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The Implications of Nursing Degree Education for Future

Workforce Planning in Saudi Arabia: A Case Study

Noura Abdulla Almadani

A thesis submitted in partial fulfilment of the requirements for the degree of

Doctor of Philosophy

University of Salford

School of Nursing, Midwifery, Social Work & Social Sciences

January 2017

Table of Contents

Table of Contents ...................................................................................................................... i

List of Tables ........................................................................................................................... vi

List of Figures ........................................................................................................................ vii

List of Appendices ................................................................................................................ viii

List of Abbreviations .............................................................................................................. ix

List of Terminology ................................................................................................................. x

Dedication ................................................................................................................................ xi

Acknowledgements ................................................................................................................ xii

Abstract ................................................................................................................................. xiii

Introduction ............................................................................................................................. 1

Significance of this Research ......................................................................................... 2

Statement of the Research Problem ............................................................................... 3

Research Aim and Objectives ........................................................................................ 4

Research Question .......................................................................................................... 4

Structure of the Thesis.................................................................................................... 5

Chapter 1 The Healthcare System in Saudi Arabia ......................................................... 7

1.1 Introduction ............................................................................................................. 7

1.2 Demographic, Socio-economic and Cultural Context of Saudi Arabia .................. 7

1.3 The Health System in Saudi Arabia ...................................................................... 10

1.3.1 Ministry of Health/ Public Health Care System ............................................ 11

1.3.2 Other Governmental Sectors ......................................................................... 15

1.3.3 Private Sector ................................................................................................. 17

1.3.4 The governmental bodies responsible for the legislation of a national policy

for health service and education ................................................................................... 18

1.4 Summary and Conclusion ..................................................................................... 21

Chapter 2 Nursing in Saudi Arabia ................................................................................. 23

2.1 Introduction ........................................................................................................... 23

2.2 History of Nursing in Islam .................................................................................. 23

2.3 Nursing Education in Contemporary Times ......................................................... 25

2.4 An Overview of Policy Perspectives .................................................................... 31

2.5 Summary and Conclusion ..................................................................................... 35

Chapter 3 Literature Review ............................................................................................ 37

3.1 Introduction ........................................................................................................... 37

3.2 Section One: An Overview of Global and Local Trends in the Nursing Workforce

3.2.1 Global trends in nursing workforce ............................................................... 38

3.2.2 Saudi Nursing Workforce .............................................................................. 40

3.3 Section Two: A Comprehensive Systematic Review .......................................... 47

3.3.1 Search strategy ............................................................................................... 47

3.3.2 Electronic database search ............................................................................. 47

3.3.3 Inclusion and exclusion criteria ..................................................................... 48

3.3.4 Searching strategy result ................................................................................ 49

3.3.5 Critical appraisal process ............................................................................... 50

3.3.6 Key Themes in the Literature ........................................................................ 63

3.3.7 Effectual impact upon patient care through degree education & experience 66

3.4 Summary and Conclusion ..................................................................................... 74

Chapter 4 Methodology .................................................................................................... 76

4.1 Introduction ........................................................................................................... 76

4.2 Philosophical Rationale ........................................................................................ 76

4.3 Methodological Approach .................................................................................... 78

4.3.1 Research Design ............................................................................................ 81

4.4 Case Study Methodology ...................................................................................... 83

4.5 Macro, Meso, and Micro Theory/Framework ...................................................... 87

4.6 Methods ................................................................................................................ 90

4.6.1 Sampling Criteria ........................................................................................... 91

4.6.2 Study Location ............................................................................................... 93

4.7 Data Synthesis ....................................................................................................... 93

4.8 Trustworthiness of the Study ................................................................................ 95

4.8.1 Truth-value/Credibility .................................................................................. 96

4.8.2 Applicability/Transferability ......................................................................... 99

4.8.3 Consistency/Dependability .......................................................................... 100

4.8.4 Neutrality/Confirmability ............................................................................ 101

4.9 Ethical Considerations ........................................................................................ 102

iii

4.10 Summary and Conclusion ................................................................................... 104

Chapter 5 Data Collection Phases .................................................................................... 106

5.1 Introduction ......................................................................................................... 106

5.2 Macro Level (Phase one): Documentary Analysis ............................................. 107

5.2.1 Sampling ...................................................................................................... 107

5.2.2 Data Collection Procedure ........................................................................... 108

5.2.3 Data Analysis ............................................................................................... 110

5.3 Macro Level (Phase Two): Face-to-Face Interview ........................................... 112

5.3.1 Sample and Recruitment .............................................................................. 112

5.3.2 Procedure of Data Collection ...................................................................... 113

5.3.3 Data Analysis ............................................................................................... 114

5.4 Meso Level (Phase Three): Focus group ........................................................... 118

5.4.1 Sampling and Recruitment .......................................................................... 118

5.4.2 Data Collection Procedure ........................................................................... 119

5.4.3 Data Analysis ............................................................................................... 121

5.5 Micro Level (Phase Four): Focus Groups ........................................................... 121

5.5.1 Sampling and Recruitment .......................................................................... 122

5.5.2 Data Collection Procedure ........................................................................... 123

5.5.3 Data Analysis ............................................................................................... 124

5.6 Reflexivity .......................................................................................................... 126

5.7 Summary and Conclusion ................................................................................... 129

Chapter 6 Documentary analysis: Results and Discussion .......................................... 130

6.1 Introduction ......................................................................................................... 130

6.2 Rationale for Change .......................................................................................... 131

6.2.1 Recognition of the challenge ....................................................................... 131

6.2.2 Changing patterns of health and disease ..................................................... 132

6.3 Nursing as an Agent for Change ......................................................................... 137

6.3.1 The Value of Professional Nurses ............................................................... 138

6.3.2 Enhanced Leadership Skills......................................................................... 140

6.3.3 Fragmentation in GCC Nursing Strategy .................................................... 142

6.4 Making the Changes ........................................................................................... 145

6.4.1 Process of the GCC Nursing Technical Committee .................................... 146

6.4.2 The intended outcomes of degree education ............................................... 149

6.5 Discussion and Critique of Documentary Analysis ............................................ 151

6.6 Summary and Conclusion ................................................................................... 165

Chapter 7 Participant Perception and Experiences: Findings and Discussion ......... 167

7.1 Introduction ......................................................................................................... 167

7.2 Macro level ......................................................................................................... 168

7.2.1 ‘A Good Decision’ ...................................................................................... 169

7.2.2 Bridging programmes, ‘I don’t see any obstacle…’.................................... 174

7.2.3 ‘Education and experience are important in giving quality care’ ................ 179

7.2.4 Conclusions from Macro-level data analysis............................................... 181

7.3 Meso level ........................................................................................................... 182

7.3.1 Nursing should be BSN ............................................................................... 183

7.3.2 Quality of care and educational levels ......................................................... 187

7.3.3 Both [experience and education are important] ........................................... 192

7.3.4 Conclusions of meso level analysis ............................................................. 193

7.4 Micro frame (phase four) .................................................................................... 194

7.4.1 Pathways to Nursing .................................................................................... 196

7.4.2 General agreement towards Bachelor’s degree ........................................... 197

7.4.3 ‘We do not have any difference between the BSN and the Diploma holders’

200

7.4.4 ‘The curriculum in the private colleges is very different from the government’

202

7.4.5 Images of Nursing ....................................................................................... 206

7.4.6 Escape from Professional Responsibility .................................................... 209

7.4.7 Education versus Experience ....................................................................... 212

7.4.8 Conclusions from the micro level analysis .................................................. 214

7.5 Synthesis of Findings across Micro, Meso, and Macro Data Sources ................ 215

7.6 Discussion of macro, meso and micro levels ...................................................... 217

7.6.1 The degree and its role in healthcare quality ............................................... 217

7.6.1 Career and healthcare development ............................................................. 222

7.6.2 Nursing education and bridging programmes ............................................. 224

7.6.3 Workforce organisation and mobilisation ................................................... 227

7.7 Summary and Conclusion ................................................................................... 229

Chapter 8 Conclusion and Recommendations .............................................................. 231

8.1 Introduction ......................................................................................................... 231

8.2 Strengths and Limitations of the Study ............................................................... 231

8.3 The research contribution ................................................................................... 232

8.4 Recommendations ............................................................................................... 234

8.5 Dissemination Plan ............................................................................................. 237

8.6 Personal Reflection on the research process ....................................................... 239

8.7 Summary and Conclusion ................................................................................... 240

References ............................................................................................................................ 242

List of Appendices ........................................................................................................ 242

List of Tables

Table

Numbers

Table Names

Page

Numbers

Table 1.1 Budget Approximate for the MoH 10

Table 1.2 Total healthcare provider workforces in the MoH 13

Table 3.1 Steps for Search Strategy 48

Table 3.2 Inclusion and exclusion criteria 48

Table 3.3 Summary of studies included in part 2 51

Table 3.4 Key themes identified from literature 63

Table 4.1 Advantages and Disadvantages of Qualitative Methods 80

Table 4.2 Relevant Situations for Different Research Methods 81

Table 4.3 Type of evidence 84

Table 4.4 The inclusion and exclusion criteria for each level of sampling. 92

Table 4.5 Four strategies to establishing credibility, transferability,

dependability and confirmability

Table 4.6 Audit trail 101

Table 5.1 The summary of the GCC documents 108

Table 5.2 Macro-level: (Descion-Maker) 115

Table 5.3 The skills of moderator (researcher) and assistant moderator

(note taker) in focus groups.

119

Table 5.4 Meso-level: (Regional Nursing Directors) 121

Table 5.5 Micro-level: Group one (Nurse managers and nurse educators) 125

Table 5.6 Micro-level: Group two (staff nurses with Bachelor degrees) 125

Table 5.7 Micro-level: Group three (staff nurses with Diploma) 125

Table 6.1 Nursing education pathways in the GCC countries 144

Table 6.2 Action plan for nursing strategy 147

vii

List of Figures

Figures

Numbers

Figures Names

Page

Numbers

Figure 1.1 The Kingdom of Saudi Arabia 7

Figure 1.2 Saudi healthcare system 11

Figure 1.3 Levels of healthcare in the Ministry of Health 12

Figure 1.4 The key government bodies 18

Figure 3.1 Search strategy steps 50

Figure 4.1 Macro, Meso and Micro levels of Analysis 88

Figure 4.2 Data collection elements. 90

Figure 4.3 Phases of Content Analysis 94

Figure 5.1 The progression of thesis levels 106

Figure 5.2 Documents searching strategy 109

Figure 5.3 Example 1 of analysis process 116

Figure 5.4 Example 2 of analysis process 117

Figure 6.1 The three thematic categories from the documentary analysis 131

Figure 6.2 The first category in documentary analysis 131

Figure 6.3 The second category in documentary analysis 138

Figure 6.4 The third category in documentary analysis 146

Figure 7.1 The themes and sub-themes for the macro level 169

Figure 7.2 The first theme in the macro level analysis 169

Figure 7.3 The second theme in Macro level analysis 175

Figure 7.4 The three themes and sub-themes within analysis of meso level data 182

Figure 7.5 The first themes in Meso level analysis 183

Figure 7.6 The second theme in Meso level analysis 187

Figure 7.7 The overall themes and sub-themes within analysis of micro level 195

Figure 7.8 Third theme in micro level 200

Figure 7.9 Fourth theme in micro level 202

Figure 7.10 Fifth theme in micro level 206

Figure 7-11 Sixth theme in the micro level 210

viii

List of Appendices

Appendix

Numbers

Appendix Names

Appendix 4.1 The process of obtaining permission to access the facilities of the MoH.

Appendix 4.2 The ethical approval from the University of Salford.

Appendix 4.3 The ethical approval from the Ministry of Health and its hospitals.

Appendix 5.1 Participant’s Information Sheet (PIS): For macro level of administration

Appendix 5.2 Research Participant Consent Form for macro level of administration in the

MoH.

Appendix 5.3 The template page for transcript data.

Appendix 5.4 Example of categorisation of the data by Nvivo at the micro level

Appendix 5.5 Sample of transcript for one-to-one interview and focus group.

Appendix 5.6 Participant’s information sheet: For (Meso level) Nursing Regional Director.

Appendix 5.7 Research Participant Consent Form for the (Meso level) Nursing Regional

Director.

Appendix 5.8 Structure and guidelines for focus group interviews.

Appendix 5.9 Qualitative interview questions guide.

Appendix 5.10 Appendix 5.9: Interview questions guidelines.

Appendix 5.11 Participant’s information sheet (PIS) For nurses from King Saud Medical City

(Micro level).

Appendix 5.12 Research Participant Consent Form for the nurses from King Saud Medical

City (Micro level).

Appendix 5.13 Poster for invitation for staff nurses at KSMC

Appendix 5.14 Sample of Reflexive Journal

List of Abbreviations

MoH Ministry of Health

GDP Gross Domestic Product

MoHE Ministry Of Higher Education

PHC Primary Health Centre

ICN International Council of Nurses

WHO World Health Organisation

GCC Gulf Cooperation Council

UK United Kingdom

USA United States of America

KSA Kingdom of Saudi Arabia

KFSH&RC King Faisal Specialised Hospital and Research Centre

SCHS The Saudi Commission for Health Specialties

SA Saudi Arabia

e.g. For example

BSN Bachelor of Science in Nursing

KSMC King Saud Medical City

NVivo A qualitative data analysis (QDA) computer software package produced by QSR

International

UoS University of Salford

NHS National Health Service

PIS Participant Information sheet

AACN American Association of Colleges of Nursing

NCLEX National Council Licensure Examination

TOEFL Test Of English as a Foreign Language

IELTS International English Language Testing System

List of Terminology

Nurse Workforce

planning

The balancing of nursing workforce demand and supply against

recruitment and retention.

Policy Decisions and plans, usually developed by government/organisational

policymakers, for determining present and future objectives of the health

care system

Competence “the application of knowledge and the interpersonal, decision-making

and psychomotor skills expected for the nurse’s practice role, within the

context of public health, welfare and safety” (Model Practice Act and

Rules, NCSBN. 1996: P.12).

Bachelor’s Degree Baccalaureate degree education generally comprises five years of study in

SA. On completion of the programme, the graduate receives a

Baccalaureate of Science Degree in Nursing (BSN).

Degree education an academic degree for entry into the nursing profession

Diploma Diploma education, in general, takes three years to complete in Saudi

Arabia. It is hospital based and exists outside typical Higher Education

Institutions.

The Saudization

Plan

The plan that aims to reduce the dependency on foreign (non-Saudi)

labour in order to create more jobs for Saudi nationals (Alhosis et al.,

2012).

Registered Nurse A nurse who has graduated from an accredited nursing programme and

met the requirements outlined by a country’s licensing body in order to

obtain nursing license.

Magnet hospitals Hospitals identified by their reputations for being good places for nurses

to work- evolved from observations that hospitals that were successful in

attracting and retaining qualified nurses resembled the most highly ranked

U.S. corporations (Aiken et al., 2014).

Dedication

By the grace and mercy of Allah

This dissertation is dedicated to my loving family: to my mother for her kind words

and wisdom, for always knowing the right thing to say and for guiding me through

my life.

It is dedicated to my loving husband, Saud Albalawi, for his endless support in

times of stress and for always believing in me. For his patience and understanding

throughout my research, this work is dedicated to my young princes, Nawaf, Bader,

Musaad, Omar and Salman, and my beautiful princess, Layan. They are the power

source of my joy and happiness, without their smile, courage, and support I

wouldn’t have overcome challenges and stress of my PhD journey.

Most importantly, this work is dedicated to the memory of the departed soul of my

father “Abdulla” who valued education and whose pride in my work has always

inspired me to achieve.

I would also like to dedicate this study to my sisters, my brother and all those in my

extended family for contributing their time and energy in the completion of this

study and I would like to take this opportunity to thank my friends for their courage

and support to continue in this work.

Finally, I dedicate this research to every nurse in the world; this thesis is very close

to my heart, as are the participants and the nursing profession as a whole. I would

like to dedicate this work to all of the nurses because I value, appreciate and

admire the work that they do every day.

xii

Acknowledgements

First, I would like to extend my deepest gratitude to my god, Allah, for guiding me

through my studies and for giving me the strength, the patience and the ability to

complete this work.

The completion of this research would not have been possible without the

assistance of a number of key people.

I would like first to acknowledge my extraordinary supervision team, Dr. Karen

Staniland and Dr. Nancy Smith for their continuous encouragement and thoughtful

suggestions; not only have they offered invaluable advice during the writing of this

thesis, they have also been a constant source of encouragement in difficult times. In

addition, special thanks to Dr. Sue McAndrew for her knowledge, guidance,

valuable comments, support and suggestion during my PhD journey.

It is my pleasure to extend my gratitude to the Ministry of Health for their kindness

and willingness to provide me with an environment in which to complete my

research for allowing me access to important data. Special thanks go to all the

participants from the MoH, Regional Nursing Directorates, and KSMC in Saudi

Arabia for their cooperation in the research.

Finally, I would like to acknowledge all of my friends and colleagues who have

been there beside me for these last years, assisting in my success, each in their

individual way.

xiii

Abstract

Health system reconfiguration in Saudi Arabia as a response to changing demographics

and related health needs is an important and timely driver for the development of nurse

education, specifically, the introduction of degree education as a basic requirement for

nursing practice. The Saudi government is trying to meet international standards by

implementing a change to nurse education by making it an all degree profession. However,

as a result, there are many challenges that still need addressing. Utilising a qualitative case

study approach, documentary analysis was undertaken and semi-structured interviews

were conducted with twenty-five key stakeholders in order to critically assess the actual

implications of a nursing degree as the baseline criteria for and to enter nursing practice.

