using participants‟ accounts on bedside care, I noticed that they were often making a
link between this care and certain nationalities. Just like the female domestic maids,
most of the foreign female nursing workforce comes from countries such as Philippines
and India (Meleis 1979, Al-Kandari & Ajao 1998; page 26 of chapter 2). This may have
enhanced the perception of bedside tasks as domestic and female type of work. Due to a
nursing shortage and the subsequent increased work load, senior nurses, mostly western,
tend to delegate the bedside care to the nurse aide groups, mostly Asian nurses. Being
109
assigned to what is perceived as domestic nursing tasks, Saudis were more likely to view
these Asian nurses as similar to Asian domestic-maids.
“Nurses are not like, say, the pharmacists. As a nurse you are expected to
make the patients‟ bed and help them get cleaned. You care for the patient
like his own mother and you do things for him or her just like the Indian
or Indonesian maid” Int.23, female student
Many participants drew attention to how people generally tend to perceive the nature of
the work-relationship between doctors and nurses as subordinate with nurses simply
following doctors‟ orders. In their view, this perceived subordinated role was similar to
the relationship between household master and employed maid. A perception which
enhanced the assisting role of nursing and low level status of nurses.
“In the hospital you do what the doctors ask you to do. So, there is no
difference between the nurse and the Indonesian or Filipino maid at
home” Int.5, female student
Some participants pointed out that highly ranked nurses might need to do the bedside
care usually assigned to the lower rank nurses. These participants emphasised that,
unlike nurse aides who deliver this type of care in a serving manner, their provision of
care was mainly to provide help and assistance to patients who cannot do certain tasks
on their own. This may suggest that these participants were trying to differentiate
between the concepts of helping or assisting and the concept of serving. A distinction
that helped them accept the bedside care as part of their responsibilities at a transitional
phase of their career.
“We [Saudi nurses] do bed making only when the patients need our help
but the Filipinos‟ work is more to do with housekeeping” Int.2, female
student
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Some participants, mostly from the students‟ group, believed they can escape the
bedside care by choosing managerial work. Unlike staff nurses, participants from the
students‟ group were not aware that administrative work requires a minimum of five
years work as a staff nurse. Alternatively, to avoid the social embarrassment associated
with providing bedside care, many participants from the staff nurses and students‟
groups have decided to work with or were considering the option of working with
children or the critically ill adults. Children are minors who need the care and attention
of their mothers, sisters or any other member of the family particularly when they are
sick and vulnerable. As such, providing bedside care for this group of patients was not
perceived by these participants as embarrassing. Alternatively, the critically ill adults are
usually semi-conscious, bed ridden and, due to limited visiting hours, have few visitors
around. These conditions tend to minimise any perceived embarrassment associated with
providing this level of care. With reference to the participants‟ area of work, five of the
21 staff nurses were working in the Dialysis Unit where bedside care is not part of the
daily routine.
“Nurse! Sister! You clean patients, change beds, deal with…you know
urine and stool. As Saudis we will not do all these tasks, it depends on
your field, I might specialise in Paediatrics or choose office work. In
nursing you may sit in an office and do papers‟ work” Int.8, female
student
After 3-year (associate degree) or 4-year (BSN) of nursing education, most participants
from the staff nurses‟ group felt hurt and disappointed for being expected to do the
bedside care. They believed that staff nurses are expected to delegate these tasks to the
nurse aides and should free themselves for more professional nursing procedures. Staff
nurses with BSN degree felt that being more qualified they should not do the bedside
care i.e. bed baths, bed making and handling bed-pans. This suggests that, despite being
both assigned to staff nurses posts, BSN graduates tend to feel that they are higher in the
nursing hierarchy than those with associate degree.
111
“BSN nurses are doing the same work as the other nurses. They [BSN
nurses] say to me: we did not go for higher degrees to do this type of
work [bed making and bed bath] which is performed by the domestic
maids” Int.1, female senior nurse
To improve the image of nursing and upgrade the status of nurses, many participants
indicated that the “unclean” bedside tasks should be carried out by nurse aides (Saudis
or non- Saudis). The male nurse in the quote below sounded bitter and unhappy about
the severe shortage which is forcing nurses to do all type of nursing and non-nursing
work. With almost five years experience and specialised training, he was expecting a
promotion or salary adjustment. His negative feelings in relation to being stuck in a staff
nurse post were behind his decision to apply to another hospital.
“We actually give bed-bath. Why do we have to do these tasks for the
patients? It feels like working for them [the patients]… There should be
other staff [nurse aides] for this work but we do not have them in our
unit” Int.10, male staff nurse
“Nursing is not for the Saudis”
When asked about the wider public‟s perceptions of nursing in comparison to the other
professions and other medical specialities, there was a consensus among participants that
nursing is not highly ranked socially or professionally. This finding is consistent with
the reviewed literature (Jackson & Gary 1991, Mansour 1992, Hamdi & Al-Hyder 1995,
Al-Johari 2001). Some participants, male and female, tribal and non-tribal, made it clear
that Saudi people may acknowledge the value of nursing; however, they view it as a
service to be provided by “others” (the non-Saudis). They attributed this to the perceived
menial nature of nursing work which includes cleaning and serving others.
“Some people agree that nursing is needed to help the patients but they
will not allow their own daughters to go for nursing… Nurses are needed
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by the society but nursing is not for us, it is for the others, bring other
people to do this job” Int.1, female senior nurse
“Nursing is a low status job; nurses turn, position and clean patients.
People do not accept nursing for their children just in the same way as
they may reject the idea of them working as maids” Int.20, male staff
nurse
The comfortable lifestyles experienced by most Saudis until early 1990s (shortly after
the first Gulf War) and the classification of jobs as prestigious and unacceptable seem to
have made the choice of certain jobs more difficult than others. Many participants
pointed out that people in general tend to view medical doctors as bosses giving orders
to other supporting medical or nursing staff. This image tends to conform to the type of
job they aspire for themselves and their children. Many participants indicated that most
Saudis perceive nursing as a service assisting medicine; a perception that is consistent
with the reviewed literature (Jackson & Gary 1991, Mansour 1992, El-Sanabary 2003)
and (Hallam 1998, Darbyshire 2000). This perception, however, may conflict with what
many Saudis are used to or brought up to accept. Three students, one staff nurse and one
senior nurse described the young Saudi generation as spoiled expecting others to serve
them or do things for them. In their view, this generation may look down at certain
technical and manual jobs even if they provide paid-work opportunities.
“I feel that Saudis live in a luxury, they do not do the low status work.
They do this type of work in other Arab countries. We do not have Saudi
nurses; we do not have Saudi janitors or Taxi drivers … very strange! It
is work and it generates money” Int.4, female student
“It was very difficult at the beginning. We are spoiled here and the work
at hospitals is tough and provocative. Nurses say do this and do that, I
used to feel as if they were ordering me. I could not accept that, I am not
used to being ordered” Int.34, female student
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Role of the media
The media was frequently cited by the participants as having a major influence on the
prevailing negative images of nursing. Half the participants believed that television and
local newspapers had a role in constructing and shaping the public image of nursing.
Media portrayals
Regardless of age, gender and educational qualifications, participants indicated that the
frequently portrayed fictional images, of dancers and prostitutes who decide to devote
their lives to nursing and make a fresh start, are contributing to the negative images of
nurses. They also believed that people have a tendency to link the negative movie
images to real-life nurses. In their views, negative media images have contributed to the
public‟s classification of nursing as women‟s job and to a socially less respected status
of female nurses.
“What I always see in Egyptian movies is a woman of bad reputation who
decides to be a nurse to make up for her wrong doings, this is why people
think that nursing is for bad [indecent] young women” Int.15, female
student
“Arabic media portrays negative nursing images, it shows nurses stealing
patients‟ meals or trading service for money… People‟s opinion is
influenced by what they see on the screen” Int.9, male senior nurse
Participants drew attention to the role of the media in shaping the image of nursing as a
career option for people from low income group who may take advantage of their
nursing jobs and underlying responsibilities. By frequently showing nurses who are at
the service of patients and doctors, many blamed the media for the prevalent maid image
of the nurse.
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“The maid image came through the media. I really do not like the
Egyptian television dramas; they do not help in image building” Int.16,
female staff nurse
Three female participants from the staff nurses‟ group referred to two recent television
series starring famous Egyptian and Kuwaiti actresses wherein the former actress played
the role of a nurse who exchanged two babies in return for wealth and power while the
latter played the role of an illegal child who had to work as a nurse to support herself
(Appendix11) 14
. The interviews suggested that these fictional images are not necessarily
linked to real characters and the scripts are not intended to critically or objectively
review factual incidences of system abuse and illegal practices. Nevertheless, the two
television dramas were broadcasted on almost all Arabic satellite channels.
“I was very furious about the Kuwaiti television series Al-Laqetah [the
illegal child]. The whole story was about her resorting to nursing because
she had to support herself. Nursing was the only escape from the social
and economic pressure” Int.14, female student
The media may sometimes portray directly and indirectly negative images of nursing by
restricting attention to the basic aspects of nurses‟ work and ignoring the more technical
and professional aspects. Frequently cited examples include hospital background scenes
with nurses sitting behind a nursing station sorting files, answering phones and calling
patients. Other participants pointed out that almost all programmes transmitted by Arab
satellite channels particularly those on family and health tend to host medical doctors but
never a nurse. This was attributed to ignorance on the media‟s part but it may reflect a
less than proactive role on the part of Saudi nurse-leaders.
“The media is not doing the nurses any good. Even in recent drama the
nurse is just there as an accessory decorating the hospital setting or giving
14
Appendix 11 includes brief reviews of the 2 TV dramas and the staring actresses as appeared in a local
newspaper and a popular magazine.
115
a hand to the physician. The television for instance is not directing light
to the different professions… There was one commercial of a girl next to
a patient saying I am a Saudi and I am a nurse but it was broadcasted
once or twice” Int.17, female staff nurse
There was a consensus among participants regarding the missing positive contribution of
the media in promoting nursing as an occupational choice across the Arab countries.
Fifty percent of the participants called for a proactive and promotional strategy to be
initiated by nursing leaders and concerned authorities. This suggests that there is also a
missing role of nursing leaders and that prevalent negative images cannot be entirely
blamed on the ignorance of the media outlets.
“Nursing is not highly regarded within our societies. It is not like
medicine… The media has served the medical doctors and gave them the
prestigious status they achieved” Int.13, female staff nurse
“… the media always attacks nursing. It makes you feel that the nurse is
nothing. Doctors are the heroes; nurses are just there in the crowd” Int.14,
female student
The cultural values
Participants‟ accounts highlighted religious values associated with nursing work. These
values were often referred to in contexts where they were recalling examples of highly
respected early Muslim nurses; talking about the mixed-gender work settings; describing
the spiritual and moral rewards of nursing service; and highlighting some work-related
aspects such as caring for patients of the opposite sex and working night duties. These
contexts were grouped under three basic themes: historical images of nurses, work-
related images, and religious motives.
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Historical images of nurses
Despite the glorious images and respected status of the early Muslim nurses (chapter 1,
pages 9 & 10), a negative perception of nursing had surfaced since the nineteenth
century. This negative perception was attributed to the choice of female slaves and
orphans to learn midwifery and nursing skills (Hasan 1982, Sultan 1990 in page 24 of
chapter 2). As discussed earlier (page 112), the poor images of nursing and the low
status of nurses that have been identified in the literature may be linked to perceptions in
relation to nursing as a work designated for women, to the social class of women taking
up nursing, and the basic level of education offered between 1960 and early 1970s
(Meleis 1979, El-Sanabary 1993 in page 25 of chapter 2). They may also be associated
with historical accounts of the emergence of nursing as providing assistance to medicine
(Jackson & Gary 1991, Mansour 1992, Hallam 1998, Darbyshire 2000, El-Sanabary
2003).
During the interviews, it was pointed out many times that nursing was a service provided
since early Islamic era and had been approved by Prophet Mohammed. Regardless of
gender, a few participants made explicit reference to the dilemma of living in a society
where people undermine nurses and look down at them when, on the contrary, early
Muslim women who worked as nurses were recognised and encouraged by Prophet
Mohammed (Hasan 1982, Sultan 1990, Al-Osaimi 1994a in pages 10 & 11 of chapter 1).
These participants were puzzled regarding the discrepancy between what they
considered to be the current prevalent images of nursing and those of early Muslim
nurses almost 1400 years ago. Despite feeling proud of those early images, for them, the
current low status and negative images did not seem to conform to the highly respected
image of the early heroic nurses.
“Early Muslim women used to work as nurses, yet we as Saudis or
generally as Arabs have very bad image of nursing… People view the
nurse as a private domestic maid; that bad” Int.4, female student
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In Saudi Arabia, nursing was proposed as a field of study for women in the early sixties.
A time when formal public education for women was strongly opposed and aggressively
rejected by the conservative segments of the Saudi population (Parssinen 1980).
Participants from the senior nurses and staff nurses‟ groups believed that the prevailing
negative images of nursing were influenced by the social status and level of education of
the early Saudi female nurses who graduated from the early nursing schools.
“Nursing for women [Saudi] was not a traditional type of work but
teaching was. The history of nursing in Saudi Arabia has caused the
prevailing low status image of nursing… even in western countries,
nursing started as part of medicine… it was an apprenticeship not a
profession, so people continued to perceive it as an occupation assisting
medicine” Int.8, female senior nurse
Thirty years ago, the newly established nursing programmes had no criteria for
acceptance or standards for selecting students. Interested female students who completed
four years of primary schooling were taken by the early nurse aide programme. Many
participants cited the elementary education and basic training of that group of Saudi
nurses as factors that influenced the poor image of nursing and low status of nurses.
Some participants viewed the nursing curricula prior to the early 1990‟s as unscientific
apprenticeship type of nursing programmes.
“Saudi nurses from those early programmes are still working out there.
They portray negative images; they used to study nursing after nine years
of schooling. Their nursing standards were low and they had no ambition
or desire to change” Int.18, female staff nurse
The participants I interviewed often drew attention to the differences between their own
views of nursing and those of their families and the wider community. For instance,
many participants perceived nursing as a good career competing with other available
career options. They thought that their own positive views on the value of nursing were
118
often in sharp contrast to the perceptions of nursing that they experienced from families,
friends and others in their community which are usually associated with low status and
poor images of nursing.
“We should not be ashamed of our work as nurses, this type of service
date back to our Prophet‟s time. Female nurses used to care for the male
victims and no one said anything then. On the contrary nurses were
encouraged and paid. This aspect has been totally forgotten and what
people care about is pure traditions” Int.5, female staff nurse
Work-related images
Just over half the participants reported that their families, relatives, friends and the
general public continue to perceive nursing as a source of shame and humiliation. This
was attributed to the mixed-gender work settings, the bedside care provided by nurses
and the long shift work. Traditionally, Saudi women were generally expected to stay
home and care for the family. Education and work (paid or unpaid) implied leaving
home for part of the day; such practice was perceived by most Saudi families to be
against the prevailing traditions and Islamic guidelines (Parssinen 1980 & Al-Suwaigh
1989, page 18 of chapter 1). When the nurse-aide programmes were introduced, there
was strong government and public opposition to the entry of Saudi women into these
programmes triggered by a prevailing tradition which require gender segregation and
veiling of women (Meleis & Hasan 1980, El-Sanabary 1993 in page 3 of chapter 1).
These traditions were perceived to be based on religious beliefs about requirements to
protect women and safeguard the family honour.
“They are all against me, for them nursing is not a clean job and has no
future. My parents, my relatives, my friends, they all say: why would you
humiliate yourself, they consider nursing as serving-type of work” Int.10,
male staff nurse
119
“… it depends on the person' cultural backgrounds. In my background,
parents will not allow their daughters to go for nursing because of the
mixed working environment. It [nursing] is considered shameful, now I
see more nurses but the majority come from non-tribal origins” Int.37,
female student
Nineteen females (38% of the total females) made explicit reference that their male
relatives do not approve of the gender mixing, night shifts and weekend duties expected
of nurses. Working in a mixed-gender setting such as a hospital continues to be an issue
of debate among Saudi people. The religious and conservative Saudis tend to view such
work as forbidden (haraam) unless provided during national crises (Al-Bar 1984). In
contrast, liberal Saudis may believe that work is a matter of personal preference
particularly with high demand in the labour market (chapter 1, page 12). Such
conflicting views kept the Saudi‟s rather divided and confused. Some participants
indicated that people‟s perception of jobs at mixed-gender settings is changing. They
linked this change to: education, personal exposure, and need for money. Nevertheless,
the nurse in the second quote below pointed out that his younger sister‟s concern about
joining nursing was her worry about the public‟s views on gender mixing. This may
suggest that prevailing cultural traditions sometimes override personal interest.
“People‟s perception of a mixed work environment has changed. If a
female nurse is respectful then she will be perceived as such even when
working in male patients‟ units. However I wish they have separate units
for women in the future, this will encourage more girls to join nursing”
Int.12, female staff nurse
“My sister is asking me about nursing, her main concern is the mixed-
work setting. I advised her to be confident, to hold on to her principles
and assured her that nothing will go wrong. Nursing implies working
with the opposite sex but this was the case during the Prophet‟s time, yet
he encouraged it” Int.11, male staff nurse
120
Some participants from the students and staff nurses‟ groups referred to formal and
informal statements (fatwa) made by religious scholars particularly in relation to certain
aspects of nursing (gender-mixing, night duties and long working hours), making it less
desirable as an occupation. These participants viewed such religious statements as
influencing people‟s opinions particularly amongst the older generation and conservative
groups. Holding on to traditional beliefs, religious statements may lead these groups to
believe that nursing is an unacceptable career for the Saudis. They voiced a concern that
many religious scholars were using their own interpretation of religion to support some
highly-valued traditions such as those linked to gender segregation and face covering for
women.
“A religious scholar told me if I was his daughter he won‟t let me go for
nursing. I told him I am not his daughter and argued with him. So, his
final statement was as follows: nursing work is permitted but not
preferred” Int.9, female student
The student in the above quote was so much in favour of nursing that she, at her father
request, was willing to get an approval from a religious scholar before applying for
nursing. Talking with the person her father recommended was not an easy task; he kept
referring to the gender-mixing aspect of nursing and the night duties. After long
discussions supported by historical and religion-based accounts, the scholar could not
defend his position of declaring nursing as forbidden and had to say it may not be
(haraam), it may be permitted for Muslim women but it would be tolerated only within
strict socio-cultural conditions and should not be encouraged as a viable occupational
option for Saudi women.
Religious motives
This synthesis theme brings to light the participants‟ perceptions of spiritual and moral
rewards associated with working in nursing and providing nursing care. Three quarters
of all participants referred to a variable degree of satisfaction experienced when
providing a humanitarian service such as nursing.
121
“You are close to God; you actually witness life and death situations. You
earn great Ajr [rewards from God]; this is why I love nursing despite the
associated workload and pressure” Int.11, male staff nurse
Participants‟ responses suggested that spiritual and moral rewards are usually gained
through: expected blessings from God, sincere prayers from people in need, patients‟
gratitude, delivering charity-like work and maintaining a stock of good deeds. The
interviews suggested that these non-materialistic rewards had great impact on the
participants and served like a driving force behind the staff nurses‟ decision to continue
working particularly at the in-patient units. Participants from the staff nurses‟ group
cited these rewards as factors that helped them cope with the prevailing negative images
of nursing and low status of nurses. The majority of all participants indicated that
nursing provided them with opportunities to establish a strong spiritual link with God.
“Nursing is great; if you are honest and faithful, you will be paid back.
The patients‟ prayers and the Hasanat [good deeds] will benefit you in
this life and in the life after. Through nursing you build a relationship
with God… you are serving His people” Int.13, female staff nurse
By and large, students, staff nurses and senior nurses talked about feeling happy, content
and satisfied when providing nursing care, when patients sincerely prayed for them,
when patients‟ conditions improved and when patients expressed appreciation. Their
accounts suggest that the appreciation, praise and prayers they receive from patients may
outweigh any hardship experienced in the process. The participant in the quote below
was the only one to refer to the value of providing bedside care to patients who need that
level of assisted care.
“I need all the prayers from patients; they have a great [positive] impact
on me… I love the bedside care and I enjoy providing care to patients. I
believe our patients are not getting quality care… as Saudi nurses we
should give the best care” Int.3, female staff nurse
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Some participants perceived pursuing a career in nursing as a national duty and religious
responsibility. They believed that Saudi patients need Saudi nurses who understand their
culture, speak their language and are more sensitive to religious issues relevant to ill-
health and dying. For example, one of the participants explained that simply saying (in
the name of God) before administering any medication or doing any procedure tended to
place paediatric patients at ease and build trust with elderly patients.
“In comparison to doctors, nurses are usually underestimated. But for the
patients who experience life and death situations in the Intensive Care
Unit… they see that we work hard with them, more than the doctors.
When they recover, they say: God bless you for being Saudi and for
being Muslim nurses caring for us at a very critical time” Int.5, female
staff nurse
Participants frequently referred to a feeling of inner peace when working directly with
patients. The spiritual and moral satisfaction might be linked to a deeply-rooted religious
belief that prayers from people in need are always answered. However, it seems that this
type of spiritual satisfaction was not enough to keep Saudi nurses working at the in-
patient units and to compromise for the long hours, shift pattern and bedside care.
“Nursing is spiritual. At the hospital, things do not usually go as we
wish… but for me, a single prayer from a patient is worth all the
difficulties and pressure from the others. This is what I like most about
nursing” Int.11, female student
“Working and dealing with patients made me appreciate nursing more.
When a dying patient prays for me, I feel greatly motivated. I feel blessed
at work and in my personal life; patients are weak and vulnerable… their
prayers will be answered.” Int.12, female staff nurse
123
Ten participants cited a childhood desire to help people. Some of these participants were
lucky to have had family members or school teachers who helped them explore areas
where they can best direct their growing passion to help people.
“I like working with people, I like to listen to their stories. The human
feelings within me are high… I always loved going to the hospital and
dealing with patients. You would really love nursing when you go to
hospitals” Int.3, female senior nurse
This desire to help the others was perceived by the participants (tribal and non-tribal,
females and males) as a driving motive. The female participant (non-tribal) in the first
quote above had to leave the science college in her local area to go to the new nursing
college in a nearby city. In contrast, the male participant (tribal) in the quote below was
interested in nursing since his childhood and he was determined to join a nursing
institution after completing grade nine. To his disappointment, by the time he was ready,
the institution was transformed into a college taking students after grade twelve. He was
not put off by the unexpected change in plan and worked hard to get to the college after
he finished high school.
“Helping others is something I loved since I was young. I may do
anything good to mankind… my family directed my attention to nursing
and I started to think about it ever since” Int.11, male staff nurse
To cope with nursing and its associated pressure, two staff nurses and seven students
talked about resorting to God for help and advice. They performed a special prayer
(Istikhara) asking God for guidance, enlightenment and strength. For these participants,
nursing was not their first choice; however, they tried to accept nursing, come to terms
with the social and family pressure and convince their families that nursing is a good
career option. In Islam, Istikhara is believed to help people cope with difficult situations,
bring inner peace and enhance feelings of satisfaction. This type of prayer is a common
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practice among Muslims particularly before taking any major decision, when going
through a new phase of life or when facing critical time.
“My high-school score did not qualify me to apply for medicine. The
closest thing to medicine was nursing. I planned to study nursing for the
first year and then request a transfer to medicine. Managed to get the
straight A(s) needed for the transfer, prayed Istikhara but then I realised I
was falling in love with nursing” Int.16, female staff nurse
The social norms
As discussed in chapter one, the economic prosperity achieved after the discovery of oil
had caused a significant social change. This social change was achieved through:
urbanisation of Bedouin tribes (Al-Khalifah 1995, Frisbie 1995); increased uptake of all
levels of education for both men and women (MoEP 2003, MoP 2006 in MoH 2006); an
expanding healthcare services both public and private (MoH 2006); and slow but steady
expansion in women‟s role outside their homes (MoP 2005b).
“I am the only one in my family who chose nursing. Tribal families like
mine do not usually approve of gender mixing and they do not accept
seeing their women outside the home boundary” Int.13, female student
“My family [tribal] has no problem with nursing; they [family members]
view it as tough field and hard work. No one has entered this field before,
so they are proud of me… Most people view women who go for any
medical fields as indecent or as one with… a problem. They consider
nursing work as a disgrace and humiliation” Int.29, female student
The quotes above illustrated that, despite a predominantly negative public perception of
nursing, the tribal families seemed to have a more positive perception which enabled
them to accept nursing as an occupational choice for their daughters. This may reflect a
change in perception that is slowly and gradually taking place in Saudi Arabia. A trend
125
reflected in the number of participants from tribal origin who took part in my study (15
of the 50 females and 13 of the 18 males). This proportion (41%) and the relevant
interviewees‟ responses may suggest a socio-cultural change in favour of nursing.
“Nursing now is not limited to one place. You will find Saudi nurses even
in tribal areas like the southern region, they are in Taif, Riyadh and
Tabouk; they come from every family. Nursing is gradually spreading and
its reputation started to improve” Int.27, male nurse intern
Tribal families, like most Saudi families tend to direct their children to jobs held in high
social regard such as teaching and medicine. Participants descending from tribal
backgrounds indicated that tribal families used to view nursing as a job that brings
shame and disgrace to the family and tribe. They attributed this to resentment and
disapproval towards: women‟s work outside the home boundaries, mixed-gender work
environment and the caring nature of nursing work. However, perhaps as an outcome to
education, social exposure and global interaction, the attitude of most these families and
their perceived value of work may have been through a major change. There was a
consensus among the 28 participants from tribal backgrounds that the attitude of tribal
families regarding women‟s education and employment has been slowly and gradually
changing.
“We need nurses more than anything, the shortage is severe… Nursing is
no longer limited to a particular social class; some physicians and
academic staff are directing their daughters to nursing” Int.2, female
senior nurse
The married female nurse in the quote below was one of 13 female participants (2
interns, 9 staff nurses and 2 senior nurses) who maintained a tradition of covering the
face in public areas while leaving the eyes exposed. She indicated that her father, who
comes from tribal origin, did not mind if she left her face uncovered. She also pointed
out that her father was the one who encouraged her to choose nursing and, if she was not
126
married with children, he would have accompanied her abroad to pursue her higher
education.
“It [the perception of nursing] is changing. Unlike before, people have
more awareness now; more high school girls of tribal origin are joining
nursing these days. My father encouraged me to join nursing, he is open-
minded, he does not mind even if I leave my face uncovered” Int.2,
female staff nurse
In contrast to tribal affiliation, some participants from the three groups made reference
to the social tolerance which usually characterise the Saudi ethnic mix in a cosmopolitan
city such as Jeddah. Mixed-blood Saudis are the products of cross-marriages among
Arabs, Asians and Africans who migrated to the region. Influenced by a diverse socio-
cultural backgrounds of their parents, these Saudis tend to generally be characterised by
a great deal of cultural flexibility in relation to religion and traditions (page 15, chapter
1). Most participants from mixed-blood families reported minor to moderate family
conflict regarding their choice of nursing. Their individual account suggested that
mixed-blood families may have a tendency to respect their children‟s choice, even if it
conflicts with their own, and give them the needed support. A few from the students and
staff nurses‟ groups pointed out that working in Jeddah exposed them to „less hassle‟ in
relation to nursing work.
“In the other regions, they look down at the nurses because of the mixed-
work environment. Maybe because we live in Jeddah we do not
experience such [negative] impact. Here, it is quite normal and regardless
of what you do if you respect yourself people will respect you” Int.38
female student
Socially acceptable jobs
Participants identified perceived social acceptability as an important factor influencing
career-choice decisions. This is consistent with what has been raised in chapter one (El-
127
Sanabary 1993, Meleis & Hasan 1980, El-Sanabary 2003). There was a consensus
among participants that people perceive nursing as a socially unacceptable career choice.
For women, it implies working in mixed-gender settings and covering long hours of shift
work (Meleis & Hasan 1980, Alawi & Mujahid 1982, Jackson & Gary 1991, El-
Sanabary 1993, Hamdi & Al-Hyder 1995, Al-Johari 2001). For men, nursing implies
working within female-dominated occupation and undertaking caring tasks designated
for women (Al-Rabiah 1994, Al-Osimy 1994c).
“For parents in most families, medicine is the best thing for their sons and
daughters. It is prestigious to be a doctor… nursing is not important as the
other professions. People think nurses are involved in cleaning and
grooming patients. So, it is not an honourable job for a family member to
have” Int.9, female student
The Saudi literature reviewed in chapter two suggested that the technical-type nursing
education and the nature of nursing work are linked to the social and professional status
accorded to nursing. Most participants cited educational qualification (BSN versus AD),
acquired skills (advanced versus basic), title following graduation, job grade, salary and
financial benefits offered by employers, when describing socially accepted jobs and
professionally recognised occupations.
“Mom wanted the Dr title; it is more prestigious. She is pushing me to do
my PhD; she says [to people] my daughter has a master degree and she is
managing the nursing department. For her, nursing is a social
embarrassment. This is very painful for me” Int.6, female senior nurse
Participants often reported that people perceive certain jobs such as medicine,
engineering, teaching and administration as more prestigious. They linked these jobs to
perceived high social status and professional power. Some participants made explicit
reference to family members feeling proud if one is studying for or already holding a
post in any of these jobs. In contrast, many participants referred to the low status
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accorded to nurses. Particular reference was made to the perception of nurses as care
providers who assist the medical profession and just follow doctors‟ orders. The
undermined low status of nurses was the most frequently cited reason discouraging
participants and their families from choosing nursing and accepting it as a future career.
This subservient status is consistent with the reviewed Saudi literature (Jackson & Gary
1991, Mansour 1992, El-Sanabary 2003).
“… our society has a special ranking for jobs. First, according to their
income and second, according to their social status. So, if you ask any
high school student, he/she would say: I want to be a doctor because it is
the best socially, professionally and financially” Int.8, female senior nurse
“Nurses have always been viewed as a sub-class. In healthcare services,
they do not have an opinion, they do not have the knowledge, they do not
have an input in patients‟ care, and they just follow orders. It is pity to
find that these views are shared by people who work in the same field
[doctors]” Int.17, female staff nurse
A quarter of the participants referred to a social inconsistency in the perception of
gender-mixing practice and the application of traditional norms. They pointed out that,
unlike female nurses, female medical doctors who work in the same mixed-gender
settings are well respected and highly regarded by the general public. These participants
attributed this inconsistency to the professional title and qualifying degree which tend to
give doctors power, prestige and protection.
“… both are daring, nurses and doctors, but doctors have more highlight
being more holy than nurses… The nurse is interacting with everybody,
sick people, healthy people, colleagues and visitors. She has more
chances to mingle around” Int.3, female senior nurse
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The changing economy
It is important to clarify that not all Saudis are living in luxury and enjoying comfortable
life. Examining the participants‟ socio-demographic data, I found that a maximum of
£570 was the estimated monthly family income of five students. Fifteen other students
and seven staff nurses had a monthly family income of equal to or less than £1429. Just
over a third of the participants had a family size of 3-5 members and just over quarter
had a family size of 6-8 members (refer to table 3, page 103). Taking into consideration
the time gap between the two studies and the increasing cost of living, the above
estimated monthly income tends to place the former group among the low income group
and the latter (one third of the total participants) among the low middle income group
(Telmesani 1995).
A need for money
It has been argued elsewhere that Saudis who choose certain vocational training or
technical education such as nursing may either have limited academic prospects or come
from lower social class backgrounds (Meleis 1979, El-Sanabary1993). Some interviews
suggested that participants (men and women) have decided or it has been decided for
them to go for nursing simply to earn a living and to support their families. Of the 23
students who decided to consider nursing for its secured employment, five had an
estimated monthly income of £570.
“We should tell people about the salaries [nursing salaries] it is better than
other specialities. To start with they might be attracted to the money but
later they will find themselves in one aspect or the other. Life is getting
harder so we might use the financial reward to get through to parents”
Int.15, female student
Although nursing was not a choice for her, by the end of the first year of the programme,
the student in the quote below has realised the job security associated with a career in
nursing. She decided to pursue her nursing studies despite harsh comments from her
mother and other close family members. Her father passed away when she was a child
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and her dream was to secure a comfortable life through a job in socially acceptable
nursing areas.
“Till now [2 nd
year in nursing] I feel my mother is still not convinced
about nursing. I am trying to convince her; it [nursing] has a good salary.
This is good for people like me who needs to be independent” Int.8,
female student
In my study, almost two thirds of the participants perceived nursing as a career which
provide secured employment and believed that an increasing number of young Saudis
are becoming interested in nursing just for the job and good salary it provides. Students
from the associate degree programme made it clear that they found the job security
provided by a career in nursing an incentive that helped them cope with nursing. This is
consistent with results reported by Hamdi and Al-Hyder (1995).
“First year is a foundation. It depends on the student‟s performance and
final score. My first choice was laboratory, the second was nursing. The
college decided I should go to nursing! That was quite alright; I will
study for two more years and then get a job” Int.19, male student
The above trends were attributed to the economic hardship of the 1990s and the
increasing unemployment rate among graduates of academic specialities which are not
on demand by the labour market. Unemployment and its associated economic pressure
were cited by many participants as having a major influence on the uptake of socially
less favourable specialities such as nursing. The rapid population growth, the mismatch
between educational outcomes and labour-market demands, and the availability of cheap
foreign labour force, have been highlighted in chapter one as factors contributing to a
rising unemployment rate among high school and university graduates (page 19 of
chapter 1).
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“Things are changing; there are forty eight students at the foundation
year and all of them want nursing. High school [male] students think
mainly about having a job and salary; I was one of them. They might
think of engineering… but it will not secure an employment” Int.23, male
student
“I never thought of nursing and never wanted it… but, I was the only boy
in the family; my fathers‟ income was little [a retirement compensation],
it was not enough. Although I was an outstanding student, I had no choice
except to join the military‟s nursing programme right after high school. I
had a job immediately after graduation” Int.21, male staff nurse
With reference to the participants‟ socio-demographic data, I found that eight out of the
nine senior nurses in my study had an estimated monthly family income of more than
£2430. Seven of these senior nurses are married to employed partners who are
contributing to the total income. Fifty per cent of the staff nurses had an average
estimated monthly family income of £1930 and four had up to or more than £2430. This
suggests that having a nurse in a family with average size of four may improve the
average monthly income of the family. An incentive that kept some staff nurses in their
jobs and/or retained them at their employing hospitals.
“My high school score did not qualify me for medicine; I consulted a
male relative who advised me to go for nursing because it has more job
opportunities… To me, nursing meant a work opportunity at a time when
even medical doctors have failed to find jobs” Int.4, female staff nurse
“… money is very important these days; we have more responsibilities
and we have debts to be paid. This is why I am keeping quite and will
continue to work” Int.2, female staff nurse
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Conclusion
The underlying argument presented in this chapter is that in a rapidly changing Saudi
socio-economic context and, in spite of widespread negative images of nursing, it would
appear that nursing slowly and gradually becoming an increasingly popular occupational
choice. For this purpose, participants‟ views on nursing and their perceptions on
prevailing images of nursing held by the people around them have been explored.
Participants drew attention to the differences between their own views of nursing and
those of their families and the wider community. Throughout the chapter, themes
(synthesis and organising) were used to explore participants‟ views and perceptions and
understand how they influenced their decisions to pursue nursing and to continue as
nurses.
In summary, many participants‟ accounts suggested negative perceptions of nursing
particularly in relation to the unskilled and menial bedside nursing tasks. Half the
participants perceived the negative media images as contributing to the public‟s view of
nursing as “women‟s work” and to a socially less respected status of female nurses.
Participants were puzzled regarding the discrepancy between the current prevalent
negative images of nursing and the highly respected image of the early Muslim nurses.
Nevertheless, the non-materialistic spiritual and moral rewards associated with working
in nursing and providing nursing care were raised by three quarters of participants.
These rewards were a driving force behind the staff nurses‟ decision to continue working
particularly at the in-patient units. Some participants‟ accounts suggested some degree
of change in the perception of nursing. Two thirds of the participants perceived nursing
as a career which provides secured employment. A trend that was attributed to the
increasing unemployment and associated economic hardship of the 1990s.
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Chapter five
Challenges facing professionalism
Introduction
The explanatory theme described in this chapter includes many overlapping synthesis
themes grouped together under three organising themes: nursing education, nursing
regulations and nursing support systems. Throughout this chapter, organising and
synthesis themes are used to convey participants’ views on the importance of achieving
a nationally and internally recognised professional status of nursing. Themes are further
explored in relation to participants’ academic institutions, employing organisations and
healthcare sectors illustrating the national and organisational challenges nursing as a
potential profession is facing. As a supporting national policy and organisational
strategy, the last section of the chapter presents participants’ perceived views and
expectations of the Saudisation Policy highlighting its impact on their decisions to
pursue nursing and to remain as nurses.
Nursing education
Participants from the three groups frequently cited nursing education as having a major
contribution to the perceived low status of nursing. They raised a number of important
education-related issues represented by three synthesis themes: “reality-shock”
experiences, gaining nursing competence and developing nursing confidence. I have,
therefore, used these themes to explain the relationship between the participants’ views
on nursing education and their perception of the professional status of nursing.
“Reality-shock” experiences
Drawing on their responses, the participants described experiences that tended to occur
in a pattern. Experiences that hindered the process of acquiring a desired professional
competence and confidence occurred when participants started to realise what nursing is
all about; when they began their training at the nursing lab (skills’ centre); when they
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started practicing in hospital-settings; at the beginning of their internship period; or at
static points in their career as staff nurses.
“First year was alright. Second year we started to get down to the real
nursing, I was shocked. I requested a transfer, tried hard, but it did not
work out” Int.18, female nurse intern
“I had a reality shock. What we studied at the college did not say much
about real nursing at the hospitals… as students we did not have enough
exposure to patients’ care. We did not know what is expected of nurses or
what happens in hospitals… when we started our career life we were
shocked, confused and disappointed” Int.7, male staff nurse
Most participants from the government BSN programme drew attention to the ambiguity
experienced when registering as students under the College for Applied Medical
Sciences. They made explicit reference to feeling shocked as they realised that the field
they were studying was nursing. Their feeling was intensified as they confirmed this
reality through informal talks with students in their advanced years of study. For almost
fifteen years the college of nursing at King Abdulaziz University, was hiding under the
umbrella of a generic title (Applied Medical Sciences). For female students, this college
meant nursing, but for male students it meant medical technology. Not knowing that
they will graduate as nurses, many female students were channelled to this college when
they fail the admission criteria for medicine or pharmacy. Over the past seven years, the
same college launched several other programmes such as pharmacy, medical dietetics
and physiotherapy in addition to nursing. However, nursing remained a degree-level
specialty offered only to female students.
“I graduated from high school in 1991; I was not thinking of nursing. I
did not even know what nursing is all about… one of our relatives, a
medical consultant, said to me: your sister is a medical student, why don’t
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you try Applied Medical Sciences; if you do not like it you can request a
transfer at the end of the first year,” Int.19, female staff nurse
“I wanted medicine but did not pass the entry exams. They
[administrative staff] advised me to apply for the Applied Medical
Sciences. I was not aware it was nursing; I felt frustrated when I knew”
Int.1, female senior nurse
Interviews with participants from the government BSN programme revealed that most
students were hoping to get a transfer to their desired academic programmes at the end
of the first year in nursing. Those who have been through such experience, talked about
being worried and devastated in fear of failing to get the results required for a transfer.
Some of those who failed to get a transfer talked about feeling stuck in nursing and
about the stress of having to cope with this reality. Their interviews indicated that while
some may have managed to come to terms with nursing, the others remained frustrated
until their second year of study.
“Reviewing my performance so far, I don’t think I will make it to
medicine [will not be able to request a transfer]. I feel trapped not to
mention the pressure from my family. It feels like being locked in a castle
of horrors” Int.12, female student
In contrast, students and staff nurses from the associate degree (AD)
15 programme drew attention to decisions made by the college administration at the end
of the foundation year. Decisions which may overlook the students’ field of interest
stated in their applications and may direct students to nursing based on their academic
performance. Whether intended or not, by doing so, the college administration was
confirming the low educational status of nursing.
15
Throughout this chapter, any reference to the associate degree programmes will be abbreviated as AD.
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“Individual choices are just formalities. Those with high scores are
directed to pharmacy… if you had a low score and you have interest in
pharmacy you will not get a place. If you are not a hard worker and you
have a record of absence you are directed to nursing” Int.20, male student
Most participants from the BSN programme expressed shock and disappointment as they
came to realise that bedside care is part of their job description. Their responses
indicated that they did not know about the nature of nursing work and the tasks expected
of the nurse. This was covered in detail in chapter four under the heading “Domestic
nature of bedside nursing care”.
“The Filipino and Indian nurses have nursing diplomas; we have BSN
degree. There is a difference in ranking and grade… yet people think I
will be like those nurses and will do the same work [bedside care]” Int.4,
female student
In explaining the “reality shock” experiences, participants from the senior nurses’ group
made reference to the socialisation process within nursing and how it may influence the
students and newly qualified nurses’ experiences particularly in relation to coming to
terms with nursing.
“Socialisation is an issue. They [students] know it is nursing but they do
not know what it entails. We [academic staff] have to work on this aspect.
We need to work on the culture of nursing and the nature of the work”
Int.4, female senior nurse
In Saudi Arabia, once nursing students fulfil their academic course requirements, they
will progress to a compulsory internship phase of the programme which may range
between 24 and 52 weeks (page 7 of chapter 1). Participants from the interns’ group
(BSN government programme) talked about an unexpected pressure associated with
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their efforts to meet the expected role of the intern. This pressure is usually associated
with the interns’ feelings of clinical incompetence.
“I am studying the med-surg course materials all over again. It feels like I
have never learned any skills. As students, we were not allowed to give
medications… you hardly get opportunities to practice what you learned”
Int.17, female nurse intern
In contrast, interns from the MoH (AD) programme, being more service focused, were
more likely to find coping with similar pressure and achieving role-adjustment easier
than the BSN interns.
“We started at the surgical unit, the staff was very co-operative… the
experience there gave us [interns] good orientation to the hospital.
Medical units were mainly routine work of feeding and medications. ICU
was interesting and challenging… I was not assigned to patients, I was just
providing assistance” Int.25, male nurse intern
Some participants from the interns and staff nurses’ groups had an expectation of
working as staff nurses for a maximum of five years before getting a promotion to the
head-nurse position or before being granted a scholarship to pursue higher education.
Responses drawn from these participants (males and females) revealed anger, frustration
and disappointment. In chapter four, this expectation was linked to the participants’
desire to be promoted to a level whereby they do not have to do the bedside nursing
care. It may also be linked to the participants’ desire to be freed from the unsociable
shift work or to be granted an opportunity for higher education.
“You feel like a mule tied to water-wheel, no one is supporting you… it
is like engraving in stones. During the Postgraduate Diploma, the
administration gave us false hopes; now, four years later, we are still in
the same position… standing still” Int.16, female staff nurse
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Gaining competence
As discussed earlier in this chapter, there was a consensus among participants that
practical sessions spread throughout their taught programme were not adequate to
develop the desired nursing skills among students. I have used the participants’
responses to identify the following influences on the students’ level of competence. The
limited practical component of the programme; limited opportunities for practicing
various nursing procedures; frequency of practicing a particular procedure; shortage in
nursing academic staff and clinical instructors; lack of summer training and voluntary
work; and inadequate training facilities and resources at the various academic
institutions.
“We take the knowledge then lose it because we do not immediately
apply it in the hospital. There is no link between theory and practice,
what I learn I should practice but we do not get enough training” Int.20,
male student
Hospitals’ clinical training for students from the BSN programmes takes place over 2–3
days per week and last for 4-6 hours. Participants from these programmes raised the
following concerns in relation to students’ practical experiences. During the few hours
they spend at the assigned hospital units, students are less likely to attend the nursing
report and morning care. They may attend physicians’ rounds and may have an
opportunity to give medications, change dressings and take vital signs. Nevertheless,
their main concern is to review selected patients’ records and work on a nursing care
plan to submit to their clinical instructors for assessment. The afternoons of the students’
study days are designated for college-based classroom discussions of different case
studies. These concerns were often cited as factors contributing to what many
participants described as “an observers’ role” undertaken by students. They also suggest
that BSN students tend to take part in fragmented work experiences instead of living a
typical nurses’ day.
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“Practical training means you stay with the hospital nurse from the
beginning to the end of the shift. During the first two days, students need
to shadow nurses and observe. After that they will be assigned to simple
tasks and stable patients. Half day here [at the hospital] and half day there
[at the college] is not a good arrangement… does not work well” Int.16,
female staff nurse
In contrast, students from the MoH (AD) programme have six hours of clinical sessions
starting as early as the hospitals’ morning shift. Nevertheless, they also expressed
frustration linked to inadequate practical opportunities either at the nursing skills’ lab or
at hospital units. This might be linked to three factors: an increased number of students,
shortage of clinical instructors, and limited training opportunities at the designated
teaching hospitals.
“We work from seven in the morning till one in the afternoon three days
per week. Sometimes you may have nothing to do until shortly before
leaving. Some procedures are part of the daily routine others are not so
frequent… I really want to learn certain procedures like suctioning or
inserting a catheter but had no chance [to practice at the hospital]” Int.28,
female student
Participants from the students’ group (diploma, AD, and BSN; government and private)
raised two concerns in relation to developing their nursing skills. First, the availability of
practical opportunities and second the frequency of practicing a particular nursing
procedure either in a nursing skills’ lab or at the hospital. There was a consensus that
practicing a nursing procedure once is not like doing it five times; for the students,
frequency enforces competency.
“I have taken part in annual summer training at different hospitals since
the second year … but I have inserted an intravenous cannula only five
times throughout my years of study. I still do not have the confidence to
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perform certain procedures on patients… Our programme focus on
theories, we have great knowledge base but our practice is poor! Time is
limited [at the hospitals] and supervision is inadequate” Int.18, female
nurse intern
Some students pointed out that practicing on a doll at the nursing skills’ lab is not like
practicing on a real patient who experiences real pain and discomfort. To develop their
nursing skills and improve their practice, these students expressed a need for more
supervised practice on patients in a hospital setting. Their responses placed high value
on the guiding and supporting role of clinical instructors.
“In the second year we practice at the nursing lab… but it is different
when you start practicing on real patients. They [patients] feel; they
might be in pain. If they are upset, we [students] cannot do the procedure
right” Int.22, male student
Most interviews with the students suggested that their practical experiences do not seem
to provide opportunities for repeated supervised practice. Even students attending the
nursing lab may not have an opportunity to practice the demonstrated nursing
procedures supervised by an instructor. Depending on the initiative and interest of the
individual students, some may remain mainly observers throughout their years of study;
others are more assertive and adamant about their right to learn.
“We [students] are divided into groups… I like to take the initiative; I
always practice first after the instructor [in the nursing lab]. Well, I make
mistakes but you learn better this way… we all have a go, sometimes two
students will work together” Int.7, female student
Students, staff nurses and senior nurses drew attention to the increasing number of
nursing students (diploma, AD and BSN, government and private). The annual increase
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in the numbers of nursing students seems to have reduced the practical opportunities
available for them at the designated teaching hospitals.
“With reference to clinical training, we do not have enough qualified
trainers… numbers [of students] are increasing and places for clinical
practice [teaching hospitals] are limited. The students’ chances to get
clinical training are reduced… this influences the quality of educational
outcome. You read that in the newspaper but it is not supported by
findings from a formal study” Int.4, female senior nurse
Senior nurses at the academic institutions made explicit reference to the lack of human
and material resources. There was a consensus among these senior nurses and
participants from the students’ group that an increasing number of students if not
paralleled by qualified academic staff and adequate training facilities would adversely
influence the quality of nursing education. Their responses suggested that the size of the
nursing skills’ lab and the resources available for training purposes including teaching
hospitals and clinical instructors had a major impact on students’ supervised practice
sessions and eventually their skills.
“I do not have enough clinical instructors. Imagine 160 students and only
five instructors. The ratio for clinical practice is one instructor for fifteen
students… if I do not have enough staff how could I guarantee quality! I
have 40 students in one small nursing lab. Students at the back cannot see
anything, this is not fair… it has been said that students are not
competent; but this is not their fault” Int.5, female senior nurse
Students from the private diploma programme talked about having access to a very basic
nursing skills’ lab and very limited training opportunities in their first year. They
indicated that a new lab was ready in the academic year 2005-2006 (almost two years
after commencing the nursing programme). These students were not satisfied with the
training, supervision and follow up performed by their clinical instructors.
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“We took the course of fundamentals at level one of the [nursing]
programme, it was only theory no practice. We had no lab then. Now
with the new lab we started to spend one day at the lab and one day at the
hospital” Int.35, male student
“The old lab was ready by the second semester of the first year, it was not
as organised as the new one… the instructor used to explain the
procedure with no equipment… no demonstration. It is much better with
the new lab and instructor” Int.38, female student
Some students and senior nurses pointed out that volunteering and summer training
programmes are important complementary opportunities to compensate for the theory-
practice gap. Students indicated that these opportunities helped them develop new
nursing skills and enforce those gained during the course of their clinical practice.
Participants’ responses revealed that summer training and voluntary services continue to
be initiatives taken by the interested individual students. Many students expressed
interest in these complementary experiences but they were worried about arranging such
opportunities on their own with no support from the college.
“I have not practiced all the nursing procedures we covered so far… so,
we [group of students] arranged for practice sessions over the weekends.
I am also considering a voluntary work during the holidays” Int.3, female
student
“We lag behind in terms of practical work. We are really struggling… I
am in my fourth year and I am not good at inserting cannulas. This is why
I am considering summer training… I am sure it would be beneficial”
Int.11, female student
Due to lack of qualified clinical instructors, the responsibility of teaching and training
nursing students in clinical areas is often left to hospital nurses. Responses from senior
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nurses in academia indicated that the shortage in qualified instructors is caused by
limited posts allocated to academia restricting the number of nursing graduates who join
the field. The shortage was also attributed to the number of years it usually takes to
prepare a qualified academic nursing staff although this shortage is international in
nature (Walrath & Belcher 2006, AACN 2006, Allan & McClellan 2007, Nettleton
2008).
“… because of the limited jobs [academic posts] and the long period of
time needed to prepare a qualified member of staff… they usually do not
come back [to their posts] before six to ten years. This is very important to
consider and this is why we keep relying on non-Saudis” Int.4, female
senior nurse
Relying on hospital nurses to train and supervise nursing students was a source of
concern to most students. With the current shortage in nursing, hospital nurses are
usually working longer hours with extra load of patients. There was a consensus among
participants that, during practical sessions at the hospitals, nursing students may not
have clinical instructors or preceptors to teach and guide them as necessary. Participants
from the staff nurses’ group pointed out that not all hospitals run preceptors’ courses for
their nurses and preceptors do not usually get any incentive for their training role and
teaching contribution. They also perceived the attitude of some nursing students as
lacking an interest in nursing. Their responses indicated that they felt that these students
may not take the initiative to ask or offer help, hide when nurses are busy and feel
embarrassed when practicing the bedside care.
“This is a teaching hospital. Nurses work hard with the students but the
hospital does not pay them for their effort. With eight or ten patients you
may not have the time to explain everything to the students. It depends on
the student, if she did not try to learn no one will teach her… it is her
responsibility to chase nurses” Int.3, female staff nurse
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Participants from the three groups pointed out that some non-Saudi hospital nurses are
very uncooperative. Responses suggested that, due to the severe nursing shortage,
hospital nurses may forget about the students or continue to do their work without
involving them. They may assign students to simple tasks and keep them busy with
those tasks with little supervision. When students are given the chance to practice a
given nursing procedure on a real patient for the first time, the supervising nurse might
be critical or inpatient. These situations were cited as contributing to students’ feelings
of helplessness and incompetence.
“Skills give you confidence… but we are working with nurses who know
their job very well, sometimes they get inpatient. Our clinical instructor
would ask them to call us when performing procedures but they do not do
that. How are we supposed to learn if we do not practice!” Int.3, female
student
“… it [clinical training] depends on where you had your training and
internship. The hospital will either be very supportive or will treat you as
supernumerary and will not give you responsibilities” Int.17, female staff
nurse
Students frequently referred to a lack of supervision from their clinical instructors and
hospital nurses. Some students described their feelings during their hospital clinical
training as: “lost”, “ignored”, “forgotten”, “unattended”, “a tourist”, and “an observer”.
These feelings reflected students’ perception of the quality of clinical practice
experienced by most participants from this group.
“When we were students we used to go to the hospital two days per week.
I used to stand in the unit not knowing what to do. I felt lost… hospital
nurses were busy and I was left on my own” Int.26, male nurse intern
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There was a consensus among students and academic senior nurses that teaching
sessions at the college and training opportunities at the clinical areas need revisiting and
restructuring. Most students drew attention to the nature of some taught courses which
they found boring because the courses were not linked to a practical component.
Students’ responses suggested that nursing subjects need to be made more interesting
and should be delivered in a more attractive mode. Similarly, responses drawn from
senior nurses at the academic institutions suggested that the current nursing curriculum
whether at diploma, AD or BSN level needs to be reviewed and upgraded in terms of
theory, practice and teaching methods.
“We need a revolution. Our teaching is very classical; students are ready
for a change. They are ready for evidence based discussion and problem
solving… I feel like a clown who keeps repeating the subjects when it
could be delivered in a better way using scientific enquiry base” Int.3,
female senior nurse
Developing confidence
Most interviews with students and staff nurses of around three years work experience
indicated that working on the development of their level of competence and associated
professional confidence has been a challenging experience.
“I feel secure job-wise but I feel I have nothing to give. I do not have the
skills; I feel I am heading towards something new and unknown. I cannot
tell if I am a nurse or not!” Int.20, male student
Male students and interns from the MoH (AD) programme expressed concern regarding
their level of competence and the associated confidence. Their responses suggested a
lack of socialisation within nursing and a need for more specific educational goals in
relation to the desired knowledge base and acquired nursing skills.
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“At the second year, they [college administrators] decided that we are not
ready to go to hospitals and that we should continue practicing at the
college. We are in the third year now, we are not used to the hospital
environment; we cannot communicate with the nurses… major problem.
The college should have an educational plan with annual goals to be
achieved by the students” Int.20, male student
Students in their last year of the nursing programmes and those in their internship period
did not feel confident enough to take the responsibilities of the transitional internship
role and future staff nurse’s role. They used expressions like “I am still not confident”,
“feeling scared”, “feeling helpless”, “feeling handicapped”, “feeling lost”, and “feeling
out of place”. I have used interviewees’ responses to identify the following influences on
professional confidence: time allocated for clinical practice; number of students in any
particular area of practice; resources available for students’ clinical training; the quality
and frequency of supervised training offered; and the early socialisation into nursing.
“I am really scared. Our clinical practice is limited. We go to the hospital
four hours three days per week, this is not enough. I am scared because as
an intern I will be responsible” Int.11, female student
Similarly, literature from the UK has suggested that nursing students are not formally
prepared for the role expected of them as qualified nurses (Melia 1987, Day et al 1995,
Last & Fulbrook 2003). There was a consensus among the interns, fourth and third year
nursing students that the practical experience and clinical training sessions provided
throughout their years of study was not enough to prepare them for their future roles.
Staff nurses and senior nurses talked about readiness or “fitness for practice” and linked
it to inadequate competence, confidence and socialisation.
“Interns are not ready, they are not aware of their role after graduation.
Commitment is a problem and absenteeism is high… they are not well
147
prepared; they lack the exposure to real-life nursing” Int.4, female senior
nurse
As discussed in an earlier section, students and staff nurses had a tendency to link
competence to the quality and frequency of clinical practice and to the facility at which
students spend their training and internship period. The intensive in-service education
and on-the-job training provided by certain hospitals were cited, particularly by the
interns, as having a major role on the development of students’ competence (cognitive
and technical skills) and later confidence. Participants who spent part of their training or
internship experience at one of these hospitals expressed excitement and satisfaction
with the developmental opportunities they had as students or interns. However, not all
students or interns had equivalent opportunities; some were assigned to busy
government hospitals where they may have to learn by trial and error and with little
support from nurses or the department of nursing education. This may raise the issue of
hospitals’ magnet characteristics and their important role in attracting and retaining
interns and nurses (page 59 of chapter 2).
“As a student, I spent two years of my training experience at government
hospitals but did not learn much. After graduation, I chose to do my
internship at the other-government [name of hospital], I really benefited
there, they [nurse educators] prepared me well and got me started” Int.10,
male staff nurse
“… this hospital [other-government] supported us [interns] in so many
ways. It provided us with training opportunities which we made the best
of. We had good orientation, we repeated the drug calculation test and
passed it, we also had CPR training and we passed it… We are assigned
to two or three patients and we are fully responsible… you feel
challenged” Int.27, male nurse intern
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In contrast, many participants from the students and staff nurses’ groups drew attention
to the lack of nursing standards at the government hospitals and to nurses’ poor
compliance with organisational policies and procedures. This was attributed to the
severe nursing shortage and limited budget which may force some nurses to overlook the
policies and procedures and work with the available resources. Participants indicated
that these factors had adversely influenced their nursing experiences. In spite some
variable level of improvement observed at the MoH hospitals over the past ten years,
this finding is consistent with the study by Al-Osaimi (1994b). It also suggests that lack
of nursing standards, policies and procedures at the hospitals may conflict with what
nursing students are taught and trained to do at the college.
“… at MoH [name of hospital] sterilisation technique is poor and they
[nurses] provide no privacy for the patients. Working at these hospitals is
different; the things we learn here [at the college] are not applied there.
You feel shocked and frustrated at the beginning” Int.7, female student
“I go to different hospitals and I could see a difference in practice; I wish
they [hospitals] have the same system. Before going to [name of hospital]
government hospital, I expected it to be different, of less standard. It was
different, yet, the team was good… they worked very well together,
everything was so quick, it was amazing” Int.9, female student
The views of staff nurses were consistent with those of the students particularly in
relation to limited clinical experiences before the internship year. However, some
participants from the staff nurses’ group indicated that their internship had transformed
them into more competent and confident nurses capable of taking full responsibility of
their work. The participant in the quote below pointed out that socialisation during the
internship period helped her realise the duties and responsibilities of her future role as a
staff nurse and develop an associated level of confidence.
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“As a student, it [clinical training] was disastrous. I used to go to the
hospital and do nothing except the paper work for the nursing care plan.
During the internship I started to feel responsible… I started to get used
to the hospital and had a feeling of its distinguished smell” Int.4, female
staff nurse
Some other staff nurses indicated that it took them almost to the end of their internship
year to acquire a degree of competence in their nursing skills. The participants in the
quotes below linked professional confidence to cumulative clinical practice and years of
experience; this was consistent with the findings by Cowin (2002).
“When I started at the ICU, I was scared. During the internship we were
not allowed to do everything, we were mainly observers. I did not feel
fulfilled… I was hoping to leave the internship with some self confidence
but it did not happen” Int.12, female staff nurse
“My skills were poor as an intern. I started to feel confident when I
gained more work experience… you feel powerful when you have both
the knowledge and the experience” Int.16, female staff nurse
Interviews with students from the private sector (diploma programme) revealed a feeling
of relief when they knew that their nursing programme was finally approved by the
Saudi Council for Healthcare Specialties (page 22 of chapter 1). This suggests that
professional confidence might be linked to having trust in the credibility of the
undertaken nursing programme.
“I worked with a group of graduates from a private institute. They have
paid money but they know nothing. They need someone to start with
them all over again … we need a committee to monitor what these
colleges are teaching” Int.2, female senior nurse
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In spite of licensure and approvals related challenges, responses from students of private
programmes highlighted the following advantages for being in a private institute.
Compared to government colleges, the private ones have new buildings, modern
facilities and access to good resources. The small number of students in these private
colleges and institutes are more likely to receive more attention from their instructors
and may have more opportunities for one-to-one sessions or supervised training. The
large number of students and the limited resources at government colleges may
influence the students’ level of competence and professional confidence.
“The advantage of being at this college is that we do not have more than
twenty students in each class. Basically, we get to do all procedures and
we have an instructor with us all the times” Int.3, female student
“If I compare myself to students from the other institutions then I feel
more confident. Their theory is not well complemented with practice.
Their number is big… students have limited time to practice” Int.14,
female student
Nursing policies and regulations
This organising theme represents a group of synthesis themes concerned with national
and organisational nursing regulations and policies. These themes include: grades for
posts, salaries and financial benefits. Combined, they seem to have given some
organisations their magnet character of attracting and retaining more Saudi nurses (page
64 of chapter 2).
Grades for posts
All staff nurses and senior nurses working under the MoH made reference to a shortage
in the newly created nursing jobs under this sector. They indicated that new graduates
(diploma, AD and BSN) are experiencing some difficulties finding a vacant job with a
grade that matches their qualification particularly in the desired area of employment
(Jeddah). Senior nurses pointed out that the Ministry of Civil Service is not creating
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enough new jobs that meet the estimated number of annual nursing graduates
particularly at BSN level. In its attempts to resolve the nursing shortage, MoH hospitals
usually sign operational contracts with sub-contractors who provide technical-type low-
salary jobs which tend to attract relatively inexperienced nursing personnel from Asian
countries.
“The Ministry of Health has a severe nursing shortage yet has no
vacancies… the Civil Service Bureau is not creating new jobs. So, the
MoH had to fool the system and operate through sub-contracted
companies” Int.6, female senior nurse
Managed by the MoH, diploma and associate degree nursing students (males and
females) have reserved posts in the ministry’s five-year plan. Nevertheless, these posts
do not necessarily guarantee a vacancy in Jeddah; the most popular area of employment
for students who graduate from its nursing programmes. In contrast, graduates from the
BSN programmes (Ministry of Higher Education) who wish to work under the MoH will
have to apply and wait for a newly created post. These BSN graduates may have to
accept nursing posts of lower grades until they have opportunities to apply for an
upgrade. Disappointment and frustration were cited as causing turnover and adversely
influencing retention.
“Some of my BSN colleagues were able to get the nurse-specialist grade-
level after five and seven years of service. There was no difference
between them and the diploma graduates… they felt disappointed and
frustrated” Int.5, female staff nurse
Participants working at hospitals under the other-government sector had their own
concerns about nursing posts and grades. These concerns were linked to Saudisation and
its underlying interventions; hence, are discussed as part of the final section of this
chapter.
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Nursing salaries and financial benefits
Just like posts and grades, most participants viewed salaries and other financial benefits
as important factors influencing the perceived social and professional status of nurses.
Nursing salaries
Interviews suggested that basic salaries offered for the different nursing categories tend
to vary considerably across sectors with the MoH hospitals offering lower salaries than
those under the other-government sector. However, compared to other medical
specialities, nursing salaries seem to be among the lowest in the healthcare system
(government and other-government). Despite the 2005 15% salary increment awarded
by King Abdullah to all government employees, nurses’ salaries remained less than
nursing salaries offered at the other-government sector. Most participants from the staff
nurses and senior nurses’ groups drew attention to the variation in the nurses’ salary
scale. This variation in salary was cited as contributing to the poor retention of qualified
and experienced Saudi nurses within the government sector. Nurses who value salary
and financial benefits may decide to leave the government sector in favour of the other-
government sector.
“The technical-level nurse [associate degree graduate] takes only SR
4,500 [£640]. This is not enough these days… while few [nurses] might
be desperate for work, others may work here to gain experience and once
offered a better salary they will run to other hospitals” Int.1, female
senior nurse
“With my seven years experience here [government hospital] my salary
just reached SR 9,000 [£1300]. In contrast a fresh graduate I know is
taking around SR 13,000 [£1800] at one of the other-government
hospitals” Int.3, female staff nurse
Most participants from the three groups viewed money, in the form of salary or other
financial benefits, as an important factor influencing the recruitment and retention of
Saudi nurses. Many staff nurses, particularly those working in government hospitals, felt
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that their salaries do not match their efforts or the nature of the work performed.
Concern about nursing pay and its impact on the recruitment and retention of nurses has
been highlighted by others (Price Waterhouse 1988, Shields & Ward 2001, Aiken et al.
2001, Cowin 2002, Callaghan 2003, Coombs et al. 2003, Hoffman & Scott 2003).
Participants from the staff nurses’ group indicated that nurses have longer and more
strenuous contact hours with the public (patients, families and visitors); they work
rotating shifts; and have weekend duties. They often made comparison between their
work and that of pharmacists, medical technologists or even teachers and administrators.
Staff nurses and senior nurses working at the government sector felt that grades
allocated to posts, associated salaries and corresponding benefits designated for the
different specialities were not fairly allocated by planners and decision-makers at the
Ministry of Civil Service. As an outcome to the severe nursing shortage and the 48
working hours per week (Article 98, Labour Law, Royal Decree No. M/51), staff nurses
and senior nurses believed that they have been overloaded with nursing work and have
not been compensated.
“The financial incentives are important… the [nursing] grade and
[designated] salary. Those who design and issue the grades’ system
should look at the nature of the work. Nurses, teachers and administrators
do different type of work… the salaries and incentives should be
equivalent to the work performed and effort exerted” Int.9, male senior
nurse
Staff nurses and senior nurses working at the other-government hospitals made reference
to a link between the high salaries offered to them and an observed change in the
perceived nursing image of their immediate family members and colleagues.
“My father used to say: what do you do? Clean patients! But when he
knew about the salaries offered to nurses, he realised such salaries are not
given to nurses who just perform cleaning tasks” Int.14, female staff
nurse
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Unlike the bureaucratic government sector, other-government hospitals have a flexible
system that allows for the review of salaries based on budget allocation and
administrative priorities. Participants from the senior nurses and staff nurses’ groups
drew attention to the new policy implemented by some other-government hospitals in an
attempt to retain more Saudi nurses within in-patient units. This policy implies that
nurses working in Special Care Units are offered higher salaries than those working at
the in-patient units and that nurses in the latter group are given higher salaries than those
at the out-patient units. Interviewees’ responses suggested that such policies (specialities
differentials) should reduce the outflow of nurses to areas where they can work straight
hours and get the weekends off e.g. Infection Control, Quality Improvement or Nursing
Education.
“This hospital did something which turned to be good. They increased the
salary for the nurses working with the in-patients; the difference is around
SR 3,500 [£500] per month. This has forced many nurses to think
thousand times before requesting a transfer to the out-patient department”
Int.13, female staff nurse
“… the [name of unit] is considered a special care unit, our monthly
salary is SR 1000 [£150] higher than the other in-patient units… I think
ICU nurses get SR 1400 [£200] more” Int.20, male staff nurse
Regardless of gender, most MoH nurses expressed disappointment and frustration about
the lack of incentives for nurses covering rotating shifts and for those working in the
highly specialised units. They indicated that a lack of financial incentives has
encouraged many Saudi nurses to request initial assignment or later transfer to out-
patient clinics or Primary Healthcare Centres. Saudi literature suggested that most Saudi
female nurses prefer to work at Primary Healthcare Centres and out-patient departments
(Alawi & Mujahid 1982, Tumulty 2001); both services have the added advantages of a
lesser workload, day shifts and free weekends.
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“Fifty per cent of the graduates want comfortable work, so they go for
Primary Healthcare Centres. There, they do not work under pressure…
the number of nurses there is more than the workload. They divide the
two shifts among themselves, they work four hours and take the same
salary” Int.7, male staff nurse
Despite the lower salaries, participants working in government hospitals cited the
following advantages for working under this sector. It provides job security and caters
for the Saudi nurses’ needs which may include nine hours duty and a free choice
between male and female in-patient units.
“… the advantages of working at a secured government sector such as the
MoH include: more flexibility, respect for family life and the choice of
nine hours and two off days working schedule” Int.5, female staff nurse
Financial benefits
This synthesis theme draws together participants’ discussion of incentives such as: job
compensation entitlements, risk or infection allowance, housing and transportation
allowances. In addition to the monthly salary, most staff nurses and senior nurses
expressed concerns over other financial incentives Saudi nurses may receive as part of
their employment packages.