The formal and informal documentary analysis indicated that there was a clear lack of

involvement from nurses in the consultation process prior to implementing the degree

education policy. However, the interviews conducted with nursing staff (at a macro, meso

and micro level) indicated general agreement that a Bachelor degree in nursing would

further support the knowledge and communication requirements for improving the quality

of nursing practice.

Factors affecting degree attainment included a personal commitment/passion for self-

improvement, private versus government institutions, the quality of programmes of

education and financial issues. Data indicated the increased knowledge base gained

through degree education, supported a growth in confidence, decreased absenteeism,

enhanced nursing skills and responsibilities, and gave opportunity for advancement. More

importantly, such benefits increased the quality of nursing practice and patient safety

outcomes.

Recommendations based on the findings of this study, highlight the importance of a

process of consultation between governmental bodies and relevant nursing staff, who are

affected by future policy changes. The need for a national curriculum, and a differentiation

of nursing job descriptions, based on the education level attained, together with improved

clinical supervision for nurses in practice.

Introduction

I have twenty years’ experience in a variety of nursing roles including clinical and

administrative positions within the Ministry of Health (MoH) in Saudi Arabia (SA). I

qualified from a Diploma nursing programme as a Registered General Nurse in 1994. In

2000, I achieved a Bachelor’s degree in nursing and worked in clinical and managerial

positions. In 2003, I joined a newly established General Directorate of Nursing at the

central level of the MoH as Head of Training and Nursing Programmes. In 2009, I

obtained my Master’s Degree in nursing education from Marymount University, United

States of America (USA) and became actively involved in the development of nursing

departments in twenty regions of SA, to promote nursing as a profession. I have been

involved in a five-year strategic plan of nursing, promoting it as a competitive and

professional choice. In 2011, I became Director of Training and Nursing programmes. This

role focuses on the assessment of the educational needs for nursing across twenty regions

in SA. In 2012, I joined the Nursing Technical Committee of the Gulf Cooperation Council

(GCC), a political and economic alliance of six Middle Eastern countries. Working in a

national leadership position in nursing helped me to select a topic that has presented a

challenge within my current role. My role as a researcher and the influence that I may have

exerted upon this study is discussed throughout this thesis (Section 5.2; 5.3; 5.5; 8.6).

The rapid transition and expansion of health services in SA and the current enrolment

standards for hospital accreditation (Section 1:3) will change the increasing demand for

allied health services in the Saudi health system because of the current shortage of

healthcare providers. For example, between 2008 and 2012, both the number of MoH

hospitals and the number of beds provided within them has increased by 0.9% (MoH,

2014). However, demographic, socio-economic, technological and cultural changes affect

the care that is needed and also raise questions about how that care can best be delivered.

Likewise, the recruitment and retention of nurses needs further exploration.

According to Lamadah and Sayed (2014), the Saudi nursing workforce is already under

pressure due to nursing shortages, the comparatively poor status of nursing roles and an

ageing nursing workforce that is set to retire over the next few years. Furthermore, there

are not enough newly qualified nurses to replace the experienced nurses lost through

retirement. Almutairi et al., (2015) estimate that the government will take more than

twenty years to train enough Saudi nurses to meet 30% of SA’s nursing workforce

requirements. It is therefore evident that all of these issues need to due consideration in

terms of future nursing workforce planning, and this needs to be undertaken within the

context of the nursing degree policy requirements for qualified nurses in SA, in both the

short and long-term period.

The minimum educational requirement for entry to the nursing profession established by

the MoH in 2010 is a Bachelor’s degree. This was introduced in a bid to improve patient

care and to elevate the status of Saudi nurses, whilst implementing the World Health

Organisation’s (WHO) recommendations concerning nurse education. However, the

majority of the nursing workforce in SA are only educated to Diploma level (WHO, 2009).

The latest statistics in the Health Statistic Annual Book (MoH, 2014) identified 67% of

Saudi nurses graduated from Nursing Diploma programmes and 30% from Bachelor of

Science/Nursing BSN programmes. This in effect means that there are many diploma-level

nurses employed in MoH hospitals. This fact has implications for future nursing workforce

planning and development in SA and in light of this, the significance of this research will

be explained in the following section

Significance of this Research

Nurses are the largest staff group of the healthcare workforce in SA, and play importance

role in promoting health and preventing illness (Aldossary et al., 2008). It is therefore

important to understand the implications of nursing degree education as a minimum entry

requirement to enter the nursing profession in order to undertake future workforce

planning and to evaluate the role of nurses educated to degree level. This research

therefore will have the potential to inform future nursing workforce planning and the

changing role of the nurse in SA. For example, nursing education is the most important

factor to enhance the professionalism of a nursing workforce (Tanaka et al. 2014). The

systematic literature review of the impact of degree education upon patient care, presented

in Section 3 of this thesis, has not been previously undertaken in SA. The literature review

provides an evidence base to inform this thesis. Furthermore, the results of this study will

enable recommendations to be made to the MoH on how to best develop a national nursing

workforce planning strategy. The study is unique in that it will illuminate the experiences

and views of nurses from one region of SA, drawing upon key stakeholder opinions at the

macro (strategic), meso (regional) and micro (operational) levels of nursing policy and

practice. Whilst degree education and its outcomes are explored within the global

literature, to date there is, comparatively little emergent evidence to inform the national

policy and planning of health care and workforce within SA. This study will therefore

make an original contribution to nursing knowledge, practice, and policy within SA

through the key outcomes of this doctoral study.

Statement of the Research Problem

The MoH implemented the policy of degree education for the nursing profession in SA.

Consequently, Diploma-entry nurse education programmes have closed, and there has been

no measurement, evaluation or evidence to underpin the implications or impact of the new

degree-entry policy. Because of this initiative, employment prospects for newly qualified

Diploma nurses are challenging, as they may only be employed in the private health sector

on a very low salary. Diploma nurses educated prior to the implementation of the MoH in

2010, policy remain in the hospitals and primary health centres of the MoH, and those

working in the public sector face an uncertain future, in terms of career progression and

development, as there is no current policy to address their situation, and this will be further

explained in Section 1.3. Presently, in SA there are insufficient education opportunities to

enable Diploma nurses to convert to a degree qualification. Therefore, it is important to

know what the impact is of the degree entry requirement for future workforce planning.

Reliance on degree-educated nurses is in itself potentially problematic, as there are not yet

enough degree nurses to address the workforce-planning requirements, and there are

nursing shortages. In essence, the implications of the MoH policy of degree education in

nursing have resulted in some national tensions. For example, it is estimated that 14,000

students in SA have a health-related Diploma, spanning a range of different disciplines;

their qualifications have been obtained from private health colleges (Section 2.3). Of these,

25% are nursing students (SABQ 2011). None of these students have been recruited into

the nursing profession following the introduction of the Bachelor’s degree nurse education

policy; the entire health sector, which encompasses public hospitals run by the MoH and

private hospitals, has refused to employ them because they do not meet the minimum

requirements for practice. The argument is that the health system requires registered nurses

who can not only practise across several health settings, both within and beyond hospitals,

but who can also work independently in clinical decision-making roles and accept

responsibilities that are more diverse. This policy (2010) has therefore become a serious

problem for diploma holder, appearing to be a quick fix by Royal Decree at the time of

implementation, but has resulted in some unintended consequences.

Research Aim and Objectives

The aim of this research is to: Critically assess the implications of nursing degree

education for future workforce planning in Saudi Arabia, in order to determine a baseline

from which to develop a five-year National Nursing Strategy.

Research Objectives

To:

1. Review the MoH rationale for introducing degree level entry for nurse education

and assess intended outcomes in terms of national workforce planning.

2. Determine the views of key nursing and administrative stakeholders at the

strategic/macro levels of nursing policy and practice, regarding the influence of

degree entry requirements on nursing workforce planning.

3. Critically appraise the experiences of a sample of practising nurses at the middle

management/meso level of nursing practice, and those at the frontline/micro level

of nursing practice, regarding degree education as a minimum entry requirement to

the nursing profession.

4. Critically analyse the data and make recommendations that will underpin the future

development of a five-year SA National Nursing Strategy for Workforce Planning.

Research Question

The research question is based on the literature review and an assessment of nursing

education requirements in SA, as detailed in Chapter Three:

How will the requirements for a Bachelor Degree nurse education impact on the future

nursing workforce planning in Saudi Arabia?

Structure of the Thesis

This thesis is divided into eight chapters:

Chapter One provides an overview of the Saudi context, and contains details regarding the

demographic data for the country as well as economic and socio-cultural life in SA. The

chapter also gives an explanation of the health system, which is divided into public

healthcare sectors, other governmental sectors, and a private sector, as well as its

challenges and opportunities. Finally, the chapter discusses the government bodies

responsible for the legislation of national policy for the health service and education in SA.

Chapter Two provides an explanation of the nursing profession in SA, including a history

of nursing in Islam, nursing education in contemporary times, nursing regulation and

practice. The chapter also provides information about the history of the GCC Nursing

Technical committee and its roles in the Gulf countries. Finally, the chapter concludes by

providing an overview of policy perspective and an analysis of global developments in

degree nurse education.

Chapter Three reviews the literature that is relevant to the research topic. The literature

divided into two sections, the first section gives an overview of worldwide trends in

nursing, and the current challenges related to the nursing workforce in SA. The second

section involves a comprehensive systemic review of available research. Within this

chapter, I critically review the available evidence related to degree education as it relates to

nurse workforce planning, as well as exploring the effectual impact of professionalism,

degree education and experience on the quality of patient care.

Chapter Four addresses the philosophical and methodological approaches underpinning the

study design of this research. The chapter introduces the conceptual framework used in

this study; provides details of the research methods, including the sampling strategy, and

outlines the data synthesis approach for each aspect of the study, including documents,

interviews and focus groups. Furthermore, the trustworthiness, reflexivity and ethical

considerations of this research are discussed.

Chapter Five details the data collection phases for the three levels of staff, macro level

(socio-political organisational and national level); meso level (policy begins to take shape

in regional level); and micro level (policy operates in local level) working within the MoH.

The chapter explains the process of data collection including sampling, and analysis for

each level. Finally, the outcomes of each level are presented.

Chapter Six provides the results and discussion of the documentary analysis. The chapter

analyse the GCC’s implementation process on the changes regarding the degree nurse

education policy in SA.

Chapter Seven offers the themes emerging from the focus group and interviews. These are

presented and discussed in terms of the three levels of staff participating in the study. The

chapter ends with a summarised conclusion of the three levels.

Chapter Eight outlines the conclusion of the thesis. It presents the research’s contribution

to both new and existing knowledge and, in particular, to workforce planning for the

healthcare sector within SA. The strengths and limitations of the study are also presented.

Furthermore, the chapter provides recommendations for policy makers in SA. Finally,

reflexivity and the researcher’s role within the study are outlined.

Chapter 1 : The Healthcare System in Saudi Arabia

1.1 Introduction

The Introduction has highlighted the structure of the thesis. In order to set the context for

the study, this chapter will firstly discuss the demographic, socio-economic and cultural

context of Saudi Arabia. Secondly, an analysis of the Saudi health system, which includes

three sectors: the public health sector (the MoH), other governmental sectors, and the

private sector, will be provided. Finally, the chapter will discuss the government bodies

and their roles in legislation of national policy for the health service and education in SA.

1.2 Demographic, Socio-economic and Cultural Context of Saudi Arabia

Saudi Arabia, officially known as the Kingdom of Saudi Arabia, is the largest Arab state in

Western Asia. Saudi Arabia was founded by King Abdulaziz Al Saud (Cooper & Simmons,

2005). King Abdulaziz united minor regions of the Arabian Peninsula to form the kingdom

in 1932. SA covers an area of 2.25 million square kilometres and is about the size of

Western Europe, occupying 80% of the Arabian Peninsula. The country location is

strategically important, lying between Africa and mainland Asia, with long borders on the

Red Sea, the Arab Gulf and the Suez Canal near to its north-west border (Cooper &

Simmons, 2005). The Red Sea lies on the West coast and the Arab Gulf, Bahrain, Qatar

and the United Arab Emirates lie to the East. SA has borders with Yemen and Oman in the

South, and Jordan, Iraq and Kuwait in the North as illustrated in Figure 1-1.

Figure 1-1: The Kingdom of Saudi Arabia (Central Department of Statistics & Information, 2014

The current total population of SA is 31.2 million; 22.2 million of these have Saudi

citizenship, and there are 9 million immigrants (World Population Review, 2016). The

latest statistics documented that there has been a significant increase in the total Saudi

population over recent decades. In 1960, the total population was only four million people;

by 1980, there were 9.8 million people living within the borders of SA. By the 1990s, an

increase of over six million people was documented, with the population having reached

around 16.14 million people. Subsequently, the population grew by 24.2% and reached 20

million people by 2006, with approximately 22% being non-Saudi. In 2013, the population

had reached 29.9 million – 67.6% of them being Saudi and 32.4% non-Saudi – which is

almost eight times more than it was just half a century before (World Population Review,

2016; MoH, 2014). It is therefore evident that the Saudi population is rapidly increasing.

The resulting financial benefits of this population growth have provided opportunities for

the development of Saudi social organisations, including the health and education sectors.

Saudi Arabia is one of the richest and fastest growing countries in the Middle East, and the

world's largest producer and exporter of oil (Cooper & Simmons, 2005; Almalki et al,

2011). In 1936, oil was discovered in SA and commercial production started during the

Second World War. Oil wealth has precipitated a rapid socio-economic transition over the

past years, causing a discernible impact on health status and lifestyle (Aldossary et al.,

2008). The Saudi economy is sound and a well-established industry base benefits Saudi

society by increasing incomes. Based on the Human Development Report (HDR 2010) SA

is ranked at a high level in the human development index (0.75), giving the country a rank

of 55 out of 194 countries. Oil wealth has allowed the Kingdom to build development

plans and infrastructure. This improvement in the national income is expected to impact

positively on healthcare services (Almalki et al., 2011).

The economic and social development of SA has taken place in the context of Islamic

religious beliefs (Littlewood & Yousuf, 2000). The Holy Quran (the Holy book of Islam)

and the Sunnah (prophetic practice as interpreted by the Prophet Mohammed - peace be

upon him [PBUH]) are the main sources of the Islamic religion. Saudi citizens do not

practise any religion other than Islam. Islam is thus the main aspect that frames Saudi

culture. However, economic status, level of education and environmental factors are also

responsible for the formation of culture in SA (Littlewood & Yousuf, 2000; Al-Shahri,

2002). Muslims believe that health, disease and death all come from Allah (the Arabic

name for God) (Rassool 2000).

Islam promotes health by encouraging Muslims to practice the Islamic roles that promote

health and wellbeing (Al-Shahri 2002), for example, through moderate eating and regular

exercise, no alcohol and drug use, good personal hygiene, and breastfeeding (Rassool

2000). On the other hand, the cultural beliefs and habits strongly affect the lifestyle of the

Saudi population. For example, rice with meat or chicken (Kabsa) is considered an

important dish for Saudi families, and it is provided at lunch and dinner times. This kind of

food is rich in fat and carbohydrates, which increases the risk of disease prevalence in SA.

Non-communicable diseases account for around 70% of deaths in SA. An alarmingly

increasing rate of physical inactivity among Saudis has also been documented (Mahmoud

& Faramawi, 2015). Young Saudis are affected by a global epidemic of obesity. The

International Diabetes Federation (IDF) reported that there were 3.6 million cases of

diabetes mellitus and 22,113 deaths in 2013 related to this illness.

Therefore, the Saudi health system needs to enhance its response to such health issues

through a relevant national strategy. The structure and communication between

government bodies, which could help to reduce the prevalence of this disease, have been

observed to be lacking for many years. For example, (Abdulhadi et al., 2013) clearly

highlight the effect of diabetic education on the patients’ outcomes, which helps to

promote health and to prevent illness. Cardiovascular disease (CVD) is a major health

issue that causes 42 % of deaths in SA, and is considered as a leading cause of mortality

(WHO 2011). This is the result of the sedentary lifestyle of the Saudi culture, and includes

poor diet, smoking, and physical inactivity (Mahmoud & Faramawi 2015). Moreover,

asthma, breast cancer, and other non-communicable diseases can lead to death if they are

not diagnosed and treated at an early stage.

Women’s roles in Saudi Arabia are based on Islamic values, and include being caregivers

and housewives (Rassool, 2000; Al-Shahri, 2002; Gazzaz, 2009). Men are considered as

the protectors and maintainers of women and family (Rassool, 2000). The Saudi social

system maintains the power of men over women and respects older people (Gazzaz,

2009).The Islamic ethical principles control the relationships among Saudi families

(Aldossary et al., 2008) , for example, honesty, truth telling, respect, loyalty and sympathy.

Having considered population development and socio-economic issues, it is important to

highlight the healthcare services and the challenges they face in SA. These are discussed in

the next section, which also considers governmental and private sectors and their role

regarding the policy of the minimum degree education requirement for entry into nursing

practice, as well as the implications of this decision.