As per the Saudi Labour Laws, it has been long approved that professionals receive
financial compensation for certain aspects of their work e.g. shift work and on-call
duties in the case of healthcare personnel (Financial Benefits, MoCS 2008). This
additional fixed percentage of the monthly basic salaries is meant to financially
compensate these professionals for the nature of their work. Staff nurses and senior
nurses working under the government sector were not satisfied with the small job
compensation they receive compared to the other healthcare personnel. They linked
salary compensation to the professional status of the healthcare speciality and associated
the latter with the prevailing negative perceptions of nursing. Most staff nurses and
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senior nurses from the government sector described the compensation plan as unfair
because nurses usually work long shift pattern and their job involves direct contact with
the patients and their families.
“Medical doctors receive 70% of their basic salaries as job compensation
and pharmacists receive 40%. Nurses [in contrast] have just started
receiving 30% of their salaries as compensation. So, it is the Civil Service
Bureau which ranked it [nursing] last” Int.1, female senior nurse
Participants from the senior nurses and staff nurses’ groups, who worked or are still
working rotating shifts at the in-patients’ units, believed they should get financial
bonuses for working night shifts and weekend duties. In their views, such bonuses (shift
differentials) would encourage more nurses to cover these less favourable shifts
whenever convenient.
“Working on weekends should be considered as overtime… this is an
incentive for nurses. Alternatively, nurses should take two extra off days
if they worked a weekend. The hospital should implement this as a pilot
project, I am sure nurses will accept it” Int.12, female staff nurse
Participants from the senior nurses and staff nurses’ group also believed that nurses, who
work closely with patients, should receive a monthly allowance for being exposed to
high risks of accidents and infections. They made reference to laboratory and x-ray staff,
of the government and other-government sectors, who receive risks’ entitlement.
“Financial incentives are very important. We [nurses] should be paid for
being exposed to high work-related risks such as risk of infection” Int.11,
male staff nurse
“We [MoH nurses] should be paid for being exposed to risks and
infections. We work with patients so why not! Laboratory staff here is
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paid for such risks… I believe there is something wrong with MoH
system. We do not get housing allowance. Nurses have written letters and
sent complaints but reached to nothing” Int.7, male staff nurse
Just like the other staff nurses and senior nurses who are working under the MoH
system, the staff nurse in the quote above was very disappointed because he was not
entitled for a housing allowance like his counterparts in the other-government sector.
This group of participants often described their employment packages as less attractive.
In general, as per organisational policies, employees working in the other-government
sector receive a monthly amount of around £140 as a transportation allowance and an
annual amount of two extra basic salaries as a housing allowance.
Male participants (students and nurses) pointed out that nurses working at the MoH
Psychiatric hospitals are the only nurses who receive around £200 per month as risk
entitlement (hazardous duty pay). In their view, this extra pay had increased the
attractiveness of this service.
“My brother works in Psychiatry, that was his interest. Working there
has two advantages: priority in employment and an attractive salary
package” Int.24, male student
Support systems
This organising theme includes a group of overlapping synthesis themes such as in-
service education and on-the-job training, appreciation and recognition, and scholarship
opportunities. These themes have emerged from the data and represented areas the
participants perceived as inadequate at their respective hospitals and, hence, as
influencing/hindering the professional status of nursing. Participants’ views on the
Saudisation Policy are presented in this section and their expectations of its underlying
programmes, as supporting interventions for the process of nursing professionalism, are
highlighted.
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In-service education and training
Most participants (interns, staff nurses and senior nurses) cited in-service education and
on-job training as factors influencing their decision to stay or leave a particular
organisation. They perceived opportunities for continuous education and advanced
training as important aspects of their motivation, satisfaction and retention. For them,
on-the-job education and training are opportunities which enhance their professional
knowledge and practice. An outcome which would, consequently, influence the
perceived professional status achieved by nurses
“We need moral [non-financial] support… we need to be encouraged to
attend courses and pursue higher education; such things will enhance
nurses’ job satisfaction” Int.11, male staff nurse
“Professional development is the most important thing. They [nursing
administration] cannot just give you a job and ask you to work, they
should send nurses to courses and provide them with scholarships… you
know, personal and career developments” Int.9, male senior nurse
However, on-the-job services seemed to vary considerably across the different hospitals
and sectors. Compared to their counterparts at the other-government sector, staff nurses
and senior nurses working at the government hospitals sounded more frustrated and
disappointed for having less opportunities for attending such services.
“Jobs here [MoH hospital] are secured, salaries are not bad… but I wish
we have access to opportunities for continuous education or speciality
courses like the Oncology Postgraduate diploma” Int.6, female staff nurse
Appreciation and recognition
Staff nurses and senior nurses talked about the severe nursing shortage and the
associated work-related pressure. Their interviews suggested that all types and forms of
appreciation and recognition are needed to keep Saudi nurses motivated particularly at
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times of severe shortage. This in turn was perceived as having a major influence on the
nurses’ satisfaction and retention. For these nurses, recognising the heavy workload and
appreciating the extra hours of service undertaken by nurses does not have to be material
(money or days off), a simple thank you note or a letter of appreciation were believed to
have the same effect.
“One of the major problems here [government hospital] is the lack of
recognition. Whether you work or you do not, it is the same thing. We are
not asking for money, a letter of appreciation may have a great impact”
Int.3, female staff nurse
Compounded by increased workload, low pay and lack of financial incentives,
participants’ concerns about the lack of recognition and appreciation seem to have
generated frustration, disappointment and regret which adversely influenced the
participants’ work satisfaction and hence their retention. Hospitals which have a system
which regularly provide recognition for nurses were perceived as hospitals which value
their nurses and which make efforts to keep them satisfied (refer to the magnet
characteristics, page 64 of chapter 2).
“I worked in three different hospitals under two different sectors… you
work hard but you are not appreciated. You go home at the end of the day
feeling you have been treated unfairly… the financial incentives play a
major role” Int.9, male senior nurse
Other participants believed that as Saudis working among a foreign majority, they need
special attention from higher management (nursing and administrative). However, there
was a consensus among staff nurses that nursing and hospital administration do not
listen to their concerns. For these nurses, this might be an indication of a lack in interest
in them as Saudi nurses and a reflection of a lack of support from the non-Saudi nursing
administration for their progression and development.
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“We [Saudi nurses] need support from our seniors and the
administration… we will shine, we want to learn and develop. The
Director of Nursing should meet with us and should listen to us… at least
twice a year. I am sure there are things she does not know about; unit
managers may not report everything to her” Int.19, female staff nurse
Scholarship opportunities
Students from the private sector (AD and BSN) emphasised that scholarship
opportunities offered to high-school students to study nursing had encouraged more
students to join nursing. Students indicated that their parents felt proud when they
earned fully paid scholarships to study nursing and that these scholarships helped their
family members change their views on nursing. For the parents, if a sponsor is willing to
invest in nursing and nurses, then it must be worthy. Educational scholarships
particularly when linked to future jobs at recognised facilities were cited by participants
as factors which would most likely change the public image and perceived professional
status of nursing. The student in the quote below was proud talking about his family
members who used to consider him a failure until he convinced them to pay for his first
semester at a private nursing institute and then judge him from there.
“I was one of the outstanding students at the end of the basic module
[first semester]. As a reward for good performance, the institute offered
to cover fifty percent of our total fees… so my family paid SR 30,000
[£4,300] in total” Int.36, male student
For the staff nurses, scholarships meant sponsored opportunities by the employing
hospitals to enable them to pursue their higher education. Interviews with this group of
participants suggested that higher education (master and doctoral degrees) was linked to
high professional status for the individual nurses and for nursing in general. Despite
promises for scholarship opportunities, interviews with many staff nurses indicated that
their employing hospitals were most likely unwilling to support such opportunities or
even approve an unpaid self-sponsored educational leave. They linked organisational
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disapproval to the overall nursing shortage; the duration of master or PhD programmes
(3-5 years); and the lack of support from western staff dominating the nursing
administration. Some participants expressed that they were not expecting a fully paid
educational leave; for them, even partially paid leave would reflect a gesture of support
and recognition.
“After graduation I was planning to work for two years and then pursue
my higher education. I have been working for five years now and I could
not get a scholarship yet… even if I want to go on my own, the hospital
will not approve a paid leave” Int.15, female staff nurse
Other participants from the staff nurses’ group pointed out that hospitals which used to
run free, specialised and approved post-graduate diplomas are no longer offering such
programmes for free. This was linked to budget constraints and increased number of
applicants. Nevertheless, it was perceived as a lack of organisational support for
professional development.
“It is very unfortunate for the new groups of graduates. When we had the
[name of post-graduate diploma], we used to take salaries… students now
have to pay SR 20,000 [£3000] for the one year specialised programme.
Things have changed!” Int.12, female staff nurse
Saudisation programmes
At a time of a severe nursing shortage and challenging international recruitment efforts,
interviews with staff nurses and senior nurses suggested that the establishment of
Saudisation programmes should be viewed as the only alternative strategy to overcome
the shortage and build a national nursing workforce. A strategy to promote the uptake of
nursing among young Saudis, increase the supply of Saudi nursing graduates and
improve the retention of qualified Saudi nurses. For most participants from the staff
nurses and senior nurses’ groups, Saudisation programmes were perceived as providing
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national and organisational support which would, eventually, improve the professional
status of Saudi nurses and, gradually, change the public’s perception of nursing.
However, interviews with interns, staff nurses and senior nurses also suggested that the
commitment to and application of the Saudisation Policy varied considerably across
hospitals and academic institutions under the different sectors. Seven participants out of
the nine senior nurses indicated that Saudisation Policy is highly dependent on two
factors. The number of Saudi nursing graduates and the availability of Saudisation
programmes at different hospitals. These participants pointed out that the small numbers
of nursing graduates (AD and BSN) and the absence of Saudisation programmes in
many hospitals might have influenced the implementation of this policy. Rather than a
carefully planned strategy to change the perception and uptake of nursing as an
occupational choice at schools’ level and improve the professional status and retention at
hospitals’ level, in these participants’ views, what is currently taking place is a routine
process of replacing non-Saudi nurses with Saudi nurses.
“There is not much of a Saudisation in our hospital [other-government]. It
might start with the opening of the nursing college! The Saudis are faced
with many obstacles from the day they apply for jobs. This is mainly
because we have more non-Saudi nurses in charge” Int.20, male staff
nurse
“The number of graduates is increasing every year. Thirty students have
graduated this year [associate degree government programme] but
hospitals do not give the Saudi nurses opportunities to take over” Int.5,
female senior nurse
Senior nurses and staff nurses viewed hospital-based Saudistion programmes as
structured individualised development plans to train, monitor and support nursing
graduates. Through these plans, graduates are provided with skills and clinical
experiences needed to fulfil the different nursing jobs. They viewed Saudisation
interventions as responsible for attracting and recruiting interested school students to a
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career in nursing, and supporting them throughout their years of study and work. Having
more of these interested qualified Saudi nurses should improve their professional image.
Senior nurses also emphasised that Saudisation may not materialise until the employing
hospitals, senior nurses and medical directors become highly committed to providing
fresh Saudi nurses with training and developmental opportunities.
“… Saudisation should start as early as school age. It should provide
nursing scholarships and summer training for high-school students just
like what ARAMCO is doing. It is easy to take someone if you train
her/him” Int.3, female senior nurse
“The good thing here [other-government hospital] is that the person in
charge of Saudisation is a Saudi, this has helped in attracting more Saudi
nurses… however, nursing administration is exerting a great pressure on
her… they keep changing policies” Int.18, female staff nurse
Most participants, including students, talked about the international nursing shortage and
agreed that Saudi Arabia should have its own supplies of nurses who understand patients
and are more sensitive to their needs. Their accounts suggested that having more
qualified Saudi nurses, who speak the language and understand the patients’ spiritual as
well as physical needs, should be a national priority.
“I think most young women should go for nursing. We have enough
teachers [Saudis], our country needs nurses. We do not have enough
Saudi nurses; schools should encourage and direct students to [name of
nursing programme]. The labour market needs more of these specialities”
Int.13, female student
The severe nursing shortage was a major concern for staff nurses and senior nurses.
With 12-hour shifts, minimal financial incentives, lack of appreciation and absence of
Saudisation programmes, participants indicated that a shortage in nursing tend to
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encourage many Saudi nurses to work in areas such as out-patient units and primary care
centres leaving in-patient units highly dependent on non-Saudi nurses. A trend that may
defeat any effort for hospital-based Saudisation.
“This is a very busy government hospital with a severe nursing shortage.
During the morning shifts nurses may take up to seven patients each; in
the afternoons and nights, two nurses may cover a whole unit of 25
patients” Int.8, female staff nurse
“They [nursing graduates] want to work in the academic field or out-
patient clinics. They believe academic work is more comfortable… they
only think of the working hours. I do not believe it is… academics may
need to work long hours at home. In the clinics, nurses work only day
shift… less responsibility and they take the same salary [as speciality
nurses]” Int.2, female senior nurse
Staff nurses from the other-government sector had their own views on Saudisation. In
their views, other-government hospitals have plenty of nursing jobs occupied by non-
Saudi nurses. With reference to Saudisation Policy, these jobs should be made available
for qualified Saudi nurses. Qualification is usually defined in terms of educational level
or academic degrees, nursing competency level, professional judgment and years of
experience. Staff nurses and senior nurses working at the other-government hospitals
talked about challenging employment procedures which they had to go through in order
to get a job. This is consistent with the discriminatory hiring practices described by
Lovering (1996). One of the important criteria for employment is having years of
experience which is not usually fulfilled by fresh Saudi graduates.
“… they ask for experience but I am just a new graduate. This is my
country and they [hospitals] have to provide that experience. They [the
non-Saudi nurses in charge] do not want to give us chances; they are
worried about their positions” Int.19, female staff nurse
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The above participants emphasised that hospitals with a non-Saudi nursing majority
should provide the Saudi nursing graduates with in-service education and on-job training
needed to prepare them to replace the non-Saudi workforce. However, I have used the
staff nurses’ responses to identify the following frequently raised concerns. Saudisation
programmes and individualised development plans are not available in all hospitals.
Newly qualified nurses (government and other-government) are often left to learn
through trial and error or they might be provided with poorly monitored training
programmes. Some hospitals did not seem to have clearly defined policy in relation to
time scale and outcome expected of Saudi nurses as they progress through a career path.
Other hospitals may have what some participants described as “unfair policy” for
Saudisation. A policy, which cannot be modified or revoked even if the Saudi nurse has
proved competent and confident in undertaking the responsibilities associated with a
particular job.
“There is Saudisation but there are many obstacles… during my six years
experience in [name of unit], the hospital brought three non-Saudi head
nurses and I acted in between. They [non-Saudi staff] have higher salaries
not to mention the airline tickets and accommodation” Int.14, female staff
nurse
Most participants working at the other-government hospitals did not seem to have
progressively worked their way through a planned career path. Some of them
experienced a hard time moving up the career ladder and attributed it to having non-
Saudi senior nurses monitoring their development. For these participants, the non-Saudi
senior nurses might be keen to support the non-Saudi nurses who may have plans to
work in the region for certain years and are determined to pursue their plans. They might
be threatened by the Saudi nurses who want to prove that they are capable of fulfilling
their roles and responsibilities. Not having enough work experience was cited by
participants (staff nurses and senior nurses) as the most common excuse given by the
non-Saudi senior nurses for not recommending Saudi nurses for promotional
opportunities including higher nursing posts.
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“The increasing number of Saudi nursing graduates is a threat to the non-
Saudi nurses… Saudi nurses tend to face some resistance from some
[non-Saudi] staff who constantly keep challenging them” Int.4, female
senior nurse
“Nurses with higher education should be given positions or granted
grades based on their educational qualifications. Yet, we have nurses here
[other-government] with master degrees and they are still at the staff
nurse positions… this does not help in attracting new graduates” Int.18,
female staff nurse
Despite the increasing demand for a Saudi nursing workforce, there was a consensus
among participants that many hospital administrators, senior nurses and medical doctors
have rather negative and stereotypical perceptions of Saudi nurses. Participants’
accounts suggested that most of these professional and non-professional groups
perceived Saudi nurses as having: inadequate competency level; high absenteeism; poor
punctuality; a tendency to refuse night shifts; and an inability to accept challenges.
Similarly, Lovering (1996) suggested that non-Saudi nurses tend to view Saudi nurses as
spoiled or irresponsible because they tend to request day shifts, flexible working hours,
paid or unpaid leaves in order to meet family commitments. In their efforts to cope with
the social and professional pressure associated with a career in nursing, Saudi nurses
were possibly demonstrating a high absenteeism common among the female nurses; and
a low commitment common among the male nurses. These performance-related attitudes
might explain these negative perceptions. Earlier in this chapter, under the section
allocated for nursing education, concerns about competence, experience and professional
confidence have been discussed.
“I conducted an interview with [name of hospital director] and asked him
about the negative views held against the Saudi nurses. He said that,
compared to the Saudis who do not have any experience, the non-Saudi
nurses are more competent and more professional” Int.10, female student
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“… some Saudi consultants believe that Saudi nurses know nothing! An
[name of consultant] used to come to the unit and would not even address
me; she is in charge of my patient but would not talk to me… deals just
with the non-Saudi nurses. Now, she talks with no one but me and she
wants me to work with her in the new [name of unit]” Int.19, female staff
nurse
Conclusion
This chapter has explored participants’ views on nursing education, nursing policies and
regulations and nursing support systems as selected aspects of professionalism.
Throughout this chapter, themes (organising and synthesis) have been used to convey
the participants’ perceptions of the national and organisational challenges hindering the
achievement of a professional recognition and the attainment of a desired professional
status.
In the first section of this chapter, participants’ accounts on “reality shock” experiences,
gaining competence and building professional confidence brought to light a number of
nursing education related areas that need serious interventions before nursing may
achieve a professional status in Saudi Arabia. Interventions that may include but are not
limited to: implementation of strategies to promote nursing as an occupational choice for
high school graduates; a revision of the admission criteria for the nursing programmes;
an evaluation of the theoretical and practical components of the nursing curriculum; and
a collaboratively coordinated nursing training programmes between the education and
service segments.
In the second section, participants’ accounts indicated that they viewed money, in the
form of salary, incentives or other financial benefits, as an important factor influencing
the perceived social and professional status of nurses and, hence, their recruitment into
and retention within nursing. However, this section reveals that the variation in the
salary scale and financial benefits offered to the same category of nurses across the
different sectors has been a source of frustration and disappointment among participants.
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Nursing policies concerned with pay; shift and speciality differentials; shift pattern;
leaves and other non-financial entitlements were believed to improve the professional
status accorded to Saudi nurses and reduce their outflow from in-patient units.
In the third section, participants’ views on in-service education and on-the-job training,
appreciation and recognition, and scholarship opportunities were explored. Participants’
accounts suggested that these synthesis themes were perceived as influencing their
professional status and, consequently, their decision to stay or leave a particular
organisation or nursing as an occupation. Higher education (master and doctoral
degrees), in particular, was linked to high professional status for the individual nurses
and for nursing in general. The Saudisation policy with its underlying programmes were
perceived as providing national and organisational support to improve the professional
status of Saudi nurses and to change the public’s perception of nursing. However,
commitment to and application of the Saudisation Policy seemed to vary considerably
across hospitals and academic institutions under the different sectors. Rather than a
carefully planned strategy to change the perception and uptake of nursing as an
occupational choice at schools’ level and improve the professional status and retention at
hospitals’ level, in these participants’ views, what is currently taking place is a routine
process of replacing non-Saudi nurses with Saudi nurses (quick fix).
In summary, participants’ accounts suggested that achieving a recognised professional
status would most likely enhance their retention within nursing and improve its public’s
perception as an occupational choice for the increasing numbers of Saudi high-school
graduates.
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Chapter Six
Dealing with personal struggle
Introduction
This chapter advances the argument that participants are experiencing personal struggle
as they are learning to live with nursing as an occupational choice. Throughout the
chapter, participants’ accounts are used to convey individualised efforts invested in
coming to terms with pervading and predominantly negative images of nurses, and
coping with national and organisational challenges associated with efforts exerted by
nursing to achieve professional status. Three organising themes are explored: barriers to
choosing nursing as an occupation, gender-related struggle and generation-related
struggle. The underlying synthesis themes are used to illustrate variation in the
individual nursing experiences.
Barriers to choosing nursing as an occupation
Two thirds of the participants (n = 44) indicated that medicine was their first career
choice. Their choice was based on a set of perceived social characteristics such as
qualification, title, power, prestige and respect. These characteristics seem to have
influenced the occupational choices of the individual and the family at large. They also
contributed to rendering the choice of occupations such as nursing more difficult than
the others. There was a consensus among participants that nursing is perceived as
socially unacceptable and professionally less prestigious. This perception seems to have
influenced recruitment into and retention within nursing.
“I love nursing but I think we need twenty more years to improve the
image. Meanwhile, if I have a daughter I will not direct her to nursing. It
is really hard for me to say what I just said… I hope one day people will
realise that nursing is more important than teaching!” Int.3, female staff
nurse
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Examining participants’ accounts, I was able to identify four barriers perceived as
having influence on the choice of nursing as an occupational choice: lack of nursing
awareness; lack of interest in nursing; nursing is perceived as an alternative field of
study; and lack of family support. These barriers are examined below to illustrate the
associated struggle experienced by the participants.
Nursing awareness
Participants frequently cited a lack of public awareness in nursing as an occupational
choice. Participants’ responses suggested a number of factors contributing to this. First,
a lack of career counselling and advisory services at schools level. Second, inadequate
marketing interventions on the part of academic institutions. Third, poorly represented
media coverage on nursing and nurses.
“I heard about the nursing programme by chance, I was excited…
although I volunteered to work at one of the hospital, I was not focusing
much on nursing there and then. People were not encouraging me to go
for nursing. Later, when I suggested that we [prospect students] spend a
month at [name of hospital] and the college approved and arranged an
orientation programme [to explore nursing work]; only then I was 100%
confident I wanted nursing” Int.14, female student
There was a consensus among participants that Saudi high school students, who are the
future candidates for the two available tracks of nursing education, knew very little
about nursing. Participants linked this lack of nursing awareness among school children
to limited promotional interventions at national and institutional levels. Most students,
staff nurses and senior nurses indicated that they themselves did not know much about
nursing until they joined the respective programme and did not realise nursing was
taught at a degree level until they applied to the College of Applied Medical Sciences.
“… The transfer came late. My enrolment in nursing was mere chance,
registration at the medical school was over, what was still available was
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places at the Applied medical Sciences. I did not know it was nursing”
Int.8, female senior nurse
“When I go to hospitals, I do not give attention to nurses, I deal directly
with the doctor. I never thought of nursing as a field of study especially
here [in Saudi Arabia]” Int.11, female student
Participants from the three groups pointed out that most Saudi students generally reach
high-school level with no particular interest or plan for the future. These students might
feel lost or torn between what their parents want and their own wishes. Students, staff
nurses and senior nurses made explicit reference to the limited nursing-related college
tours, field visits and career-day events available for school children and pre-college
students. They also referred to the absence of Career Counselling and Academic Advice
services either at school level or at the under graduate foundation level.
“There is a need for more awareness especially in schools, we have
students graduating from schools but they do not know where to go! They
need guidance… someone to tell them why go, say, for nursing; that they
will find a job afterward, a good pay… I really like the idea of having
school children go and see what the nurse does in the hospital; they will
get the whole picture of nursing and get the feel of what it is all about.”
Int.3, female student
Interviews with most participants suggested that, during their childhood, they never
dreamed or even thought about becoming nurses. To promote nursing as a competitive
career option, most participants believed it needs to be marketed among school children
and their parents. In their views, nursing needs to be introduced to young children in
order to change perceptions and establish early interest.
“Nursing needs marketing. Children always dream about becoming
physicians or engineers. They usually do not have any interest in nursing;
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they have no motivation to become nurses. So, we need to create that
interest and develop it along the way” Int.6, female senior nurse
There was a consensus among participants that young children and school students need
all possible resources to explore nursing and to become familiar with nurses’ work at an
early stage. To achieve this goal, many participants talked about launching a national
nursing campaign targeting not only school children but also their parents and the Saudi
societies at large. A campaign which includes a wide range of promotional interventions
and uses the powerful media channels to guide school children through a planed learning
experience geared towards promoting nursing as an acceptable, respectable and
recognised occupational choice.
“The problem is not school students; it is their families… families are
rejecting the idea. We have to encourage nursing in schools and introduce
it to children. We have to promote nursing in many interesting ways.
Have it on billboard signs, put it up on posters, run campaigns… we
should have a separate budget allocated for this purpose.” Int.9, female
student
“. School children have fresh and open minds… Media programmes
hosting distinguished guests might help particularly at occasions such as
the nursing international day. We have a great history; just reinforce the
role of early Muslim nurses like Rufaidah… and open baccalaureate
programmes for interested male students to encourage them to go for
nursing” Int.16, female staff nurse
Students, staff nurses and senior nurses indicated that they had to justify nursing to their
family, friends and relatives. These experiences were most likely associated with a lack
of awareness on the value of nurses’ work and contribution of nursing on part of these
groups. This lack of awareness was not viewed as ignorance on part of the general
public but rather due to inadequate promotional interventions by nursing leaders and
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decision makers. Participants also had to work very hard to prove themselves
professionally among non-Saudi nursing colleagues, their fellow medical staff, the
patients and the society at large.
“There was general objection from everybody; why nursing! Why not
medicine or engineering… you know, for a family in a Saudi society, as a
man you should be a doctor… However, there is a big difference between
now and 1991. Patients [males] rejected me when I first worked in a
medical unit; they were asking for a female nurse when I attend to them”
Int.9, male senior nurse
Lack of interest in nursing
A lack of awareness on nursing coupled with a preference for prestigious academic
fields of study and a lack of family support were often used by the participants to
explain the development of an interest in nursing as an occupational choice and illustrate
the associated struggle experienced by the participants. This struggle was understood as
being specific to Saudi nurses working in a Saudi context.
“Nursing is a good career, we need it badly. Saudis must take over; we
cannot rely on the foreigners [non-Saudi nurses] forever. Saudi nurses will
help in changing the image… Since nursing has a non-Saudi majority,
some patients feel that Saudi nurses are intruder and unqualified” Int.11,
male staff nurse
Individual stories showed that, due to lack of interest, most participants went through
phases of rejection, anger, frustration, fear, worry, regret and disappointment. Some felt
angry for having to study nursing, a field they had never considered. Some were worried
about their future in nursing and scared of the negative perceptions held by their
immediate family and greater society. These overwhelming mixed feelings seem to have
hindered the participants’ coping mechanisms and were always linked to the prevalent
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nursing images, perceived low status of nurses, expectations of a career in nursing, and
lack of support systems.
“The Saudi nurse [female] is hassled at work and pressured at home”
Int.1, female senior nurse
Nursing as an alternative field of study
For the 44 participants, who were originally interested in medicine, failing to have a
place in medicine, dentistry or pharmacy forced them to enter nursing. This was done
mainly to secure a place at an academic institution. In Saudi Arabia, if school students
are determined to go to medical sciences and engineering, they will have to work hard to
get high-school scores of more than 90%. Students who have an interest in certain fields
but fail to get the right score will not have the opportunity to even apply to some
academic institutions. As such, some school students may decide not to worry about
occupational choices and leave it to their high-school scores. If the score is high, most
school students tend to apply for the socially prestigious and professionally approved
fields of medicine, pharmacy, engineering or computer science.
“Here in the Kingdom we are restricted by the high-school score, you
choose the college according to your score. My score was 82%, could not
go for medicine so I applied to the MoH College. I was advised to try
nursing for one semester… as I progressed more I started to respect and
love nursing more” Int.10, male staff nurse
Since the late 1990, medical colleges at the government universities raised their entry
criteria to a high-school score of 95% while other science colleges went up to 90%. In
contrast, nursing kept a flexible range of 80 – 90%. This might have directed students,
who had nursing as their third or fourth choice, to the nursing college. Participants who
had no original interest in nursing cited various reasons for accepting a place in the
nursing programme. These included: using the first year as a bridge to the preferred
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programmes; using the nursing programme to obtain an academic degree; and exploring
the pros and cons of the nursing programme.
“You will find a good number of students in the first year; they are in
nursing because of their high-school scores not because they have
interest… This does not help the college, having students who consider a
transfer and working with them for a year! We usually have around
hundred students; those who manage to get straight A(s) [i.e. will qualify
for a transfer to medicine] are few; never reached 10%. With the new
medical specialities opening up this year, the percentage of those who
want a transfer to these specialities went up to 25%” Int.4, female senior
nurse
Participants who found themselves in nursing not through choice felt stuck in nursing;
nevertheless, they decided to hang on until they get the academic degree and then think
of an escape after graduation. As an escape, some may consider the community-focused
Primary Healthcare Centres where they might work less hours and get free nights and
weekends. Some may resort for higher education; applying for a baccalaureate or master
degrees would give nurses around three years break away from hospital work.
“It is too late to change now. The only escape is to start studying all over
again. Alternatively, I might work on my qualifications or study
something different in nursing… nothing will stop me” Int.8, female staff
nurse
Half of the 44 students who were originally interested in medicine went on to develop an
interest in nursing. Moreover, by the second semester of the second year, a further
quarter (n = 11) of the participants who had no original interest in nursing had an
emerging interest in nursing. Their responses suggested a developing interest in nursing
secondary to a realisation of its humanitarian and religious values. Other students might
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have started to consider the range of work and higher education opportunities available
to them.
“I had a high school score of 95%. My academic choices were pharmacy,
medical technology, science and finally nursing. I was accepted in
nursing, was seriously thinking of requesting a transfer but I started to
like it. I felt that my personal characteristics fit more with nursing” Int.7,
female student
Motives such as serving one’s country, or the need to care for others were often raised
by participants as influencing their decisions to remain as nurses. Many participants
agreed that the country has to have its own supplies of Saudi nurses to serve its own
people. Despite a lack of interest in nursing, these participants said that they chose to
continue in nursing because they believed that working as nurses will reduce the
country’s dependence on non-Saudi nurses who are becoming very difficult to recruit.
Being part of nursing, some students may have started to realise the seriousness and
impact of the international nursing shortage.
“I always say to the students: think of the patients as your own family;
they need you… this country is ours, these non-Saudi nurses will go and
we will stay. I repeat this with every group, like a broken record” Int.1,
female staff nurse
Family support
Family support was frequently cited as a major factor that minimised the social pressure
and enhanced the participants’ coping and stamina. However, more than one third of the
participants (n = 29) reported a lack of support and encouragement from their immediate
family members. The forty four participants who wanted to study medicine explained
that their families like most Saudi families encouraged them to choose socially and
professionally respectful fields of study. Their accounts suggested that nursing continues
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to represent one of the less preferred occupational choices for middle and high social
class families.
“Nursing is a good career but it is not yet accepted by the Saudi people.
Certain social class and reputable families will not buy into the idea.
Nurses work hard and they receive orders; we [Saudis] are not used to
this” Int.34, female student
Lacking an interest in nursing and the needed support from the family, responses
obtained from the three groups of participants suggested that, as students, they may
progress in their nursing studies not convinced of their role as nurses and feeling
ashamed of what they do.
“I asked the fourth year students: who at this stage is still not convinced
of her role as a nurse? The majority of the class had their hands up, only
10% did not!” Int.4, female senior nurse
One fifth of the total participants had nurses in their immediate family. These
participants indicated that having a family member in nursing made it easier for them to
cope with the negative public images and social pressure. Interviews suggested that the
first nurse in the family is usually faced with rejection and criticism which tends to
slowly fade out over time. In contrast, the second nurse may easily be accepted and
spontaneously be supported by family members.
“My father is a retired military man; he admires mom’s work [nursing],
he is very supportive and feels proud of all us [3 female nurses in the
family]. He believes we are knowledgeable particularly in dealing with
doctors; so when he goes to the hospital he takes one of us as a
consultant,” Int.12, female staff nurse
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Earlier experience with nurses in the family was cited as a factor that brought about
positive feelings of appreciation, recognition, motivation and pride by the other family
members. However, not all the participants who had a nurse in the family had developed
an interest in nursing by the time of the interview. Only six of the thirteen participants
who had a family member as a nurse genuinely wanted to become nurses; all were
women. In contrast, eighteen participants out of the twenty four who had original
interest in nursing did not have a nurse within their immediate family.
“The first year of the programme [associate degree] was a foundation. I
wanted pharmacy; it is the best as a career choice but with my grades… I
just could not get into pharmacy. I registered in laboratory and then
requested a transfer to nursing… my eldest brother and one of my
maternal uncles are nurses.” Int.24, male student
Gender-related struggle
Repeatedly reading through the transcribed texts and carefully listening to the way
participants articulated their responses were needed to fairly present the gender-related
personal struggle which characterised the individual stories. Most students, staff nurses
and senior nurses viewed their nursing experiences as a social and professional struggle.
Socially, nursing has been perceived as an unacceptable occupational choice for the
Saudis. Professionally, nursing continues to pursue a recognised professional identity
among the other healthcare specialities.
“Nursing is striving to prove its existence among the other healthcare
specialities. In the process and in the absence of a supporting Saudisation
plan, nurses are trying to survive; they are trying to prove themselves in
their work units and within their communities” Int.7, female senior nurse
There was a consensus among participants that nursing is a challenging occupational
option placing them under a great deal of family and social pressure. Participants’
responses suggested that students, staff nurses and senior nurses were striving to:
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overcome nursing-related “reality-shock” experiences; cope with social and family
pressure associated with nursing; defend nursing among family members and the society
at large; and prove themselves as important members of the healthcare team. To achieve
all these goals, these participants employed a wide range of coping strategies which
often began with mechanisms to deal with their personal feelings towards nursing; and
gradually progressed to mechanisms to deal with the perceptions and attitudes of people
around them.
“Nursing is a struggle; if you are not up to it, you will not continue.
Nurses need to be prepared… they need to fight for survival. They have to
prove themselves against all type of pressure [social and professional]”
Int.9, female staff nurse
The social and professional challenges experienced by male and female participants
varied considerably. Responses obtained from the participants suggested that female
participants had two advantages over their male counterparts. They have access to higher
education in nursing (baccalaureate and master levels); and they work in a
predominantly female occupation. In contrast, the male participants had minimal social
constraints in relation to their choice of work settings, working hours and late or
weekend duties. Nevertheless, both were faced with variable degrees of social resistance
associated with the choice of nursing as a career. Participants’ accounts illustrated a
range of gender-related issues which influenced their nursing experiences. Issues faced
by female and male participants are examined below in order to explain the gender-
related struggle.
Issues faced by women
This synthesis theme draws together female participants’ discussion of five frequently
raised areas of concern experienced by the Saudi working women in general and female
nurses in particular. Interviews with female participants indicated that the following
areas have contributed to their individual struggle: social challenges, 12-hour shift
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pattern, marriage and family issues, transportation, and Maternity leave and on-site
crèche.
Social challenges
In traditional Saudi societies, women are not allowed to work outside their home
boundaries (Al-Suwaigh 1989). Hence, the emergence of nursing as an occupation for
women has been perceived as a challenge for the social norms (Meleis & Hasan 1980,
El-Sanabary 1993). Analysis of interviews with the female participants suggested that
they were experiencing social pressure associated with working in socially unacceptable
mixed-gender settings and having to cover long hours of unfavourable night and
weekend duties.
“In our society, they do not like women to mix with men, they do not like
women to work nights, they do not like women to work late or long
hours, and they do not like women to work weekends. All these apply to
nursing… so as a husband I must reject nursing” Int.1, female senior
nurse
Many participants used terms such as “free”, “liberal”, “daring”, “strong headed
women”, “women who do not care about the social norms” and “women who do not
care about the public opinion” to describe the perceived public views of Saudi female
nurses. As members of a patriarchal social system, participants used these descriptions
to reflect negative public images of Saudi nurses. Saudi female nurses were also
perceived by people as women who chose to swim against the tide, break the social
norms and deviate from the religious values. According to the participants, these public
views were formed based on work-related issues which have social and religious
implications.
“Female nurses are daring young women; they work in a mixed-gender
environment. Some are conservative they stick to the veil, others are
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liberal they do not have restraints and they do not care” Int.3, female
senior nurse
“People think Saudi female nurses are free women, they come and go as
they wish, they interact with men, they have strong personalities and they
simply do not care about people’s opinions” Int.13, female staff nurse
Most female staff nurses and senior nurses made explicit reference to the social status of
women in Saudi Arabia. A country where women, to a great extent, are subordinate to
and dependent upon their male family members particularly their guardians.
“As women we have [social] limits we cannot go beyond… even the
educated ones have no say on what they want to do. They [the public]
underestimate us and put us under pressure. They deal with you as a
woman who should be suppressed, not as a responsible human with a
mind of her own” Int.2, female senior nurse
In accordance with the prevailing Saudi social norms, some employing organisations
tend to request written approval from the male guardian (father, brother or husband)
before processing any job application submitted by a female applicant. In some cases,
guardians may use their social authority to approve or reject the choice of work for their
female family members. This is consistent with what has been reported by Alawi and
Mujahid (1982) and Hamdi and Al-Hyder (1995). Female staff nurses and senior nurses
pointed out that most married female nurses would eventually encounter family conflicts
regarding work-related issues. They made reference to the female nurses’ need for work
permission from their husbands. A permission that would most likely demand a
particular shift, unit and area of work.
“… female nurses experience a serious struggle when they get married;
their husbands do not want them to work with male patients and do not
accept the night duties. The change is forced on her... You can
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immediately tell she has a family conflict… she comes to us and says: I
want to work in the clinic. Husbands also come to us and speak on their
wives’ behalf; they even bring the needed paper work” Int.6, female
senior nurse
Some participants from tribal backgrounds suggested that their families and the tribe at
large used to perceive nursing as an occupation that brings shame and disgrace to the
family. They explained that, for some tribal families, women (wives, daughters, sisters)
are not allowed to interact with men who are not close family members. A traditional
norm which linked the reputation of women to the perceived honour of their families
(page 18 of chapter 1). Women who pursue nursing were generally viewed as violating
this norm and, hence, were most likely perceived as bad and indecent.
“The Saudi societies consider nursing as shameful and disgraceful
particularly for women. In the southern region nursing was perceived as
harram [forbidden]. Anyone who goes for nursing is not a good woman
and she will not be a good wife… I was the first in the bigger family,
three enrolled after me. They were worried about the societal perceptions;
now, it [nursing] is like any other occupation” Int.31, female student
Seven students and two staff nurses of the fifty female participants made explicit
reference to a widespread perception that nurses are not suitable as wives and future
mothers. This perception was highlighted in the Saudi literature and was linked to work-
related social concerns such as long work hours, night shifts and mixed work
environment (Jackson & Gary 1991, Al-Johari 2001). Participants’ responses revealed
that their mothers had a nagging fear that their daughters may not get married because of
their work as nurses and consequently were worried about their social status.
“My mother was not really happy about it [studying nursing]; this was for
social reasons like the image of nursing in the country. She was and still
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is afraid that I won’t get married. The long working hours and the night
shifts… you know, mothers are protective” Int.17, female staff nurse
Three female participants of tribal origin raised the issue of socially acceptable dress-
code. They indicated that their male guardians perceived the nurses’ white uniform as an
unacceptable contrast to the traditionally approved long black gown. A dress code that
people were brought up to accept as a traditional dress used by females outside the home
boundaries. Responses obtained from these three participants suggested that regardless
of the decency and modesty which characterises the nurses’ white uniform, some Saudi
men may view the white uniform as a violation of the traditional black dress code.
Coming from a tribal origin or religiously conservative background, men may perceive
Saudi female nurses in the white uniform as socially unprotected and as more liable for
social offence.
“My husband does not want me to work in a hospital. He says: you mix
with men and you are dressed in white. Even my brother who works in
the health field cannot see me dressed in white. When I successfully
complete the internship period my husband wants me to work in a
Primary Healthcare Centre” Int.32, female nurse intern
Representing one of three, the participant quoted below expressed her preference to
work in segregated in-patient units; all three linked the availability of segregated units to
a possible increase in the uptake of nursing as a career.. She indicated that the
community at large continue to perceive the mixed work settings as socially
unacceptable. She also attributed her personal preference to feeling uneasy when
providing sensitive type of care to male patients.
“This unit [Day Care] is mixed [has male and female patients]. It is
important to have male nurses… at the MoH, they have a number of
excellent Saudi male nurses. Unlike women, nothing will harm the
reputation of men; we need them to care for male patients. We live in a
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conservative society, I do not feel comfortable working with male
patients but we have only one male nurse around” Int.2, female staff
nurse
Female participants, in particular staff nurses and senior nurses, had other work-related
issues that they felt equally important in enhancing satisfaction, enforcing retention,
promoting nursing as a career option, and improving Saudisation of nursing workforce.
These issues included: scheduling, working hours, transportation, maternity or nursing
leave and the availability of on-site crèches for child care. Interviews suggested that
these work-related issues are likely to pose social pressure on female nurses.
The 12-hour shift pattern
Working 12-hour shift pattern was frequently cited as one of the major deterrents for the
choice of nursing as an occupational choice. Depending on the available staffing level,
hospitals or units within a hospital tend to decide on the most cost-effective shift pattern.
There was a consensus among all participants, single and married, males and females,
student and seniors, that working rotating shifts is physically exhausting and socially
isolating.
“My family life is hectic. I work twelve hours over the weekends, eight
hours during the week and I take two days off. My wife is a nurse… she
is off when I am working, we hardly see each other” Int.7, male staff
nurse
Nevertheless, working shift pattern was of a major concern for female participants.
Unlike participants working at the MoH, those working at the university hospital and
hospitals under the other-government sector were expected to work 12-hour shift
patterns. Unmarried female participants (n = 9) were more tolerant of the 12-hour work
assignments and tried to adjust their social life accordingly. In contrast, married female
participants (n = 14) experienced conflicts while trying to meet the responsibilities of
their work and family. Increased work-family conflict was cited as a major factor
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adversely influencing female nurses’ decision to continue working at the in-patient units.
Interviews with married female nurses suggested that their husbands, even those
described as supportive, do not perceive the 12-hour of morning and night shifts as
family friendly and have a preference for shorter hours and day shifts.
“Most of the nurses at the clinics are Saudis; why! They are needed at the
in-patient units but they always have the excuse of husbands and children.
They lose their skills… but they take the same salary as the nurse at the in-
patient units” Int.6, female staff nurse
Three of the eight married female staff nurses were working in units operating day time
only such as Day Care and Dialysis. Two had recently got jobs as co-ordinators for Pain
Management and Bone Marrow Transplantation. These jobs involve office hours five
days per week. This is consistent with the reviewed Saudi literature which suggested that
most married female nurses tend to request assignment at the out-patient clinics and
Primary Healthcare Centres; or seek administrative posts like the head nurse positions
(Alawi & Mujahid 1982, Tumulty 2001). Many students, staff nurses and senior nurses
indicated that, for social reasons, most female nurses may apply for nursing jobs that did
not require working unsociable hours.
“We have ten Saudi nurses in this unit; all have been through a post-
graduate diploma programme. Unfortunately the hospital did not keep
them… they wanted to get married and have families but the working
hours [12-hour] did not help. Three resigned and three applied to
administrative jobs” Int.13, female staff nurse
Interviews with staff nurses and senior nurses suggested that nursing under various
sectors will continue to lose married female nurses working at the in-patients units as
long as nursing administration and higher management continue to overlook the Saudi
nurses’ family and social needs. Alternative policies such as part-time work or flexible
scheduling are either not yet developed or have not yet been implemented at hospitals
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under the different sectors. Participants felt it might be about time to work on instituting
these family friendly policies to encourage Saudi female nurses to continue working
particularly at the in-patient units.
“The out-patient department has 100% Saudi nurses. At the units, they
[Saudi nurses] work two or three years, then, they get married and that is
it… because of the shifts [they request a transfer]. This is a problem; the
hospital should be flexible with scheduling… meet the nurses’ needs and
they will work to meet your demands” Int.9, female staff nurse
Nevertheless, under the existing nursing shortage, responses from the senior nurses’
group suggested they had little control over nursing policies concerned with scheduling,
shift pattern and working hours. Being few in number and mostly females, these senior
nurses pointed out that they need the support from their fellow nurses’ majority. They
urged Saudi nurses at the front line to be more proactive in dealing with challenges at
work indicating that complaints may not be the best way to solve major issues to do with
well established policies.
“The system is not a holy book. We are short of nurses, the 48 hours per
week were approved and followed to simply cover longer hours with less
nurses. If nurses [Saudi] have problems with the designated working
hours then I wish they propose alternatives instead of simply
complaining” Int.7, female senior nurse
Staff nurses and senior nurses drew attention to the single-status contractual agreement
offered to non-Saudi nurses. They pointed out that these non-Saudi nurses have no
family life and usually have transportation and accommodation arranged for them.
Participants from the senior nurses and staff nurses’ groups were expecting more nights
and weekend duties assigned to the non-Saudi nurses who make up to 70% of the
nursing workforce and who do not have family commitments. This scheduling
arrangement was proposed as a transitional compromise until the number of Saudi
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nurses becomes adequate to cover the national needs. Staff and senior nurses claimed
that these non-Saudi nurses usually prefer to work for two or three days and then take
three days off for rest and recreation.
“… twelve hours, this is a long shift. I am still working because my
husband is very understanding… The administration should give Saudi
nurses the priority to work shorter shifts or selected hours. Non-Saudi
nurses finish their shift then go home to sleep. Saudi nurses have social
commitments… If they [hospitals] need Saudi female nurses, they have to
help them live a normal life” Int.14, female staff nurse
Marriage and family issues
As discussed earlier, for social reasons, the concept of nursing and the rationale behind
the service might be new or foreign for most Saudi men who may not accept the idea of
having their own female family members working outside the home boundaries. They,
are not used to the idea of women dealing or interacting with men while wearing an
untraditional dress code. To maintain a harmonious marital relationship, three married
female participants made it clear that the best workable compromise was to avoid any
talks or discussion about work issues. They further explained that knowing the details of
what, where and who would most likely cause jealousy, conflicts or quarrels. Not
knowing is like hiding the head under the sand, it does not change the reality but it helps
keeping it hidden or invisible.
“I got married while I was in my third year of nursing. He [has Dr title]
supported me throughout my studies. Initially, we had some clashes about
the shifts and the mixed work environment but I was determined to
continue working. He has female colleagues… I asked him to respect my
work as I do his. He suggested we work at different hospitals, does not
want to hear or know anything” Int.6, female senior nurse
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Staff nurses and senior nurses pointed out that, in case of financial difficulties, men may
not object to women’s work per se. They may encourage their female relatives to work
and may even take the full salary of their daughters, sisters or wives. The economic
hardship of the late 1990s seems to have helped many Saudi men to accept the role of a
working wife and to value the added income.
“At the previous hospital, I used to work shifts… had daily quarrels with
my husband… Money is very important these days; we have more
children and more responsibilities. We have debts to be paid, this is why I
am keeping quiet and will continue to work” Int.2, female staff nurse
Married female participants drew attention to being deprived of their right to spend
enough time with their growing children; this was attributed to several factors. I have
used participants’ responses to identify the following most frequently cited ones:
inflexible working schedules, short maternity leave, unavailability of crèches for
childcare and the severe nursing shortage. Their responses suggested a variable degree
of guilt feeling associated with leaving children at those critical milestones of their lives.
Some of these female participants pointed out that while their young children may
develop an emotional attachment with the maid who is always home with them; older
ones may develop anger and resentment toward their own mothers for being away when
mostly needed.
“My poor children, I do not recall when they crawled, stood or walked. I
was very busy I did not witness these major milestones. It really hurts…
I did not give them the needed care and attention” Int.14, female staff
nurse
Transportation
Women in Saudi Arabia are not permitted to drive; moreover, safe and reliable public
transportation services are not available. Female participants from the staff nurses’
group (government sector) indicated that relying on someone else to provide them with
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means of transportation to and from their place of work was not usually an easy task
particularly for evening or night shifts. This is consistent with what has been reported by
Al-Rabiah (1994), El-Gilany and Al-Wehady (2001) and El-Sanabary (2003). The same
participants pointed out that male members of the family may have their own work
schedule and they may not be happy or willing to compromise their time or incorporate
others’ daily schedules into theirs. To go to their desired destinations, some staff nurses
and students had access to the family’s private care and driver. They pointed out that, for
several dependent members of the family using the same car, going to different
destinations (schools and work places) at almost the same time tended to cause some
delay or overlap.
“As Saudi nurses, we have hard time arranging transportation. Some have
drivers while the others may have to come to work with their brothers or
husbands… I think it is better if the hospitals provide us with
transportation” Int.5, female staff nurse
Female staff nurses drew attention to a reputation that classifies many Saudi nurses as
unpunctual. They further explained that hospital administration and senior staff often
overlook the reliance of female nurses on the others for means of transportation.
Participants’ responses suggested that, unless Saudi female nurses have supporting
family members and/or reliable private drivers, punctuality and attendance cannot be
claimed to be entirely within their control.
“… for instance, I phoned to explain that my husband was sick and I have
no means of transportation. They [staff at nursing office] told me they
cannot help. For them, that was not a valid excuse not to show to work”
Int.2, female staff nurse
In the absence of a designated transportation allowance and to overcome reliance on
male member of the family, most female nurses working at the government sector
expressed their need for transportation services similar to those provided to their
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counterpart at the other-government sector. Their response suggested that cars or buses
with the logo of the employing organisation tend to give a sense of security and
reliability to the family and surrounding community.
“It would be better if hospitals provide us with transportation [more
secure and reliable]. I am willing to pay for such a service; I do not mind
even if I have to come a bit earlier but it is very embarrassing not to be at
work on time” Int.4, female staff nurse
Maternity leave and on-site crèche
Responses obtained from married female participants revealed that short maternity
leave, absence of on-site crèche, 12-hour shifts and lack of reliable transportation are
major deterrents for their decision to work particularly at the in-patient units.
“I am expecting a baby soon [first one]. I need to spend time with my
baby but I also need the money… but with the new regulations we are
entitled for only forty days as paid maternity leave. It might be better if I
was a housewife, such pressure [emotional] makes you regret” Int.4,
female staff nurse
With reference to the Saudi Labour law, a female employee is entitled for ten weeks of
maternity leave; after resuming work, she has the right to one hour per day as nursing
(breast feeding) time for around two years. During maternity leave, the female employee
is entitled for 50% of her monthly salary if she has less than three years of service; if
more, she is entitled to her full salary (Article 151, 152 & 154 of Labour Law, Royal
Decree No. M/51).
Similar to what has been documented in the Saudi literature, married nurses in my study
were also concerned about the lack of accessible, reliable and affordable nurseries or
crèches for childcare (Moores et al. 1983, Zuraikat & McClosky 1986, Price Waterhouse
1988, Ghazi et al. 1994, Stewart & Arklie 1994, Rabiah 1994, Al- El-Gilany & Al-
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Wehady 2001, Whittock et al. 2002, Demir 2003). Due to unavailability of crèches, the
distance factor and transportation difficulties, most mothers could not even benefit from
the approved feeding hour. While on duty, the 12 or even the 8-hour shifts may be too
long for nursing mothers and breast-fed babies. Ironically, women under the directions
of Islam 16
are expected to feed their new-born babies for two full years; nevertheless,
Saudi working women may enjoy such a right only if they apply for unpaid leave. Most
female nurses (staff and seniors) believed that applied national policies regarding
maternity and nursing leaves do not seem to encourage many female nurses or their
husbands to consider work options particularly at the in-patient units.
“Mothers need a crèche on site, this would give them more incentive to
work and be productive. If hospitals expect good performance then they
should make their staff satisfied” Int.12, female staff nurse
Issues faced by men
In Saudi Arabia, like in many Arab and Muslim countries, nursing is perceived as a
female job. Just over one fifth of all participants (n = 14) mentioned that nursing was
widely perceived as an occupation for women. The participant in the second quote
below was the only one who clearly said that she believes mothers do not like their sons
to be nurses. This suggests that recruiting men to nursing needs special strategies that
should aim at changing the prevalent perception of nursing as a women’s occupation.
“It is a female occupation, Saudi male nurses are missing. They [Saudi
male nurses] have just started to become professionals... a baccalaureate
programme for young men has been launched only recently” Int.8, female
senior nurse
“… I encourage everybody around me but I take in consideration the
readiness of the family. In case of men, I will think; I know mothers do
not like their boys to be nurses. They always feel men should be
16
Refer to verse number 233, Al-Baqara
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engineers or teachers but not nurses… it conflicts with the male figure”
Int.3, female senior nurse
These participants expected that Saudi men who choose nursing as a career might be
faced with resentment and ridicule from their families, relatives and friends. Seven of 12
male students talked about being referred to as workers doing women’s or maids’ job.
Nursing students and interns were more vulnerable to harsh comments which may
adversely influence their interest and confidence. Responses obtained from male
students and staff nurses suggested they have experienced tough time and hardship
going through their nursing studies and early years of work.
“Nursing is a new field for Saudi men. There is resistance from the
society but as the number of male students increases the image will
gradually change” Int.7, male staff nurse
“I used to hear comments from colleagues in the other programmes. They
refer to nursing as a career for women, they also make reference to
certain women-designated tasks like the bed making… I was new I used
to get embarrassed” Int.22, male student
The lack of BSN programmes for male students interested in nursing was cited by most
male participants as an important factor influencing their perception of nursing as an
occupational choice and, hence, their recruitment into and retention within nursing. They
drew attention to a link between their career progress in nursing and their attainment of
nursing degrees. Male students and staff nurses expressed frustration and disappointment
for not being promoted to nursing posts that require higher level of qualifications. They
felt stuck at a technical rather than professional work level with limited opportunities for
higher education.
“The problem is worse with male nurses; they leave the clinical and
become administrators… what is bothering the male nurses is the dead-
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end [to their career]. Job wise they do not get promoted, they stay as
nurse technicians, no advancement” Int.3, female senior nurse
Almost all male participants indicated their desire to pursue a degree-type of education.
They expressed concern about the availability of only one newly established BSN
programme for male students across the whole Kingdom. To attract more Saudi young
men, these male participants believed that baccalaureate nursing programmes should
replace the diploma and associate degree ones. For them, degree education would
improve the status of male nurses and enhance their career progression.
“Some of our graduates [MoH associate degree programmes] travelled
abroad to pursue their BSN and Master education… this is unfair [not
widely affordable]. I really want to pursue a higher degree; it makes a lot
of difference. A baccalaureate or a master degree reflects an educational
status” Int.11, male staff nurse
Most participants from the MoH government sector, including students, drew attention
to the outflow of male nurses outside the nursing service. While maintaining the nursing
posts they had upon graduation, many male nurses used to request and get transferred to
administrative posts at catering, supplies and quality control departments of the MoH
sector. This is consistent with what Al-Rabiah (1994) has highlighted that suggests that
some early nursing graduates are occupying nursing posts without having to work as
nurses. However, this trend has recently been banned by a new MoH directive.
“Men [Saudi male nurses] prefer administrative posts over clinical ones.
They like to have an office and to wear their Thobe [traditional male
costume]. They come to me saying they do not like the nursing work and
do not like to dress as nurses… They do not like to work at the in-patient
units for long, those who are not really into nursing may get a transfer;
most administrative personnel working at the MoH are originally nurses”
Int.6, female senior nurse
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Staff nurses and senior nurses (males and females) pointed out that most Saudi male
nurses are ashamed of their clinical posts and embarrassed of its underlying tasks. This
might explain the lack of commitment attributed to these male nurses who tend to prefer
administrative posts where they do not have to wear a nursing uniform.
“Saudi nurses have a problem with discipline… they have a high record
of absenteeism, they may just disappear from the unit… I see it more
among male nurses than the females. They [Saudi male nurses] have
patients and they are accountable but they usually take time before they
get committed” Int.7, male staff nurse
“Saudi male nurses may not be interested in nursing. They feel
embarrassed… embarrassed of the bed-making and bed-bath, cannot say
they are nurses, not even to their friends. They prefer the administrative
work and once they get the employment slot they request a transfer to
administration” Int.6, female staff nurse
All male participants from the staff nurses and students’ groups cited job security as the
main reason for their choice of nursing. These male participants felt that nursing is
becoming an appealing occupational option for new school graduates. The male student
in the quote below (private nursing programme) linked the need for job security to the
socio-economic changes taking place in the country over the past twelve years.
“The young Saudis now will think of anything that provides job
opportunities and guarantees a comfortable life. The quality of education
[qualifications and social classification] is not an issue anymore… If it is
mere choice, male students will not go for nursing; they do not want to
face their friends, they feel embarrassed” Int.36, male student
Male students from the MoH (AD) programme often drew attention to the variation in
resources in favour of female students. Many of them made reference to the male
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clinical instructors who are graduates of the same programme with no added
qualifications or clinical experience. Their responses suggested that they have less
manpower and material resources compared to the female students; and that they had to
work hard to become recognised in a female dominated occupation.
“We are twenty students; our clinical instructors take attendance and
spend five minutes with each. Professionally, they are not competent; just
graduated from the college [with an associate degree]. Sometimes they
feel embarrassed because they do not know the answers to our questions.
Hospital nurses are busy; if we [students] do not chase them they will not
teach us… most of the times, we stay with nothing to do” Int.19, male
student
Male students from the MoH (AD) programme had inconsistent views about the nursing
skills’ lab as a training facility at their college and about the availability of training tools
or equipments. Three students talked positively about their experience at the lab; in
contrast, six were more negative. These latter students described their nursing lab as a
class room with a doll and some equipment which was not similar to those found in real
hospital settings.
“… go and see for yourself, there is no nursing lab! The instructor used to
bring his tools and equipment to the classroom, demonstrate the
procedure and then work with a group of students. At the Primary
Healthcare Centres, co-operative nurses would teach us how to use the
different equipments and we learn through practice” Int.21, male student
Male students observed a gap caused by the absence of Saudi male nurses’ role-models
and male nursing leaders. Not having a Saudi male-nurse role model to look up to may
adversely influence the students’ enthusiasm and motivational levels and, consequently
their decisions to remain as nurses and to pursue a career in nursing.
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“Our clinical instructor [Saudi] sits in an office. He does not know the
answers to some simple questions. He is not trained to be an instructor, he
studied and graduated from the same college, has the same qualifications
as any one of us! A female instructor trained and taught me things along
with her students [females]; their level [female students] is much better…
If I was the instructor, I will stay with my students, show them things and
supervise them” Int.26, male nurse-intern
“There is one Saudi male nurse at the hospital where I do my training; he
has a BSN degree. The college should recruit him to teach us… this
would be better because he speaks our language [Arabic]. He was a
student like us and was faced with challenges before obtaining his
degree… he knows what we need and how to reach across to us” Int.20,
male student
A concern about the competency level of male students was raised by the majority of the
male participants (students, interns, staff nurses and senior nurse). This concern was
linked to a shortage in qualified male nursing staff and to a perception that the nursing
programme was not adequately evaluated and monitored. Two of the twelve male
students felt the MoH (AD) programme is so poor it should be closed. They felt that the
existing curriculum does not meet the needs and expectations of the students and does
not prepare them to be competent or confident nurses.
“We [students] do not feel confident! I am in my third year and I feel I
have not benefited education-wise… work-wise, we [male nurses] are not
accepted. We have only a couple of interns who are up to the expected
standard. They worked hard on themselves; the programme and the
educational plan had no contribution to their achievements. The female
interns are better; I think they should close the college for male students”
Int.20, male student
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Nevertheless, participants’ responses suggested that although many female participants
continued to feel helpless and handicapped throughout the internship period, male
participants felt more confident towards the end of their six months internship period.
“I knew what is expected of a nurse and how it feels to be a nurse only
when I started my internship. Six months are not enough; there are many
things I still need to learn. Generally, I feel competent about 60-70% of
all nursing procedures, the rest I will learn on-the-job” Int.26, male nurse
intern
The five male staff nurses and the male senior nurse made it clear that in the socially
conservative Saudi societies, male nurses are needed to care for the male patients. In
contrast, two out of the twelve male students pointed out that, patients in general
(including male patients), tend to prefer female nurses. These findings may suggest that
progressing from student status to staff nurse status tend to help male students realise the
importance of their role and the value of their contribution within the healthcare
services.
“Patients think that Saudi male nurses are less qualified, so they have to
work hard to prove themselves. In our unit, work is divided: male nurses
take male patients and female nurses take female patients. Women might
not accept male nurses but men in general do not mind having female
nurses caring for them” Int.20, male staff nurse
All female participants from the staff nurses’ group agreed that Saudi male nurses are
just as important as female nurses. Their responses revealed a degree of cultural
sensitivity associated with providing certain nursing procedures to patients of the
opposite sex e.g. care of a genital area and inserting a Foley catheter. To my knowledge,
in Islam, men and women may provide any medical and healthcare intervention to a
patient of the opposite sex in the absence of a qualified person of the same sex and
provided it is a case of emergency. The male staff nurse in the quote below pointed out
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that cultural un-easiness during sensitive procedures might also be experienced by male
patients.
“We need male nurses particularly in our [Saudi] societies. Some male
patients may prefer male nurses; for religious or cultural reasons, they
feel more comfortable. Sometimes we [male nurses] get such special
requests through the nursing office” Int.10, male staff nurse
“When we [female nurses] care for male patients… there is some
sensitive stuff, no one will accept it. For instance, our religion does not
allow us to insert a Foley catheter to a male patient” Int.14, female staff
nurse
Few female staff nurses have made reference to the strenuous physical efforts they
exhaust while taking care of heavy patients; they felt that male nurses and male nurse
aides should be assigned to all units to help with positioning and transferring these
patients.
“We need male nurses. There are tasks only men can do… like when you
have to turn or transfer male patient weighing a hundred kilograms”
Int.16, female staff nurse
Participants from the senior nurses’ group (women majority) were concerned about the
shortage of qualified male nurses. Representing the social-group with power and
authority, qualified male nurses were perceived as an influential group supporting
nursing claims for social and professional recognition. It might be easier for senior male
nurses to reach to the male dominated higher management and to make their voices
heard. It might be more convenient for policy makers (men) to address the needs and
concerns of nurses of the same sex.
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“Our social system is controlled by men and nursing is a female-
dominated profession. Women [female nurses] cannot set the professional
requirements on their own… there is a real confusion over nursing. This
is why I wish we have more men” Int.8, female senior nurse
Generation-related struggle
The struggle experienced by the three groups of participants seemed to be linked to the
generation of Saudi nurses the individual participant belongs to/fits in with. I have used
the participants’ responses to identify three generations of the Saudi nursing workforce:
the old, the early and the new. To explain this organising theme, perceived challenges
experienced by the early and new generations are presented below. The old generation
represent the group of nurses who graduated from the first nursing schools or
institutions. Not meeting the recruitment criteria, the old generation were not invited to
take part in this study. As discussed earlier, due to their elementary education and basic
nursing training, these nurses, mostly women, were often blamed for contributing to the
perceived poor image of nursing.
The early generation
This generation of nurses represent the early groups of nurses who graduated from the
baccalaureate programmes or from post high-school associate degree programmes. Most
Saudi nurses with master and doctoral qualifications come from this generation; they
currently hold senior positions and are involved in decision making and promotional
activities.
Participants from the senior nurses’ group represented this early generation. Their
interviews revealed hardship, challenges, frustration and persistence. Their responses
suggested that they were determined to change the perceived public images of nursing
and improve the status of nurses. To achieve their goals and reach their target, they had
to work very hard on themselves and on the people around them. They perceived their
nursing experience as a challenge and had to keep themselves motivated despite
obstacles.
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“… there is a great deal of satisfaction despite the hardship. I felt
respected later on; people would say: you are from the early graduates,
you were excellent. Now it [satisfaction] comes it was not clear then”
Int.3, female senior nurse
Responses obtained from the early generation suggested that they did not expect
immediate rewards; they worked hard and progressed slowly towards their targeted
goals setting the foundation for newly-created nursing posts. As the early groups of the
AD and BSN programmes, they were subjects to trial and error in relation to the newly
established nursing programmes and nursing career paths. However, because they were
few, they were able to identify opportunities for work and further studies.
“I worked hard to achieve my goals, was faced with challenges but my
effort and determination were stronger. Bottom line, I developed myself
the place did not do anything for me. I do not expect that of each and
every one… I took the initiative and I had determination so they had to
give me the opportunity” Int.8, female senior nurse
Before 1995, the annual number of graduates from the government baccalaureate
programme in Jeddah had never exceeded an average of fifteen female students (page 7
of chapter 1). Consequently, there were only a few Saudi nurses who eventually
managed to pursue their higher education and were, therefore, capable of holding senior
positions at the various healthcare sectors. Responses from senior nurses indicated that
they were involved in establishing and managing the Scientific Nursing Board which
operates under the umbrella of the Saudi Council for Healthcare Specialities and the
Saudi Nursing Society which operates under King Abdul-Aziz University. Their
responses also suggested that they are still left with many nursing-related challenges to
deal with.
“We [Saudi nurses in senior posts] need to develop policies, we need to
change the system, we need to design a model, but how many are we!
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There are three in education sector and three in service… we form the
nursing board but we cannot resolve all problems at the same time” Int.4,
female senior nurse
All senior nurses and staff nurses with more than five years nursing experience felt they
were better than the new generation in terms of education and practice. They believed
they had more commitment to learning as well as working and saw themselves as more
determined to develop and upgrade their knowledge and skills. In contrast, these same
participants perceived the new generation of nurses as having a theory-practice gap and
described them as lacking the interest and commitment to nursing. The difference in
perceived competence and the associated professional confidence between the two
generations might be due to the increasing number of nursing students and the shortage
in academic staff and clinical instructors which have become more evident since late
1990s. Being small in number (average seven), as students, participants from the early
generation must have had more attention from their tutors and instructors in relation to
their knowledge and practice experiences.
“We were few in number; we could easily monitor ourselves and see
where we are going to be. Unfortunately, the new ones tend to go with
the tide; they do not know what they want or what are the needs of their
country” Int.7, female senior nurse
“… we were better; there is a theory-practice gap. Before we were very
strong in theory and we were decently competent; we needed polishing
and support to be independent and self reliant… now, they [new
generation of nurses] are neither good in theory nor in practice; they need
more effort and more exposure” Int.17, female staff nurse
The above participants believed that most nursing students (the new generation) have no
genuine interest in nursing. In their views, it is the job security and financial reward that
seem to have attracted many young Saudis to nursing. In their accounts, there was no
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reference to the job security or nursing salary as a reason for choosing nursing. This
might be explained in relation to the time (economic hardship) and contexts (post 9/11
and the two Gulf Wars) influencing the choice of nursing as an occupational choice of
this particular generation of Saudi nurses.
“Over the past ten years, I felt that the increasing number of high school
graduates coupled with the lack of jobs had helped in keeping students in
nursing” Int.4, female senior nurse
“For the young generation, nursing represent job security. Nursing
graduates from the diploma level get SR 4,500 [£600] monthly plus other
benefits, their future is secured… other university graduates including
engineers may not find jobs” Int.6, female senior nurse
The early generation of nurses viewed the new generation as being interested in holding
senior nursing positions without having the patience or stamina to go through a
progressive career path. They often described the new generation as lacking the required
formal preparation; this was attributed to constraints at the education and service
segments of nursing. The students and interns were perceived as a nursing generation
who tend to feel embarrassed carrying out the bedside care.
“I feel that the new ones care only about positions. They are not willing
to work and care for patients, they are not willing to do bed bath and bed
making, they feel embarrassed emptying the urine bag… they do not
want to do the work expected of domestic maids!” Int.18, female staff
nurse
The nine senior nurses were more confident about their feelings towards nursing.
Nevertheless, after long years of struggle, the accounts obtained from two suggested that
they do not blame the new generation of nurses or the Saudi people at large for the
perceptions they continue to hold for nursing. Coming from a participant who had a
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record of nursing achievements and accomplishments, I did not expect a quote such as
the one below.
“I see nursing as a non- profitable career. You do not win financially and
you do not win professionally… this might be caused by issues to do with
the system, with nursing as an occupation or with nurses as individuals.