1.3 The Health System in Saudi Arabia

The health system in SA is divided into three sectors. The MoH is the key governmental

provider and financer of health services in SA (Almalki et al., 2011) and it delivers around

60% of free healthcare services for the Saudi population (see Section 1.3.1). Other

governmental sectors provide around 9% of care for defined population and include

referral hospitals, teaching hospitals, military hospitals, and the Arabian American Oil

Company (ARAMCO) hospitals – these will be explained further in Section 1.3.2. Finally,

there is the private sector, which provides around 31% of healthcare services for a fee

( Section 1.3.3). All governmental health services in SA are free of charge at the point of

service delivery. Healthcare financing in SA is provided primarily from the government

budget, which is largely based on oil and gas revenues (Al-Yousuf et al., 2002). The Saudi

health system’s sound economy and well-established industry base positively affects the

Saudi community by increasing their income, leading to a per capita income of

US$ 24,911 in 2012 (MOH, 2014). According to Al-homayan et al, (2013) the Saudi

governmental budget indicates that there has been a visible increase in the total budget

from 2010 to 2014, as illustrated in Table 1-1.

Table 1-1: Budget Approximate for the MoH (MoH, 2014)

Year Governmental budget Total budget %

2010 540,000,000 35,063,200 6.5

2011 580,000,000 39,860,200 6.9

2012 690,000,000 47,076,447 6.8

2013 820,000,000 45,350,355 6.6

2014 855,000,000 59,985,360 7.0

Saudi healthcare services have been given high consideration by the government at all

levels of care (Al-Yousuf et al., 2002), and those services have increased and improved

significantly during recent decades (Al-Yousuf et al., 2002; Almalki et al., 2011).

Currently, the MoH plays a significant role in the planning and implementation of

healthcare services in SA (Almalki et al., 2011). Figure 1-2 shows the current structure of

the country’s health system.

Figure 1-2: Saudi health system, Ministry of Health: e-Health/ICT Strategy (2014).

1.3.1 Ministry of Health/ Public Health Care System

The MoH in SA, established in 1950, is the operational body for health services (Ram,

2014). However, the greatest improvement in health services in SA began in 1970, with the

expansion of the 5-year developmental plan within the MoH. This aimed to improve health

status and services in SA (Al-Rabeeah, 2003). The MoH is responsible for managing,

planning and formulating health policies and supervising health programmes, as well as

monitoring health services in the private sector (Al-Yousuf et al., 2002). It is also in charge

of advising other government agencies and the private sector on ways to achieve the

government’s health objectives. The MoH supervises 20 regional General Directorates of

Health Affairs (Almalki et al., 2011). Each directorate has a number of hospitals and health

sectors and every health sector supervises a number of PHC centres. The role of the 20

directorates includes implementing policies, plans and programmes dictated by the MoH,

managing and supporting public health services, supervising and organising private sector

services, and collaborating with other government agencies and other relevant bodies.

Levels of Healthcare Services in the MoH

The MoH delivers health care services at three levels of care: primary, secondary, and

tertiary (Almalki et al., 2011); with a total number of 259 hospitals (35,828 beds) and

2,259 PHC centres, which include 59.5% of health care services (MoH, 2014). However,

all health sectors are undergoing rapid growth. The preventive and curative services

provided by primary care centres and cases that require higher levels of care are referred to

secondary care (public hospitals). Furthermore, the complex cases are transferred to

tertiary care (specialised hospitals) as illustrated in Figure 1-3.

Figure 1-3: Levels of health care in MoH (Annual Statistics Book, 2014)

However, the referral system between the three levels of healthcare services is not well

organised (Almalki, 2012). There are no clear communication channels or planned policies

for transferring patients back to PHC from tertiary or secondary care. According to

Primary

Health Care Centres

Secondry

Health care (Public Hospitals)

Terciary

Health care (Specialised Hospitals)

Almalki (2012), more effort is required to address this gap and to develop strategies in

order to reduce the overloading of specialist and secondary care services.

Transfer of Hospital Services to PHC Services

The health care services were mainly curative until 1980 and most of these were dependent

upon the provision of treatment for all types of health problems (Almalki et al., 2011). The

strategy of curative care was costly for the MoH, especially as many cases of health

complications can be minimised by preventative strategies (Almalki, 2012). This strategy

comes in response to a series of major challenges facing the Saudi healthcare system (Ram

2014). There is a high level of expectation of better healthcare services that can be easily

accessed in accordance with a high level of care due to educational awareness of the new

generation of Saudi population (Albejaidi, 2010). Applying referral systems within the

public health services and focusing on PHC centres decreases overloading, improves

public health care services and reduces the overall cost of care services (Albejaidi, 2010;

Almalki et al., 2011; Almalki, 2012; Ram, 2014).

The Current workforce in the MoH

In keeping with the challenges that face the Saudi healthcare system, the workforce in the

MoH relies on the expertise of healthcare workers recruited from different countries (Ram,

2014). In fact, the dependence on these workers reflects a serious issue with the stability

of the general workforce (Al-Homayan et al., 2013). In addition, the MoH is suffering

from a lack of national healthcare providers such as doctors and nurses. The latest

available statistics in 2014 still indicate that non-Saudi healthcare workers make up about

54.7% of the total workforce in the MoH as illustrated in Table 1-2.

Table 1-2: Total healthcare provider workforces in the MoH (2014).

Healthcare provider Saudi Non-Saudi Total % of workforce

Physicians 7,886 19,975 27,861 9.1

Nurses 37,162 33,843 71,005 23.1

Pharmacists 1,940 266 2,206 0.72

Allied health personnel 35,659 3,574 39,233 12.8

Although there has been a large influx of foreign nurses into the country to meet the

demands of the local population, SA is ranked last among Gulf countries in this field, with

a current rate of 32.2 nurses to every 10,000 people (Cooper & Simmons 2005). This

leaves SA behind other countries such as Qatar, where there are 54.8 nurses for every

10,000 people and, in Europe, where the typical rate is 66.3 per 10,000. Considering that

the population of SA is expected to expand to 45 million by 2025 (Al-Homayan et al.,

2013), this nursing deficiency could cause real problems in the future and a more robust

recruitment strategy will be essential. In order to manage the situation, the Saudization

plan was implemented by the SA government, with the intention of introducing more

Saudi workers into the healthcare system and becoming less dependent on the expertise of

nurses from other countries.

The Saudization plan

The Saudization plan is a strategy aimed at reducing the dependency on foreign employees

(non-Saudi) in order to create more vacancies and opportunities for currently unemployed

Saudi nationals (Gazzaz, 2009; Alhosis et al,. 2012). The implementation of the

Saudization programme began with a development plan after the realisation that a heavy

reliance on expatriates would create a huge gap in an unbalanced labour force, should the

expatriates decide to leave the country (Alhosis et al., 2012). Due to the failure of a

national workforce to meet the increased demand for labour, there was an increased

dependence on foreign labour. For example, the current estimate of population growth is

about 2.2% per year and the predicted population in 2020 is 31.6 million, with an increase

in the “elderly” population (60 years old and above) from one million to 2.5 million by

2020 (HDR, 2010). With the fast growth of the Saudi population, the country will need an

additional 15,000 to 20,000 hospital beds and roughly 15,000 more doctors (Cooper &

Simmons, 2005). At the current levels of recruitment of Saudi physicians and nurses, the

prospect of meeting that demand, without importing expertise, is almost zero.

However, it is very important to note that most Saudi healthcare providers are currently

working in the public sectors, with the planned divestiture of publicly owned facilities; the

Saudis presently employed in the public sectors will have to compete with non-Saudis in

the rapidly growing private sector. In a competitive market place, it seems that non-Saudi

healthcare providers, who are willing to work for lower wages, will fill many of the new

vacant jobs in the private sectors. Despite the availability of a number of public and private

programmes, self-adequacy in the supply of healthcare providers will not occur in the near

future. Landry & Taylor (2012) state that given the projected reliance on foreign

employees to meet the healthcare needs of Saudi citizens, the country needs to reconsider

the policy of “Saudization”. Moreover, in order to improve the Saudization plan within the

private sector, the authorities are in the process of establishing a minimum salary,

decreasing working hours to eight hours per day and providing social insurance or

allowance devices similar to those in the government sector (Al-Homayan et al., 2013).

In summary, the healthcare situation has improved significantly over the past few decades

and numerous strategies have been utilised to tackle tough challenges in this field.

However, despite these developments, SA is still experiencing difficulty recruiting nursing

staff and has a major shortage, the worst of all the gulf countries. On top of this, most of

these nurses are foreign workers on which the MoH has become dependent, leaving them

in a precarious situation. With the aim of having a majority Saudi workforce in the health

sector, the Saudization plan was introduced and is currently being improved.

1.3.2 Other Governmental Sectors

The other government sectors in SA (See Figure 1-2), include ‘referral’ hospitals, such as

King Faisal Specialised Hospital and Research Centre (KFSH & RC), the Ministry of

Higher Education Hospitals (Teaching Hospitals), School Health Units of the Ministry of

Education, Security Forces Medical Services, the Arabian American Oil Company

(ARAMCO) Hospitals, National Guard Health Affairs, the Royal Commission for Jubail

and Yanbu health services, and the Red Crescent Society. Each of these sectors provide

free services to defined populations, usually employees and their families. Recent statistics

suggest that the governmental sector operate 39 hospitals with a total capacity of 11,043

beds (MoH, 2014). The total number of nurses in employment at facilities of other

governmental sectors is 28,380, of which 13.5% are Saudi; this number increased by

20.6% between 2008 and 2012 (MoH, 2014).

The other governmental sectors involved are highly efficient and function separately from

the MoH, as they are structured through their direct budget. Their facilities are

administered internally, and they proceed with their own levels of staffing and personnel

affairs. For instance, KFSH and RC have now become members of the best group of

hospitals around the world, having achieved a Magnet rank (see list of terminology). The

Executive Director of Nursing Affairs of KFSH and RC, Judy Moseley, states that nurses

at KFSH & RC display ideal professional practice compared with other private and

governmental sectors in SA. In approved Magnet hospitals such as KFSH and RC and

King Khalid Teaching Hospital, decision-making is decentralised and the staff relationship

with physicians and other care providers is more collegial. One of the requirements for

achieving Magnet status, which is recognised for nursing excellence and improved patient

outcomes, was that all nurse leaders and nurse managers were to hold a baccalaureate or

graduate degree in nursing by 2013 (AACN, 2016), the belief being that a highly qualified

nursing staff creates a more professional environment (Aiken et al., 2014).

Other governmental healthcare sectors services can be accessed through primary and

secondary care facilities, with the possibility of referral to tertiary (specialist) care

facilities; this proves beneficial for the employees and relatives within the healthcare

sector. Moreover, the implementation of e-health and electronic information systems have

been successfully applied in a number of governmental hospitals, while such services in

the MoH are still moving slowly in some regions, especially those that are not directly

connected to each other or to the private sectors (Altuwaijri, 2008). The facilities for health

in the other governmental sectors were initially designed with a focus on providing

employees of various establishments and their families with the best services. Additionally,

these services are not usually accessible to outside establishments, as it is the responsibility

of the MoH to develop and deliver services for them (Al-Yousuf et al., 2002).

Nevertheless, some of the government sectors will react to extreme situations to provide

and administer specialised healthcare services that are required by the public, for example

those that are essential for certain cancer treatments.

In summary, it is evident that other governmental sectors are in a more advanced level of

care than the MoH, because they provide only 9% of healthcare to a specific population

(employees and their families) with an independent budget. This section gives the reader

the opportunity to understand the other governmental sectors and their relation to the

MoH. The following section will discuss the healthcare services in Saudi private sectors.

1.3.3 Private Sector

The private healthcare sector in SA includes different types of healthcare facilities that

provide most of the outpatient treatments for a fee, through their hospitals, clinics,

dispensaries, pharmacies, medical laboratories, and physiotherapy centres (Ahmad, 2012).

The role of the private sector has expanded over the past two decades due to the high

demand for and the restrictions placed on access to MoH facilities. The total number of

private sector hospitals, beds and dispensaries increased during the period of 2008-2012

with increased inpatient treatments. For example, between 2008 and 2012, there was an

11.4% increase in the number of private hospitals, from 123 to 137 hospitals (MoH, 2014).

Simultaneously, there was an addition of 2,803 beds (representing a 24.7% increase in the

number of private hospital beds). The number of nurses in health facilities within the

private sector stands at 28,373, and the proportion of Saudi employees increased from

5.3% in 2007 to 6.3% in 2011 (MoH, 2014).

Saudi nurses working in private healthcare can face difficulties related to various issues.

These constitute pay levels, excessive working hours, restricted professional development

and minimal opportunities for promotion. Hence, nurses in SA have seen that employment

in the private health sector is not meeting their initial expectations, and, as a result,

although the professional nursing workforce in the Saudi private sector has risen in

numbers, in relation to foreign staffing levels it remains low. It has been highlighted that

native nurses in SA constitute a mere 6.3% of the overall total nursing population within

this sector, which demonstrates the lack of appeal of this sector to indigenous workers

(MoH, 2014). While the public sector in SA has always needed to provide education to

nurses, within the last decade there has been a marked increase in educational investment

for nursing at diploma level throughout the private sector (Gazzaz, 2009). For instance, the

western province of Jeddah has developed seven programmes for private nursing, which

are separate from two other government projects. The majority of these programmes in the

private sector are connected to the Saudi Commission For Health Specialties in SA

(SCFHS, 2016), which promotes the development and enhancement of native workers in

the country’s workforce. Therefore, the Saudi government has provided private funds to

encourage young Saudi people, through education and training opportunities, to secure

future employment (Gazzaz, 2009).

In summary, this discussion has indicated a notable increase in the private sector health

service facilities in SA, although with limited opportunities, and noted that foreign nurses

constitute the majority of its workforce. This section provides valuable information that

allows the reader to understand the context of the health system in SA. The following

section will discuss the important governmental bodies and their role in initiating the

degree education policy.

1.3.4 The governmental bodies responsible for the legislation of a national policy for health service and education

This section provides a brief overview of the governmental bodies in SA and an

explanation of the ways in which they work together. The integration encompasses the role

of the MoH and other government bodies such as the Ministry of Higher Education

(MoHE), the Saudi Commission for Health Specialties (SCFHS), the Ministry of Civil

Service (MOCS) and the GCC. These governmental bodies have an active role in the

implementation and legislation of policy to make Bachelor degree education a minimum

requirement for entry into nursing practice. The government bodies are illustrated in

Figure 1-4.

Figure 1-4: The key government bodies responsible for legislation of national policy for health service and

education

Overall, the MoHE is the supervisory body for academic education, the MOCS is the

legislative body, the SCHS is the accredited body for health programmes, the GCC is the

Ministry Of Higher Education

academic education Saudi Commission

for Health Specialties

accredited body for health programmes

Ministry of Civil Service

legislative body

The Gulf Cooperation

Council

consultant committee for

healthcare system

Ministry of Health

operational body

enact legislation for the development of

nursing

consultant committee for healthcare system, and the MoH is the operational body. All

those bodies have a close involvement with the MoH in decision-making; and they enact

legislation for the development of nursing, as explained in the following section.

 Ministry of Higher Education (MoHE)

Through higher education programmes, every nation tries to fulfil its needs for a

knowledgeable and skilled labour force, which both the labour market and its national

development require (Alamri, 2011). Entering a new era of rapid development in the

country’s infrastructure and economy in the early 1970s, SA made a commitment to

developing higher education (Alamri, 2011). In 1975 the MoHE was established in

Riyadh, the capital city of SA, by Royal Decree 1/236, to regulate education policies and

to implement a long-term plan for higher education. The MoHE has one of the most

important roles in developing human resources, which is considered a strategic investment

for any country (Alkhazim, 2003). According to Alkhazim (2003), the MoHE only

supervises the universities, while other private colleges are managed directly by various

governmental sectors such as Saudi commission for health specialities.

 Ministry of Civil Service (MOCS)

The MOCS is a supervisory body, in accordance with the terms of reference, with the

responsibility of monitoring the implementation of the civil service regulations and

decisions relating thereto (MOCS, 2015). In addition, it performs studies and research on

the civil service, especially in the areas of job classification, allowances, bonuses, wages

and compensation, and makes recommendations relating to the affairs of the civil service

(MOCS, 2015). Other functions of the Ministry include proposing rules and regulations

related to the affairs of the civil service, which are submitted to the Civil Service Board.

The Ministry also establishes controls and record-keeping procedures for employees in

order to ensure the integration of the required information for each employee, in addition

to the other powers exercised by the Ministry (MOCS, 2015).

 The Saudi Commission for Health Specialties (SCFHS)

The SCFHS is the only accrediting body specifically for health programmes in SA.

Established by Royal Decree No. M/2, dated 6/2/1413 AH (6/8/1992), it is a scientific

commission with a legal responsibility, and its headquarters are located in the Diplomatic

Quarter, Riyadh, with several branches across SA (SCFHS, 2016). The SCHS is

responsible for supervising and evaluating training programmes, as well as setting controls

and standards for the practice of health professions. It launched its work through its

competent supervisory, executive and specialist boards and committees (SCFHS, 2016).

The Scientific Nursing Board (SNB) was established in 2002 under the authority of the

SCHS and aims to develop the nursing profession, nursing accreditation and registration

(Almalki et al., 2011). The professional development of nursing centres on the standards of

education, practice and ethics by establishing a system of accountability, and by

conducting and supporting nursing research (Almalki et al., 2011). The accreditation role

attempts to evaluate and approve all health programmes, educational institutions and

training centres, whilst reviewing nursing qualifications from outside SA (Almalki, 2012).

In addition, the SNB focuses on classifying and renewing the licences for nursing

institutions, colleges and professionals (Abu-Zinadah, 2007).

The SCFHS classifies nurses with the high school equivalent of Nursing as nursing aides;

nurses who hold a Diploma in Nursing are classified as Technical Nurses; nurses who hold

a Bachelor’s Degree in Nursing (BSN) are classified as Specialist Nurses. Furthermore,

nurses with a Master’s Degree in Nursing (MSN) are classified as Specialist One Nurses,

and those with PhDs are classified as Nursing Consultants (SCFHS, 2016). Currently, all

nurses in SA are registered with the SCFHS based on their academic qualifications, and

attendance for the required number of hour’s continuing education programmes is required

(SCFHS, 2016). For example; 30 hours of continuing education programmes is required

for technicians (Diploma) and 60 hours for specialist nurses (Degree) to renew their

registration every three years.

 The Gulf Cooperation Council (GCC) Nursing Technical Committee

The GCC was formed in 1981 to create economic, scientific, and political cooperation

among its members; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab

Emirates (Luomi, 2014). These countries have experienced rapid economic growth that

influences health and illness. Increasingly chronic illnesses have promoted greater

investment in health, education, and research (Lowe & Altrairi, 2014). The major initiative

that provided an incentive for the development of a strategic nursing plan in the Gulf

countries was the establishment of the GCC Nursing Technical Committee (Lowe &

Altrairi, 2014). The GCC Nursing Technical Committee, formed in 1993, was based on

Arab Ministers decree no.4, to achieve unity among its members founded on their common

objectives (Lowe & Altrairi, 2014). The GCC technical nursing members worked together

in order to develop a strategic nursing plan (Luomi 2014). This was a significant

achievement, aiming to improve the quality of nursing care in GCC countries. For

example, the five-year strategic plan, 1993-1997, was the first stage of the plan and

revolved around legislation, nursing care, and nursing education. Moreover, the technical

committee of nursing in GCC countries conducted eleven symposia for nurses. Each year,

the Gulf nursing symposia focus on a different significant theme, accommodated by the

assigned Gulf country.

In summary, there has been a rapid development of the healthcare structure in SA. The

MoH’s current strategy also emphasises the shift of healthcare services from hospitals to

community centres as a significant change that supports the implementation of degree

education for the nursing profession. As part of that development, it is essential to

highlight that a number of key government bodies play a role in the implementation of the

degree education policy. This background explanation of the government bodies provides

the reader with a context in which to place the documentary analysis of the GCC meetings,

presented in Section 6.1.

1.4 Summary and Conclusion

This chapter has provided an overview of the healthcare system in SA. As a result of the

continuing support from the government, the Saudi healthcare system has improved

drastically over recent years. The Saudi population is rapidly increasing and the resulting

financial benefits of this population growth have provided opportunities for the

development of Saudi social organisations, including those in the health and education

sectors. In addition, as part of development in the Saudi healthcare system, it is essential to

note that a number of non-communicable diseases can be prevented through increased

community awareness of health and disease patterns (Al-Mazrooa, 2011). Healthcare

services in the three aspects of care, primary, secondary and tertiary, have enabled

improvements to better deal with communicable and non-communicable diseases

compared to a decade ago. Furthermore, Saudi economic and socio-cultural development

has taken place in the context of Islamic religious beliefs.

The implementation of the Saudization strategy began with a development plan after the

MoH realised that there was heavy reliance on expatriate employment, created by a lack of

Saudi nationals in the labour workforce. The Saudi government has faced important

challenges, including the need to create a group of highly qualified Saudis able to work in

complex modern economic and cultural expansion. With more than 70% of nurses being

non-Saudi, public healthcare, along with other government and private sectors, have

developed plans to achieve the Saudization programme in the nursing workforce. Finally,

the key government bodies and administrative structures are outlined to give the reader an

insight into the decision-making processes related to the nursing workforce policy and the

practicalities of case study design, planning and implementation, which will be presented

in detail in Sections 5.2, 5.3, 5.4, 5.5.

The following chapter will give an overview of nursing in SA, including the history of

nursing in Islam and nursing education and practice in contemporary times. Finally, the

chapter will provide an overview of the global development of degree nurse education

from a policy perspective.

Chapter 2 : Nursing in Saudi Arabia (History,

Education, Contemporary Influences and Policy)

2.1 Introduction

The previous chapter discussed the historical and current developmental structure of the

healthcare system in SA, including demographic changes and the socio-economic context

in relation to the different types and levels of healthcare services. This chapter presents an

overview of the development of the nursing profession in SA, including its history in the

era of Islam, its educational development and contemporary influences. Finally, the

chapter will explore and analyse the global development of degree nurse education from a

policy perspective.

2.2 History of Nursing in Islam

Florence Nightingale is recognised as the founder of modern nursing. Historically, nursing

services evolved through caring for sick and wounded people in the Arabian Peninsula

(Almalki et al., 2011). Although little was documented about the nursing profession during

the pre-Islamic period (before 570 AD), it is believed that nursing and medicine were

practised by the same healer (Almalki et al., 2011). Before the spread of Islam, the Arab

community called the nurse "Al asiya" and "Al awasi". In the Arabic language, the word

''Asiya'' was used for a single female nurse, while the plural was ''Awasi" (Miller-Rosser et

al., 2006). The word ''Asiya'' describes holistic care that includes physical, psychological,

social, emotional and spiritual care (Tumulty 2001). These terms come from the Arabic

verb ‘aasa’, meaning, caring and emotionally supporting injury people (Tumulty, 2001).

Currently, the words ‘momarredhah’ for a female nurse and ‘momarredh’ for a male nurse

are used (Almalki, 2012).These two terms come from the Arabic verb ‘marradha’, meaning

"caring for sick people".

Islamic literature has a different view of nursing. Nursing in Islam started in the era of the

Prophet Mohammed (PBUH) in the 8th century (Miller-Rosser et al., 2006; Al-Hassani,

2010). This occurred when the Prophet Muhammed (PBUH) recognised nursing caregivers

as a crucial part of the Muslim Army (Al-Hassani, 2010). Nursing care in the religion of

Islam is the manifestation of love for Allah and the Prophet Muhammad (PBUH). During

the pre-Islamic era, nursing work was acknowledged within the faith, as well as being

sponsored and actively encouraged; during the pre-Islamic period, the role of Arab women

focused on reassuring and encouraging males to fight (Gazzaz, 2009). Muslim women

worked as volunteers in the battlefield, providing first aid and wound care to the soldiers

(Miller-Rosser et al., 2006). During that period, nursing gained strength with the

participation of women as volunteers, causing an upsurge in nursing as a religious duty.

This developed into organised social healthcare services (Gazzaz, 2009).

However, nursing services in Islam were not limited to the war period; it was documented

in Islamic literature that Rufaidah Bint Sa'ad Al Ansareyah, sometimes called Koaiba, was

recognised as the founder of nursing in the Islamic era, many centuries before

Nightingale's time (Miller-Rosser et al., 2006; Gazzaz, 2009; Al-Hassani, 2010; Lovering,

2012). Rufaidah’s father was a physician, and it was through him that she developed her

knowledge and training in nursing skills, as she assisted regularly with caring for patients

and soldiers. In addition, she was a nurse educator, and during times of war, she practised

nursing by teaching and training Muslim women in her tent with the permission and

support of the Prophet Muhammed (PBUH) (Lovering, 2012). She erected a small tent in

Al Madinah near the prophet’s mosque, which is now recognised as the first portable

hospital in Islam, in order to treat injured soldiers and solve social issues (Miller-Rosser et

al., 2006). In her tent, many volunteer Muslim women learnt nursing skills, enabling them

to care for ill and wounded Muslims. Rufaidah is described as a model nurse, a leader and

a great teacher; passing on her clinical knowledge to others she trained (Al-Hassani, 2010).

She did not limit nursing practice to the clinical field, but went out into the community to

address and solve the social issues that contributed to disease. According to Al-Hassani

(2010), Rufaidah was both a public health nurse and a social worker.

Many different names of women who worked with Rufaidah have been recorded in the

history of Islam: Om Senan Al Esla Mey (Om Ammara), Om Ayman, Safiyat, Om Sulaim,

and Hind. Other well-known female Muslim nurses included: Nosaiba Bint Ka’ab Al

Mazeneya, Amiinat bint Abi Qays al Ghifariyat, Om 'Atiyyah al Ansariyat, Om Matawea

Al Aslameya, and Om Wareka Bint Hareth (Miller-Rosser et al., 2006; Al-Hassani, 2010).

The recognition of Rufaidah Al Ansareyah as the first female Muslim in nursing is a

current phenomenon (Lovering, 2012). Until recently, nursing was not considered a

respectable profession in Saudi society (Gazzaz, 2009). To improve this negative image,

the national nursing organisation and GCC looked at the history of Islam to place the role

of nursing within a religious framework, and this has had a positive influence on the

acceptance of nursing as a good choice for women (Lovering, 2012). Moreover, the MoH

in SA set aside 13 March 2008 to celebrate Gulf Nursing Day, a date parallel with the 17th

day of Ramadan, the date of the battle of Badr in the second year of the exodus, the day

that Muslim women’s names were recorded as nurses for the first time in Islam. This day

was selected by the GCC Nursing Technical Committee in its twenty-third meeting, held in

Jeddah, Saudi Arabia in March 2008, and through recommendation No. 22 at meeting No.

69 of the Executive Body held in Riyadh in December 2008, it was formally adopted. The

Gulf Nursing Technical Committee selected Nosaiba bint Ka’ab as the example of the best

nurse in Islam; they set criteria for the Award of Nosaiba bint Ka’ab, by selecting the best

nurse among those who met the criteria to receive an award.

There is little documentation of nursing history in the Arabian Peninsula in the years

between the death of the Prophet Mohammed (PBUH) in 632 AD and the 1950s. However,

the literature has described the practice and education of nursing in other parts of the

Islamic world (Lovering, 2012). Interestingly, the story of Rufaidah can be linked to the

work of Florence Nightingale at Scutari during the Crimean War. There is also the added

similarity of the emergence of nursing in the face of the civil unrest and tensions of war.

Again, religion and caring are entwined, similarly to nursing in the UK, where the early

nurses came from religious orders and monasteries. Yet, the basis of Islam and nursing has

had comparatively little representation or discussion within the global repertoire of nursing

history, when compared to icons such as Florence Nightingale.

In the following section, the history of nursing education in contemporary times will

presented including the curriculum outline of degree education in nursing.

2.3 Nursing Education in Contemporary Times

This section provides a brief history of the education system and nursing education in the

Kingdom of Saudi Arabia. Saudi Arabia, formerly a poor, nomadic, tribal country, was

catapulted into the twentieth century by the oil wealth of recent decades (Section 1. 2),

which made it a middle-income country (El-Sanabary, 1993). Major educational and

economic changes occurred in the early 1960s within a traditional framework (Section

1.2), without deviating from traditional social and religious values prominent within the

country (El-Sanabary, 1993). Ever since the first Saudi development plan in 1970,

education has been given the highest priority in the country. Education at all levels is free

to Saudi citizens and students from the age of seven years have strictly gender-segregated

educational facilities. In contrast, the role of the private sector in the provision of

education services has expanded over the last few decades. Currently, 29.12% of the Saudi

population is under the age of 15 years (MoH, 2014), which places extra demand on

educational and healthcare services. Hence, the nineteenth development plan (2010-2014)

suggests the growth of the private sectors at an average annual rate of 6.6% over the period

of the plan, thus increasing its percentage share of Gross Domestic Product (GDP), to

around 61.5% by the end of the plan (MOEP, 2010).

An outline of the history of Saudi nursing education is explained in the following

timeline:

1958-1976

The first Saudi health institute programme was initiated for young men in Riyadh by the

MoH in 1958, with the collaboration of the World Health Organisation (WHO). Fifteen

students who had completed six years of elementary school were enrolled for a one-year

programme in nursing as Health Inspectors (Tumulty, 2001). Following the success of this

initial programme, a further two Health Institute Programmes were established in the main

cities, one in the capital city (Riyadh) and the other in the largest seaport and commercial

centre (Jeddah). Both of the institutes opened in 1962 to enrol Saudi women (Tumulty,

2001). Students who graduated from these health institutes were appointed as nurses’ aides

(Miller-Rosser et al., 2006). Gradually, the MoH extended the initial one-year programme

to three years and opened more institutes in different cities, recruiting students with

secondary school preparation, that is, nine years of schooling (Miller-Rosser et al., 2006).

1976-1987

One of the most important steps towards professionalising nursing education was taken by

the MoHE in 1976 by introducing the first programme of Bachelor of Science degree in

Nursing (BSN) in Riyadh, following in the footsteps of the US, who had introduced the

first degree programme in 1965. The BSN was a 5-year course, taught in English and

focusing on theory and practice (Al-Osaimi, 1994). In addition, incentives for nursing

students included free textbooks and uniforms and a monthly allowance of around £150

(Gazzaz, 2009). In 1977 and 1987, BSN programmes were initiated at King Abdulaziz

University (Jeddah) and at King Faisal University in the largest city in the Eastern

Province (Dammam) respectively (Tumulty, 2001). With the population increase, and the

subsequent increase in the number of high-school graduates, and the limited number of

colleges offering Bachelor’s degrees, medical and health science colleges were forced to

establish strict criteria for admission, which included aptitude and admission tests (Gazzaz,

2009). More than ten years after the establishment of the university programmes, only 117

female students had graduated from the three universities with a BSN (Al-Osaimi, 1994).

This small number of graduates reflects the negative image of nursing as low-level work,

and the socio-cultural context that was explained in Section (1.2).

1987-1992

In this period, women’s participation was low in nursing, since it remained a low-status

occupation rejected by both women and men due to the negative image of the nursing

profession (Almalki et al., 2011). In 1987, King Saud University in Riyadh announced a

Master of Science in Nursing (MSN) to improve the image of nursing and to encourage

female students to consider nursing as a career (Tumulty, 2001; Almalki et al., 2011).

There were 33 health institutes by 1990; 17 institutes offering nursing education

programmes for females and 16 for males in their early teens (Almalki et al. 2011).

Gradually, the MoH opened more health institutes in different regions of the kingdom,

offering a range of specialised facilities such as pharmacies, laboratories, anaesthesia,

physiotherapy, x-ray facilities and nursing. Teaching was carried out in the Arabic

language and the duration of the programmes was two years, focusing on basic nursing

knowledge and skills. Students were provided with free accommodation, uniforms and a

monthly allowance of £100 (Gazzaz, 2009). This was to encourage admission to nursing

and other healthcare-associated programmes. However, this period shows that the MoHE

and MoH were working towards different goals; the former being focused on

professionalism to improve the image of nursing, whilst the aim of the MoH centred on

finding a solution to the nursing shortage in the country.

1992-2011

Junior health colleges, established in 1992, upgraded the level of training for Saudi nurses

for the recruitment of high school prepared students, that is, those who had 12 years of

education (Abu-Zinadah, 2007). Thus, the MoH operated two levels of nursing education

through the health institutes and junior colleges. By 1993, 18 health institutes had been

established for males and 26 for females (El-Sanabary, 1993). Three of these institutes

were transformed into health colleges, accepting students with twelve years of education.

In 1996, a PhD scholarship programme was introduced, enabling Saudi nurse leaders and

educators to study overseas (Abu-Zinadah, 2007). In 2008, the governmental nursing

programmes providing nursing Diplomas shifted from the MoH to the MoHE (Almalki,

2012; Jradi, Zaidan, & Shehri, 2013). In 2010, all Diploma programmes gradually began to

close and the policy of requiring the BSN as the minimum educational requirement for

entry into nursing practice was implemented. Recently, after the implementation of the

policy, some governmental sectors and private universities have begun to deliver their own

nursing education programmes to train high school prepared students for the BSN.

The previous section has provided a brief history of nursing education in SA during

different historical periods. The following section will discuss the curriculum for the

Bachelor’s Degree programme in governmental and private colleges/universities, including

the duration, content, theory and clinical hours of practice.

Governmental vs. Private College

Government universities are typically larger than private universities and comprise of

many colleges. Co-educational universities operate with segregated classes such as

medical college. Most research actively takes place in the large government universities.

Universities operate under Royal Decree, and currently, there are 25 operating across the

country including an additional three universities established this year. In contrast, private

universities tend to be smaller than governmental universities and focus on the

undergraduate level in specific disciplines such as medical sciences and nursing. Private

universities operate under licensure from the MoHE. Currently, there are nine licensed

universities in SA. However, the number of universities operating in SA has grown

significantly in recent years, with many new universities created through upgrades or

mergers of colleges. However, Alamri (2011) states that the private institutions (33)

outnumber government institutions (23), meaning there is stiff competition to get into

nursing programmes at government universities, which forces students to go to private

institutions.

In both the governmental and private universities, the BSN programme is often delivered

over five years in ten semesters and consists of 50% theory and 50% practical work,

including classes, clinical practice and laboratory work (Al Mutair, 2015). The five-year

private nursing colleges are significantly different from governmental colleges. For

example, the private colleges allow for little flexibility and do not have restrictive criteria

for admission. The clinical practice conducted in private hospitals only covers a small

number of patients compared to the public sector; governmental colleges provide clinical

placements in public hospitals that give nursing students the opportunity to practise a

variety of skills with many different patients.

The course is only available as a full-time option and it prepares nurses in general nursing

practice only; it is not until after successful completion of the Bachelor’s degree that a

nurse will specialise. University, faculty and nursing requirements influence the

curriculum design and the curriculum outline differs between governmental

universities/colleges and private colleges (Al Mutair, 2015).

Al Mutair (2015) state that the mandatory classes for the BSN include the basic nursing

foundations, such as medical and surgical fundamental nursing, research and ethics.

Typical faculty requirements include nutrition, Pharmacology, Chemistry, Physics and

Biology, and English or Islamic studies, all of which is provided in foundation classes.