We [Saudi nurses] have no professionally defined standards for
promotion and progress… no security or motivation” Int.7, female senior
nurse
The new generation
This group included nursing students and nurses who have around three years of
experience. Participants from the students’ group (AD and BSN, government and
private) talked about the two Gulf Wars and their impact on the socio-economic
conditions of the country and people. Observing the escalating unemployment rate
among Saudis graduating from socially favourable fields of studies, the new generation
were willing to consider options that were traditionally tabooed (socially perceived as
shameful and disgraceful). By and large, they indicated that young Saudis are no longer
fixed on an academic education for prestigious or professional jobs approved by the
family or wider society. On the contrary, high school graduates are after the job security
provided through certain programmes demanded by the labour market.
“It [nursing] is a good choice. I think the young generation may accept
any type of work… if they only had the opportunity to know about what
is available to them. Young Saudis have realised that shame is never
associated with lawful work. Some inherited customs and tradition were
behind the current widespread unemployment, so they are determined to
break barriers and obstacles” Int.1, female student
“People need jobs. They need the money, money is everything, we cannot
do anything without money. There are two types of people; some will go
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for any decent job that provides a legitimate source of income and some
will stay at home and that is it…either go for certain jobs or nothing”
Int.4, female student
Participants from the students’ group and the two staff nurses with three years of
experience were unclear about their future. Some expressed their desire to pursue higher
education in order to apply for educational or administrative jobs. Others were
considering the locally available specialised clinical training such as Critical Care or
Oncology courses. Almost three quarters of the students’ group expressed strong interest
in pursuing their higher education. Students with an associate degree in nursing were
determined to pursue a baccalaureate degree. They believed an academic degree would
improve their status and enhance their career progress.
“My future is unknown… it is my third year [as a staff nurse]. Sometimes
I think of pursuing my education [to get BSN degree] and sometimes I
get interested in specialised courses like Critical Care or Emergency. I am
not quite sure, I have not made up my mind yet” Int.8, female staff nurse
“As a student, I worked three days per week [6 hours per day] and I am
happy so far… but I have not experienced a full duty for five days, it
might be alright. I am planning to pursue my higher education… I want
to develop myself. I would love to work in the emergency or operating
departments, might take specialised courses but I really do not know what
the future might bring” Int.28, female student
Some of the early generation described the new generation as “fragile”; this term was
used to refer to their vulnerability and their need for social support and professional
empowerment. In contrast, students and staff nurses with three years experience
perceived coping with the social and professional challenges as requiring them to learn
the art of counter-fighting and techniques of survival. These findings suggest a lack of
supportive services at the education and service segments of nursing.
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“The new generation of nurses are fragile. The education they had did not
shape their personality; they come to the hospitals and get shocked. They
need to be prepared psychologically and professionally… how is it at the
hospital, what will they do, how to deal with doctors and patients and
how to deal with their conflicting personal issues” Int.18, female staff
nurse
For the students and staff nurses with three years experience, coping with the wide-range
of challenges associated with nursing required learning a great deal of assertiveness and
survival’s techniques. Their accounts revealed their vulnerability and their need for
social support and professional empowerment which seem to be missing at the education
and service ends.
“No one should go for nursing unless they really like it or else they will
not continue… they will face challenges in their studies and at work.
They will experience pressure [family and work] and will have
responsibility… nurses are always at the front line dealing with doctors
and patients; if not up to all this, the person will not continue… I got fed-
up several times, could not take it [works at in-patient unit] any more and
requested a transfer. Then, I would change my mind and say to myself: I
will get used to it” Int.8, female staff nurse
The impact of prevailing images and perceived status of nursing varied considerably
among the participants; however, the intensity seemed greater among the students,
interns and staff nurses with three years experience. In comparison to nurses from the
early generation, participants from the new generation found coping with widespread
perceived images very difficult. As members of a generation born and brought up at a
time when many Saudis expected the non-Saudi others to serve them, it was more
difficult and challenging for participants from the new generation to accept images such
as the maid image.
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“I am not really convinced about nursing. When people ask me about my
field of study… I get hurt, keep quiet and cry. I could sense how they feel
about nursing; at the same time, I do not know what to say to them or
how to defend nursing… I have no words and no feelings [towards
nursing]” Int.4, female student
Perceived as similar to domestic service to be performed by women, the male participant
in the quote below felt that bedside care is an embarrassing aspect of nursing.
Forecasting the future, he visualised his future children being ashamed of his post and
the associated tasks. The participant did not mind working as bedside nurse for a number
of years after graduation; however, he could not see himself providing bedside care as a
middle aged man with family and children.
“… what will happen after twenty years when I have grown up children?
I cannot keep doing the same type of work, impossible. It will be very
difficult to perform certain tasks as middle-aged adult… well; this might
change when I start practicing” Int.22, male student
With a majority interested in medicine rather than nursing, participants in the students’
group were easily hurt and offended when exposed to what they perceived as ridicule
and criticism. Not knowing whether they would continue in nursing or whether they
would learn to accept nursing caused further feeling of worry, confusion and frustration.
“We [first year students] are shattered and confused. Till now, I do not
know if I will continue in nursing or I will manage a transfer to science. I
am worried, I do not want to regret… I do not want to waste a whole
year. If I were in charge, I will share my experience and how I reached to
where I am now… we need more of this. We are young, we need support.
We need to learn how to defend nursing. I want to explore the good
aspects of nursing… I am really scared nursing may turn to be a bad
choice” Int.12, female student
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Students and staff nurses with three years experience expressed their needs for a great
deal of family support. For these participants, the perceived views of close family
members were highly valued. Their responses suggested that their families were highly
influenced by the prevailing negative perceptions of nursing. Parents, in particular, were
disappointed that their children failed to get a place in the academic field of choice.
Parents were also not happy about the choice of nursing as an alternative to medicine,
dentistry or pharmacy. These negative feelings of disappointment and resentment were
perceived as an emotional pressure exerted at a time when the participants were most in
need for their parents’ consolation and support.
“It is very hard when the people closest to you are against you. Mom
always says: as long as you are in nursing, I will not be happy. I cannot
even discuss this matter [being enrolled in nursing] with her; I feel so bad
because I really need her by my side” Int.11, female student
Many students were frustrated and disappointed particularly when the pressure came
from close family members like a mother or a father. The emotional pressure exerted
from these close family members might have caused a feeling of guilt among students
for not being up to their parents’ expectations. Their interviews suggested that it was
very difficult for them to come to terms with nursing and, at the same time, cope with
the perceived nursing images of their families and relatives.
“Nursing will never be perceived as a good choice, impossible. Every
time I meet with my uncle he would say: are you still in nursing? Even if
you are convinced, you will be influenced by the opinions of the others…
you know, the act of continuous hammering will break any solid surface”
Int.8, female student
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Conclusion
The argument presented in this chapter is that participants have been experiencing a
personal struggle as they were learning to cope with the prevalent negative images of
nursing at social and professional levels. To understand the third explanatory theme and
the underlying argument, this chapter explored three organising themes: barriers to the
choice of nursing as an occupation, gender-related struggle and generation-related
struggle. Participants’ accounts suggested four barriers influencing the choice of nursing
as an occupational choice: lack of nursing awareness; lack of interest in nursing; nursing
as an alternative field of study; and lack of family support.
The social and professional challenges experienced by male and female participants
varied considerably. Female participants had two advantages over their male
counterparts: they have access to higher education in nursing; and they work in a
predominantly female occupation. In contrast, male participants had minimal social
constraints in relation to their choice of work settings, working hours and late or
weekend duties. Nevertheless, both were faced with variable degrees of social resistance
associated with the choice of nursing as a career. The struggle experienced by the three
groups of participants seemed to be linked to the generation of Saudi nurses the
individual participant was a member of (early or new). Throughout the chapter, a range
of participants’ accounts were presented to support the underlying argument.
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Chapter Seven
Discussion
Introduction
Recruitment and retention of Saudi nurses is believed to be best understood when
approached, analysed and discussed in relation to a framework of concepts derived from
the literature. These are: nursing images; status of nursing; perceptions of nursing as an
occupational choice; nursing education; gendered-nature of nursing; and the existence
and nature of nursing support systems (including Saudisation).
Findings from my qualitative study were presented using three explanatory themes:
perceptions of nursing; challenges facing professionalism; and dealing with personal
struggle. These findings suggest that nurses in Saudi Arabia face shifting boundaries
brought about by dynamic changes in social values, religious beliefs, division of gender-
roles, economic and global developments. In taking up nursing and deciding to continue
in nursing, the individual nursing experiences of the students, staff nurses and senior
nurses who took part in my study revealed serious attempts to transcend these shifting
boundaries. Findings also suggest that forces raised by Meleis and Hassan (1980)
continue to impact on nursing in Saudi Arabia particularly in relation to recruitment of
new students and retention of graduates. In their review of the nursing crisis in the
Arabian Gulf countries, Meleis and Hassan (1980) highlighted three main forces: status
of women, image and status of nursing and control of the nursing profession.
The purpose of this chapter is to discuss how shifting gender, social, economic and global
boundaries, within a Saudi context, might have impacted on the perceptions of nursing,
challenges facing nursing professionalism and dealing with personal struggle. Hence,
illustrating how these shifting boundaries might have influenced the participants‟
decisions to become nurses, pursue nursing and remain as nurses (their recruitment into
and retention within nursing). Therefore, the three explanatory themes used for the
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presentation of findings are dealt with in the context of: 1) gender boundaries; and 2)
social, economic and global boundaries. The chapter is divided into three sections. In the
first section, I present a critical review of the strength and limitations of the study. In the
second section, gender boundaries, I argue that negative gender-related perceptions of
nursing have for many years contributed to its perception as a professionally less
prestigious and socially unappealing occupational option. Simultaneously, this has
hindered and limited the number of men and women who wanted to become nurses. The
third section, social, economic and global boundaries, argues that Saudi Arabia is
experiencing an emerging economic-driven interest in nursing. It discusses how changing
political, economic, social and global boundaries, combined, have been influencing
nursing appeal. A social and professional appeal for an occupation that requires a
minimum of 50 years to Saudise around 60% of its workforce (Abu-Zinadah 2006).
Strengths and limitations of the study
Study sample
Recruiting a purposive sample of participants with different educational backgrounds, a
range of study-work experiences, and representing the three existing healthcare sectors
had increased the likelihood of obtaining a wide range of views drawn from diverse
nursing experiences. The recruited sample also brought to light the participants‟ (insiders)
own accounts on what brought them into nursing, what had kept them so far and what
might encourage them to stay. Indeed, the final sample represented a fair mix of females
and males (50 and 18 participants respectively); of married and single (23 and 45
participants respectively); of tribal and non-tribal backgrounds (28 and 40 participants
respectively); and of participants from the three sectors (44 government, 12 other-
government and 12 private).
This sampling strategy was necessary to answer my research question. It helped ensuring
that variation in the nursing population was most likely represented in the data. This in
turn might make it possible to claim that similar sample groups could be drawn from the
Saudi nursing population in the country particularly from areas of similar socio-cultural
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context. Barriball and While (1994) suggested that broad selection criteria of a sample
would improve its representativeness and enhance the validity of the findings.
Moreover, one of the identified gaps in the Saudi nursing literature has been the
exclusion of Saudi male nurses from previous research. This study attempted to address
this gap by recruiting male participants from the three selected groups. The recruitment of
Saudi male nurses has given this study opportunities to examine the perceptions, views
and concerns of an important group of the future Saudi nursing workforce. Twelve male
students (almost one third of the total number of students), five staff nurses (almost one
quarter of the total number of staff nurses), and one male senior nurse from the nine
agreed to take part in the study. Male participants‟ accounts revealed their own unique
experiences; they enhanced an understanding of the gendered nature of nursing and its
influence on the recruitment and retention of Saudi nurses.
Qualitative data
In most studies, by deciding between a qualitative or quantitative approach researchers
make a trade-off between the depth and breadth of data. In my study, conducting semi-
structured interviews with sixty eight participants representing students, staff nurses and
senior nurses from the government, other-government and private sectors was an added
bonus. Employing a purposive sampling technique has enabled me to get the perspectives
of a mixed sample and provided a wealth of data with the desired depth (individual
experiences) without sacrificing breadth. It is worth mentioning that participants may
have talked about and conveyed their own interpretation of the views, opinions and
perceptions of people around them (family, friends and other professionals). For instance,
the prevalent images of nurses as women with bad reputation or perception of nursing as
a female occupation are not necessarily an expression of the participants‟ own
perceptions; rather, they are interpretation of public‟s perceptions. Nevertheless, many
participants frequently raised, referred to and/or acknowledged the importance and
influence of these views and perceptions on their recruitment and retention. Their
accounts indicated that these public views and perceptions had an impact on their
individual nursing experiences. Throughout the presentation and discussion of findings, a
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distinction has been made between the participants‟ accounts and public views and
perceptions.
Timeliness
Conducting this study at a time of marked social, economic and political changes was
needed to establish baseline knowledge to compare with previous and future studies.
Much of the Saudi literature has cited prevalent negative images of nursing and perceived
low status of nurses as important factors in explaining the severe shortage of Saudi
nurses. This study was therefore needed to explore the impact of these negative
perceptions on the experiences of Saudi nurses and to uncover what is perceived as
challenges to the recruitment and retention of these nurses in the midst of changing
political, economic and social contexts. Moreover, at a time of a severe international and
national nursing shortage, there was a need for an approach that invites Saudi nurses to
talk about their experiences, express their views and enable them to voice their concerns.
Many western studies have emphasised the importance of addressing issues of concerns
drawn from the nurses‟ own accounts (Price Waterhouse 1988, While & Blackman 1998,
Coombs et al. 2003, Callaghan 2003).
The variation in age group, educational level and service sector, made it possible to
identify and discuss social, cultural, economic, global and gender-related factors
contributing to the recruitment and retention of nurses. There was an overall agreement
among participants that negative images of nursing and nurses continue to prevail in
Saudi societies. Nevertheless, despite these negative images, some participants‟ accounts
suggested a degree of change in the perception of nursing. These findings suggest that
with the rapid socio-economic developments, a change in the perceptions of nursing is
taking place. Indeed, the findings have highlighted the political and economic forces,
such as the increasing unemployment and the associated economic hardship of the 1990s,
which influenced the uptake of nursing. The nursing shortage and challenges facing
international recruitment have inspired planners and policy makers to develop the
Saudisation Policy to reduce reliance on non-Saudi nurses. However, the implementation
of this policy has varied across services and sectors. It was, therefore, necessary to
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examine the impact of variation in organisational resources on Saudisation plans and
interventions as perceived by Saudi nurses. Sharing research findings with all hospitals
and academic institutions involved in the study might help concerned personnel in
planning their future recruitment and retention strategies (Saudisation).
Gender as a methodological issue
Being the first woman to gain access into the male section of the MoH Nursing College,
the ministry demanded that a male mahram (guardian) should initiate contact with the
college administration and be my chaperone during my visits to the college and
throughout the interviews. Such a condition was the best workable compromise to cross
the gender boundary of a highly segregated educational system.
The presence of my husband may have helped making it easier for male students to relax
and feel at ease. Being of the same gender, he tried to “break the ice” and helped to create
a relaxed atmosphere in which the interviews were conducted. On my part, in addition to
being courteous I was aware of the need to be socially sensitive. In spite of all these
measures, some male students were more inhibited and guarded than their female
counterparts. These students were mainly second year students who have not yet had
much hospital-based training and mixed-setting exposure. In contrast, the more
experienced male interns were relaxed and out-going. The inhibition experienced by
some male students was expected; it has been attributed to the gender difference between
the interviewee and the interviewer; a difference that was acknowledged and discussed by
western researchers who have conducted interviews in societies that have less rigid
gender codes.
“the sex of the interviewer and of the respondent does make a difference
as the interview takes place within the cultural boundaries of a
paternalistic social system in which masculine identities are differentiated
from feminine ones” (Fontana & Frey 1994, p. 369)
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Despite the gender difference between the interviewee and the interviewer, an
examination of the findings suggested that male participants‟ responses and their
individual accounts were similar to those of the female participants. For example, male
and female students and staff nurses made reference to: 1) the prevailing perception of
nursing as a career for women; 2) the similarity between the nurses‟ work and the work
of domestic maids; 3) the low status accorded to nursing e.g. menial and subservient; 4)
the role of media in confirming the negative images and low status of nurses; 5)
experiencing social embarrassment associated with performing bedside care; 6) the lack
of financial benefits associated with a career in nursing; and 7) the link between an
increase in the uptake of nursing and the need to secure a job.
Compared to their female counterparts, male participants talked about being treated
unfairly in terms of equal educational opportunities. They were concerned about the lack
of Saudi male role-models and shortage in experienced male tutors and qualified clinical
instructors. The only difference between the responses of male and female participants
from the students‟ group was the rather brief answers given by the formers compared to
the detailed accounts of the latter. Being cautious or reserved might be linked to the male
participants‟ manly nature characterised by not being very expressive in terms of feelings
and not very keen into details. Identifying similarities and differences between male and
female participants was employed to check validity of responses obtained from male
participants. Nevertheless, conducting gendered interviews in sex-segregated traditional
context, it was rather inevitable to get some responses from some male participants that
might vary from those of their female counterparts. Future interview studies conducted
by male interviewers should bring more insight into the issue of gender differences in
research settings.
The interview guides
The pilot work enabled me to make informed adjustments to the interview guides before
the main study. However, the semi-structured nature of these interview guides; the
average 1-hour time-frame allocated for each interview; and the attempts to fit all
questions within the time frame were important practical constraints limiting the
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opportunity to follow up on all leads and to explore certain avenues in the desired greater
depth.
The retrospective nature of some data
The findings were characterised by a wide range of individual accounts dependent on
nursing experiences over a changing and developing period in the history of nursing in
Saudi Arabia. For some of the participants, having a minimum of ten years of nursing
experience meant that they often had to recall events that occurred and decisions that
were made long ago. Questions such as “how did you start in nursing“, “how did your
family members feel about nursing”, and “what were the prevailing nursing images”,
demanded that these participants look back at past events recalling memories and
retrieving feelings and meanings. Bringing back certain scenes or events is highly
dependent on an individual‟s ability to remember important details of that particular
times or events.
Participants were asked to talk about their career choice retrospectively. For some, this
implied recalling details that took place up to 20 years ago. Barriball and While (1996)
have acknowledged such issue as a limitation for their own sample of qualified and
unqualified nurses with different career choice profiles. Simultaneously, they reported
that the hazards of relying upon memory have been widely discussed in the literature.
However, they maintained it has been a method successfully used in studies exploring
career motivation and occupational choice. Despite differences in age and the wide range
of experiences, similar accounts were obtained from the three different sample groups.
Having a wide age range had given me the opportunity to, diachronically; explore
concepts believed to impact on the recruitment and retention of Saudi nurses. As such, I
was able to record and monitor images of nursing and nurses, perceptions of nursing as
an occupational choice, views on nursing education, and views on support systems over
and through a changing period of time which, in turn, has provided the study with a
broader perspective.
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Gender boundaries This section discusses how shifting boundaries between women and men may affect and
be affected by perceptions of nursing, nursing professionalism, and dealing with personal
struggle. Hence, illustrating their subsequent impact on the recruitment and retention of
Saudi nurses.
Perceptions of nursing
Findings from chapter four indicated that negative gender-related perceptions of nursing
still prevail in Saudi Arabia. These perceptions are grouped under two categories: nursing
as an occupation for women and nursing as similar to domestic service. The former
category will be covered under this section and the latter will be covered when discussing
the impact of social and economic boundaries on perceptions of nursing.
Some participants referred to the emergence of nursing as an occupation for women and a
majority believed that this has contributed to people having mixed feelings about nursing
as a career. As a service which provides nurturance, care and support, nursing has been
perceived as a natural extension of the domestic roles performed by women (El-Sanabary
1993, Davies 1995, Evans 2004). This was instrumental in the perception of nursing not
only as an occupation for women but as one that is unskilled, of low value and low status.
Participants from the senior nurses and staff nurses‟ groups believed that these negative
images were influenced by the social status and level of education of the Saudi female
nurses who graduated from the early nursing schools.
In Saudi Arabia, like in many Arab and Western countries, nursing started off as a career
for women and continues to be an occupation where women outnumber men (Salvage
2002). In the early 1950s and in the absence of Saudi nurses, there was a pressing need
for newly established MoH to contract non-Saudi nurses of which a majority was made of
women. It would appear that, in spite of strictly observed gender segregation tradition,
the Saudi government and public had managed to find justifications for female nurses
(Saudi and non-Saudi) providing nursing care to male patients. These nurses were women
working in mixed-gender settings, covering rotating shifts and providing all levels of care
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to male and female patients. They were not wearing the approved dress code for Saudi
women and were interacting with men who were not immediate relatives. Not complying
with the traditional codes, these non-Saudi nurses were perceived as foreign women who
do not fit with the social system.
Being unacceptable to the mainstream of Islam, Saudi people viewed these foreign
female nurses as enjoying religious and moral sexual freedom (El-Sanabary 1993). Such
stereotyping further damaged the image of nurses and discouraged Saudi families from
considering nursing as a career for their own daughters. In addition to being
predominantly foreign and female, these nurses were expected to assist medical doctors,
follow their orders and provide a level of care perceived as menial and unskilled. While
commenting on some fifteenth century depictions of nurses, similar images of pre-
Nightingale western nurses were described by Kampen (1988, p. 23):
“They nurse patients who are most often men lying in bed; they work in a
distinctive location that does not look like a house; they wear distinctive
costumes; their activities are domestic and religious rather than
specifically medical”
Gradually, negative stereotypical perceptions of nurses such as that of indecent women
who are not suitable for the role of wives and mothers started to prevail. This is
consistent with what has been highlighted in other Saudi studies (Jackson & Gary 1991,
Al-Johari 2001). Similarly, the western literature reported a widely perceived image of
nurses as sex symbol (Kalish & Kalish 1982, Kalisch & Kalisch 1987, Hallam 1998)
which at some point in history (1966 - 1982) has given nurses a stereotypical
disrespectful professional image. Such negative gender-related perceptions may explain
why Saudi women who may have interest in nursing would be discouraged from pursuing
it as a career.
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The changing role of Saudi women and their participation in the labour market
By and large female participants in my study indicated that educated Saudi women are
increasingly aspiring to a wide range of work opportunities including nursing.
Urbanisation, education and economic growth might have been the main forces which
induced such social change; similar factors were identified by Dodd (1973). Indeed,
Saudi women have gone a long way since the establishment of their formal public
education in 1959. Following opposition and rejection, most Saudi families managed to
accept women‟s education and many have started to appreciate their work achievements.
In 1999, Saudi women were making up to a third of the total students enrolled at the six
main universities in the Kingdom (Al-Abdul-Qader 2003). By 2006, they constituted
45% of all university graduates (MoP 2006). Empowered by education, Saudi women
became increasingly interested in taking part of the labour force particularly in jobs
designated suitable for Muslim women. A relatively small percentage started to engage in
female-designated jobs at government-services particularly the segregated education
sector. While 83% of the female workforce in the year 2002 was serving at the gender-
segregated education sector, only 8% was working in healthcare services as physicians,
nurses and other supportive healthcare specialists (MoEP 2003). There was a consensus
among all groups of female participants that teaching, being gender-segregated career,
has been viewed as the most respectable profession that suits young Saudi women.
Examining the gender gap in oil rich states, Holian (2003) claimed that education is the
key to increased female labour force participation. She argued that even in the religiously
conservative Saudi Arabia where gender segregation is the norm, women in general
cannot drive and married women have an average of six children, women do manage to
pursue their post-secondary education and gain paid employment. Women‟s education,
however, was not paralleled by the desired participation in the workforce. Despite
representing 50% of the total Saudi population, only 10% of the women in the work age
group were working (MoP 2005b). This was attributed to the limited career opportunities
available for Saudi women which, simultaneously, have limited fields of education
targeted at this potential workforce (MoL 2004). Al-Suwaigh (1989) argued that the
limitation in women‟s education was the major deterrent to their participation in the
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labour market. Women‟s employment, she maintained, was restricted to traditionally
female jobs such as education, social services and healthcare. Compared to Saudi high-
school students who selected computer science, teaching and business administration as
their occupational choice (Al-Omer 2004), participants in my study acknowledged that,
due to limited work opportunities, graduates from these fields continue to be jobless.
They highlighted that female nurses in particular are in high demands because they can
work with male and female patients. With employment‟s restriction persisting well into
the twenty first century, more young women may choose nursing particularly when they
have less chance of enrolling in the socially preferable field of medicine.
Representing many members of the Saudi Council of Senior Ulama, religious scholars
such as Sheikh Abdul-Aziz Bin Baz and Sheikh Saleh Al-Fawzan were against women‟s
employment. They believe that the western world is encouraging Muslim women to quit
their prime work and utmost responsibility at home to compete with men over paid jobs
outside the home boundary. In their opinion, if Muslim women start to take up jobs
particularly in mixed-gender settings, Muslim societies would eventually be transformed
into free and liberal societies (Al-Bar 1984). Some authors suggested that the
participation of Saudi women in the labour force is restricted by socio-cultural factors
such as religious values, social norms and division of labour which expect women to stay
home (El-Sanabary 2003, Holian 2003).
Since the 1990s, the country has been experiencing social change which produced
another group of educated open minded Saudi leaders and decision makers who tried to
encourage women to participate in the labour force. With emphasis on adhering to
Islamic principles, this latter group gave women the freedom of choice between their
valuable role at home and their contribution to the bigger society (Al-Bahnasi 2003).
Consequently and although not necessarily in agreement with all groups within the Saudi
social system, the Council of Ministers approved a set of regulating measures and
mechanisms aimed at maximising women's participation in the country's socio-economic
developments and providing them with more employment opportunities to reduce
reliance on non-Saudi workforces (Resolution 120 on 31/5/2004 cited by MoP 2005b).
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This historical shift in government„s position towards women‟s labour-force participation
reflect a slight change in the deeply rooted gender boundaries that restricted women‟s
paid work opportunities.
In his book on the challenges that faces Saudi women, Al-Abdul-Qader (2003)
emphasised that women opt to work for two major reasons financial motives and self-
driven motives. In reference to the former set of motives, I could argue that the economic
hardship of the 1990s, has forced an increasing number of Saudi women to seek
employment to support their families. For many, particularly women from middle class
families, this economic context served as an opportunity to use educational qualification
and justify self-driven motives to work particularly at the socially less favourable jobs
such as nursing and banking or less desirable work settings such as hospitals and shops.
Consequently, many families particularly those living in big cities and towns started to
appreciate and acknowledge the extended role played by their female members.
It has been argued that, in a relatively short time, Saudi Arabia has gone from an era in
which women‟s expected role was to settle down in marriage and to take care of their
husbands and children to an era in which women are expected to have a paid job to
support their families. Long (2003) suggested that the population explosion has greatly
reduced the per capita income which, subsequently, forced many women to seek
employment outside their homes. This may suggest that a change in perceptions
concerned with gender-role might override socio-cultural taboos. Indeed, many educated
Saudi women started to gradually claim more job opportunities to achieve their
professional aspirations and to fulfil their long-term dream of altering their social status.
Gender-role boundaries in the workplace
Over the past three decades, there has been an increased research interest in the reasons
behind crossing traditional gender-role boundaries in the workplace. Of particular
interest, here, is the uptake of occupations such as nursing by Saudi men.
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There was a consensus among staff nurses and senior nurses that most Saudi male nurses
are ashamed of the bedside aspect of nursing care and that they do not like to be seen
wearing a nursing uniform. Contrary to the hiring advantage suggested by Williams
(1995), these negative feelings were believed to adversely influence Saudi male nurses‟
long-term commitment to their work. Male and female participants explained that most
Saudi male nurses choose to work in areas where bedside care is not part of the daily
routine e.g. emergency room, operating room, anaesthesia and dialysis. Working in these
specialities helped male nurses to engage in a technical type of work and provided them
with opportunities to hide behind a green rather than white uniform. Staff nurses and
senior nurses also indicated that Saudi male nurses preferred administrative posts.
Holding an administrative post would relieve the male nurse from the responsibility of
providing bedside care and allow him to wear the traditional costume for men (white
Thobe). Another possible explanation is linked to the associate degree educational
qualification attained by a male nurses‟ majority. An educational qualification which tend
to keep male nurses at a post or grade far below their aspiration and should justify the
professional frustration they may experience.
Some male students referred to being viewed as workers doing women‟s or maids‟ job.
This indicates that the Saudi patriarchal societies might be critical of men who choose
occupations socially designated for women. With a predominant perception that nursing
is a female profession, Irish male nursing students found it difficult to reconcile their
desire to study nursing with factors against their entry (Mooney et al. 2008). Similarly,
American college students from non-nursing majors rated “women are better suited for
nursing” higher than students from nursing majors (Seago et al. 2006). The authors
concluded that this result highlights the ongoing challenge of recruiting men into nursing.
In spite of the above perceptions, a male-participants majority seemed to have some
degree of support from their family for their choice of nursing. This might be linked to
the nature of patriarchal societies which expect men to earn a living and be the sole
provider. Accordingly, Saudi families tend to most likely support any serious move in
that direction. This suggests that, Saudi male nurses and their families may learn to cope
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with the stereotypical views and harsh societal criticism of nurses in return for job
security. The traditional breadwinner role was claimed by Williams (1995) to work for
male nurses‟ hiring advantage over women.
From a feminist perspective, Evans (1997) raised several arguments in relation to the
hidden advantages for men in nursing. Three are discussed here for their relevance to my
findings. Her first argument referred to western male nurses who, despite being
numerically less, are occupying elite administrative positions. In contrast, having very
few qualified Saudi male nurses left all senior positions available for the more qualified
Saudi female nurses. Hampered by their educational qualification (Tumulty 2001), male
nurses‟ opportunities for career advancement, compared to those available for their
female counterparts, tend to be limited. Ironically, the patriarchal Saudi societies may
have, in fact, deprived male nurses from the “hidden” and powerful advantage which
assisted western male nurses in achieving high status leadership positions over female
nurses. This, however, is not typical of all Arab and Muslim countries; the male to female
nurses‟ ratio has reached 1:1 in Palestine and 2:3 in Jordan (Shukri 2005).
Evans‟ second argument suggested a link between the specialities chosen by men and
their compatibility with male traits such as: physical strength, technical prowess,
autonomy and cool-headedness. An argument that is consistent with what has been raised
by Egeland and Brown (1989) and Williams (1995). Evans (1997) also claimed that the
choice of nursing specialities such as psychiatry or anaesthesiology tended to enforce the
masculine identity. An identity that stands in contrast to the feminine traits of touch and
tender care. Similarly, of the five male staff nurses in my study, two worked in Intensive
Care; two worked in Dialysis; and one worked as an Emergency nurse. Specialities that
are renowned for their high pay and potential for promotion (Rognstad & Aasland 2007)
and which allow male nurses to avoid the white uniform and do not require giving
personal care (Bush 1976).
Evans‟ third argument was about male nurses‟ role in improving the image and status of
nursing. The literature reviewed by Evans (1997) revealed that, unlike Saudi male nurses,
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their western counterparts have more university degrees than female nurses. Representing
the social-group with power and authority, qualified male nurses were perceived by some
participants from the senior nurses‟ group as influential members supporting nursing
claims for social and professional recognition. Nevertheless, Ryan and Porter (1993)
suggested that the entry of men into nursing has been largely of benefit to male nurses in
the UK and that women, without the assistance of men, have made significant gains in
elevating the status of nursing. Findings from Boughn‟s qualitative study (2001)
suggested that, compared to female nursing students who are socialised to think of others
before they think of themselves, male students were more inclined to empower
themselves as professionals. Whether it is attainable to achieve a competitive Saudi male
to female nurses‟ ratio as other Arab neighbouring countries; or, whether having more
qualified Saudi male nurses in senior posts might empower nursing as an occupation are
future matters still to be seen.
Male participants pointed out that they were not permitted to work in female and
paediatric units; this has limited the training opportunities available to them and
adversely influenced their level of competence. In Saudi hospitals, male nurses are not
assigned to female patients because the idea of a male nurse providing personal direct
care which may involve touching the female body is considered a cultural taboo.
Similarly, Evans (1997) suggested that gender has limited male nurses‟ training in areas
such as obstetric, gynaecology and general paediatrics. For socio-cultural factors, Zeilani
(2007) indicated that sixteen Jordanian women interviewed during their admission to an
intensive care unit preferred female nurses. These women were uncomfortable and
embarrassed when male nurses touched their body while providing nursing care.
It would appear that in countries where Islam is applied as a social system and governing
law such as Saudi Arabia, people have managed to find justifications for nursing care
provided by female nurses to male patients. The opposite (nursing care provided by male
nurses to female patients), however, continues to be a controversial issue. Many western
studies have highlighted the discrimination male nurses experience when desiring to
work in nursing specialities designated for female nurses (Egeland & Brown 1989,
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Williams 1995, Evans 2002). Discussing her argument about the sexualisation of the
male nurses‟ touch Evans (2002, p. 446) suggested that:
“Unlike women‟s touch which is considered a natural extension of
women‟s traditional caregiver role, men‟s touch is surrounded with
suspicion that implies that men nurses‟ motives for touching are not care-
oriented, but sexual in nature”
Nevertheless, findings indicated that, due to the job-security appeal of nursing, male
participants were determined to transcend through gender boundaries and overcome
challenges associated with working in a female-dominated occupation. These findings
suggest a socio-economic shift in favour of nursing; a shift that may continue to attract
more Saudi men. In her literature review of male nurses, Evans (2004) reported that
during the depression years of the 1930s the number of male nurses in USA had slightly
increased. This was attributed to advantages associated with nursing education which
included room, board and a small stipend. Similarly, several western studies reported that
male nurses have cited job security as their main reason for becoming nurses (Bush 1976,
Murray & Chambers 1990, Galbraith 1991, Boughn 2001). Furthermore, Galbraith
(1991) and Boughn (2001) have also highlighted the value of relationship and caring for
male nurses.