According to Al Mutair (2015), the first year of the programme comprises the core subjects

required by the university. It includes simulation sessions in the laboratory, preparing

students for placements in clinical settings. It is recognised that nursing students require

more than traditional theoretical approaches, as there is much to be learnt from experience

in the field. With this in mind, students undertake clinical practice from the second year

onwards and are required, in the fifth year of their degree, to complete a full internship

lasting two semesters. On this placement, students rotate between each speciality to obtain

clinical practice (Al Mutair, 2015).

Clinical instructors are required to have completed the undergraduate degree, followed by

at least three years’ post-registration experience; these instructors work closely with the

course co-ordinator and bring the students into their place of work in order to give first-

hand clinical demonstrations. Those teaching the theoretical side of the course, the

lecturers, hold a Master’s degree or a PhD in nursing, and are also expected to have a

clinical background (Al Mutair, 2015). The main goal of the curriculum and of the faculty

is that nursing students should graduate with a high level of professional clinical

competency.

In summary, the Saudi nursing workforce started with very few nurses; only men were able

to enrol in nursing education and the course covered very basic nursing skills. It was not

until 1962 that women became nurses. Women’s education was perceived as a social

revolution encouraging women to leave their home and go to school; a change that might

challenge the prevailing tradition. Since then, nursing education has developed

consistently and now there are an increasing number of educational institutions for nurses

across the country. In 2008, all governmental nursing programmes that provided nursing

Diplomas shifted from being under the control of the MoH to the MoHE (Jradi et al., 2013;

Almalki, 2012). The latter only provides degree education, in order to improve the quality

of nursing programmes. Most recently, Degree education for nurses has been implemented

as a minimum requirement for nursing practice. Introduced in 2010, this policy was

recommended by the World Health Organisation (WHO, 2009) with the intention of

improving the quality of healthcare at a national level.

However, with this strategy, the workforce is experiencing an increase in the number of

nursing students graduating from private health allied colleges with Diploma

qualifications, at a time when nursing is diversifying and there are changing expectations

of role development. Nursing students who have graduated with a Diploma no longer meet

the minimum requirements for enrolment to be a professional nurse with the MoH and it is

important to consider the consequences of this situation. For those only educated to

Diploma level, it is now more difficult to find employment in the nursing profession within

the MoH. Prior to this shift, it was much easier to gain employment because the nursing

programme led to direct progression to jobs in the field. Despite an increasing interest in

enrolment for different nursing education programmes, (Abu-Zinadah, 2007) has estimated

that it would take 25 years to train enough Saudi nurses to comprise just 30% of the

Kingdom’s nursing workforce. Until that time, health services in SA will potentially still

rely upon a mobile expatriate workforce who will come and go, compounding the

challenges not only of communication, but different levels of nursing professionalism,

based upon the diverse backgrounds, experiences and different expectations of nursing

roles (Abu-Zinadah, 2007)

This section has outlined the historical timeline of the nursing education up to the present

day. It has described the Bachelor’s degree in SA and the difference between the public

and private sector courses. Finally, it has further explained the need to train new Saudi

nurses. The following section will provide an overview of the policy perspective to analyse

the global development of degree nurse education.

2.4 An Overview of Policy Perspectives

The idea of degree education as a minimum entry requirement for nursing practice began

many years ago in developed countries and was envisaged, by global health organisations,

as a strategy for future nursing (Smith, 2010). It is therefore important to give an overview

of the policy, the background effort and the perspective of global organisations to improve

nursing education. This section will analyse the specifics of this policy, newly

implemented in SA.

Nurse education has seen important changes throughout the 20th and early 21st centuries

(Klainberg & Dirschel, 2010). Prior to 2009, global standards for nursing developed in a

random manner with no orientation towards standardisation of skills and training

(Almadani, 2015). Since then, the development of global standards for the initial education

of Nurses and Midwives has taken place in a more organised and integrated manner, led by

the World Health Organisation (WHO) and Sigma Theta Tau International (WHO, 2009).

The principles articulated at this stage were that nursing education should be based on

developing competencies, evidence-based learning and life-long learning, interaction

between client and nurse, and inter-professional collaboration (Klainberg & Dirschel,

2010).

In 2008, the Nursing and Midwifery Council (NMC) in the UK indicated that the

minimum level for nurse training would be at Bachelor degree level (NMC, 2010). The

impetus for this came from the belief that nurses’ need to have a high level of knowledge

and skills, commensurate with the requirements of a profession meeting the needs of

complex care delivery. Additionally, the changes were intended to safeguard the interests

of the public through quality nursing education, providing equal opportunities to nursing

students and to create learning opportunities through practical training. (Donley &

Flaherty, 2008) suggest that new and emerging issues need to be dealt with by a qualified

workforce. For example, the majority of the nurses still lack essential education in certain

areas such as health promotion, which is linked to the prevention and treatment of illness, a

shortfall in nursing education that could easily be covered in a nursing degree programme,

but unlikely to be covered properly through ‘on the job’ experience (Almadani, 2015).

In the post-war period, significant developments in nursing degree education were made.

Across the policies reviewed in this chapter, these developments have been inspired by the

relevant social and economic considerations of the time. Of these the most significant has

possibly been the 1965 proposal by the American Nursing Association (ANA), which

inspired similar efforts to implement a degree education policy in the UK and other

countries (Reiter, 1965; Donley & Flaherty, 2008). The ANA published an early paper

about degree-based entry into nursing practice in 1965, advocating that a Bachelor degree

should be the minimum level for entry into nursing practice (Reiter, 1965). The reasons for

this proposal included a need to strengthen a nursing education system to meet the current

and future needs of healthcare (Donley & Flaherty, 2008; Smith, 2010). The Bachelor

degree would provide the necessary foundation from where nurses could pursue either

practitioner training or research work. According to Smith (2010), during that time only

one state (North Dakota) implemented degree education as an entry requirement for

nursing practice because it had the power to introduce such a change through its own

nursing regulatory board.

The American Association of Colleges of Nursing (AACN), (the national voice for

baccalaureate and graduate nursing programmes in the US), believed degree education has

a significant impact on the knowledge and competencies of all qualified health care

providers (AACN, 2016), and nurses with Bachelor degrees are well prepared to meet the

demands of the current and future health care system. Smith, (2010: P3) summarised that

the rationale underlying the ANA position paper of 1965 addressing entry to practice;

“the changing role of government, especially its investment in nursing education

and manpower training; the changing pattern of education in the US; the

increasing availability of collegiate education for women; the expansion of

science and technology and its impact on health and healthcare; and the new

insights into human health problems”.

Despite the limited success in North Dakota, other states in the US and other countries

continued to experiment with the policy and implement it in their unique context (Smith,

2010).

Historically, in the UK two failed attempts were made to introduce the policy in the 20th

century, but were met with resistance. The reluctance in adopting the policy has been due

to concerns from nurses already in the profession, patients, Trade Unions, universities and

the government (Brooks & Rafferty, 2010). There were concerns that making nursing a

degree only profession would create a hierarchical environment, making the profession

more academic, stripping the field of its compassion, kindness, common sense,

communication and caring skills (Brooks & Rafferty, 2010). Furthermore, there were

concerns from many that nurses would be too busy dealing with paperwork to be providing

the services required from a nurse (Almadani, 2015). For example, some believed that

highly educated nurses would be reluctant to meet the personal needs of patients, such as

bed bathing. This was evident from the opinions voiced by some trade unions who

opposed the policy, suggesting degree educated nurses will generate a segment of the

workforce ‘too posh to wash’ though this has been refuted by the Willis Commission

(Willis, 2012). The government did not want the extra financial burden of making the

policy work and funding it (Brooks & Rafferty, 2010).

However, some of the arguments for the adoption of the policy from nurses already in the

profession have centred on degree-educated nurses having more medical knowledge in an

ever-evolving field (Donley & Flaherty, 2008). A degree will give nurses more autonomy

and will enhance the characteristics of nursing as a profession (AACN, 2016). With an

increase in population and a global increase in the shortage of medical staff, degree

educated nurses will have the capability to develop the skills necessary to ease the burden

on healthcare systems (Smith, 2010). For example, nurses in the US can progress their

degree education and skills acquired to become practitioners with prescribing powers (non-

medical prescribers) which could allow better health care delivery and more readily meet

the needs of the patients (Scrafton, McKinnon, & Kane, 2012; Black & Dawood, 2014;

Carberry, Clements, & Headley, 2014). This shift in policy of degree nurse education

supporting research in the field has already encourage nurses to have greater involvement

in the development of nursing education, practice, policies, and changes in the work

environment, among other calls for demonstrating how the change has already given

nurses autonomy (Varjus et al., 2011).

Traynor and Rafferty (1999) proposed some of the reforms needed to make such a policy

work in the UK and globally. The authors described three sets of conditions required for

the transition in making degree education mandatory in nursing; context, convergence and

contingency. Traynor and Rafferty (1999) describe context as the need to create positive

opinions or pressurise the need for change; convergence is described as the merger of

professional and government opinions; and contingency as the need to provide a plan to

deal with unforeseen events following implementation, resulting in evolution of the policy.

Following the uptake of the degree education policy, graduate nurses have been successful

in the work force according to initial results despite fears that the quality of care would be

compromised (AACN, 2016).

The duration of the pre-registration programme in developed countries may vary, likewise

the Bachelor of Nursing programme is a three to four-year education programme

administered at university level leading to professional entry into nursing practice (Smith,

2010). The WHO, (2009: P18) for the initial education of nurses and midwives, stated that

“Nursing or midwifery schools have entry requirements that meet national

criteria for higher education institutions including, but not limited to,

completion of secondary education.”

Conversely, university admissions in SA have entry requirements to study nursing

including, but not limited to, completion of secondary education, the General Aptitude Test

(GAT) and the Standardized Achievement Aptitude Test (SAAT) administered by the

National Centre for Assessment in Higher Education, named QIYAS, and meeting the

national criteria for MoHE (Siddiek, 2011). The five years’ duration of the BSN

programme in SA is considered a long-term period comparing with the developed

countries (Almadani, 2015). For example, in Canada, Australia and the US state of North

Dakota, the four-year Bachelor of Nursing qualification is currently required as a standard

for entry to practice (WHO, 2009). However, compared to the more common 3-year

programme, the 4-year programme inducts students at a more basic level and provides the

requisite foundation for formal nursing education. Since 2013, the biggest change era, only

degree level pre-registration nursing programmes have been offered in the UK (Willis

2012).

Nevertheless, the Bachelor programme for nurses’ contrasts with the Diploma. It includes

course work taught in associated degree and diploma programmes, but at a higher level of

knowledge that appraises the skills of nurses in critical thinking, research based

knowledge, leadership, case management and health promotion (Hendricks et al., 2012).

These skills are vital to the performance of evolving nursing roles given the dynamic

context where technological development and sophisticated health care practices are

creating a complex environment.

In essence, the previous discussion shows how the initial proposal by the ANA to

introduce the degree policy was a starting point to bring structure to nursing education. It

documents the initial resistance on the part of health care professionals, the difficulties

experienced by the educational authorities and the slow progression of the policy in

developed countries.

2.5 Summary and Conclusion

This chapter has provided an overview of nursing profession in Islam, history of nursing

education, and the nursing workforce in the Saudi context. It has reflected on the concern

that the Saudi Heath system is dependent on foreign educated nurses, recruited from

different countries, even though the Gulf War in 1990 led to the country facing difficulty

recruiting foreign nurses and resulted in severe shortages in the non-Saudi nursing

workforce. Despite this fact, the number of Saudi nurses remains too small to meet the

national workforce needs and it has been that it would take the country 25 years to build up

a qualified national nursing workforce to meet 30% of healthcare services needed in Saudi

Arabia (Abu-Zinadah, 2007). This is a key issue, considering that globalisation and

education are highlighted as significant indicators of the rapid socio-economic

developments in Saudi context. There has been consideration of education delivery and

entry requirements by nursing organisations globally and the wealth of information SA has

access to from this field has been discussed in order to relate to developing its own

healthcare system and manage its workforce, making it fit for the 21st century. The

advantage of studying countries that have already implemented the policy to make degree

level education a minimum requirement for nursing have been noted as particularly

valuable, offering SA the opportunity to consider the positives and negatives of

implementing such policies to shape its own policy. This initiative was driven by the need

to reform nursing education as the world entered the 21st century, and to address the

global impetus to reassess old policies and standardise education, that could more readily

meet diverse nursing roles and the global migration of nurses from one country to another.

Furthermore, other health related fields were already one-step ahead in offering and

making degrees’ mandatory for practice such as physiotherapy, pharmacy and social care.

The next chapter will review the current literature in two different sections. The first

section will provide an overview of the global and local trends in the nursing workforce,

and the second section will use a systemic review of global literature to explore the

effectual impact of degree education on patient outcomes in relation to professionalism,

education, and experience.

Chapter 3 : Literature Review

3.1 Introduction

Chapter’s one and two provided an overview of the context of this study including, socio-

economic and cultural issues that have affected the health and disease pattern in SA, and

the health care system developments that are currently influencing nursing education and

practice. In order to develop a case study theory/framework, a comprehensive critical

review strategy has been implemented to establish what was already known about the

implications of degree education as a minimum entry requirement into the nursing

profession. This allowed the identification of methodologies used, findings and any gaps in

the literature.

As previously stated this chapter will present the literature review under two sections:

 The first section gives an overview of the global and local trends in the nursing

workforce and explores the current shortage in nurses and the high rates of

turnover. It also examines current nursing education levels and entry requirements

and focuses on integrating knowledge with practical training in order to maximise

the utility of the labour workforce. Finally, this section discusses the views of

current nursing staff and aims to emphasise why nursing workforce planning at a

national level is required in order to benefit the nursing sector in Saudi Arabia.

 The second section involves a comprehensive systematic review of current

literature. A systematic review strategy informs the emerging study aim and

explores empirical research literature that contains information on related studies

as well as gaining insight into degree education as it relates to nurse workforce

planning. It explores the effectual impact of professionalism; education; and

experience on the quality of care. Finally, the accessible evidence is discussed, to

explore knowledge that already exists and identify gaps in knowledge for Saudi

workforce planning, and to determine the need for further research.

3.2 Section One: An Overview of Global and Local Trends in the Nursing Workforce

This section will discuss the nursing workforce trends in the global and local nursing

workforce and explores the current shortage of nursing. It also examines current nursing

workforce challenges which include education challenges, system challenges, and social

challenges focusing on integrating theory with practical training in order to maximise the

utility of nursing workforce.

3.2.1 Global trends in nursing workforce

A nursing career is one of the most demanding professions in all countries (Al-Ahmadi,

2014). It has been argued that nursing, comprises the most important healthcare provider;

this being largely due to the fact that nurses spend a great deal of time with patients and

are directly responsible for their quality of care and safety (Clarke & Donaldson, 2008).

Furthermore, nursing forms an integral part of social, cultural, and educational

improvements and the emphasis on the importance of this practice is expected to increase

in the future as the global healthcare models are continuously developed with a strong

focus on prevention (Clarke & Donaldson, 2008). Today, health sectors face a serious

shortage of professional nursing staff worldwide (Yun et al. 2010; Oulton 2006). Nursing

shortages mean that the situation in which the demand for a nursing workforce is greater

than the available supply (Yun et al., 2010). According to the AACN (2016), due to this

shortage, some nations are reportedly hiring unqualified nursing staff, resulting in patients

not receiving the required level of care. This is particularly concerning as nursing is a

profession that requires comprehensive and adequate training for standard care to be

delivered (Alyasin & Douglas, 2014).

In the United Kingdom, there is a vast shortage of registered nurses in the healthcare

sector. According to Aiken et al., (2014), within the National Health Service (NHS), 83%

of the heath care organisations and hospitals face a shortage of nursing staff. In order to fill

this gap, many nations, including England and Wales (in the UK), hire nursing staff from

other countries. This affirms that it is not only Saudi Arabia that has a problem with a

shortage of health care workers. Aiken et al., (2014) note that for developed countries such

as England to seek nurses and other medical professionals from outside of the country

indicates a serious glitch in the nursing systems and a quick remedy for this should be a

priority.

The NHS has lost 4,000 nursing staff since the year 2010 (Aiken et al., 2014). Similarly,

there is a shortage of 2.4 million nurses in India according to (Nyland et al., 2015). The

United States of America has the largest nursing workforce in the world, about 3 million,

but it failed to produce enough nurses to meet the heath care and growing demand (Yun et

al. 2010). In a similar way, it has been projected that the US will face an increasing

shortage of registered nurses (RN) due to the increase in health care requirements and this

shortage is believed to intensify during the period from 2009-2030 (Juraschek et al., 2012).

It is estimated by the Administration of U.S Health Resources and Service that the

shortages in the nursing sector will exceed 500,000 by 2020 and potentially reach one

million (Rother & Lavizzo-Mourey, 2009). This is because of the low enrolment in

nursing, with recruitment dropping in the past few years and available nurses retiring

(Fulton et al. 2014).

Similar statistics can also be seen concerning china and, according to Yun et al. (2010),

many reasons for nursing shortages in China are the same for many other countries, despite

the cultural, political, historical, and economic differences. Invariably, this situation will be

compounded by an ageing population and the perpetual biomedical and pharmacological

developments in modern times, which ultimately enhance life. Yet, this also results in a

requirement for greater levels of quality nursing for patients receiving interventions

(Fulton et al., 2014). Despite the acute shortage, potential student nurses are repeatedly

rejected, due to failing entry requirements or because of inadequate resources and faculty

(Juraschek et al., 2012). With this in mind, this limited numbers of nurses is recognised as

a global issue (Oulton, 2006; Juraschek et al., 2012; Fulton et al., 2014; Alyasin &

Douglas, 2014; Aiken et al., 2014).

In the same way, it has been stated Saudi Arabia has a deficit of Saudi nurses in the

country and greater levels of turnover will persist (Al-Ahmadi, 2014). However, education

and training for nurses worldwide are producing qualified nurses with diplomas or degrees

(Majeed, 2014). Certain scholars perceive this educational development in nursing to be

the enhancement of clinical professionalism (Al-Ahmadi, 2014). Indeed, advanced

educational levels in nursing, together with a specialization role, are commonly attributed

to professionalism, as the majority of western educated students deem this to be imperative

to the process of nursing (Almutairi et al., 2015).

3.2.2 Saudi Nursing Workforce

This section gives an overview of the Saudi nursing workforce and explores the current

shortage in nurses and the high rates of turnover. It also examines the current level of

nursing education and entry requirements, focusing on integrating knowledge with clinical

training in order to maximise the utility of the labour workforce. Finally, this section also

discusses the views of current nursing staff in Saudi nursing workforce.

Aboul-Enein (2002), states that the Central Nursing Committee was established in 1987 at

the MoH to advance the quality of nursing care. Prior to 1987, as the profession was

dominated by physicians, there was no representation or formalised voice for nurses by

nurses at national level. The Regional Nursing Committees were formed in 1990 to

achieve delegation of decision making for nurses (Al-Osaimi, 1994). By 2003, the General

Directorate of Nursing was established in the MoH under the direction of highly educated

and experienced Saudi nurses, few of them holding a Master’s degree (Almadani, 2015).

These were the first wave of educated nurses who progressed to policy roles to

subsequently inform the wider development of nursing in Saudi Arabia (MoH, 2014). This

was followed by the establishment of nursing departments in twenty regions of Saudi

Arabia. Such advances are expected by the public to provide evidence for the need to have

nursing representation and regulation to shape nursing, recognising it as a profession that

is central to the MoH and, as such to facilitate its development and presence (Almadani,

2015).

The largest group of health care professionals in Saudi Arabia are nurses; they deliver the

highest percentage of health care (Lamadah & Sayed, 2014). Despite this, the nursing

profession has experienced an acute shortage of qualified nurses, affecting the delivery of

healthcare worldwide Almalki et al., 2011 (Fochsen et al., 2006; Almalki et al., 2011;

Lamadah & Sayed, 2014). Similar to the global situation, Saudi Arabia is challenged with

chronic shortages of qualified Saudi nurses, accompanied by high rates of turnover. Within

the large numbers of Saudi students studying all over the world, there is a low percentage

of nursing students locally and internationally (Alamri, 2011). The admission level of entry

into nursing practice to a Bachelor degree qualification, further limits the number of

qualified nurses and, adds to the problem (Alamri, 2011).

Today, according to Majeed (2014), over fifty percent of the healthcare workforce is

comprised of nurses. The focal point and centre of the health care system are the nurses

and without them, the health care system would not be functional (Alyasin & Douglas,

2014). In Saudi Arabia, the healthcare sector workforce mostly comprises of migrant

nurses; only 34% are Saudi nurses (AlYami & Watson, 2014). A major proportion of the

migrant nurses use the Saudi Arabian healthcare opportunities temporarily in order to gain

experience and knowledge. After gaining the required experience, they return to the

healthcare sectors of the developed nations such as the USA, the UK and Australia (Black

et al., 2012).

This high turnover rate among professional nurses in Saudi Arabia is adding to the

concerns regarding management issues, organisational plan obstruction and bad service

delivery, thus affecting the workforce and those in need of nursing care (Al-Ahmadi,

2014). The effectiveness of various healthcare systems is threatened by such problems; for

example, a constant need to replace and train nursing staff. There are no reliable statistics

related to this important issue in Saudi Arabia, but for the managers of the health care

facilities, this emigrant movement raises concern (AlYami & Watson, 2014). High turnover

of nurses creates an unstable healthcare system where the burden of the workload falls on

the remaining staff (Almadani, 2015). This inevitably has the potential to compromise the

care given to patients, creating an environment of discontent and affecting morale and

motivation of the remaining staff (Lamadah & Sayed, 2014).

However, lower staff turnover rates, higher staff retention and increased nurse/patient ratio

have been shown to be linked to higher quality of care and a reduction of in-patient stays

(Collier & Harrington, 2008). High turnover of nursing staff also has a significant impact

on the finances of a healthcare system (Collier & Harrington, 2008). A survey of Jordanian

nurses showed job satisfaction was a significant factor in retaining nursing staff

(Alsaraireh et al., 2014). As stated, Saudi nurses make up a small percentage of the total

nurse workforce; this percentage is even smaller in the private health sector where native

nurses make up only 4.1% of the workforce (AlMakhaita et al., 2014). This shows that the

lack of local nurses is a big problem for the countries health sector that carries a number of

social, educational and individual issues.

3.2.2.1 Education Challenges

In SA, most of the nursing workforce are Diploma holders and many nursing staff do not

have a Bachelor’s of Science nursing degree (AlMakhaita et al., 2014). This indicates a

lack of education and training among nursing staff and is seen as a hindrance in providing

high quality nursing care to the patients who need an advanced level of care (Al-Ahmadi,

2014). AlYami & Watson (2014), suggest that the increasing requirements of the Saudi

healthcare sector are not being met by the low number of students inducted into nursing

degrees each year; this means that there are not enough graduates from Saudi Nursing

schools to meet patient needs and health system demand. However, Black et al., (2012)

stated the training of people, meaning the forming their personality and preparing them for

accountable practice, is the responsibility of a university.

Almalki et al., (2011) stated that all nursing colleges and health institutes were transferred

from the MoH to the MoHE in 2008 as the first step to improving nursing education in the

KSA. Following this initiative, a Bachelor of Science in Nursing is awarded following

completion of a five-year curriculum at all the universities offering the BSN programme in

SA (Almadani 2015); the five-year period studied in English language was seen as

adequate to impart the required skills, knowledge, and communication (Al-Homayan,

2013; Almalki et al., 2011). Nursing programmes started to improve in Saudi Arabia with

the development of the curriculum and practising at graduate level. Today, applications

from female Saudi nationals with the right set of abilities, skills, intelligence and

motivation for the study of nursing science are encouraged in some government

universities (Almutairi et al., 2015).

However, the disadvantage is that, with a five-year degree programme, the time

commitment required, before being able to practice and earn a salary, could prevent people

from committing to the profession (Almadani, 2015). This is particularly poignant given

that professional nurses already have several complaints concerning resources and time

issues. This puts SA in a dire situation because very few people have the BSN

qualification, the country still ranks low in this regard, and it is accurate to state that most

of the nurses in the country are Diploma graduates (Almadani, 2015). Romp et al., (2014)

explains in America, the lack of financial incentives and limitations concerning individual

financial situations leads to a large number of nurses choosing not to study a Bachelors’

degree. Other reasons for this choice, highlighted by Romp et al., (2014), include the

individual facing restrictions in their current job or family commitments.

3.2.2.2 System Challenge

Due to the decrease in nursing staff in Saudi Arabia, the Saudi government and private

healthcare sectors are becoming more and more dependent on expatriate nurses to fill the

void (see Section 2.2 & 2.3). However, one of the implications of making a degree the

minimum requirement for nursing practise in Saudi Arabia, which depends so heavily on

foreign nurses, is that it may reduce the expatriate workforce considerably (Almadani,

2015). If a country that supplies nurses to SA does not offer nursing degrees or does not

make it mandatory, SA will start reducing its recruitment from these countries.

The nursing care provided differs due to the diversity in educational and cultural

backgrounds, especially among expatriates who have to adapt to and sustain the culture

changes in foreign lands where they intend to practice (Almadani, 2015). Aldossary et al.,

(2008) suggests that the Saudi nursing department should develop Saudi national nursing

staff training, in order to provide quality healthcare through familiarity with the cultural

and linguistic aspects of care provision. In the absence of such measures, it would be

increasingly difficult to provide high quality healthcare to the Saudi nationals. Aldossary et

al., (2008) predicted that the rising requirement of health care services for the elderly was

expected to increase further in the coming years and that the problem needs to be

addressed immediately by the Saudi government to make the necessary improvisations to

the systems to facilitate and attract more female workers (Majeed, 2014). Currently,

training the nurses in specialised departments such as gerontology needs to be encouraged

to cater for the growing percentage of elderly people (Al-Ahmadi, 2014).

Al-Ahmadi (2014) and Majeed (2014), asserted that with the introduction of policies

attracting women to opt into the nursing profession. Although this shift is quite slow, the

experts claim it will be fully achieved within the given timeframe. The cultural and

religious reasons for this delay are previously detailed and evidenced by a number of

researchers, notably (AlMakhaita et al., 2014). These factors are also responsible for the

small proportion of female applicants when the recruitment programmes open (Al-

Ahmadi, 2014). The apropos system for recruiting and training nurses is inconsistent

owing to the diversity of professionals working in Saudi hospitals (Majeed, 2014). Most

often, females resort to taking administrative jobs owing to the high promotional chances

(Almutairi et al., 2015).

Moreover, the number of female nursing professionals are affected by the social norm,

dictating that a female will leave their job once married (Al-Makhaita et al, 2014). This

means that nurses are trained, which costs them a lot of time and money, and then leave

their work to start a family, this could make training to be a nurse less appealing and also

decreases the possibility of retaining female staff, once trained. Overall, it has been agreed

that the Saudi health system must increase the numbers of nurses in the hospitals and

primary healthcare centres to meet the needs of the rising population (Aldossary et al.

2008; Al-Ahmadi, 2014; AlMakhaita et al., 2014; Majeed, 2014; Almadani, 2015;

Almutairi et al., 2015).

3.2.2.3 Social Challenge

Social and cultural traditions create a number of barriers for Saudi women considering a

nursing career; firstly, there is disfavour in the community towards women accepting paid

work outside of the home (Gazzaz, 2009) and, secondly, the nature of the job involves

working long hours in a mixed gender team. According to Gazzaz (2009), there is a lot of

social pressure on Saudi nurses as the profession has a negative image. In Saudi society,

nursing is widely considered akin to a house cleaner’s job. With this in mind, Gazzaz

(2009) explains that there are mixed opinions in Saudi communities concerning nursing as

a profession for females and this can make applying to study nursing less attractive. Other

factors that make nursing less appealing include low salaries and shift schedules; studies

show that nurses are paid less than many other professions and, furthermore, are expected

to work 48 hours a week, 30% more than the average for other professions. Amongst the

negativity, however, Saudi women are increasingly entering the nursing profession; they

are aware that once they gain skills and knowledge in this field they can advance and

consider breaking some of the barriers in order to make improvements and further

developments in this sector (Al-Homayan et al., 2013).

It is worth noting that Saudi female nurses are more likely to work in a health care centre

than in a hospital (Mebrouk, 2008); due to the separation of sexes in the working

environment, set working hours and less responsibility as well as the fact that it is not

necessary to work night shifts. Some families will not allow a daughter to work in a

hospital setting due to the mixed gender-working environment. Another negative impact of

mixed gender working environments is that it is less likely for a female working as a nurse

to get married as caring for, and working with men, combined with unconventional

working patterns, is deemed undesirable in a wife (Gazzaz, 2009). In addition, males tend

to avoid nursing as a profession because it is considered a woman’s job. The unattractive

image of nursing in the Middle East and the fact that it is frowned upon for women to seek

employment, helps explain why Saudi Arabia relies so heavily on foreign nurses (Al-

Homayan et al., 2013).

As a result, many researchers suggest that an improvement on financial rewards for nurses

is necessary, especially considering that it is one of the few jobs that requires employees to

work at all hours of the day and all days of the week (Gazzaz, 2009; Al-Hassani, 2010; Al-

Homayan et al., 2013). Based on the above evidence, the future of the nursing sector is

bleak and calls for extensive reforms in various perspectives for high quality of service to

satisfy the country’s citizens and expatriates. According to Al-Homayan et al., (2013) the

expectations of the citizens of the country, regarding the nursing profession, could

materialise by the removal of the social elements attached to the profession. In spite of all

of the concerns previously, the government hospitals have not addressed this issue and

have not increased their female nursing staff by reducing working hours, neither have they

improved benefits compared with other countries across the globe (AlYami & Watson,

2014). The deficiency of nurses is affecting the patients, especially the elderly groups in

the community. This concern requires a profound scrutiny on the current and future

nursing system, which includes training facilities. Almutairi et al., (2015), state that the

hospital management in Saudi Arabia needs to address social, organisational and cultural

issues in the system and maintain them periodically.

Most of the issues discussed are related to female nursing; this is because, whilst it is well

known that nursing is a female dominated profession globally, it is more so in SA

(Mebrouk, 2008). Although limited numbers of females are interested in the profession,

due to its social image and pressures, even fewer men would consider nursing as a career

(Almalki et al., 2011). There are calls for health care workers across various fields to

overhaul the policies affecting nursing in Saudi Arabia; as the current policies are seen as

inadequate.

In summary, this discussion indicates that the dire shortage of nursing staff in the health

care sector is compromising the quality of health care in SA. This is not only a

phenomenon here, but it is a global issue. Proper professional education and training; and

providing adequate job facilities to nursing staff is required in order to bring about

improvements. The shortages highlighted are caused by a number of factors ranging from

lack of replacement to withdrawal from the profession and the lack of resources for

effective training (Yun et al., 2010; Alyasin & Douglas, 2014; Aiken et al., 2014; Fulton et

al., 2014).

3.3 Section Two: A Comprehensive Systematic Review

This section presents the comprehensive search strategy, results, and key findings from the

literature review. The literature review involves a systematic review of existing literature,

exploring the impact of degree education entry upon care outcomes. Finally, an overview

of the accessible evidence is discussed in order to explore the gaps in the global literature,

and to determine the need for further research.

3.3.1 Search strategy

A systematic search strategy was used to identify gaps in the existing literature and to

collect evidence about Bachelor Nursing as a minimum requirement to enter the nursing

profession; this included searching a wide range of online database. The approach also

analyses and summarises research findings. The first stage of a systematic literature review

is a well-planned search strategy, which includes the identification of the databases to be

used and the key terms to be searched (Coughlan et al., 2013).

3.3.2 Electronic database search

The Cumulative Index of Nursing and Allied Health Literature (CINAHL) is the most

comprehensive resource comprising four databases and offering complete coverage of

English-language nursing journals and publications from the National League for Nursing

and American Nurses’ Association. This database also covers nursing, biomedicine, health

sciences librarianship, consumer health and 17 allied health disciplines. MEDLINE

databases contain in excess of 4,800 academic and medical scientific journals and provides

authoritative medical information on medicine, nursing, healthcare system, pre-medical

science and much more. PubMed is the US National Institute of Health (NIH) free digital

archive of biomedical and life sciences. OVID databases contain in excess of 1200

academic and medical scientific journals. These databases have been selected for this

study for different reasons: the most relevant database for my topic; offering complete

coverage of English Language Nursing Journals; and provides authorities medical and

educational information on nursing and healthcare systems. The searches were carried out

using numerous combinations of several keywords as illustrated in Table 3-1

Table 3-1: Steps for the Search Strategy

Sources

Searched

Key words Result Related Selected Final result

CINAHL Nursing

Degree education

Entry requirement

Qualified nurse

Workforce

Minimum entry

Baccalaureate

Bachelor degree

Professional

Quality of care

Initial: 26,789 873 8 23

Related: 412

MEDLINE Initial: 16,875 1

Related: 320

OVID Initial: 583 9

Related: 110

Pub Med Initial: 80 3

Related: 11

Google Scholar Initial: 399 2

Related: 20

3.3.3 Inclusion and exclusion criteria

Searching these databases resulted in the retrieval of a large number (873) of related

articles. To reduce this number, the following inclusion criteria were applied based on the

relevance to the research aim and objectives as illustrated the Table 3-2.

Table 3-2: Inclusion and exclusion criteria

Inclusion criteria Exclusion criteria

Published between 2005 and 2016. Exclude all paper that published before

2005.

Only English language. Other language.

Studies using Qualitative, Quantitative,

mixed methods, and systatmatic.

Policy, report, essay, and review paper.

Studies that focusing on degree education

as a minimum requirement for professional

nurse to entry into practice are included.

Studies that focus in other health

professional.

The preliminary search paved the way for a more focused search, based on the relevancy

and period of publishing.

1. Online studies published between 2005 and 2016 were included. This decision was

made based on the fact that the development of global standards for the initial

education of nurses and midwives took place over a three-year period, starting from

2005, led by the World Health Organization (WHO) and Sigma Theta Tau

International (WHO, 2009). Studies published prior to this period were used in the

policy perspective and analysis of global development in degree education section and

in chapters one and two, to compare and contrast the development of nursing

education and as background information as the world entered the 21st century.

Furthermore, widening the search area too much would have led to a less focused

study with meaningless outcomes as there could be dilution of information. A ten-year

search period which covers the main transition phase of nursing education in Saudi

Arabia should yield sufficient data for this study to ensure that only the latest evidence

on the minimum requirement for a nursing degree is included.

2. Only articles published in the English language were included as English is the main

professional language for health publication and medical teaching in SA (El-Sanabary,

1993).

3. Research papers were included; that is to say studies using qualitative, quantitative

mixed studies, and systematic reviews.