In a gender-segregated country like Saudi Arabia, where women are not permitted to
serve in the Armed Forces, Navy and National Guards, Saudi male nurses are particularly
needed for these sectors. These sectors provide male nurses with work tasks that are more
geared to men and their masculine role e.g. travelling to remote areas, transporting
patients across the Kingdom and providing first aid and nursing procedures exclusively to
men. Instead of establishing a military-type degree nursing programmes (BSN) that offer
applicants a military ranking and associated benefits, these other-government sectors do
not appear to be promoting nursing as an occupation that caters for the masculine traits.
Combined, degree qualification and military ranking might improve the status of nursing,
change gender-related perceptions and enhance nursing popularity among Saudi men;
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placing an emphasis on nursing as a religious duty and national responsibility may have
an extra value.
In his historical study of men in nursing, Mackintosh (1997) highlighted an equally valid
historical role for English men and women within the occupation. He argued that with
nursing facing another period of falling birth-rates and shrinking recruitment pools, its
tendency to be promoted as a single-gender occupation must be ended. Nevertheless,
Muldoon and Reilly (2003) suggested that nursing continues to be viewed as “women‟s
work” and that sub-disciplines within nursing are gender-typed impacting on students‟
career preferences.
Challenges facing professionalism
Findings from chapter five suggested that gender boundaries had an impact on nursing
education and nursing policies and regulation, both, at national and organisational levels.
Most participants made explicit reference to the public perception of nursing as low
status and less prestigious occupation compared to other healthcare and non-healthcare
fields. This is consistent with findings from previous Saudi studies (Jackson & Gary
1991, Hamdi & Hyder 1995, Al-Johari 2001). In Saudi Arabia, professions like medicine,
pharmacy, engineering and teaching are known to offer the highest financial benefits.
Apart from the gender segregated field of teaching, these professions are dominated by
men and, with the exception of interior design, most fields of engineering are not open
for women. Despite variation, these male designated professions are known for their
knowledge-based power and practice-driven authority. In patriarchal societies, this type
of man-controlled power and authority tends to automatically ensure professional status
and social prestige which entail respect, control and autonomy.
Nursing, by contrast, has always been perceived as subservient and menial work (Meleis
& Hasan 1980, El-Sanabary 1993, Al-Kandari 1998, Okasha & Ziady 2001, Marrone
1999, El-Haddad 2006). Feminists writers argued that, compared to other health
professions, the low status of nursing is explained by its gendered nature (Cheek &
Rudge 1995, p. 312). Aspiring to prestigious professions and high status jobs should
226
explain why 44 participants wanted to become medical doctors as their first choice. An
exploratory study using focus group interviews with Irish students on a general nursing
programme indicated that nursing was not the first choice for over one third of the
participants (Mooney et al. 2007). Many western studies have found that school and
college students did not perceive nursing as having the characteristics they preferred in a
career (May et al. 1991, Stevens & Walker 1993, Hemsley-Brown & Foskett 1999, Seago
et al. 2006). Regardless of the socio-economic and cultural backgrounds, participants
taking part in my study have identified similar characteristics for their preferred career
including: respect, value of the work, autonomy, scientific knowledge and pay.
Nursing education
The historical background of nursing covered in chapter one showed that, ever since the
establishment of nurse-aide programmes in the early 1960s and launching of BSN
programmes in the 1970s, nursing education in Saudi Arabia has been gender specific –
targeting women candidates. While Saudi women in their primary education were
recruited to the newly established nursing programme, men were prepared to work as
health inspectors following their primary education. In 1961, three years following the
launching of the Health Institutes, nursing was introduced to men as one of many
optional health specialities. However, enrolment to nursing remained small compared to
other specialities. In contrast, health specialities such as x-ray and physiotherapy were
introduced to women only in 1990.
Whether intended or not, the government seem to have contributed to maintaining
nursing “women-dominated” as opposed to “men-dominated” field of medicine. In a
patriarchal society such as Saudi Arabia, this has maintained a traditional norm similar to
the Victorian household model of doctor/husband/father; nurse/wife/mother; and
patient/child (Salvage 2002). A model which has, conveniently, kept power and control
of nurses (women) in the hands of doctors and managing directors (men). The scientific
biomedical model that governs nursing education in Saudi Arabia demonstrates a good
example of the control exerted by the medical profession over nursing. Brennan (2005, p.
282) suggested that the medical profession developed “a legal monopoly over the control
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of caring interventions and health policy”; consequently, nursing “became occupationally
situated at the lower end of a hierarchy of control of care”.
As discussed earlier, the shifting gender boundaries resulted in an increasing number of
Saudi male high-school students opting for nursing as an occupational choice. All male
participants cited the lack of BSN programmes as a major deterrent for the uptake of
nursing by Saudi men. It was only until 2005 that Saudi men had access to a BSN
programme at King Saud University in Riyadh the capital. This shift might have been a
government response to an increasing demand for this level of education. Interviews with
male participants suggested that launching BSN programmes across the country would
encourage more Saudi men, who aspire to degree education and career advancement, to
become nurses. This is consistent with the argument that, in countries where higher
nursing qualifications are required, more men will join nursing (Whittock et al. 2002).
However, with more qualified Saudi male nurses, female nurses may have to expect a
challenge posed by such competitive group particularly when applying for managerial,
leadership and educational positions. Under the patriarchal Saudi system, qualified male
nurses previously deprived of their “hidden” advantages might get full support from the
male-dominated managing administration (at national and organisational levels). Support
which might enable them to claim back their professional rights in the field of nursing.
Findings also revealed that a students‟ majority were interested in pursuing higher
education opportunities. This is consistent with results reported in the western literature
(Park et al. 2007, Rognstad & Aasland 2007). Associate degree and diploma students
(males and females) were particularly determined to pursue a baccalaureate degree in
nursing. They believed a degree education will improve their status and enhance their
career progression. Indeed, of the ten female staff nurses with a baccalaureate degree two
were originally diploma holders. In contrast, male nurses tend to experience difficulties
trying to pursue similar educational opportunities across the country or abroad.
Moreover, compared to their female counterparts, male nursing students in my study did
not have role models to look up to; this was expressed as a concern by all male
participants. Lack of role models coupled with limited opportunities for degree education,
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may have influenced recruitment of the desired quality and quantity of future male
nurses‟ workforce.
Rognstad and Aasland (2007) reported that the desire for higher education became less
intense among Norwegian nursing students towards the end of the programme and two
years after graduation. This may suggest that depending on nursing experience, the value
students attach to higher education might change. Furthermore, despite a consensus
agreement that nursing is becoming more scientifically based and academically focused,
many participants expressed concern about a negatively perceived shift away from
practical skills towards nursing theories. A theory-practice gap and inadequate
preparation for future qualified nurses‟ role were highlighted as areas of concern in
western literature (Landers 2000, Watkins 2000, Maslin-Prothero & Owen 2001, Maben
et al. 2007).
An interest to pursue higher education might pose the risk of having more qualified Saudi
nurses who may have a tendency to delegate bedside care to lower rank nurses and may
also carry the risk of moving away from primary nursing care. Most participants
perceived the bedside care as requiring basic skills and minimal knowledge far below
their acquired degrees. In their opinion, these nursing tasks should be carried out by nurse
aides or nurse assistants. This is consistent with the views of Iranian RNs (Nasrabadi &
Emami 2006). Speedy (2002, p. 129) argued that caring has been perceived as “unskilled
activity intrinsic to domesticity and womanhood”; a position that overlooks and
underestimates the advanced knowledge and skills involved in the therapeutic caring
interventions of nurses. Examining these care-related risks, it would appear that existing
nursing education curriculum (theoretical and practical) may have failed to achieve two
desired outcomes: enforcing the philosophy and essence of nursing among students
particularly in relation to the value of nursing care and rationale of the bedside care.
Empowering students with psycho-social skills such as communication, coping,
assertiveness and confidence building needed to counteract family and social pressure
related to the perceived domestic nature of nursing work.
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Compared to bedside care, most participants attached high value to the technical aspect of
nursing. Even in western societies, tasks such as toileting, dressing, mobilising, feeding,
bathing and bed-making have been often described as “undervalued care” and/or “basic
nursing care” expected to be carried out by junior nursing staff such as nursing students
and auxiliaries (Melia 1984, Beardshaw & Robinson 1990, Brennan 2005). The diversity
in nursing work was viewed by Davies (1995, p. 91) as a spectrum of different activities
whereby at one end nursing responsibilities shade off into the medical and technical
interventions which include wounds‟ care and monitoring of drug effects. At the other
end, these responsibilities shade off into domestic tasks. Acknowledging such diversity,
Beardshaw and Robinson (1990) argued that basic nursing care is as important to
patients‟ well-being as the technical tasks delegated by doctors. Nevertheless, Brennan
(2005) suggested that, in their pursuit of occupational status, nurses are moving away
from undervalued areas of care towards the clinically advanced nurse practice. Driven by
their aspiration for professional status or forced by an increasing workload, nurses‟
decision to delegate aspect of their work (bedside care) to junior nurses might be an issue
for an ongoing debate on professionalism.
Just like their male counterparts, a majority of the female staff nurses in my study chose
to work in Specialised Units such as Intensive Care, Oncology, Dialysis, Accidents and
Emergency. This suggests that Saudi female nurses are aspiring to high-tech specialities
that involve a great deal of decision-making and autonomy. An aspiration that might be
attributed to their desire to change the prevailing perception of nursing as a low-level
service involving simple skills and submission to the knowledgeable medical doctors. In
their pursuit of specialised areas and advanced care, Saudi nurses, just like their western
colleagues, might be migrating to areas of high status and sacrificing the core of nursing
care. From her experience in primary nursing, FitzGerald (2002) suggested that
individualised nursing care has three associated benefits: continuity of care, quality of
service and accountability for the delivery of nursing care.
Some nurse theorists have questioned if the pursuit of professionalism is worthy and
desirable (Salvage 1985, Davies 1995). In response to the “new professionalism”, Davies
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(1995) suggested that “there is too much in the model that is directly antithetical to what
nurses wish to do”.
“The question we should ask is not - is nursing a profession? But, should
we want nursing to be a profession; and if so, what do we mean by it?
What are we hoping to achieve and is this the best way go about it”
(Salvage 1985, p. 92)
Nursing policies and regulations
Participants particularly female staff nurses and senior nurses identified the long working
hours and inflexible nature of nursing work as major deterrents to working at the in-
patient units. To illustrate the impact of gender on professionalism, it is important to
understand that, in Saudi Arabia, most nursing policies and regulations were issued under
the prevailing patriarchal system governing the socio-cultural system, economy, and
organisations including healthcare facilities. They were formulated either by men
(doctors and managing directors) or by a group of non-Saudi nurse consultants (mostly
Westerns and other Arabs). Both groups were not representative of Saudi nurses and
could not meet their needs and resolve their concerns. Consequently, most work-related
policies such as working hours, flexible scheduling, full-time and part-time options were
not gender sensitive. Moreover, most regulations concerning nurses‟ financial
entitlements (salaries, compensations, housing and transportations, educational leaves,
maternity and nursing leaves) were not in the best interest of the nursing workforce
female majority.
Western feminist thinking suggests that “gender is deeply embedded in the design and
functions of organisations” (Davies 1995, p. 44). Davies argued that, even in the western
world, workplaces are not gender-neutral; on the contrary, they are socially constructed to
operate on “masculine values” to gain “legitimacy and affirmation”. This might explain
why the female participants from staff nurses and senior nurses‟ groups felt challenged
with institutional inequalities and found it difficult to function within gendered work
places such as hospitals. Indeed, women‟s decision to take up careers and get paid jobs
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exposed them to different controlling forces including societal norms, religious values,
organisational regulations and work standards. For instance, with short paid maternity
leave, seven out of the nine married female staff nurses in my study expressed their need
for on-site childcare facilities. Working mothers, employed by organisations that have no
means for childcare services, have the extra burden of worrying about their young kids.
To support Saudi married female employees, the Ministry of Labour issued a work
regulation that binds any employer who has more than 50 working women to provide a
crèche (Labour Laws, chapter 9, issued on 27/09/2005). However, the application of this
regulation has not been monitored or enforced by the concerned ministry. Investigating
factors which hinder the efficiency and practice of Saudi nurses at the MoH, Al-Husaini
(2006) listed the lack of childcare facilities. A number of American studies have
emphasised that child care facilities or the reimbursement for such service were benefits
that only a small percentage of nurses have access to (Begany 1995, Ventura 1997).
In the absence of gender-sensitive legislations to facilitate and protect their rights,
working Saudi women, including nurses, continue to struggle in order to achieve and
maintain the desired balance between their family obligations and work responsibilities.
Whether they do so by choice or driven by need and necessity, they have dared to be
ambitious and have challenged the prevailing norms, values and gender- specific role
expectations. Hence, they are expected to take full responsibility for their employment‟s
decision and bear all the consequences.
Dealing with personal struggle
Findings from chapter six indicated that, while learning to come to terms with the
prevalent negative perceptions of nursing at social and professional levels, participants
from the students, staff nurses and senior nurses have also been dealing with personal
gender-related struggle. Representing the majority (within the nursing population and my
study), the female participants‟ attempts to deal with gender-related struggle could be
understood by discussing the cultural values and social norms in Saudi Arabia with
emphasis on the social status of women. The male participants‟ struggle has been covered
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under the “shifting gendered boundaries in the workplace” and to be covered in the third
section of this chapter when discussing how social, economic and global boundaries
might influence perceptions of nursing and dealing with personal struggle.
Cultural values and social norms
Public‟s attitude towards women‟s paid employment particularly in areas where men and
women mix together has been a major deterrent influencing the uptake of nursing. Three
females, pointed out that religious scholars (all men) may disseminate formal statements
(fatwa) against nursing rendering it unappealing to the general public. Using their
interpretation and understanding of religion, these scholars may declare nursing as a
forbidden (haraam) field of work that should not be encouraged among Saudi women. To
support their argument, they refer to the highly valued traditions such as face covering
and seclusion of women. This might explain why some religiously conservative Saudis
continue to view nursing as socially unacceptable and culturally forbidden.
In these scholars‟ views, nursing would be permitted and tolerated only within strict
socio-cultural conditions. Al-Bar (1984), believes that women should work as nurses and
medical doctors only to care for women within strictly segregated work settings. If such
settings are not available, as it is the case in Saudi Arabia, then Muslim women are not
expected to provide the service. In reference to the early Muslim nurses, who were all
women, he argued that they volunteered as nurses for a religious cause during times of
war. In contrast, Al-Bahnasi (2003) argued that there is no clear-cut statement under
Islamic (Shariaah) Laws that forbids women from working outside their homes. The
Egyptian author clarified that God‟s order for women to stay home (Holy Quraan, Al-
Ahzab, Verse 33) is not a religious duty and should not be generalised to all women and
all type of work.
It has been more than twenty years since Al-Bar wrote his book and I believe that he
overlooked the rapid socio-economic changes which have been taking place since the
early 1970s. These changes have produced more educated women; delayed the age of
marriage; increased the percentage of unmarried young women; increased the cost of
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living; and increased unemployment among young Saudis. To expect educated unmarried
young women to stay home is a social and economic waste particularly at a time when
gender boundaries started to shift slightly in favour of women. In reference to his views
on women serving as nurses during national disaster or alarming emergencies, it could be
argued that nursing has developed into an evidence-based science. It is no longer a first-
aid based voluntary service that might be taken up during national disasters or war times.
Moreover, there is no record that early Muslim female nurses of the seventh century were
covering their faces or hiding their identity. There is no evidence of any objection
regarding the care they provided to wounded men in the battlefield or to male patients at
peace time. On the contrary, Imam Ahmed 17
gave permission to women to nurse men
during sickness (Sultan 1990).
Some participants used terms like “free”, “liberal” and “daring” to describe people‟s
views of the Saudi female nurses. These characteristics are not acceptable in patriarchal
societies where women are expected to be obedient wives and submissive members of the
family. From a similar perspective, AbuGharbieh and Suliman (1992) have questioned
how Jordanian women, living under a patriarchal system, could ever exercise
independent decision-making, initiate change, take responsibility for their own judgment
and develop collegial-type or teamwork-based relationships with their male colleagues
particularly medical doctors.
As an explanation to the above three terms, the participants clarified that female nurses
were perceived as strong-headed women who do not care about the social norms or the
public‟s opinion which may be critical of women working in mixed gender settings and
which tend to disapprove of night duties. It would appear that nursing as a career for
women presented a revolution to the Saudi social norms and inherited traditions.
Simultaneously, nurses were perceived as women who were trying to challenge the
patriarchal system, violate the social norms and deviate from the religiously followed
17
Imam Ahmed Ibn Hanbal is one of four Muslim scholars who established the foundation for Islamic
jurisprudence (Fiqh),
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traditions. These perceptions have contributed to a resentment for nursing by a population
living in a socially conservative and religiously strict country.
Dodd 18
(1973) suggested that much of the organisation of the Arab family can be
understood through the value of “Ird”. Ird” is an honour code; it refers to “the honour of
the family; this honour is characterised, as preoccupation, with sexual purity and chastity;
or as a cause of suspicion and jealousy between men and women” (Dodd 1973, p. 40).
Dodd had several arguments in relation to “Ird”. He argued that “Ird” does not appear in
the Quraan; hence, it is a secular value. “Ird” is usually an attribute of an individual and
of a family; however, men are the possessors of “Ird”. For instance, a husband may
regard his wife‟ reputation as a reflection of his honour. “Ird” highly depends on what
people classify as important. For instance, the norms surrounding “Ird” extend to include
actions such as loud speech and appearing in public places. Nevertheless, the penalties
for the violation of “Ird” may include death.
So it was not much of a surprise that interview accounts of over a quarter of the female
participants suggested they were experiencing family pressure. A pressure associated
with working in socially unacceptable mixed-gender settings, covering family unfriendly
hours and unfavourable night and weekend duties. Work characteristics that may have
contributed to the prevalent negative social perceptions of nursing. Similar socio-cultural
issues were highlighted by a number of Saudi studies (Mansour 1992, Hamdi & Al-Hyder
1995, Al-Rashidi 2000, Al-Johari 2001). Many female participants mentioned that their
male family members are resenting their shift work particularly when they are assigned to
male patients. Perceiving nursing work as foreign to the Saudi societies, most Saudi men
may not accept the idea of having their own female family members working in such
field. Some may express opposition and hostility; behaviours that might be viewed as
aggressive reactions to what is perceived as violations of societal norms and often reflect
a difficulty in accepting the mixed-gender work settings and long shift pattern. This
problem was frequently raised in local newspapers. A good example is illustrated in an
18
An American sociologist and anthropologist who taught at the American University of Beirut between
1960 and 1985.
235
article from a local newspaper published in English (Appendix 12) where the reporter has
claimed that some female Saudi nurses are facing strong opposition from members of the
family (Arab News, 17 th
November 2006).
Despite a perception that the caring aspect of nursing is a typically traditional role for
women, this caring role is also perceived as involving close contact, intimacy and touch.
Marrone (1999) suggested that, due to the intimate nature of some nursing care tasks,
nursing in modern Saudi Arabia is not perceived as a well-respected profession. For the
conservative Saudis (men and women), providing this type and level of care to male
patients who are not immediate family members is in conflict with the traditional female
role. Furthermore, in traditional societies, working with men who may recognise a female
by face and address her by name has been perceived as a cultural taboo. Thus, veiling and
segregation of women has been a strictly observed tradition. Many female school
students cited “not being able to use a face cover” as one of the main deterrents of
choosing nursing as an occupation (Hamdi & Al-Hyder 1995). In contrast, three female
participants indicated that their male guardians found it difficult to accept the white
nursing uniform. Compared to the black gown Saudi women use when out in public, the
white uniform was perceived by some Saudis as not complying with the traditionally
approved dress code. The tendency to view female nurses as indecent women with bad
reputation was attributed by half the participants to the nature of the nurses‟ work which
involves working in mixed-gender settings and implies wearing a uniform which does not
conform to the traditional dress code. This may explain the women-related negative
perceptions and associated struggle which all female participants had to deal with.
Gender boundaries have, for many years, restricted Saudi women‟s occupational choices
and work opportunities. Nevertheless, women were determined to transcend the
boundaries and claim back their social rights. Some female participants chose to maintain
the tradition of covering the face while keeping the eyes exposed. Not exactly
conforming to the traditionally approved dress code in terms of colour and style, these
participants designed nursing uniforms that have all the characteristics of an Islamic dress
code. This practice suggests that, despite social pressure, determined female nurses may
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pursue compromises without challenging the prevailing tradition. Exploring women‟s
power among elite Saudi families in Jeddah, Al-Torki (1977) suggested that increased
employment opportunities for educated Saudi women would most likely extend the social
and legal emancipation of women within the Saudi societies.
In contrast, participants often drew attention to Saudi female medical doctors who,
despite working in the same mixed-gender settings, are highly regarded. They further
explained that doctors are usually socially protected by virtue of their profession, titles
and qualifying degrees. This may suggest that gender mixing, on-call duties and shift
pattern do not have similar impact on the reputation of female doctors nor that of their
families. It may also suggest that the very nature of nursing work, which involves bedside
care, is what people resent and find offensive. El-Sanabary (1993, 2003) argued that
despite sharing the same working conditions, medicine has not been stigmatised like
nursing. Compared to female medical doctors, it would appear that Saudi female nurses
continue to experience family and social pressure in relation to the nature of their work
rather than to work-related perceptions.
Social status of Saudi women
All female participants referred, either directly or indirectly, to the social status of women
in a man-controlled country where women are treated as second class citizens. Indeed,
education has significantly changed the mentality and shaped the character of most Saudi
women. However, changes in social norms and traditional values controlling women‟
lives were minimal. On the basis of an interview-based study it has been argued that
attitudes towards Saudi women‟s education and work have contributed to a status
wherein women are locked into their traditional roles (Al-Suwaigh 1989). Pointing to the
social status of Saudi women, participants might have been referring to a link between
perceptions related to the low status of nursing and the second class citizenship status
accorded to Saudi women. It might appear that negative nursing perceptions are tied to
the broader gender-related perceptions; Davies (1995) argued that the ground that nursing
has developed in is gendered and it is a reflection of a broader societal devaluation of
women and the work they do. Similarly, Lavinia Dock wrote that “the status of nursing in
237
all countries and at all times depends on the status of women” (Lynaugh 1980, p, 270
cited in Fletcher 2007. p. 210).
Perceptions related to gender mixing and shift work might explain why a written
approval from the Saudi woman‟s mahram (male guardian) is often requested when
applying for a job at the other-government and private sectors. With no discrimination to
age or educational level, this practice has restricted women‟s participation in the labour
market particularly in the socially less favourable occupations such as nursing. As
protective guardians, Saudi men have the authority, social superiority and religious right
to interfere with the work of women if they feel it will threaten the family reputation
(Dodd 1973).
One of the traditional values controlling women‟s lives is concerned with a restriction on
their freedom to drive. Although it has been expressed by only three female participants,
the need for transportation service in the only country where women are not permitted to
drive should be given a special attention. In order to arrive to their work place on time,
these participants were concerned about the availability of safe and reliable
transportation. Close proximity and easy access to employing hospital was the main
reason behind the choice of residence for two other female participants. The need for
transportation was raised by Saudi female nurses involved in the study by El-Gilany and
Al-Wehady (2001). Similarly, issues of work or placement sites, travelling time and
reimbursement for travelling were also raised in western studies (Last & Fulbrook 2003).
Saudi women‟s reliance on men for transportation and the distance between their home
and workplace were cited as major obstacles for their participation in the labour market
(Al-Abdul-Qader 2003, Holian 2003, MoEP 2003). Implications on women‟s lives and
work are, therefore, typical to Saudi working women particularly the nurses who work
hectic hours and rotating shifts.
Social, economic and global boundaries
This section discusses how shifting social, economic and global boundaries may affect
and be affected by perceptions of nursing, nursing professionalism, and nursing-related
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personal struggle. Hence, illustrating their subsequent impact on the recruitment and
retention of Saudi nurses.
Perceptions of nursing
Most participants perceived the bedside nursing care as menial and subservient. This
might be linked to the domestic nature of bedside care which involves cleaning and
serving. This prevalent perception might be linked to the country‟s socio-economic
developments which accompanied the oil-boom of the 1970s. Most families from almost
all social classes were having at least one domestic maid, a family driver or a helper of
any kind. Most maids are female recruits coming mainly from the Far East. This social
luxury has contributed to the delegation of many tasks, including those concerned with
cleaning and serving, to domestic maids. With nursing involving similar domestic tasks, a
link between nurses and maids‟ work was established. The increasing number of Asian
nurses further enhanced the similarity between maids and nurses and between certain
tasks and certain nationalities (Meleis 1979, Al-Kandari & Ajao 1998).
The impact of socio-economic developments on occupational choices
Most Saudis born or brought up between 1970 and 1990 were more likely used to other
people serving them. Most of them may have attitudes such as “I am not used to being
ordered”; “Saudis do not do this humiliating type of work”; or “nursing is not for the
Saudis”. Thus, they tend to experience conflicts trying to accept and get used to
performing work-related tasks which are similar to those carried out by domestic maids.
Moreover, the perceived power relationship between medical doctors and nurses is
similar to the relationship between household masters and employed maids. This
perception tends to conflict with what many Saudis are used to or brought up to accept.
This might be why half the interviewees suggested that Saudis were more likely to view
nurses as similar to domestic maids and perceive nursing as equivalent to domestic
services. In contrast, Hamdi and Al-Hyder (1995) reported that Saudi female students
(from high school and diploma nursing programmes) have disagreed with the statement
“some people tend to view the nurse as a domestic maid”. This might be attributed to
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methodological differences. The participants in my study were provided with
opportunities to talk and express their views on selected topics. The term “domestic
maid” was used by participants to describe the public‟s perception of nursing.
A study which adopted open participant observation method by Hart (1991) showed that
the English domestic assistants involved in her study felt stigmatised by their job. They
experienced a feeling of shame attached to being publicly labelled as “cleaners” and they
preferred the term “domestic assistant” over the term “cleaner”. In a similar way, many
participants in my study hinted at feeling stigmatised when performing the domestic-type
bedside care. They were experiencing feelings of shame and humiliation associated with
performing domestic tasks such as changing patients‟ beds, providing bed bath and
handling bed-pans in hospital units where visitors, doctors and other healthcare
professionals were watching. These Saudi participants believed that such domestic duties
further enforced the low status and subservient image people hold for nursing and nurses.
The above findings suggest that comfortable lifestyles experienced by most Saudis have
made the choice of certain jobs more difficult than others.
Some participants from tribal backgrounds described the bedside nursing care as
“unclean” work. The term “unclean” refers to tasks or duties that involve cleaning the
patient‟s body and dealing with bodily functions. Nine students and staff nurses used the
term “disgust” to describe their feelings of these tasks. In a paper aimed at using the
concept of abjection to understand nurses‟ reactions of disgust and repulsion regarding
patients or clinical situations, the Canadian authors Holmes et al. (2006) suggested that
burned flesh, cadaverous, wounds, stomas, vomit, urine and faeces are part of nursing
work that threaten the clean bodies of nurses. In two UK studies involving school
students, the sample described nursing as unattractive emphasising the physical and
domestic demands of the job (Firby (1990, Hemsley-Brown & Foskett 1999).
Many participants explained that the economic advantages attached to having a secured
job, good salaries and opportunities for higher education, had minimised the negative
perceptions (women‟s career and maids‟ job) of an occupation such as nursing.
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Participants‟ views on the public perception of gender mixing and shift patterns which
characterise a career in nursing suggested a slow and gradual change from religiously
forbidden and socially unacceptable to a viable means of long-term job security.
Urbanisation, social exposure and education were frequently cited as factors contributing
to such change. These findings reflect a socio-cultural change in favour of nursing.
More than one third of the participants, mostly men, came from a tribal background.
Except for two, these participants were either second or third generation born and brought
up in the cosmopolitan city of Jeddah. In Saudi Arabia, the socio-economic development
was paralleled by a massive movement to urban areas. Urbanisation was encouraged and
facilitated by the government since late 1930 (Long 2005). By 2004, the number of urban
areas with a population of over one million has increased from five in 1992 to seven
(MoP 2005a). With social status designated according to tribe, family and wealth (Al-
Yassini 1982), reference to tribal/non-tribal affiliation was made in the presentation and
discussion of findings to provide voices from the different social subgroups and to link
certain findings with the social status and background of certain participants i.e. placing
findings in context.
In addition to tribal families who moved and settled in the main cities, Jeddah as an
example had a population of mixed-blood Saudi families (like my own family) who
descended from Asian, African or other Arab origins. The majority of the participants
who came from mixed-blood families were more likely to experience minor to moderate
resistance from their families regarding their choice of nursing. Some participants pointed
out that working in a cosmopolitan city like Jeddah, inhibited by mixed-blood families,
tended to expose Saudi nurses to less hassle particularly in relation to gender mixing.
They linked this to the more relaxed social life and less restricting traditions which
characterises a city like Jeddah. This finding suggests that ethnicity and place of
residence may have an impact on the uptake of nursing. Similarly, Hamdi and Al-Hyder
(1995) highlighted an increased interest in nursing among young Saudi women from the
coastal cities of Jeddah (western region) and Damam (eastern region) compared to
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Riyadh the capital. In contrast, Al-Johari‟s mixed sample from Jeddah viewed nursing as
low status compared to eight other occupations (Al-Johari 2001).
Of particular importance in these latter studies is the reported interest in nursing among
female high-school students from Jeddah and Damam which is growing despite their
families‟ disapproval. This conflict between two generations of Saudis reflects a social
shift in favour of nursing. A shift common in cities where the young generation has been
exposed to different cultures imported through an influx of non-Saudi labour force and
various forms of media outlets. Moreover, the young Saudi generation appears to have
more opportunities to travel outside the Kingdom either for study, business or for leisure.
Need for money
Participants‟ responses suggested that those who did not have an original interest in
nursing have decided to stay in nursing for a number of reasons. They started to become
interested in nursing and wanted to further explore the field; or they started to recognise
the job security, wide range of work and higher education opportunities promised for
nurses. This suggests that, in spite of the negative perceptions of nursing and nurses,
other factors might be influential in improving the attractiveness and increasing the
appeal of nursing among potential candidates. The most important factors raised by the
participants were the economic hardship and the escalating unemployment. The country‟s
economic difficulty started in 1991 following the first Gulf War and worsened after the
second in 2001. The political unrest in the region appears to have contributed to a decline
in oil prices reaching their lowest level. In a pessimistic prediction, Hirst (2008) argued
that “apart from a brief flurry at the end of 1996, the price of Saudi oil stabilised at $16-
18 per barrel, far lower than the $26 of the boom years”. “Defence” continues to absorb
30-33% of the country‟s entire budget and 10-16% of the national income (IISS, The
Military Balance 1999/2000 cited by Hirst). Consequently, the kingdom announced cut in
government spending by 16%; a decision that have directly affected the Saudi people
(Hirst 2008).
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The challenged economy appear to have changed people‟s perceptions and attitudes
towards the socially less acceptable, yet, highly demanded occupations such as nursing.
Such socio-economic shift in favour of nursing was demonstrated through a decision
made by male guardians, of three female participants from tribal backgrounds, to
overlook their resentment for the white nursing uniform in order to maintain the good
salary that comes from the secured jobs of their female relatives. Western and Saudi
literature has shown that nursing is generally perceived favourably in relation to job
security, job opportunity and income (Moores et al. 1983, Hamdi & Al-Hyder 1995,
Williams et al. 1997, Jensen & Aamodt 2002, Rognstad & Aasland 2007).
With reference to unemployment, most participants referred to the escalating
unemployment and acknowledged the job security guaranteed by a career in nursing. The
increasing number of young Saudis aspiring to work as doctors, engineers, academic
staff, teachers and administrators may have led to, an inevitable, high unemployment rate
among this work-age group particularly in the highly-populated main cities. Al-Omer
(2004) claimed that the competitive nature of the preferred professions (medicine,
computer science, teaching and business administration) is behind the minimal interest in
nursing among Saudi high school students. Nevertheless, participants in my study talked
about a difficulty in getting accepted at the school of medicine or the other preferred
fields of study. For them, nursing presented an alternative field of study renowned for its
wide range of jobs at prestigious hospitals and its ample opportunities for higher
education. They also referred to teaching as a career that no longer guarantees a job
within geographically desired areas. Furthermore, some participants from the students‟
group pointed out that young Saudis are no longer looking for prestigious or professional
jobs; on the contrary, what these young people want is what a male student has described
as “anything that provides job opportunities and guarantees a comfortable life”.
Pay was cited in some western studies as deterrents for choosing nursing as an occupation
among school and college students (Firby 1990, Kohler & Edwards 1990, May et al.
1991, Williams et al. 1997). This suggests that young people in western countries may
consider occupations other than nursing because they offer more pay and better status. In
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contrast, young Saudis might be choosing nursing for its secure and well-paid jobs.
Interviews with almost a third of the participants indicated that they decided or it has
been decided for them to go for nursing simply to earn a living and to support their
families. Thus, it would appear that the changing Saudi socio-economic context has been
influencing the uptake of nursing. In the sixties, Saudis of low income status took up
nursing to secure a fixed income (Meleis 1979, El-Sanabary 1993). Similarly, at the turn
of the twentieth century, young Saudis from middle class families started to choose
nursing to avoid the risk of unemployment and the associated financial hardship. Despite
its historical emergence as a humanitarian and religious occupation, nurses of the
twentieth and twenty first centuries are more likely expecting financial and moral
incentives in return for their highly demanded service. Hallam (1998) suggested that
upper middle-class concepts of femininity which defined professional nursing in terms of
a vocational commitment to care have changed. She argued that, due to low pay and poor
working conditions, nursing has been viewed as a job rather than a career.
The media
Half the participants believed that television and local newspapers had a role in
constructing and shaping the public image of nursing. They felt that people have a
tendency to link the negative fictional nursing images to real life nurses. In a country
where cinema and movie-theatres are banned as a means of public entertainment,
television, with its wide-range satellite transmission, tends to be an accessible way to
watch educational and entertainment programmes. Through internet access or the silver
screen, television represents the only window to view the world‟s news and events. Based
on people‟s previous experiences and their social and educational backgrounds, they may
to a varying degree be influenced by what they see on the television. Darbyshire (2002)
claimed that images and perceptions of nursing are important because we live in an era
where images have a marketing power.