3.3.4 Searching strategy result

Search sequences for conducting the electronic searches were generated by suitable

combinations of the key words and by using the Boolean search technique. Boolean

terms include the combination between terms using “AND” or “OR” in an attempt to

retrieve all relevant studies (Coughlan, M., Cronin, P. & Ryan, 2013). Unrelated

articles that do not meet the inclusion criteria were excluded by deliberately omitting

them from the search list. Using the inclusion/exclusion criteria highlighted in Table

3-2, the search process was conducted with reference to the issues under study. The

researcher carried out the review on the understanding that only the relevant articles

(23) relating to the research topic were required to ensure a thorough literature review.

See Figure 3-1.

Figure 3-1: Search Strategy Steps

3.3.5 Critical appraisal process

A comprehensive systemic approach was employed to analyse the quality and rigour of the

retained studies that were incorporated into the literature review. These studies were

subjected to appraisal using the Critical Appraisal Skills Programme (CASP) tools (CASP,

2013). CASP tools are used to help the researcher think critically and comprehensively in

order to appraise qualitative and quantitative studies (Essays UK, 2013). Goldsmith,

Bankhead, and Austoker (2007), note that this tool is useful in appraising qualitative and

quantitative research in health and social studies. These tools contain guideline questions

that critically evaluate study aims, samples, methods and results (CASP, 2002). In the

following Table 3-3, the reviewed literature in the 23 selected papers is presented

according to the type of study, country of origin and methodological approaches.

Table 3-3: Summary of studies included in part 2

Author(s)/year/

country Method Sample Aim Results Key findings

1. Aiken et al.

(2009)

(USA)

Quantitative

Survey

n=10,184

nurses and

232,342

surgical

patients

To analyse

the net effects of nurse

practice environments

on nurse and patient

outcomes after accounting

for

nurse staffing and

education.

Nurses reported more positive job

experiences

and fewer concerns with care quality,

and patients had significantly lower risks

of death and failure to rescue in

hospitals with better care environments.

Significance association

between educational

level of nurses and

hospital outcome.

2. Aiken et al.

(2011)

(USA)

Quantitative Large mail survey

undertaken in the

four States.

n=272,783

nurses

To determine the conditions

under which the impact of

hospital nurse staffing,

nurse education, and work

environment are associated

with patient outcomes.

The effect of decreasing workloads by

one patient/nurse on deaths and failure-

to-rescue is virtually nil in hospitals with

poor work environments.

Level of education of

nurses decreases the odds

on death and failures.

3. Aiken et al.

(2014).

(Europe)

Quantitative

Survey n=422 730

patients and

n= 26, 516

nurses.

To assess whether

differences in patient to

nurse ratios and nurses'

educational qualifications

in nine of the 12 RN4

CAST countries with

similar patient discharge

data.

Nurse staffing cuts to save money might

adversely affect patient outcomes. An

increased emphasis on bachelor's

education for nurses could reduce

preventable hospital deaths.

Increasing the number of

nurses with bachelor’s

degree (60% of nurses)

and reducing the number

of patients cared for by

these nurses to 6 would

lower mortality rate.

4. Kendall-

Gallagher et al.

(2011)

(USA)

Quantitative,

Secondary analysis

survey 2005-2006.

n= 28,598 To determine if hospital

proportion of staff nurses

with specialty certification is associated with risk-

adjusted inpatient 30-day

mortality and failure.

A 10% increase in hospital proportion of

baccalaureate and certified baccalaureate

staff nurses, respectively, decreased the

odds of adjusted inpatient 30-day

mortality.

Increasing the proportion

of baccalaureate and

certified. baccalaureate

staff nurses decreased the

odds of adjusted inpatient

30-day mortality

Author(s)/year/

country

Method Sample Aim Results Key findings

5. Kendall-

Gallagher and

Blegen (2009)

(USA)

Quantitative,

secondary data

analysis of 48

intensive care units.

29 hospitals To examine the

relationships between unit

certification rates,

organizational nursing

characteristics and rates of

medication administration

errors, and falls.

Unit proportion of certified staff

registered nurses was inversely related

to rate of falls, and total hours of nursing

care were positively related to

medication administration errors.

Receiving care from

highly specialised/trained

nurses significant reduces

the odds of death

6. McHugh and

Lake (2010)

(USA),

Pennsylvania

Quantitative cross-

sectional design data from 8,611

registered nurses

The sample for

this analysis

included acute

care staff

nurses n =

9,445

To examine effects of

hospital contextual factors

and individual nurse

education and experience

on clinical nursing

expertise.

The hospital context significantly influences clinical nursing expertise.

Nurse level of education

and years of experience

were related to clinical

nursing expertise.

7. Bobay et al.

(2009)

(USA)

Quantitative,

descriptive,

correlational study

n=261

registered

nurses

To determine what are the relationships of nurses'

professional characteristics,

including years of experience,

certification, basic nursing

education, continuing education, and

other factors, to levels of clinical nursing expertise.

Experience as an RN was found to be

highly correlated with initial level of

expertise. Educational preparation and certification were not

correlated with expertise.

Significant correlation

between healthcare

experience as a registered

nurse, self-reported non-

mandatory continuing

education with level of

expertise.

8. Sales et al.

(2008)

(Canada)

Quantitative, A retrospective

observational study

n=129,579

patients from

453 nursing

units.

To evaluate the association

of in-hospital patient

mortality with registered

nurse staffing and skill mix.

An association between RN staffing and

skill mix and in-hospital patient

mortality depends on whether the analysis is conducted at the hospital or

unit level.

No significance

association between

BSN education and

mortality risk.

Author(s)/year/

country

Method Sample Aim Results Key findings

9. Dellon et al.

(2009)

(USA)

Quantitative. A retrospective

analysis of screening

colonoscopies

performed..

n=3631

eligible

screening

colonoscopies

To determine whether the

nurse experience was

associated with screening

colonoscopy complications,

procedure length, and cecal

intubation.

Nurse inexperience was associated with

increased odds of screening colonoscopy

immediate complications, prolonged

procedure times, and decreased cecal-

intubation rates.

Complications during GI

endoscopy increased with

nurse inexperience and

education

10. Kanai‐Pak et al.

(2008)

(Japan)

Quantitative, Cross-

sectional survey n= 5956 staff

nurses

To describe nurse burnout,

job dissatisfaction and

quality of care in Japanese

hospitals and to determine

how these outcomes are

associated with work

environment factors.

Fifty-six per cent of nurses scored high

on burnout, 60% were dissatisfied with

their jobs and 59% ranked quality of

care as only fair or poor.

Significance association

between staffed hospital

and quality of care

11. Kutney-Lee et

al. (2013)

(USA)

Quantitative, survey

patient

discharge data

from 1999 and

2006

To examine the association

between bachelor degree

education and mortality rate

The result found that a ten-point

increase in the percentage of nurses

holding a baccalaureate degree in

nursing within a hospital was associated

with an average reduction of 2.12 deaths

for every 1,000 patients

Significance association

between educational level

of nurses and hospital out

come e.g. decrees mortality rate

12. Estabrooks et al.

(2005)

(Canada)

Quantitative, cross-

sectional analysis

18,142

patients

discharged

from 49 acute

care hospitals

To assess the relative

effects and importance of

nurse education and skill

mix, continuity of care, and

quality of work

environment in predicting

30-day mortality

Using multilevel analysis, it was

determined that the log-odds for 30-day

mortality varied significantly across

hospitals

Significant association

between level of

education and patient

outcome

Author(s)/year/

country

Method Sample Aim Results Key findings

13. Friese et al.

(2008)

(USA)

Quantitative, Nurse survey data collected

Pennsylvania

for 1998–1999

To examine the effect of

nursing practice

environments on outcomes

of hospitalized cancer

patients undergoing surgery

Nurse staffing and educational

preparation of registered nurses have at

least a baccalaureate-level education

were significantly associated with

patient outcomes.

There is a significant

association between the

quality of the nurse

practice environment and

outcomes for surgical

oncology patients.

14. Blegen et al.

(2013)

(USA)

Quantitative, a cross-

sectional study. data from 21

University

Health System

Consortium

hospitals,

to examine the effects of

registered nurse (RN)

education by determining

whether nurse-sensitive

patient outcomes were

better in hospitals with a

higher proportion of RNs

with baccalaureate degrees.

Hospitals with a higher percentage of

RNs with baccalaureate or higher

degrees had lower congestive heart

failure mortality, decubitus ulcers,

failure to rescue, and postoperative deep

vein thrombosis or pulmonary embolism

and shorter length of stay.

Significant association

between level of

education and patient

outcome

15. PARK et al.

(2007)

(UK)

Quantitative, Self-

completion

questionnaires

employing open and

closed questions

were sent to

graduates 9 months

after graduation and

at intervals over the

next 6 years.

n = 180

graduating

between 1994

and 2000

This paper reports the

views of nurses graduating

from the University of

Nottingham School of

Nursing, UK, 1994–2000,

Bachelor of Nursing (Hons)

course, concerning career

aspirations, progress and

reflections on their

qualification.

Most respondents were confident and

motivated in their nursing careers.

Promotion, increased responsibility,

further study, specialization and

qualifications were career priorities.

Recent qualifiers also focused on

changing jobs, travel and working

overseas

Nurse motivation is

increased with promotion,

responsibility,

specialization and career

priorities.

16. Spetz et al.

(2013)

(USA)

National Sample

Survey

Registered

Nurses

n=120,000

To examine the return to

baccalaureate education

from the perspective of the

nurse.

Lifetime earnings for nurses whose

initial education is the BSN are higher

than those of AD nurses only if the AD

program requires 3 years and the

discount rate is 2 percent.

Higher nursing education

translated to higher

earnings and of being an

advanced practice

registered nurse

Author(s)/year/

country

Method Sample Aim Results Key findings

17. Yakusheva et al.

(2014)

(USA)

Retrospective

observational

patient-level analysis

of electronic data.

Linear and logistic

regression modeling

with patient controls

and diagnosis and

unit fixed effects.

n=1477 direct

care nurses

To conduct the economic

analysis of meeting the

80% BSN threshold on

patient outcomes and costs,

using linked patient-nurse

data.

Continuous BSN proportion was

associated with lower mortality.

Compared with patients with <80%

BSN care, patients receiving ≥80% of

care from BSN nurses had lower odds of

readmission and 1.9% shorter length-of-

stay. Economic simulations support a

strong business case for increasing the

proportion of BSN-educated nurses to

80%.

There was an inverse

association between the

continuous BSN

proportion and the odds of

in-hospital mortality (Association Between

Patient Outcomes and Nurse Education)`

18. Hwang et al.

(2009)

(Seoul, Korea)

A cross-sectional

survey was

conducted.

The

participants

were

comprised of

693 nurses at

three general

hospitals in

Jinan, People's

Republic of

China and 593

nurses at two

general

hospitals in

Seoul, Korea

To compare the factors

influencing job satisfaction

among Korean and Chinese

nurses.

Professionalism was the common factor

influencing job satisfaction in Korean

and Chinese nurses.

Professionalism was

positively related to job

satisfaction

19. Kubsch et al.

(2008)

(USA)

Online survey

developed by the

researchers tested

perceived

professional values

n=198

Compared perceptions of

professional values of 198

RNs according to their

level of nursing education

and other potentially

influential factors.

A significant difference was found in

perceived professional values according

to level of nursing education, position or

title, and professional organization

membership.

Significant association

between the level of

education and

professionalism.

Author(s)/year/

country

Method Sample Aim Results Key findings

20. Tanaka et al.

(2014)

(Japan)

A descriptive design n=1501 registered

nurses

To examine the levels of

and differences in nursing professionalism.

Comparisons of the total

level of professionalism in

educational preparation,

current position, years of experience, and

current practice

The results revealed that Japanese nurses

had low levels of professionalism, and professionalism was related significantly

to higher educational preparation, years

of experience as a nurse, and current position as a nursing administrator or

faculty.

Higher educational

preparation and years of

experience as a nurse

were associated with high

levels of professionalism

21. Solomon et al.

(2015)

(Ethiopia)

Mixed method Data

were collected from

the study participants

using pre-tested

Likert scale type

self-administered &

In-depth interview

were held with 6 key

informants

n=332

registered

nurses

(survey) n= 6 (in-depth

interviews

To identify the relationship

between organizational

culture and nursing

professionalism in addition

to socio demographic,

personal and societal factor.

Self-image was a significant predictor of

professionalism score The overall result

indicated that slightly over 6% of the

variance in nursing professionalism

could be explained by self-image. Those

nurse who have positive self-image

scores 0.207 times more on

professionalism score than those with

negative self-image.

Organizational culture,

societal factors, personal

(education) factors were

associated with

professionalism

22. Ross et al.

(2009)

(USA)

A survey design. Critical care nurses

from 10 Critical

Access Hospitals.

To determine the influence

of registered nurses'

certifications and years of

experience on comfort level

in emergencies

Number and type(s) of certifications and years of experience as an RN were

associated with higher comfort levels.

Number and type(s) of

certifications and years of

experience as an RN were

associated with higher

comfort levels. 23. Friese et al.

(2008)

(USA)

Quantitative survey

of nurses and

aggregated to the

hospital level.

n= 25,957 To examine the effect of

nursing practice

environments on outcomes

of hospitalized cancer

patients undergoing surgery

Receipt of care in National Cancer

Institute-designated cancer centers

significantly decreased the odds of

death, which can be explained partly by

better nurse practice environments

The practice environment

of registered nurses was

significantly associated

with surgical outcomes

for cancer patients.

A total of 23 primary research papers were selected for the present review. The majority of

the studies were found to explore the impact of degree education on patient outcome from

a quantitative perspective. Most of the studies utilised the quantitative methodology

(n=22), only one paper (Solomon et al., 2015) used a mixed-methods approach. In

addition, the country of origin is included to highlight the fact that few studies emerge

from Europe, by comparison with those from the USA. The table summarises the methods

used in the selected papers, sample size and how data were analysed. These articles will be

further discussed within four key areas:

 Study aims;

 Sample;

 Method; and

 Results.

3.3.5.1 Study aims

The aims of 19 studies focused on the relationship between degree nurse education,

hospital nurse staffing and health outcomes of the patients. Four of the studies examined

the relationship between nursing education and professionalism (Kubsch, Hansen, &

Huyser-Eatwell, 2008; Hwang et al., 2009; Tanaka et al., 2014; Solomon et al., 2015).

These four studies also investigated if professionalism was related to health outcomes of

the patients and nursing job satisfaction. Further, factors that were related to

professionalism were explored in these studies. Only one study (Solomon et al., 2015)

used a mixed methods approach when investigating the relationship between

organisational culture and nursing professionalism. Solomon et al., (2015), also explored

whether personal factors, which included level of education, was associated with

professionalism.

Five of the studies (Estabrooks, Midodzi, & Cummings, 2005; Friese, Lake, Aiken, Silber,

& Sochalski, 2008; Kanai-Pak, Aiken, Sloane, & Poghosyan, 2008; Aiken et al., 2011,

2014) also investigated the impact of the work environment and patient outcomes. For

instance, Aiken et al. (2011) specifically examined if decreasing the workloads of the

nurse or decreasing the ratio of nurse to patient could help reduce mortality risk within

hospital settings. In addition, the study investigated if the nurse to patient ratio was related

to the level of nursing education of the nursing staff. In Aiken et al. (2014), a further

assessment was undertaken on nurse to patient ratio and educational qualification of nurses

from nine European countries. Friese et al.'s (2008) study examined the practice

environments of the nurses and how these influenced health outcomes of cancer patients

who underwent surgery. Similar to the study of Friese et al., (2008), Kanai-Pak et al.

(2008), investigated how nurse inexperience and work environments influence the quality

of care received by patients in the hospital setting. The quality of work environment and

patient outcomes was also examined in Estabrooks et al., (2005).

All of the studies included in the present review presented clear aims. This is crucial when

appraising the quality of the studies. Polit and Beck (2013) explain that clearly presented

aims would inform the readers and other healthcare practitioners whether the study is

worth reading and if results could be applied to their local practice. All articles included in

this review were relevant to the present study since all focused on the impact of degree

nursing education. It is noteworthy that all retrieved studies were not conducted in Middle

Eastern countries and more specifically SA abroad. The main aim of the present review is

to examine the influence of nursing degree education on nursing workforce planning in

Saudi Arabia. However, there is still a paucity of qualitative studies on degree nurse

education in Saudi Arabia’s healthcare system and/or how this may correlate with patient

care, health outcomes and patient safety. As part of evidence-based care, using results

from published studies undertaken in other countries could help inform current nursing

practice and workforce planning in Saudi Arabia. Greenhalgh (2014) explains that findings

from quality published studies could be used to inform practice, policies and healthcare

planning. It should also be noted that there is also a paucity of literature on how nursing

degree education could influence nursing workforce planning in a particular country.

However, using available evidence from the studies retrieved for the present review could

increase the knowledge of policymakers regarding the impact of raising education levels of

nursing staff.

3.3.5.2 Sample

Study samples were drawn from registered nurses in different fields of nursing practice.