Most participants were concerned about the media portrayals of nursing. They indicated
that what the Saudis usually see on television are fictional images of female nurses who
used to work as prostitutes or dancers then decided to go for nursing to make it up for
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what is socially and religiously believed to be wrong-doing. Like most Muslim countries,
in Saudi Arabia, prostitutes and dancers are viewed as indecent and morally suspect
women. On the television screen, people also see portraits of unskilled nurses assisting
medical doctors, following their orders and carrying out basic tasks similar to what the
domestic maids do. In contrast, media images of male nurses are not as common in the
Arab world as those of the female nurses. When it occurs, the nurse is usually a middle
aged or an old man whose work is more clerical than nursing. The literature reviewed by
Fletcher (2007) suggested that stereotypical images of nurses continue to be portrayed in
the media.
Fifty percent of the participants in my study called for proactive and promotional
strategies to be initiated by Saudi nurse leaders. These participants felt it is the nurses‟
responsibility to provide accurate and positive alternative images in order to influence the
public‟s perception. Darbyshire (2002) argued that the media in general is an easy target
to blame for any misrepresentations of nursing. Alternatively, he continues, it would be
more effective to work with the media “to create more realistic portrayals of the nursing
work” (Darbyshire 2002, p. 43). The argument that readers and viewers are not passive
recipients who absorb all type of information without filtering or critical interpretation
was also supported by Hallam (1998). In her review of nursing image in post-war Britain,
Hallam (1998, p.33) suggested that readers and viewers are “interactive agents who
partake in an interpretative process of meaning production”, rather than being “uncritical
receivers of messages who unquestioningly digest the authority of the image”. In order to
“attract creative, committed, intelligent and passionate people into nursing”, Darbyshire
(2002, p. 39) suggested that the public need to view nursing as competitive as any other
occupational option.
In Saudi Arabia, nursing-related up-to-date figures and the formulation of regulation, like
many other matters, are considered government‟s concerns; the public should not know,
worry about or get involved with. This might be the case even in western countries where
the public may not see the whole picture or get the true story despite governments‟
emphasis on transparency. Thus, it would appear that media outlets play limited role in
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providing Saudis with accurate facts and figures relating to nursing and nurses. Public‟s
ignorance on the national and international nursing shortage is an example of lack of
information. Hence, it would be unrealistic to expect the average Saudis to be “interactive
agents in a process of meaning production” and to, consequently view nursing as
competitive as the other socially and professionally recognised careers. Nevertheless,
with the gradual shift in social system over the past ten years, television programmes and
local newspapers have started to publicly discuss, analyse and criticise government
matters such as issues related to the healthcare system. To my knowledge, there is no
Arabic literature that examines how nursing and nurses are portrayed by the Arabic
media.
Challenges facing professionalism
The socio-economic prosperity and the massive wealth of the period between 1970 -1990
appear to have impacted on the Saudis at national, regional and individual levels. As an
outcome to the two Gulf Wars and associated terrorist attacks, the government realised
that the huge non-Saudi workforce may not wish to serve in a country where their safety
is at risk. Nursing, being one of the few services staffed by around 73% non-Saudi
nationals (MoH 2006), was severely affected by the departure of its nurses particularly
those from western countries. Recruiting qualified nurses to replace those who left
proved ineffective and the country had to live with fresh unskilled nurses mostly from
Asia and the Far East.
The nursing shortage
Participants from staff nurses and senior nurses‟ group acknowledged the severe nursing
shortage ever since the first Gulf War in 1991. They all agreed that Saudi Arabia needs
its own nurses who understand the culture, speak the language and are willing to serve
their country during times of crisis. This was consistent with the study by Al-Moaiqel
(1991) who examined the impact of the first Gulf War on nursing at King Faisal
Specialist Hospital and Research Centre. The situation he monitored at one major
hospital in Riyadh the capital was, in reality, more or less the same across all hospitals in
the country. Two of the male staff nurses who took part in my study, indicated that they
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joined the military nursing programme during the nursing crisis caused by the first Gulf
War. One of them described how some critical care units at a hospital where he used to
get his training were closed down because the western nurses working there decided to
leave for security reasons.
Although students in their first year of study were not aware of the international and
national shortage, many participants from the students‟ group talked about having to
work as nurses to replace the non-Saudi nurses and to reduce reliance on western non-
Muslim nurses. This might be attributed to personal conviction that serving own country
as nurses is a national duty and religious responsibility. Similarly, Hamdi and Al-Hyder
(1995) reported that female nursing students agreed that replacing the non-Saudi nurses
was one of the reasons for choosing nursing. Even the sample of school students who had
minimal interest in nursing was in favour of future replacement. Once again, the
difference is, in Hamdi and Al-Hyder‟s study “replacing the non-Saudi nurses” was an
item on the questionnaire. In my study, this response emerged as one of the religious
motives.
Examining the political, economic and social contexts within which nursing shortage in
Saudi Arabia is viewed, it would appear that the country was ready for a national plan to
overcome its dependence on international nurses. It also deemed necessary to focus on
developing Saudi human resources to take over from the non-Saudis who may decide to
leave the country for any reason. Gradually, the government, other-government and
private sectors began to direct their attention to nursing; a vital occupation which has low
proportions of Saudis within its workforce.
The institution of Saudisation to face nursing supply and demand
Acknowledging that the nursing shortage in Saudi Arabia is partly a response to
international as well as national factors, healthcare planners and policy makers were
forced to consider Saudisation. A policy which, in the case of nursing, implies replacing
non-Saudi nurses with qualified Saudis. Participants‟ responses brought to light
challenges facing Saudisation of the nursing workforce. One of these challenges is the
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variation in resources allocated for the institution and implementation of Saudisation
programmes and associated interventions. Interviews with senior nurses indicated that
any Saudisation plan is highly dependent on two factors. The annual supply of Saudi
nurses which continue to be inadequate and Saudisation programmes which seem to be
missing from most hospitals.
It has been estimated that, between the year 2000 and 2020, the Saudi population will
reach 36 million of which 40% would be less than 15-year of age. Such a shift in
demographic trends poses a serious challenge on public services such as healthcare and
education and on the country‟s economy. To meet the projected health needs and
demands, Schieber (2002) suggested that the number of nurses would need to increase
from 65,000 to 120,000. Nevertheless, despite the steady increase in the number of
students enrolling in the two major nursing programmes since mid 1990s, Saudi nurses
represent only 27% of the total nursing workforce (MoH 2006). This would most
probably keep the country highly dependent on non-Saudi nurses for another 50 years.
What current Saudisation plans appear to be focusing on is ensuring that nursing
graduates are placed in hospitals or Primary Care Centres to eventually replace the non-
Saudi nurses. In my view, the concept of Saudisation particularly in the case of an
occupation such as nursing should be approached and implemented differently. Based on
participants‟ accounts, a “new model” of Saudisation is proposed; a model that uses all
possible strategies to promote nursing as a competitive occupational choice among school
students targeting different age groups. A model that recruits informed candidates who
appreciate nursing; provides nursing students with educational and clinical experiences to
retain them within their selected programmes; and empowers graduates with
developmental opportunities to motivate them to stay within the un-Saudised in-patient
units. Saudisation of nursing workforce should also consider a partnership agreement
between the education and service segments of nursing that provide in addition to the
educational and technical support a professional recognition for nursing. Participants‟
responses indicated that the decision to continue with their nursing programme or place
of work was highly dependent on the individual experiences at either the education or
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service segments. This suggests that these segments are instrumental in the process of
recruiting and retaining Saudi nurses and, hence, have an impact on the supply of a Saudi
nursing workforce.
Education segment
Most students from the different programmes were concerned about their nursing skills
and clinical competence. Despite looking forward to graduation, they were not ready to
take responsibilities of the transitional internship role, not prepared for the work of
qualified nurses and they were worried about functioning as future staff nurses. These
findings are consistent with previous findings reported by Melia (1984), Day et al (1995),
Last and Fulbrook (2003). The students‟ lack of clinical competence was confirmed by a
feeling of lack of professional confidence endured following graduation by all staff
nurses. Similarly, in-depth interviews with newly qualified English registered nurses
suggested that, being able to perform competently was not guaranteed upon qualification;
it was an essential part of a good day. This should explain why a majority of participants
experienced “reality shock” progressing through their nursing experience. To address
students‟ concerns, planners and decision makers concerned with Saudisation need to
regularly monitor and evaluate all levels of nursing programmes. Parallel to their efforts
to recruit more nursing students, they need to work on providing enough nurse teachers,
improving training and resource centres, and expanding the facilities for clinical practice.
Of major importance is the non-Saudi nursing workforce majority spread across the
education and service sectors and having an impact on the Saudi students and nurses‟
experience. This workforce comes from across the globe with a diverse backgrounds and
varying vision on nursing professionalism. A majority from the students‟ group talked
about a lack of cooperation from non-Saudi hospital nurses. Responses obtained from the
staff nurses and senior nurses provided a possible explanation; due to the severe shortage
and increased workload, most hospital nurses may not have the time or motive to train
and teach nursing students allocated to their clinical units. In the absence of training and
financial incentives, these nurses may not have the aptitude or desire to undertake the
instructor or mentor‟s role. Consequently, students would be less likely to receive the
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training, supervision, guidance and support needed to develop their desired competence
and associated confidence. Findings by Last and Fulbrook (2003) revealed that a majority
of their sample from UK pre-registration nursing programme has agreed that not all
qualified nurses make good mentors. This view was supported by all professional groups
who worked in close association with students and who were involved in the study.
Service segment
Despite government emphasis on Saudisation of the nursing workforce, there was a
consensus among senior nurses and staff nurses that Saudisation programmes with
different career paths and individualised development plans were not instituted in most
hospitals. With reference to the new Saudisation, the model requires an infra structure of
policies and regulations to support the training and development of nurses. Interview
accounts with most participants suggested that only few hospitals have a reputation for
recruiting and retaining Saudi nursing students and graduates. This is consistent with
results by Al-Moaiqel (1991) and Al-Mahmoud (1999). Many other hospitals may have a
tendency to turn down employment applications by fresh Saudi graduates because they
lack work-related experience (Lovering 1996).
A typical trajectory for a Saudi nurse to establish her or himself in a senior position is
particularly protracted within inpatient units. It would involve two years as a supervised
nurse followed by a further five years as a staff nurse before achieving a managerial
position. These long years tend to discourage many interns and graduates from
considering nursing career paths at the in-patient units. This might explain why in-patient
units were reported in previous studies as less popular among Saudi female nurses (Alawi
& Mujahid 1982, El-Sanabary 1993, Tumulty 2001). Alternatively, newly qualified
female nurses may opt to work at the Out Patient Departments and Primary Healthcare
Centres, or, just like most female nurses in my study, may choose areas such as Dialysis
and Day Care units. These areas would, not only, relieve the Saudi female nurses from
the social and work-related pressure associated with in-patient units but, would also,
provide all the advantages of day duty and free weekends. To improve nurses‟ job
satisfaction and to enhance their retention, Saudisation policies need to address female
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nurses‟ needs which include flexible scheduling, safe transportation, paid maternity and
nursing leaves, on-site crèche or childcare facilities, and developmental opportunities.
These needs were also identified in previous Saudi studies (Alawi & Mujahid 1982, Al-
Moaiqel 1991, Al-Motairy 1998, Al-Mahmoud 1999, El-Gilany& Al-Wehady 2001, Al-
Husaini 2006).
Tumulty (2001) argued that reducing the weekly 48 working hours should maintain the
highly valued child-bearing and family-relation norms and would promote nursing as an
attractive career option for more Saudi women. An example of a family-friendly work
schedule was proposed by Al-Husaini (2006) who suggested that Saudi nurses should
have the choice of working any 6-hour duty of 4-daily shifts. Posing a challenge for
western nurses, flexible scheduling, fulltime and part-time options have been frequently
raised and discussed in the western literature (Price Waterhouse 1988, Moores et al.
1983, Shields & Ward 2001, Aiken et al. 2001, Whittock 2002, Coombs et al. 2003,
Hoffman & Scott 2003). El-Sanabary (1993) argued that Saudi nurses do not opt for part-
time work because the difference in pay is too great to warrant the sacrifice. Similarly, a
system of full-time flexible hours was more preferable to part-time among a sample of
English qualified nurses (Whittock et al. 2002). Those electing to go for the part-time
option were mostly female nurses who reported experiencing deteriorating career
profiles.
Male and female participants had equal belief that salaries and financial benefits are
influential in the recruitment and retention of nurses. They attached more value to their
position within the nursing hierarchy and the corresponding financial benefits. This might
be attributed to a perceived link between financial gains allocated to a particular
occupation and its professional status. Similarly, Marini et al. (1996) concluded that
American male and female students had equal value for extrinsic rewards and influence.
To improve retention within nursing, it would appear that Saudiasation plans, at a
national or organisational level, need to review policies concerned with salaries, financial
benefits, posts, and grades. Participants from the staff nurses and senior nurses‟ groups
were concerned about their financial entitlements and the significant variation across the
251
three sectors. To feel professionally recognised and appreciated, participants believed that
the financial benefits allocated to nurses should be competitive to those offered to doctors
and pharmacists. Due to lack or absence of financial benefits such as shift differentials,
they were also less motivated about working at the in-patient units. Perhaps what Saudi
nurses are expecting is recognition to their contribution to patients‟ care and
acknowledgment to their work at highly demanding and less appealing jobs. Examining
the morale of nurses‟ working at the NHS, Callaghan (2003) suggested that low morale
and frustration were associated with a feeling that nurses‟ salary did not reflect the job
they do. Lavoie-Tremblay et al. (2008) suggested that a balance between the level of
effort expended and reward received plays an important role in young nurses‟ intention to
quit nursing.
Interviews with participants from staff nurses‟ group reflected a frustration for the lack of
an en-house system for professional career development. Policies to enforce and support
nurses‟ right for continuing education, on-the-job training and professional development
are important elements of Saudisation. Feeling unduly stuck and trapped in the staff nurse
post for more than five years was cited as a major cause for nurses‟ intentions to quit
working. Barriball and While (1996) suggested that career decisions made by nurses are
influenced by their personal circumstances and preferences as well as the changes and
developments in the environment in which they practice.
In a country like Saudi Arabia, where the perception of professionalism is highly
dependent on educational qualifications, attainment of power and control, a formally
recognised nursing council empowered by legitimate authority was perceived necessary
to change the professional image of nursing. Tumulty (2001) urged the increasing
number of qualified Saudi nurses to establish the foundation for a Saudi Nursing Council.
Mannix and Stein (2002) suggested that achievements of professional organisations in the
UK, particularly in areas of education and policy development, played an important role
in furthering the development of nursing within the healthcare system and wider
community. However, approving the formation of a formal organisation representing a
professional pressure group made of women majority would pose a challenge particularly
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during a time of socio-economic change. In my opinion, the missing role of a nursing
union or council representing Saudi nurses had discouraged many nurses from lobbying,
forming pressure groups or involving the media to demand the institution of equitable
and family friendly nursing policies.
Dealing with personal struggle
Findings presented in chapter six indicated that barriers facing the choice of nursing as an
occupation were important issues influencing the way participants were dealing with their
nursing-related personal struggle.
An interest in nursing
One of the key findings is that two thirds of the participants did not have an original
interest in nursing citing medicine as their first choice. They ended up in nursing because
they failed to meet one of the admission criteria for the medical school. As discussed else
where, developing an interest in nursing as a respectful competitive occupational choice
appears to be linked to its gender-related perceptions. Perceptions which have contributed
to a societal classification of nursing as low status and dishonourable. They may also
explain why most participants expressed regret, worry, disappointment, embarrassment,
frustration and anger while talking about attempts to cope with the negative images of
nursing and perceived low status of nurses.
Results from Saudi studies have showed minimal interest in nursing (Jackson & Gary
1991, Mansour 1992, Hamdi & Al-Hyder 1995, Al-Omer 2004). The samples involved in
these studies rated nursing among the less preferred occupational choices. Many western
studies reported a lack of interest in nursing among school students (Kohler & Edwards
1990, Firby 1990, Murray & Chambers 1990, May et al. 1991, Mendez & Louis 1991,
Stevens & Walker 1993, Hemsley-Brown & Foskett 1999). Findings suggested a link
between the development of interest in nursing and a lack of nursing awareness. A
majority of participants from the students‟ group indicated that they did not know nursing
was one of the academic programmes at the university and those who had some
information on nursing knew only of its domestic, assisting and clerical tasks. School
students and their parents were viewed by many participants as individuals who know too
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little about nursing to help them make an informed occupational choice. Their
information is based on personal experiences with nursing and nurses when using the
healthcare system.
In Saudi Arabia, school students do not have any community-based educational
experiences 19
that expose them to the occupational choices available to them. They do not
have access to school nurses. They are not prepared or trained for any type of voluntary
work and they do not even have access to or link with the surrounding community
services such as the local health centre, hospital or welfare society. Moreover, under the
patriarchal educational system, reading books for school children tend to refer to or use
examples of doctors, engineers and pilots who represent highly-regarded male
professionals. In contrast, examples of nurses, being predominantly women, and even
stories of heroic female nurses in the early Islamic era are often excluded from the taught
curricula and most reading materials available for school students particularly the males.
This might be attributed to efforts aimed at restricting women‟s work opportunities in the
society. Making nursing a childhood dream was a strategy suggested by some
participants who believed that introducing occupations such as nursing to young children
should promote relevant awareness and establish baseline interest.
Participants‟ responses suggested that activities such as career days and site visiting, and
support services such as career counselling and voluntary work would help children
explore the invisible characteristics of the less popular occupations such as nursing.
These characteristics include: higher educational qualifications, advanced training,
technical component, critical thinking and autonomy (Foskett & Hemsley-Brown 1998).
Some western studies found a good knowledge of nursing and nurses among school
students (Rawlins et al. 1991, Stevens & Walker 1993). Others have called for the
institution of a carefully planned career guidance programme (Moores et al. 1983,
Grossman et al. 1989, Hemsley-Brown & Foskett 1999).
19
Our Community and the People Who Help Us are two subject matters that come under Personal and
Social Education covered with pre-school and primary school children in Nottingham, United Kingdom.
These children seem also to have access to reading materials on nursing and stories about nurses (as located
in Nottingham public libraries).
254
Some participants believed that a nursing campaign would most likely change the
perceived negative images of nursing and promote it as a competitive occupational choice
among school students and their families. Indeed, the Jordanian experience is a good
example of an Arab Muslim country that used community and religious leaders in a
national nursing campaign. For instance, the Jordanian television broadcasted a Friday
Prayer and its preceding speech 20
wherein the Imam was encouraging families to direct
their daughters to an honourable career in nursing (27 th
of April 2007). The Jordanian
nursing campaign was highly supported by Princess Muna Al-Hussein, a member of the
royal family, who heads the Jordanian Nursing Council. Similar campaigns have proved
successful (see appendix 13).
Humanitarian motives
It has been noted that by the second semester second year, a quarter of the participants
who had no original interest in nursing started to talk about an emerging interest
secondary to the realisation of the humanitarian and religious values associated with
nursing work. As part of a Canadian study on students‟ socialisation, Day et al. (1995)
found that some students had drifted into nursing because they did not know what else to
do but eventually they assimilated values and developed similar views as their
classmates. Many participants talked about the international nursing shortage indicating
that a career in nursing is a national duty and religious responsibility. Similarly, the
medical students and their parents in the study by Mansour (1992) and the high school
and nursing students in the study by Hamdi and Al-Hyder (1995), have all agreed that
nursing is a humanitarian service. These beliefs, however, were not strong motives to
justify the choice of a socially less favourable occupation such as nursing.
It would appear that the socio-economic contexts within which the Saudis are brought up
may have suppressed the development of their humanitarian values particularly those
associated with certain jobs and voluntary services. By and large, the education and
social systems do not appear to invest much effort on fostering the humanitarian and
20
This is an important group-type of prayer performed at mid-day every Friday. The one used as a
reference was transmitted on Friday 27/04/2007 at 10:45 am GMT from King Hussein‟s Mosque in
Amman, Jordan.
255
vocational values of services such as nursing, social and community work. On the
contrary, these systems had a leading role in emphasising the importance of social
prestige, professional power and material gains. The religious and humanitarian values
were highlighted by Davis (1975) and Day et al. (1995). Several other western studies
indicated that part of their sample chose nursing because it provides opportunities to help
people (Moores et al. 1983, Grossman et al. 1989, Murray & Chambers 1990, Stevens &
Walker 1993, Kiger 1993, Day et al. 1995, While & Blackman 1998, Hemsley-Brown &
Foskett 1999, Boughn 2001, Jensen & Aamodt 2002, Nasrabadi & Emami 2006,
Rognstad & Aasland 2007, Mooney et al. 2008).
Rationalisation of motives and attaching meanings to work were strategies employed by
most participants to help them come to terms with nursing. With reference to Saudis who
might choose nursing for its job security, it could be argued that as they have their
financial needs met, they may eventually, through a process of rationalisation, find
humanitarian, spiritual and moral meanings in this socially less appealing occupation.
The shift in the value structure within western societies was discussed by Jensen and
Aamodt (2002) and Rognstad and Aasland (2007). Future research is necessary to
examine the durability and sustainability of the new sets of values against traditional ones
within a changing Saudi context. Reviewing the changing constructions of the public
image of nursing in post-war Britain, Hallam (1998, p. 32) suggested that modernisation
of the health care system which accompanied the rapid growth in medical science had an
impact on nursing. Nursing, she continues, has changed from:
“…a vocational profession with its own system of ideals and values rooted
in service to the patient to a more secularised career intent on serving the
ideals and values of the newly constituted National Health Service”
Conclusion and recommendations
This thesis is about Saudi nurses‟ perceptions of nursing as an occupational choice. The
thesis provides qualitative data based on individuals‟ accounts of their decisions to
become nurses, continue as nurses and pursue a career in nursing. One of its main
256
strength is the participation of male nursing students, staff nurses and senior nurses. A
strength that provided opportunities to examine the gender boundaries influencing male
and female nurses‟ perceptions of nursing and their personal struggle for social and
professional recognition. The knowledge of the powerful influence of the prevailing
negative images of nursing and perceived low status of nurses on recruitment and
retention of Saudi nurses is well established. Resulting in an existing shortage of a
national nursing workforce. The contribution this thesis has made to existing knowledge
is an identification of a personal struggle female and male nurses have been experiencing
in their attempts to transcend through shifting gender, social, cultural and economic
boundaries. A struggle they had to deal with in order to cope with gender-related
perceptions and to survive challenges of professionalism.
Three explanatory themes were proposed: perceptions of nursing; challenges facing
professionalism; and dealing with personal struggle. Interviews indicated that negative
images of nursing continue to have a powerful impact on nursing occupational appeal.
These images are attributed to historical accounts on nurses such as female slaves or
orphans and educationally or economically disadvantaged women; work-related aspects
of nursing such as gender mixing and shift pattern; the domestic nature of bedside
nursing care; and negative predominantly female media portrayals of nurses.
Nevertheless, despite these gender-related perceptions, an increasing awareness of the job
security of a career in nursing has been gradually spreading among Saudis over the past
fifteen years. This shift appears to be economically driven. The rising unemployment rate
among graduates of favoured academic specialities not demanded by the labour market
and the associated economic hardship encouraged an increasing number of young Saudis
to choose occupations previously classified as socially unacceptable such as nursing.
Future research is required to examine the shift in value system which guides
occupational choices within a changing Saudi context.
The participants acknowledged the pressing need for nursing to achieve professional
status. They were aware that nursing is becoming more scientifically based and academic
oriented. Nevertheless, gender inequality has been a major finding. Saudi male students
257
interested in a degree type nursing education did not have such opportunity until 2005
when a BSN programme was launched at King Saud University in Riyadh. Gender-
related perceptions appear to have been influencing the key characteristics of
professionalism. By maintaining nursing as predominantly women‟s occupation with
very few qualified male nurses, power and control over nursing education and practice
has been a legitimate right for different groups of male-dominated decision makers such
medical doctors and managing directors. As such, nursing national regulations and
organisational policies remained gender insensitive for the female-majority workforce.
The Saudisation national plan as implemented across all service sectors appear to have
failed in Saudising the nursing workforce. A new model of Saudisation has been
proposed in this thesis wherein concerned planners and policy makers are requested to
divert their strategies from focusing only on graduates from the nursing programmes to
targeting Saudi school children. They are expected to design and implement Saudisation
strategies that aim at changing the prevailing gender-related perceptions of nursing as an
occupation among male and female prospect candidates and potential nurses (tackling the
very root of the problem). For such goal to materialise, decision makers from a number of
ministries need to collectively work on different challenging levels starting from inducing
a change on the education system, moving on to creating an impact on the social values,
and ending with modifying labour laws and nursing policies. Unconventional approaches
such as involving influential media outlets, gaining the support of public figures and
community leaders, using pressure groups and launching independent legal organisation,
should be employed for this purpose. Whether this goal is feasible, realistic or achievable
highly depends on the degree of commitment toward Saudisation of the nursing
workforce and the budget allocated for such national interventions.
Moreover, the above goal could be achieved through a national promotional long-term
campaign funded by the government and private sectors. Drawing on participants‟
accounts, this campaign should aim at increasing the public‟s awareness regarding the
contribution of nursing within the healthcare system and the valuable roles undertaken by
contemporary nurses in the provision of healthcare. It should highlight the achievement
258
of Saudi nurse leaders; emphasise the recognised role of early Muslim nurses and the
seriousness of the international as well as national nursing shortage; and involve,
religious figures and members of the royal family. The campaign should also clarify that
the concept of care as illustrated in the holy Quraan and in the prophet‟s sayings 21
is the
responsibility of men and women equally. Media outlets in the form of television, radio,
popular newspapers and the internet to be invited to take part in all interventions. Similar
campaign proved successful in some Arab and western countries.
Participants‟ accounts reflected a struggle experienced by the individual participant as
she/he was attempting “to come to terms with being a nurse” or “holding on to a belief in
nursing”. Interviews suggested that dealing with personal struggle is highly dependent on
participants‟ position in relation to wanting to become a nurse; barriers facing the choice
of nursing; disapproval from family; challenges experienced while nursing is achieving
professional status; perceived spiritual and moral rewards of working as a nurse; and the
need for secure job. Planners and decision makers concerned with recruitment and
retention are, therefore, expected to place the shortage of Saudi nurses beyond the
healthcare context and view it more as a cultural, social and economic challenge. They
are expected to listen to nurses‟ voices, investigate sources of concern and address factors
contributing to nurses‟ struggle for social and professional recognition. Overlooking
causes of struggle would indeed risk Saudi nurses‟ recruitment into and retention within
nursing. Saudi male nurses, in particular, need serious attention if the country is planning
to have a male workforce to care for the male patients and to serve the country in strictly-
segregated services such as the army, national guard and navy. Future nursing research
involving male nurses is of prime importance for future workforce planning.
21
Refer to verse 23 Al-Israa in the holy Quraan and the famous saying by Prophet Mohammed describing
the compassionate and sympathising believers as forming one body if one part falls sick the rest of the body
will stay up to care (narrated by Al-Bukhary & Muslim)
259
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Appendix 1 - 1
Royal Embassy of Saudi Arabia
Cultural Bureau
London
Student Number S 526
Researcher /Lamya Asaad Gazzaz Respected
Peace be upon you and the mercy of God and his blessings
The office of the Saudi Cultural Bureau in the United Kingdom would like to inform you of
receiving a letter from the Vice Minister for Cultural Relations/Ministry of Higher Education
number (18705) dated Thursday 21 July 2005 which includes the approval of His Excellency the
Minster of Higher Education for you to conduct your PhD field research and data collection in
the Kingdom.
We do hope that you will get in touch with our office to arrange your travel plans. We also hope
that you, upon your return from the Kingdom, supply us with a detailed report from the
organization concerned with your research indicating that you have completed your fieldwork.
The report should also include dates of commencing and completing such work. A copy of your
passport is necessary so we can issue the allowance for the scientific field trip.
Best Regards…
The Cultural Attaché in the United Kingdom
Abdulla Bin Muhamed AlNasser
Appendix 1 - 2
Acknowledgement
Student Reference Number S 526
The office of the Saudi Cultural bureau in the United Kingdom acknowledges that the
student/ Lamya Asaad Gazzaz is on scholarship by the ministry of Higher Education
starting from 21/09/2003 to attain the Doctoral degree in Nursing at the University of
Nottingham in the United Kingdom.
This Acknowledgement was granted according to her wishes to be submitted to
whoever is concerned to facilitate the needed work in conducting her field research
and data collection including personal interviews and any other information to fulfil
the requirement of the Doctoral Degree.
May God grant you His blessings
The Cultural Attaché in the United Kingdom
Abdulla Bin Muhamed AlNasser
Appendix 1 - 3
Appendix 1 - 4
The Dean’s Office
Dear researcher /Lamya Asaad Gazzaz God protect her
Peace be upon you
In Reference to your letter directed to her Excellency the Vice Dean of the Faculty of
Applied Medical Sciences with regard to your intention to conduct interviews with
students and faculty members of the nursing college to gather data needed for a
research to fulfil the requirements of Doctoral Degree from the University of
Nottingham in the United Kingdom.
You are herby informed that there is no objection whatsoever to conduct your
interviews and gather any needed data to complete your research. Wishing you all
success.
Please do accept our utmost respect and appreciation
Dean of the Faculty of Applied Medical Sciences
Dr. Gazzi Damenhori
Appendix 1 – 5
The Dean’s Office
Her Excellency the Dean of the Female Division God protect her
I inform you that the student / Lamya Asaad Gazzaz is on a scholarship by the
Ministry of Higher Education to attain Doctoral degree in Nursing at the University of
Nottingham in the United Kingdom. She has submitted a request to her Excellency
the Vice Dean of the Faculty of Applied Medical Sciences to conduct a research titled
(Nursing as a career choice in the Kingdom of Saudi Arabia- strategies to recruit new
nursing students and to retain the graduates) and the Nursing College has approved
her request.
The college administration has no objection whatsoever that the student / Lamya
Assad Gazzaz conduct her study and gather any needed data which involve
interviewing students and faculty members of the nursing college. Wishing her all
success.
Since such research is valuable and the outcome may contribute to the future of
Nursing in Saudi Arabia, we herby hope that you extend all possible help to her.
Please do accept our utmost respect and appreciation
Dean of the Faculty of Applied Medical Sciences
Dr. Gazzi Damenhori
Appendix 1 - 6
Appendix 1 - 7
Appendix 1 - 8
In the Name of God All Merciful
The Kingdom of Saudi Arabia
Ministry of Health
Researcher /Lamya Asaad Gazzaz Respected
Peace be upon you and the mercy of God and his blessings
In reference to your letter by fax dated 14/11/2005 regarding your request to conduct
interviews, as part of your PhD research, with the faculty members and students at the
College of Allied Health Science in Jeddah (women and men sections), we inform
you that you can coordinate with the two colleges directly regarding this project
taking in consideration the requirements we have mentioned earlier in our letter
number T/35/2134 to his Excellency the General Director of Students’ Scholarship at
the Ministry of Higher Education.
Best Regards and Wishes.
General Supervisor
The Directorate of Health and Scientific colleges and institutions
Dr. Khalid Al-Roshoud
Appendix 1 - 9
Her Excellency the Dean of DHC God protect her
Peace be upon you and the mercy of God and his blessings
In reference to your letter number (S K D H/05/11/197) dated (21/11/2005) regarding
the permission to academic researcher/ Lamya Asaad Gazzaz whose on a scholarship
by you on account of the Ministry of Higher Education to attain Doctoral degree in
Nursing.
We hereby inform your Excellency that we have no objection for her to visit the
University Hospital to conduct her study and gather data through interviews with
members of the nursing department.
Please do accept our utmost respect and appreciation
The Vice Dean of the Medical School/
General Manager of the University Hospital
Dr. Adnan Al Mazrou
Appendix 1 - 10
Her Excellency the Director of Nursing Services Respected
Peace be upon you and the mercy of God and his blessings
A request was submitted to us by the research student/Lamya Asaad Gazzaz to
conduct a study which involve interviewing male and female nurses and accessing
their views on the image and status of nursing as an occupational choice in Saudi
Arabia. This research is a requirement to obtain her Doctoral Degree.
We hereby have no objection whatsoever for her to carry out this study and hope that
your Excellency will arrange a meeting with the researcher to coordinate a working
mechanism and informing us of the outcome.
Best regards.
Director of Training
Dr. Muhammad Zahran
Appendix 1 - 11
Appendix 1 - 12
1
Appendix 2
Participants’ Information Sheet
Dear Colleagues/nurses/students,
You are being invited to take part in a research study that will be conducted by Lamya A.
Gazzaz – a lecturer at Dar Al-Hekma College and a PhD student at the University of
Nottingham, UK. Before you decide to take part it is important for you to understand
why the research is being carried out and what it will involve. Please take time to read
the following information carefully and share it with family members. Feel free to call
me if you or your family would like more information. If you decide to take part you may
keep this leaflet and return the attached Consent Form.
The proposed research will be carried out to fulfil the requirement of a PhD in nursing. It
aims at exploring links between recruitment and retention factors and the main
characteristics contributing to the promotion of nursing as a recognised profession in
Saudi Arabia. Research results will be part of the researcher's PhD thesis. Findings may
also be reported to decision/policy makers involved in the future planning of nursing
workforce.
The plan is to follow semi-structured informal interviews to allow you to talk and express
yourself. Before the interview, you will be requested to sign the consent form. Each
interview will not exceed 60 minutes and will be tape-recorded and anonymised "names
removed". Recorded data will be transcribed "typed", translated to English and selected
quotes will be used to support the presentation of findings.
You will be interviewed once but a second interview might be needed for clarification
and confirmation of data. Your name and personal details will not be recorded during the
interview and will be removed from all typed hard copies. Only the researcher and her
supervisors should have access to the tapes and the typed data.
You are a valuable member of the nursing population; hence, your participation and input
are highly appreciated. You are free to change your mind or withdraw your participation
at any time and without giving a reason.
Finally, I would like to express my appreciation to you for taking the time to read through
this Information Sheet and for agreeing to participate in the study. For future contact and
further information, please call,
Investigators Name: Lamya Asaad Gazzaz
Telephone number: 0505567252
E-mail Address: [email protected]
Appendix 3 - 1
Interview Guide
Group 3 (Nursing Students)
General Questions:
1) To begin with, tell me your nursing story? How did you start and where are you now?
2) How does your mother/father/husband/wife feel about nursing? *How do they feel about you working as a nurse? *
3) What do you think of nursing as a career option for Saudi high school graduates (boys and girls)?
4) Where do you see nursing in comparison to the other medical and health careers? In your opinion, how do people view nursing
compared to the other medical and health careers?
5) From what you see or hear around you, what are the prevailing nursing images?
6) In your opinion, what could be done to change such image of nursing?
7) From your experience, what do you think of the Saudi male nurses?
8) In your opinion, what might attract the Saudis to nursing? (students and college staff) What might contribute to keeping Saudi nurses in
nursing? (hospital staff)
Group Specific Questions:
9) At this level of your study, what do you think of nursing and how do you feel about being a nurse?
10) From your own experience, what might help you to continue your studies and encourage you to pursue a career in nursing?
11) What do you think of the nursing curriculum both theoretical and practical?
12) Tell me about your practical experience at the hospitals? What are the main pluses and minuses? (all students except 1
st year)
13) Tell me about your experience with the internship year? What are the main pluses and minuses? (internship students)
14) Compared to Saudisation programmes in the other sectors, what do you think of the Saudisation process in nursing? (internship students)
15) How do you see your future? What are your plans after graduation?
Appendix 3 - 2
Interview Guide
Group 2 (Staff Nurses)
General Questions:
1) To begin with, tell me your nursing story? How did you start and where are you now?
2) How does your mother/father/husband/wife feel about nursing? *How do they feel about you working as a nurse? *
3) What do you think of nursing as a career option for Saudi high school graduates (boys and girls)?
4) Where do you see nursing in comparison to the other medical and health careers? In your opinion, how do people view nursing
compared to the other medical and health careers?
5) From what you see or hear around you, what are the prevailing nursing images?
6) In your opinion, what could be done to change such image of nursing?
7) From your experience, what do you think of the Saudi male nurses?
8) In your opinion, what might attract the Saudis to nursing? (students and college staff) What might contribute to keeping Saudi nurses in
nursing? (hospital staff)
Group Specific Questions:
9) Compared to 5 years ago, how do you see the uptake of nursing as a career in recent years?
10) Compared to Saudisation programmes in the other sectors, what do you think of the Saudisation process in nursing?
11) Looking at your personal experience, what kept you working in the
inpatient units?
12) Why do you continue working at this particular hospital?
13) What do you think of the nursing interns in terms of their nursing knowledge, skills and capabilities?
14) Nurses may work in the inpatients units, the outpatients, primary care,
health education, academic or in-service education and administration,
in your opinion, which of these fields are most preferred by Saudi
nurses and why?
15) Finally, how do you see yourself now compared to 5 years ago?
Appendix 3 – 3
Interview Guide
Group 1 (senior nurses)
General Questions:
1) To begin with, tell me your nursing story? How did you start and where are you now?
2) How does your mother/father/husband/wife feel about nursing? *How do they feel about you working as a nurse? *
3) What do you think of nursing as a career option for Saudi high school graduates (boys and girls)?
4) Where do you see nursing in comparison to the other medical and health careers? In your opinion, how do people view nursing
compared to the other medical and health careers?
5) From what you see or hear around you, what are the prevailing nursing images?
6) In your opinion, what could be done to change such image of nursing?
7) From your experience, what do you think of the Saudi male nurses?
8) In your opinion, what might attract the Saudis to nursing? (students and college staff) What might contribute to keeping Saudi nurses in
nursing? (hospital staff)
Group Specific Questions:
9) From your experience, how do you see recent enrolment to nursing programmes compared to 5-10 years ago? (College Staff)
10) What do you think of the nursing curriculum both theoretical and practical? (College Staff)
11) What do you think of the nursing interns in terms of their nursing knowledge, skills and capabilities?
12) Compared to Saudisation programmes in the other sectors, what do you think of the Saudisation process in nursing?
13) Nurses may work in the inpatients units, the outpatients, primary care, health education, academic or in-service education and
administration; in your opinion, which of these fields are most
preferred by Saudi nurses and why?
(Managers/Directors)
14) Any news about the latest developments on the establishment of the SaudiNursing Association? (Managers/Directors)
15) Finally, how do you see yourself now compared to 10 years ago?
Appendix 4
Participants' Consent Form
Please read this form and sign it once the investigator has explained fully the aims and
procedures of the study to you,
I voluntarily agree to take part in this study.
I confirm that I have been given a full explanation by the investigator and that I have read and understood the attached information sheet given to me.
I have been given the opportunity to ask questions and discuss all aspects of the study with the investigator and have understood the information given as a result.
I understand that I can ask for further information or explanations at any time.
I authorise the investigator to disclose the results of my participation in the study but not my name.
I understand that recorded information during the interview will be kept in a secure database. If data is transferred to others it will be made anonymous.
I understand that I am free to withdraw from the study at any time, without having to give a reason for withdrawing.
Name: ………………………………………………………………………………………..
Address: ………………………………………………………………………………. ….…
Telephone number: ………………………………………………………………………….
Signature: ………………………………………… Date: ………………………………..
I confirm that I have fully explained the purpose of the study and have given the above
named a copy of this form together with the information sheet.
Investigators Signature: …………………………… Name: Lamya Asaad Gazzaz
Study Interview Number ………………………………………..
Appendix 5
Socio-Demographic Checklist
1) Age group:
a) 17 – 20 years d) 29 - 32 b) 21 -24 e) more than 33 c) 25 – 28
2) Gender:
a) Male b) Female
3) Marital status:
a) single c) divorced b) married d) widow
4) Nursing educational qualification:
a) Associate c) master b) Baccalaureate d) PhD
5) Professional status:
a) student nurse d) faculty b) clinical nurse e) programme director c) nurse manager f) others……………..
6) Sector:
a) Government b) Semi-government c) Private
7) Years of study or experience:
a) 1 st or 2
nd year d) 3-5 years
b) 3 rd
or 4 th
year e) 6-8 years
c) Internship f) ≥ 9 years
8) Family members:
a ) ≤ 2 c) 6-8
b) 3-5 d) ≥ 9
9) Working family members:
a) Father d) Wife b) Mother f) Others………. c) Husband
10) Type of work:
d) government e) semi-government f) private
11) Average family income:
g) ≤ 4000 d) 11,000-13,000 h) 5000-7000 e)14,000-16,000 i) 8000-10,000 f) ≥ 17,000
12) Family members or relatives working as nurses:
a) yes b) no
13) Tribal Affiliation
a) yes b) no
1
Appendix 6
Interview Transcript
Interview 3 Group 3 Private 23/11/2005 2:00 – 2:35
Place: Designated Office at DAHC
Q1) To begin with, tell me your nursing story? How did you start and where are you now?
A) When I first graduated from school, I was thinking where to go - may be medicine. Nursing
was not in my mind. Then I heard about DAH college, thought may be I should go & see what
majors they are offering. I went one day with mom, we meet Dr. S. she was amazing, she took us
in a tour around the college & told me about the nursing programme. It sounded really good, I
was interested. Because I graduated from English school, I did not want to go to KAA University
because of the Arabic. Now, here I am in my 3 rd
year.
Since 2 nd
year we started going to the hospital & we started practicing, I really liked the
hospital’s environment, the 1 st thing that drew my attention. Nursing role is crucial in my
opinion, it was nice because we are Saudi & we can understand the patients; they can relate to us
better than the foreigners. I believe working as nurses is just like any other profession; some
people think that nursing is not a professional kind of job but I found other wise.
Q2) How does your mother/father/brothers/sisters feel about nursing and about you as a nurse?
A) They encouraged me all the way, were very enthusiastic, they had no problems with nursing
cause my grandmother was a nurse; you must have heard of her - Mrs. LK. (Her maternal
grandmother was a nurse leader in the late 60s who studied nursing in Cairo and worked hard to
improve the image of nursing and encourage it among Saudi women).
In my family we have a lot of medicals, my brother in medicine, my sister in dentistry, so I
thought I go to nursing to have a variety. My brother told me N is crucial & that he learned from
nurses in the hospitals.
Q3) At this level of your study, what do you think of nursing and how do you feel about being a
nurse?
A) I feel like after I entered N I become more organised with better time management, am more
inquisitive about things &I have learned a lot. The thing I like about N is that it teaches you
about everything; it is holistic, it looks at everything, it engages in every aspect of life.
In my opinion, if you are going to work you will work regardless of your major (area of study or
specialisation). It is just the long hours; that is one draw back. Other than that, I find the job just
2
like any other job. Why not go for N! What is the difference between the nurse & the Dr.! Why
there is stigma on nurses & Drs are fine!
Q4) From what you see or hear around you, what are the prevailing nursing images?
A) People are interested in knowing more about what N is all about; very interested. Some may
not be too happy about the whole idea of N because they do not know what N is all about. To
them N is bed linen and bed pans, that is it; so why enter such major!
Q5) In your opinion, what could be done to change such image?
A) The media would be a good way, if we have educational programmes about nurses & what
they do in the hospital. Programmes like Yala Shabab, a lot of students, school kids & teenagers
love this programme; it is quite influential. If they (school students) could go to hospitals &
interview nurses; that will draw people’s attention. We have to work together in order to have
this done. Many people ask: you are a nurse, so what do you do? Just change bed linen! We
could send nurses to schools to talk to students and to encourage them to enter N.
There should be more awareness especially in schools, we have students coming out they do not
know where to go! They need guidance, some one to tell them why enter N. Things like: you will
find a job afterward and there is a good pay. Try to motivate them in all possible ways. Tell them
with N you do not have to work in hospitals; you can work in schools, in research field, in
administration. Tell them how broad is N.
Q6) What do you think of nursing as a career option for Saudi high school graduates (boys &
girls)?
A) There are plenty of jobs available in the N field; it covers for the increasing numbers of Saudi
nurses. So high school students will graduate & most likely would find jobs. Where as with most
other majors; they may not find jobs. Teachers, we have plenty of teachers.
Q7) From your experience, what do you think of the Saudi male nurses?
Personally I would encourage school students to enter N, all (men and women). It is easier to
relate to a male patient if there is a male nurse; we absolutely need male nurses to take care of
male patients. There is a space for male & female nurses.
Q8) In your opinion, how do people view nursing compared to the other medical and health
careers?
A) When I first entered N, many people asked why! Why not medicine! You will become a Dr.
You will be recognised more. Some see that N is less than Medicine; it is not it is a separate
entity, you are independent of the Dr. You are helping Drs but it does not mean you below Drs in
ranking.
Q9) Where do you see nursing in comparison to the other medical and health careers?
3
A) Now it is less than before, previously 10 yrs ago it was worse. Now a day there is increased
awareness in the society about N. The stigma is not that bad. But I think people prefer to enter
other majors.
I conducted interviews with few fellow nurses; most of them said it is the 12 hrs work shifts that
they did not approve off. 12 hrs is quite long; the Saudi female nurses I talked with they wanted
to stay home when they are married. They are suggesting 8-hrs shift; that would increase the
number of people entering N, just like any other profession.
Q10) In your opinion, what might attract the Saudis (boys & girls) to nursing?
A) Basically the same points, I really like the idea of having them go & see what the nurse does
in the hospital cause then they get the whole picture of N & get the feel of what N is all about.
Organise trip to hospitals, small groups divided in the units; observe what the nurse does;
basically be in the nurse’s shoes, watch what the nurse does & get an idea about the whole
hospital.
(17:30 min in response to a follow up, she mentioned that her school which represent one of
the English and International schools did not have career counselling or academic advice to
guide students while making future plans)
Q11) From your own experience, what might help you to continue your studies and encourage
you to pursue a career in nursing?
A) I am facing one problem: I am trying to cope with the college & the hospital work at the same
time. When we go to the hospital we start early around 7:00 am & we stay till around 4:00 pm.
After that you have to come back & study for other courses. We have exams, it is difficult to
coordinate.
I need patience & encouragement from my family which I am getting. You do not get to spend a
lot of time with the family, so I need them to understand I am busy.
I need guidance and motivation from the faculty & plenty of practice; they have to be patient
because first time we would not get it right.
Q12) Tell me about your practical experience at the hospitals? What are the main pluses and
minuses?
A) It depends; sometimes we have patients who do not want students to do procedures on them
but most of the times we get it done. We are getting there, I have not done all the procedures but
we are practicing doing them (at the nursing lab). We arrange to go extra times, weekends:
Thursday mornings, (by doing so) we get to do more procedures. I am also thinking of volunteer
work during the holidays to cover other skills. I find it helpful; you practice your skills which
gives you confidence.
4
Negatives: we are working with nurses who know their job so sometimes they get inpatient. It is
difficult to do procedures; our instructor tell them please include the students but they do not do
that. They go in & go out & they finish the procedure. So how are we supposed to learn if we
cannot do the procedures! Positives, hospital environment is comfortable; quite prestigious. We
have a lot of supplies that we could use; user friendly and very organised. Paperless; everything
is on the computer, all type of procedures are documented, it is easy to work there. I went to
another government hospital, every thing is hand written, more papers, not organised and they do
not have supplies.
Q13) What do you think of the nursing curriculum both theoretical and practical?
A) There are few things I think should change, I feel there is repetition in terms of courses.
Biology & chemistry were repetition of what I took in school. Nutrition I feel is a repetition of
what I took in biology. They are teaching biology & chemistry as a general subjects; students
from all majors attend these courses. I think for N students they should have a different biology
course Nursing subjects are good, anatomy & physiology perhaps should be a bit more.
Pharmacology I think instead of taking it in one term we should have it in 2 terms cause it needs
longer time. The practical part is perfect, the advantage of being at DAH, we have small classes,
we do not have more than 20 students in each class, basically we get to do all procedures (at the
nursing lab) & we have the instructor with us. Duration of the programme is good; I think we
should have less of the general subjects cause they take the whole of 1 st year, perhaps condense 2
in 1 & make them shorter, the extra time we could give to our major subjects.
Q14) How do you see your future? What are your plans after graduation?
A) Bright hopefully, I am looking forward to graduation so I could go & pursue other studies I
want to do. I want to work for at least a year or two; gaining skills & reaching confidence.
I was thinking of broadening my horizon, after N I want to go for a course on physiotherapy &
add it to N; just to broaden my horizon. Right from the beginning, I wanted to enter
physiotherapy. So it is something I wanted to do. I thought I could go back & do a bit &
implement it into my N I think it will help.
1
Appendix 7
Case Summary
Int.7 G 1
Age
33 +
Gender
Female
Marital Status
Married
Educational Qualification
Master
Years of Experience
9 +
Years of Study
Not Applicable
Sector
Government
Family Members
3 - 5
Working Family Member
Husband
Sector for WFM
Other Government
Family Income
17,000 +
Role Model
No
Tribal Affiliation
Yes
2
Q1) Was interested in First Aid since I was young, My eldest sister heard about the
nursing college & took me for exploratory visit, I liked it, Never waned to be medical
doctor. Had my master & worked with WHO/UNICEF/ICN.
Q2) My family encouraged me. My grandfather was sick & needed nursing care, used to
be embarrassed when I help him with bed-pan,
Q3) Nursing is giving. It was not scientifically based as it is nowadays. The focus now is
on theory not practice & ethics. I do not feel commitment & loyalty among new
graduates; absenteeism is high. Majority of nurses view work as money, From MOH
points of view any job taken by a non-Saudi is a vacant job, so young people are joining
nursing for its available jobs & good salary (men & women). The problem is N is not
prestigious & it is hard work.
Q4) At the MOH the proportion of Saudi nurses is high. Male nurses are responsible;
they like administrative work (it is a prestige). They like ER & Critical Care (They feel
important, creative & responsible for main decisions). They do not like inpatients. The
other problem: Saudi men have no higher education opportunities which limit their
promotion. MOH is now sending more men for external scholarships (2000 have applied
for the Bridging programme).
Q5) People view N as domestic service; they get shocked to know nurses have master &
PhD. Patients appreciate N when they need the service. N background has influenced its
image. N images through media influenced people’s perceptions. N Salary was low; N
resources were limited; No Nursing Society. The image is changing; things are
improving. Nurses have a leading role - they are contributing to the perceived image.
Q6) The recent MOH era is considered the Golden Era for Nursing. Since 3-4 yrs N is
represented at MOH level & at international level - major changes. The scholarship
committee is sending nurses for internal & external grants. MOH is placing emphasis on
N Int. day. N is struggling to become visible (out of sight is out of mind). We need more
emphasis on N research & EBP,
Q8) To attract people to N we need: positive images & role models to identify with.
Introduce N to school children & take them for hospitals’ visits. Media & internet have
roles to play. Create more educational opportunities; improve College facilities &
resources. Provide more moral & financial incentives; create/establish career paths for
promotion along the career ladder,
To retain nurses within inpatient units: improve financial incentives & make it
competitive with others; cut down the non-nursing work to reduce burden & stress; the 48
hrs scheme is not holy it could be modified; promote continuing education & training for
specialisation; introduce Evidence Based Practice research; work on classification system
based on educational qualifications & job specifications.
3
Q12) Saudisation means replacing qualified non-Saudis with Saudis who received the
needed training to fulfil the job requirement. This is not happening now. N in SA is trying
to prove its existence among the other health professions & within the community. S
nurses are tying to prove themselves and prove they have not made the wrong choice.
We have a national N shortage, so hospitals are using less nurses for longer hrs. Nurses
should not complain they should make their voices heard & come up with alternatives.
MOH could reduce working hrs & pay less would that make nurses happy/satisfied!
(sounded frustrated talking from her senior position at the MOH).
N education is divided between MOH & MOHE. We need both BSN & Diploma
graduates. The focus should be on clinical training. Most MOH nurses are diploma
holders, so they need Bridging Programme. Directives from the WHO demand having
BSN nurses by 2015!
Q13) The new graduates are looking for comfortable work so they go for OPD & PHC.
Female nurses experience pressure from husbands and sometimes from other members of
the family.
Q14) It is good to have Saudi Nursing Society & Scientific Nursing Board but there
should not be any conflict of interest. Disseminate information.
(Was emotional and did not feel like talking about challenges and conflicts experienced
while establishing SNS & SNB).
Q15) I witnessed major developments under the MOH. N progressed from committee to
division to general directory reporting to the Deputy Minister & the N offices now come
under the Director for Health Affairs in all 19 regions. I am more rational thanks to age &
experience. I achieved a lot & built my fame & name.
1
Appendix 8
Questions within the interview guides
Concepts from the
literature that guided the
development of
questions
To begin with, tell me your nursing story?
How did you start and where are you now?
How does your mother/father/ husband/ wife
feel about nursing and about you working as
a nurse?
What do you think of nursing as a career
option for Saudi high school graduates?
Where do you see nursing in comparison to
the other medical and health careers? In your
opinion, how do people view nursing
compared to the other medical and health
careers?
From what you see or hear around you, what
are the prevailing nursing images?
In your opinion, what could be done to
change such image of nursing?
From your experience, what do you think of
the Saudi male nurses?
In your opinion, what might attract the Saudis
to nursing?
What might contribute to keeping Saudi
nurses in nursing?
Nursing as an
occupational choice
Nursing support
systems (role of family)
Nursing as an
occupational choice
Status of nursing
Images of nursing
Gendered-nature of
nursing (Saudi male
nurses)
Nursing support
systems (strategies to
attract students and to
retain graduates)
2
What do you think of the nursing curriculum
both theoretical and practical?
Compared to Saudisation programmes in the
other sectors, what do you think of the
Saudisation process in nursing?
From your own experience, what might help
you to continue your studies and encourage
you to pursue a career in nursing?
Tell me about your practical experience at the
hospitals?
Tell me about your experience with the
internship year?
What do you think of the nursing interns in
terms of their nursing knowledge, skills and
capabilities?
Looking at your personal experience, what
kept you working in the inpatient units?
Why do you continue working at this
particular hospital?
Nurses may work in the inpatients units, the
outpatients, primary care, health education,
academic or in-service education and
administration, in your opinion, which of
these fields are most preferred by Saudi
nurses and why?
Any news about the latest developments on
the establishment of the Saudi Nursing
Association?
At this level of your study, what do you think
of nursing and how do you feel about being a
nurse?
How do you see your future and what are
your plans after graduation?
How do you see yourself now compared to
5/10 years ago?
Nursing education
Nursing support
systems (Saudisation)
Nursing support
systems
(education-related
support system)
Nursing support
systems
(work-related support
system)
Nursing as an
occupational choice
(personal perception of
nursing)
1
Appendix 9
Grouping of Inductive Codes
(Awareness):
1. There is an increased awareness about nursing. 2. Family are rejecting nursing as an occupational choice for their children. 3. People know about nursing at the outpatient departments (vital signs and paper
work).
4. People have to appreciate nursing (it is a hard demanding work not appreciated by people).
5. People do not know about the nursing programmes and colleges. 6. People ask and want to know about nursing. 7. Volunteering at a hospital would help to see what nursing is all about. 8. Schools do not have any programmes for career counselling and occupational
awareness
9. Colleges and universities do not have regular well planned career days, site visiting or field trips for school children.
(Preference for academic programmes):
10. People prefer other majors and/or Families direct their children to business. 11. Saudis have classification for jobs and careers (Position, income, social class,
prestige and the title are highly valued occupational characteristics).
12. Families want to guarantee better life for their children.
(Family support):
13. Students need to be convinced in order to pursue nursing. 14. Nurses need to be strongly convinced in order to face social pressure and
criticism.
15. Nursing is a hectic job (rotating 12-hrs work shifts). 16. I had enough support from my family 17. My (mother, sister, brother, grandmother, uncle, aunt) is a nurse 18. My family were against nursing and continue to resent nursing. 19. My family started to accept nursing. 20. My parents do not know am in nursing. 21. My family do not know what nursing is all about.
(Women’s issues):
22. Nursing is something for girls not a masculine job. 23. Nursing is suitable for females. 24. It is not preferred for Saudi women to work as nurses.
2
25. Female nurses can work with male and female patients (female nurses on high demand).
26. Female nurses have bad reputation. 27. Female students have better resources than male students 28. Most Saudi female nurses prefer in-patient units and primary care centres. 29. Some Saudi female nurses opt to work in areas like Day Care and Dialysis to take
the advantage of office working hours.
30. Shift pattern, long hours and assignment to male patients causes family conflicts. 31. Saudi female nurses are forced to change areas of work at the request of their
husbands.
(Men’s issues):
32. Male school students do not know anything about nursing. 33. Male high school students do not usually know what they want to do for their
future.
34. The nurse image conflicts with the male figure. 35. Parents direct children when making occupational choices. 36. Men would choose nursing only when other possibilities are not workable. 37. People make fun of Saudi male nurses (critical). 38. Saudi male nurses feel embarrassed providing bedside care. 39. Saudi male nurses prefer administrative posts where they can dress in Thobes. 40. Saudi male nurses prefer speciality areas where they can avoid the white uniform. 41. Saudi male nurses do not have role models to look up to. 42. Saudi male nurses are less committed to their work. 43. Saudi male nurses have a dead end career wise. 44. Saudi male nurses have limited opportunities for higher education. 45. Saudi male nurses feel embarrassed about their diploma degree. 46. Saudi male nurses are not permitted to work with female patients or children
accompanied by their mothers.
47. Saudi male nurses are needed to work with male patients. 48. Patients and doctors call male nurses sisters.
(Social acceptability of jobs):
49. Families prefer medicine/engineering for their children particularly boys and teaching for girls (believe they are the best).
50. Medical doctors/pharmacist/engineers/teachers are highly respected. 51. Nursing is placed at the end when compared to other healthcare and non-
healthcare professions.
52. The salary and financial entitlement are not competitive to other jobs. 53. Nursing is low status and menial type of work (a source of shame, humiliation
and dishonour).
54. My family reject gender-mixing and shift work. 55. My husband does not want me to work at the in-patients units (12 hr shift). 56. Tribal families were against any mixed work particularly for women.
3
57. Nursing is perceived by the religious and conservative groups as haraam (forbidden).
(Need for money):
58. Nursing would secure a well paid job (other specialities do not). 59. Plenty of teachers and no jobs. 60. The young Saudis fear the risk of unemployment. 61. High school students/new nursing students/ fresh graduates are interested in the
job security provided by nursing.
(The media has a major role):
62. The media always attack nurses. 63. The media plays a major role in image building and career promotion. 64. Television and newspaper influenced the prevailing negative images of nursing
and nurses.
(Interest):
65. I never thought of nursing or considered it as a future career (nursing was not in my mind).
66. I always wanted to be a medical doctor/dentist/pharmacist/physiotherapist/etc. 67. I have a desire to help and work with people. 68. I feel embarrassed/proud to say am in nursing.
(Nursing images):
69. Early Muslim Nurses were highly respected and valued. 70. Prophet Mohammed approved the work of early Muslim nurses (Nursing during
early Islamic era).
71. Nursing is similar to domestic work and the nurse is similar to the maid. 72. Nurses obey orders and serve doctors and other professionals. 73. Relatives and visitors deal with nurses as maids serving the patients. 74. The Saudi role models (senior female nurses) are expected to be proactive in
relation to image building and promotion of nursing.
75. Nursing is not represented by a society, union, council or any formal body. 76. Nursing is humane and noble service providing moral and spiritual rewards. 77. Authorities need to improve image and upgrade status of nursing through a
national campaign.
(Bedside care):
78. Bedside care does not need education or training. 79. Bedside care is menial, low level and similar to domestic maids’ work.
4
80. Bedside care should be carried out by nurse-aides. 81. Asian nurses are similar to Asian maids.
(Education)
82. Participants have negative perceptions of the early nurse-aide programme (1962).
83. Participants have negative perceptions of the graduates from the early schools/institutes of nursing (12-year education).
84. Technical versus degree education. 85. Diploma nurses have more skills – BSN nurses have more knowledge. 86. Theory-practice gap.
(Education-related issues):
87. First year students are channelled to nursing based on their scores. 88. First year student tend to use the first year as a bridge to preferred field of
study.
89. Students become shocked when they start to know the tasks involved in nursing
(bedside care) and when they start their internship period.
90. Students tend to finish their years of study without feeling competent or confident about their nursing skills and judgment.
91. First/second year students feel lost, forgotten, confused, etc. 92. Students’ socialisation within nursing is a major concern. 93. Hospital nurses (non-Saudi) do not cooperate with students. 94. Clinical instructors are not around enough to supervise, guide and train
students.
95. Education sector has shortage of academic staff (Saudi and non-Saudi). 96. Nursing labs and training facilities vary across colleges. 97. There are very limited scholarships to study nursing at the private sector. 98. Students need continuous support from faculty member. 99. Students find it difficult to cope with academic work and the family/social
pressure.
(Hospital-related issues):
100. Hospitals are classified according to sector, resources, opportunities and professional climate.
101. Management and nursing administration are not supportive (lack of appreciation and recognition).
102. Medical doctors (Saudis) do not show respect to Saudi nurses (believe non-Saudi nurses are more skilled and highly qualified).
103. Hospitals do not have policies for flexible scheduling and part-time options.
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104. Hospitals do not have gender sensitive policies e.g. maternity and nursing leaves; crèches or childcare facilities; transportation service.
(Work-related issues):
105. The prayers and appreciation from patients helped in accepting nursing work.
106. Our patients need Saudi nurses who understand and respect their language and cultural values.
107. More Saudi nurses are needed to cover the needs and combat the shortage. 108. The shortage is causing work overload and pressure. 109. The pressure at work is reflected at home and vice versa. 110. Saudi nurses feel stuck and look for alternatives if they stay in a staff
nurse post for more than 3-5 years.
111. It is better to have separate units for male and female patients (it will encourage more Saudi nurses).
(Saudisation):
112. There is no Saudisation in nursing, what is taking place is replacement. 113. Hospitals do not run structured in-service education or on-job training
(government).
114. Hospitals do not support scholarships for higher education (other- government).
115. Hospitals do not have nursing career paths and individualised development plans for the Saudi nurses (government and other-
government)/
1
Appendix 10 - 1
Data Analysis (Coding to Themes)
The table below illustrate the coding process and thematic analysis. Synthesis themes were extracted from the coded text under the
question-generated codes and were then re-arranged into broader themes, e.g. barriers to choosing nursing as an occupation and
gender-related struggle, summarising and making sense of the main ideas proposed by the synthesis themes. Finally, an
explanatory theme was needed to encompass the underlying argument presented by a group of organising themes and to explain the
research findings e.g. dealing with personal struggle
Question-generated Codes
Inductive Codes
Synthesis Themes
Nursing as an occupational choice
“Now a day there is increased awareness in the
society about nursing, the stigma is not that bad; but,
I think people prefer (their children) to enter other
majors” (Int.3 G3 p. 2)
“In our society, all they know about nursing is what
happens in the outpatient; nurses just take vital signs
and they just do paper work. That is not nursing; but
unfortunately, this is what people see. The problem
is not girls or boys; their families are rejecting the
idea (the choice of nursing as a career). Families
would say it is better for boys to be doctors not
nurses; for them it (nursing) is a secondary thing”
(Int.9 G3 p. 2)
“Many people do ask me, I get them all the papers to
know more about the programme, I tell them about
There is an increased awareness about nursing (the
stigma is not that bad).
Families are rejecting nursing as an occupational
choice for their children.
People know about nursing at the outpatient
departments (vital signs and paper work).
People have to appreciate nursing.
People do not know about the nursing
programmes and colleges.
People ask and want to know about nursing.
Volunteering at a hospital would help to see what
nursing is all about.
People prefer other majors.
Families direct their children to business.
Nursing awareness
Nursing as an
2
the college if they are interested. Most of the times I
advise them to volunteer at a hospital, see what the
profession is really all about, what you do, the
rewards you get out of it. I do not really know, it will
take time; now the society is more flexible” (Int.14
G3 p. 2 & 3)
“If it was not taken seriously, it won’t be a good
choice. You have to be strongly convinced to face
the social pressure and criticism. If you are not
strong, you won’t perform well in your study.
Families think they want the best for their children in
their views medicine and engineering are the best.
Due to position and income which guarantee a stable
financial life. Also the social class, prestige and the
title. Families do that out of protection; they
(families) want to guarantee better life for their kids”
(Int.17 G2 p. 2& 3)
“Here in SA, boys do not even know anything about
nursing. When I meet people & say there is nursing
for men, they wonder where & how (there is only
one programme in Riyadh). Nursing is something for
girls not a masculine job” (Int.9 G3 p. 2)
“With reference to men; rarely, you would find
someone who chooses to be a nurse unless other
possibilities are not workable for him. I know
mothers do not like their kids to be nurses; they
(mothers) always feel boys should be engineers or
teachers; the nurse image conflicts with the male
figure” (Int.3 G1 p. 3 & 4)
Position, income, social class, prestige and the
title are highly valued occupational characteristics.
Families want to guarantee better life for their
children.
Students need to be convinced in order to pursue
nursing.
Nurses need to be strongly convinced in order to
face social pressure and criticism.
Nursing is a hectic job (rotating 12-hrs work
shifts).
Nursing is something for girls not a masculine job.
Nursing is suitable for females.
The nurse image conflicts with the male figure.
Male school students do not know anything about
nursing.
Male high school students do not usually know
what they want to do for their future.
Parents direct children when making occupational
choices.
Men would choose nursing only when other
possibilities are not workable.
“Mothers do not like their kids to be nurses; they
always feel boys should be engineers or teachers”
(Deviant)
alternative field
of study
Family support
Issues faced by
women
Issues faced by
men
Appendix 10 - 2
An Example of the Coding and Data Analysis Process
Nursing as an occupational choice
(Question-generated code)
Nursing is something for girls, not a masculine job
(Inductive code)
The nurse image conflicts with the male
figure
(Inductive code)
Male school students do not know anything
about nursing (Inductive code)
Issues faced by women/men
(Synthesis theme)
Gender-related struggle
(Organising theme)
Dealing with personal struggle
(Explanatory theme)
Thematic analysis
Coding process
Appendix 11
Appendix 11
Appendix 12
Appendix 13 - 1
Campaigns
"Medal of Honour"
National Recruitment Campaign
The First National Nursing Campaign
The Second National Nursing Campaign
Appendix 13 - 2
Appendix 13 - 3
Appendix 13 - 4
About NSCSF
Nursing Careers/Opportunities
Nursing News
Become a Volunteer
Make a Donation
NSCSF Activities
Nursing in South Florida
Contact Us
The Nursing Shortage Consortium South Florida organizes and sponsors a number of activities and programs throughout the year all with one goal in mind—to increase the supply of registered nurses to meet the healthcare needs of South Florida.
Programs include “A Day in the Life of the Nurse Program,” Future Nurses Clubs, a Speaker’s Bureau, as well as seminars, presentation to community groups and schools, career fairs, and fundraising events.
Calendar of Activities
April 30, 2003 A Day in the Life of a Nurse Program For more information, contact us.
- 01 Title Page
- 02 Ded & Ack
- 03 Abstract
- 04 Table of Content
- 05 List of Abbs &Apps
- 06 Overview
- 07 Chapter 1
- 08 Chapter 2
- 09 Chapter 3
- 10 Chapter 4
- 11 Chapter 5
- 12 Chapter 6
- 13 Chapter 7
- 14 References
- Appen 01-1 A
- Appen 01-2 A
- Appen 01-3
- Appen 01-4 A
- Appen 01-5 A
- Appen 01-6
- Appen 01-7
- Appen 01-8 A
- Appen 01-9 A
- Appen 01-10 A
- Appen 01-11
- Appen 01-12
- Appen 02
- Appen 03-1
- Appen 03-2
- Appen 03-3
- Appen 04
- Appen 05
- Appen 06
- Appen 07
- Appen 08
- Appen 09
- Appen 10-1
- Appen 10-2
- Appen 11
- Appen 12
- Appen 13-1
- Appen 13-2
- Appen 13-3
- Appen 13-4