Fifteen of the studies recruited participants or examined nursing records from the US

(Dunton, Gajewski, Klaus, & Pierson, 2007; Friese et al., 2008; Kubsch et al., 2008;

Bobay, Gentile, & Hagle, 2009; Dellon, Lippmann, Galanko, Sandler, & Shaheen, 2009;

Ross & Bell, 2009; McHugh & Lake, 2010; Aiken, Clarke, Sloane, Lake, & Cheney, 2008;

Aiken et al., 2011; Kendall-Gallagher & Blegen, 2009; Kendall-Gallagher et al., 2011;

Kutney-Lee, Sloane, & Aiken, 2013; Blegen, Goode, Park, Vaughn, & Spetz, 2013; Spetz

& Bates, 2013; Yakusheva, Lindrooth, & Weiss, 2014). One study was conducted in

Ethiopia (Solomon et al. 2015), one in the UK (Park et al. 2007) and another study was

undertaken in Korea (Hwang et al., 2009). Two studies from Japan (Kanai-Pak et al., 2008;

Tanaka et al., 2014) and another two studies from Canada (Estabrooks et al., 2005; Sales et

al., 2008) were included in this review. Meanwhile, the study of Aiken et al., (2014) used

in-patient records and observations of nurses from nine countries in Europe.

The majority of the studies included in this review recruited a relatively large sample of

nurses or used a large number of nursing records and observations from different

countries. For example, the retrospective observational study of Aiken et al., (2014) used

26,516 nursing records from nine European countries and 442,730 In-patient records.

These very large sample sizes could reduce sampling and reporting biases (Polit & Beck,

2013). This also suggests that findings from other healthcare settings could be used to

inform practice. Since the samples were taken from observations of nurses and patient

records in nine countries, this would enhance the generalisability and transferability of the

findings to a more heterogeneous group of patients and nurses (Parahoo, 2014). Secondary

data analysis was also evident in Kendall-Gallagher, Aiken, Sloane, and Cimiotti (2011),

which used 28,598 patient data to examine if the proportion of staff nurses with specialty

certification was associated with 30-day mortality risk of patients undergoing surgery. In

another study led by Aiken et al., (2009) data from 232,342 surgical patients and 10,184

nurses from 168 hospitals in Pennsylvania, USA were used to analyse if nursing staffing

and education were associated with patient outcomes. In Aiken et al., (2011) 272,783

nurses from four states in the US were recruited to the study to examine the impact of

nurse education on patient outcomes. Overall, the sample sizes of the studies included in

this review ranged from 29 to 272,783 registered nurses. Only the study of Solomon et al.

(2015) used a mixed methods design and recruited six key informants for the qualitative

part of their study. The very small sample size is appropriate for in-depth interviews since

a qualitative study does not aim to generalise findings to a larger and more heterogeneous

group of people (Bowling, 2014). Instead, smaller sample sizes would allow healthcare

practitioners to explore a research phenomenon in more depth and detail (Coughlan et al.,

2013).

While the studies reviewed provide important information for this study unfortunately

none involved participants from Saudi Arabia or countries from the Middle East. It is

argued that the socio-cultural context of the nurses in Saudi Arabia could differ from those

in the US, Japan, Korea, UK, Ethiopia, Canada and Europe. Although this could be

identified as an a limitation, it is noteworthy that the relatively large sample sizes of these

studies would reduce sampling bias. This suggests that healthcare practitioners and

policymakers in Saudi Arabia could use information from these studies in understanding

how nursing education could influence health outcomes of the patients and

professionalism. Results of these studies could also be used in nursing workforce planning

in SA.

3.3.5.3 Method

A majority of the studies used cross-sectional surveys. Cutcliffe and Ward (2007)

emphasise that a cross-sectional survey would allow researchers to randomly or

purposively select a representative sample from the target population of a study. While

generalisability of the findings of a survey may be considered a limitation, this concern is

addressed when there is random sampling and recruitment of a relatively large sample size

(Bowling, 2014). Most of the studies reviewed, which were conducted in several large

hospitals, recruited a relatively large sample size. It is also important to examine if the

survey has a high response rate, as this would indicate that the study is important to the

respondents or is easy to administer amongst the participants (Ellis, 2013). The majority of

the studies reviewed had a response rate of more than 30%, considered appropriate for

surveys (Polit & Beck, 2013). However, one of the limitations of a survey is the risk of

reporting bias (Creswell, 2013). Participants may choose not to disclose their actual

practice in healthcare settings (Greenhalgh, 2014). In the studies reviewed, the risk of

reporting bias was reduced, as responses of the participants were correlated with other data

such as, patient records and incidence of hospital infection or 30-days mortality.

In some studies, (Kubsch et al., 2008; Hwang et al., 2009; Tanaka et al., 2014; Solomon et

al., 2015), the level of education of the nurses was correlated with their degree of

professionalism. Most of the questionnaires used to measure professionalism were

developed from previous studies. For example, in Hwang et al., (2009) the study authors

developed the questionnaire on professionalism and nursing job satisfaction from results of

previous studies. The questionnaire was piloted amongst selected participants for

reliability and internal consistency. Following the pre-testing of the questionnaire, it was

revised using expert opinion and re-tested. This is crucial since validity of each scale used

in the questionnaire would ensure that questions used would measure professionalism

(Parahoo, 2014). Using Cronbach’s alpha Hwang et al.’s (2009) questionnaire scored

0.93, which indicated high reliability (Polit & Beck, 2013).

Meanwhile, seven studies, (Dunton et al., 2007; Friese et al., 2008; Sales et al., 2008;

Dellon et al., 2009 ; Kendall-Gallagher & Blegen, 2009; Kendall-Gallagher et al., 2011;

Yakusheva et al., 2014) carried out secondary data analysis using retrospective study

design. One of the benefits of a retrospective study design is the ease in gathering data.

Most studies using secondary data analysis retrieved data from electronic health records,

cancer registry or hospital records. A retrospective study is less expensive and faster to

carry out compared to a cross-sectional study (Creswell, 2013). Further, characteristics of

the respondents, which included level of nursing education, can be correlated with health

outcomes of patients (Creswell, 2013). However, it would be difficult to examine

confounding factors that might have influenced the outcomes of the patients in the studies

since the outcomes have long occurred before the gathering of data (Ellis, 2013). Despite

this limitation, secondary data analysis enabled investigators to examine the relationship

between the level of education of the nursing workforce and general health outcomes of

the patients. The latter included 30-day mortality and incidence of hospital infections.

Only one study (Solomon et al., 2015) utilised a mixed methods study design. This type of

study design would help validate the findings of a survey with results of in-depth

interviews (Bowling, 2014).

Overall, the methods used in the studies included in this review were appropriate in

answering the studies’ respective aims and objectives. For instance, a survey is not only

economical but could record several characteristics, attitudes and knowledge of

respondents in a single setting (Coughlan, M., Cronin, P. & Ryan 2013). However, an in-

depth interview could help explore nurses’ perspectives on professionalism and how their

level of education influenced their professionalism. Further, an in-depth interview could

provide rich data that can be analysed into themes and used to answer research aims and

objectives (Ellis, 2013).

3.3.5.4 Results

Importantly, almost all of the studies investigating the relationship between knowledge and

patient outcomes, reported an inverse relationship between levels of education and

preventable hospital deaths or rates of complications, such as hospital infections

(Estabrooks et al., 2005; Dunton et al., 2007; Friese et al., 2008; Kanai-Pak et al., 2008;

Aiken et al., 2009, 2011, 2014; Dellon et al., 2009; Kendall-Gallagher & Blegen, 2009;

Kendall-Gallagher et al., 2011; Kutney-Lee et al., 2013; Blegen et al., 2013; and

Yakusheva et al., 2014). Only Sales et al., (2008) reported conflicting findings with the

majority of the studies included in this review. Sales et al., (2008) did not find a significant

association between registered nurse education and the mortality of the patients in ICU

settings. It could argued that the study of Sales et al., (2008) done in small setting, with

specialised and experienced nurses rather than level of education. However, results

suggested that there was significant association between increased registered nurse (RN)

staffing in non-ICU units and mortality risk. Increased RN staffing was statistically

significantly associated with a decrease in mortality risk of the patients in a non-ICU

setting. It would appear that nurses assigned to ICU settings have higher levels of

education and expertise. Hence, when an analysis was conducted on the levels of education

of ICU nurses and health outcomes of patients, it would appear the level of education

would not influence mortality risk of the patients. In contrast, RN staffing in non-ICU

settings would have a greater impact on mortality risk since some nursing staff might only

have an associate degree. Results of this study would suggest that levels of education of

the nurses could influence mortality risk of patients especially in non-ICU settings.

The level of education of the nurses also influenced their level of professionalism in four

studies (Kubsch et al., 2008; Hwang et al., 2009; Tanaka et al., 2014; Solomon et al.,

2015) clinical expertise in two (McHugh & Lake, 2010; Bobay et al., 2009) in two, and

comfort level in one (Ross & Bell, 2009). Increasing the proportion of registered nurses

was also associated with improvements in health outcomes (Yakusheva et al., 2014). When

an economic evaluation was performed, nurses who acquired higher levels of education

were more likely to enjoy higher compensation compared to nurses with associate degrees

(Yakusheva et al., 2014). Higher nursing education also translated to career promotion and

becoming an advanced nurse practitioner (Yakusheva et al., 2014).

3.3.6 Key Themes in the Literature

The review of the literature revealed the importance of nursing education and how it

translates to improving patient outcomes and mortality risk, and reduces complications in

hospital settings. Since the main aim of healthcare is to improve the quality of care through

reducing mortality risk and complications, investing in the education of nurses could help

improve the overall health outcomes of patients. When applied to Saudi Arabia’s

healthcare settings, introducing policies that would improve nurse education and allow for

continuing professional education for registered nurses could help progress positive health

outcomes for patients. Nurse workforce planning could include provisions that would

support registered nurses when taking graduate studies or allowing nurses with a Diploma

to pursue a BSN. Most of the literature reviewed in the present study also recommends

continuing health education for nurses in order to improve the nursing environment, and

promote professionalism and expertise amongst nurses. The key themes identified from the

literature are illustrated in Table 3-4.

Table 3-4: Key themes identified from literature

Country of

origin

Authors Key themes

United State

(USA) ; Canada;

Europe; Japan;

Estabrooks et al., 2005; Dunton et al.,

2007; Friese et al., 2008; Kanai-Pak et

al., 2008; Aiken et al., 2009, 2011, 2014;

Dellon et al., 2009; Kendall-Gallagher et

al., 2009, 2011; Kutney-Lee et al., 2013

Blegen et al., 2013; Yakusheva et al.,

2014.

Nursing education is

associated with improved

patient outcomes.

Sales et al. 2008. No association between BSN

education and mortality rate.

Japan; Seoul,

Korea; USA.

Kubsch et al., 2008 ; Hwang et al. 2009;

Tanaka et al., 2014; and Solomon et al.,

2015; Bobay et al., 2009; McHugh &

Lake, 2010

Nursing education as

correlated with

professionalism and clinical

expertise.

Ethiopia; UK;

USA.

Ross and Bell (2009); Park et al. (2007);

Spetz and Bates (2013).

Nursing education promotes

career and economic

development of nurses.

The following section will discuss three key themes shared by the studies identified in

Table 3-4; (1) nursing education is associated with improved patient outcomes; (2) nursing

education is correlated with professionalism and clinical expertise; and (3) nursing

education promotes career and economic development.

1- Nursing education is associated with improved patient outcomes

Specific patient outcomes highlighted in the reviewed studies included reducing the 30-day

mortality risk and complications. For example, Blegen et al., (2013) demonstrated that

hospitals with higher proportions of nurses with BSN degrees had lower rates of mortality,

deep vein thrombosis and/or pulmonary embolism, hospital-acquired pressure ulcers and

infection due to medical care. Blegen et al., (2013) is one of the first studies to suggest that

apart from reducing mortality risks, increased BSN education has other beneficial effects.

While Blegen et al.'s (2013) study focused only on patients with congestive heart failure,

the rest of the studies reviewed indicated higher education levels were associated with

better health outcomes for different groups of patients The rest of the studies included in

the present review suggested that higher education levels were associated with better

health outcomes for different groups of patients (Estabrooks et al., 2005; Dunton et al.,

2007; Friese et al., 2008; Kanai-Pak et al., 2008; Aiken et al., 2009, 2011, 2014; Dellon et

al., 2009; Kendall-Gallagher & Blegen, 2009; Kendall-Gallagher et al., 2011; Kutney-Lee

et al., 2013; Blegen et al., 2013; Yakusheva et al., 2014).

It should be noted that these studies were conducted in multiple hospital settings across

different countries in Europe, the US, Japan, Canada, Ethiopia and Korea. Results were

consistent in demonstrating increased nursing education could lower mortality rates of

patients and improve health outcomes. Only study Sales et al., (2008) suggested that

improving nursing certification could have more impact in non-ICU healthcare settings

compared to ICU settings (Sales et al., 2008). When applied to Saudi Arabia’s healthcare

setting, increasing the education level of practicing nurses could promote positive patient

outcomes.

The majority of the studies also suggest a higher ratio of registered nurses could lead to

positive health outcomes of the patients. For instance, hospitals employing a higher

proportion of registered nurses with BSN degrees had lower failure to rescue, 30-day

mortality and cardiac deaths (Blegen et al., 2013). Similarly, Aiken et al., (2011)

demonstrated that regardless of work environment or type of patients admitted to hospital

settings, increasing the BS nursing workforce by 10% would reduce mortality risk by 30-

days mortality risk. Aiken et al., (2014) also indicated that preventable hospital deaths

would be reduced by 7% if 60% of the nursing workforce had BS degrees. It should be

noted that the studies carried out by Aiken et al. (2011, 2014) were conducted in the US

where nurses could practice with associate or BS degrees. When applied to Saudi Arabia’s

healthcare setting, the findings of Aiken et al., (2011; 2014) would suggest the hiring of

nurses with BSN would be more beneficial compared to hiring nurses with only associate

degrees.

2- Nursing education as correlated with professionalism and clinical expertise

Four studies (Kubsch et al., 2008; Hwang et al., 2009; Tanaka et al., 2014; and Solomon et

al., 2015) investigated the association between nursing education and professionalism and

clinical expertise. These studies also correlated clinical expertise and professionalism with

health outcomes of the patients. Tanaka et al. (2014) reported higher educational

preparation and years of experience as a nurse were associated with high levels of

professionalism. Importantly, higher levels of professionalism were associated with

increased job satisfaction (Hwang et al., 2009). While the study of Hwang et al. (2009)

recruited Korean and Chinese nurses, the findings of this study have important

implications in Saudi Arabia’s nursing environment. The results of Hwang et al.'s (2009)

study indicate that raising the level of professionalism could help retain nurses due to

higher job satisfaction. It has been noted previously that job dissatisfaction amongst nurses

could result to high nursing turnover (Hwang et al., 2009). Hence, when conducting

nursing workforce planning, policymakers should also consider how to retain nurses. High

turnover of nurses could result to poor patient care and poor health outcomes (Hwang et

al., 2009). Hence, increasing the levels of education of the nurses could be one way of

reducing nursing turnover (Collier & Harrington, 2008).

This review also shows that clinical expertise is crucial in promoting positive health

outcomes for patients (Bobay et al., 2009; McHugh & Lake, 2010). Interestingly, Bobay et

al., (2009) found that non-mandatory continuing education was significantly associated

with higher perceived levels of clinical expertise. Bobay et al., (2009) also acknowledged

that apart from educational preparation, years of experience as a registered nurse, is

associated with clinical expertise. In SA, institutionalising continuing professional

education, which would include pursuing higher education, could help raise the clinical

expertise of the nurses. In turn, this could improve patient outcomes.

3- Nursing education promotes career and economic development of nurses

The results of this systematic review also demonstrate that nursing education is not only

associated with clinical expertise, professionalism and improvements in patient outcomes

but also with personal outcomes for the nurses. Nurses would appear to be more confident

and comfortable in providing care to their patients if they have earned more certifications

on nursing care (Ross & Bell, 2009). The benefits extend beyond feelings of comfort, to

career development. In a UK study, (Park et al., 2007), satisfaction in nursing careers was

associated with specialisation of careers and obtaining advanced nursing degrees. Nurse

motivation also increased with promotion and career advancement (Park et al., 2007). The

impact of nursing education also results to higher earnings. Spetz and Bates (2013) explain

that higher nursing education translated to higher earning potential and actual lifetime

earnings, especially if nurses completed a BS nursing degree compared to an associate

degree. However, this review did not investigate factors that might facilitate or hinder

nurses from pursuing higher degrees. Family obligations or personal circumstances might

deter or promote nurses from pursuing higher degrees (Spetz & Bates, 2013). Employers

of nurses could also have an important role in influencing the educational decisions of the

nurses. Spetz and Bates (2013) suggest that some nurses might not pursue higher education

if they feel that there is a lack of support from their own employers.

3.3.7 Effectual impact upon patient care through degree education and experience

An increasing amount of evidence has begun to emerge that demonstrates the level of

beneficial abilities BSN graduates bring to the profession of nursing, which is thought to

enhance the care and safety of patients (Tourangeau et al., 2006; Tourangeau, 2006;

Kendall-Gallagher et al., 2011; Blegen et al., 2013; Fossen, 2014). Nevertheless, a

perpetual global challenge arises from the lack of qualified nurses, as a multitude of entry

levels persist in nursing practice, resulting in disparate educational levels for nurses.

Through the modern era, it has been suggested nurses should attain a minimum education

level of a Bachelor's degree that enables the expansion of knowledge, as educated nurses

within interdisciplinary healthcare teams irrefutably improve patient outcomes

(Tourangeau et al., 2006; Tourangeau, 2006; Kendall-Gallagher et al., 2011). Very few

studies exist that compare dynamics (influencing factors) within nursing, although there is

a growing body of research providing evidence of improved patient outcomes being

derived from better educated nurses (Fossen, 2014). For instance, lower mortality rates

within hospitals are linked to nurses who provide care possessing a minimum education

level of a BSN (Estabrooks et al., 2005; Tourangeau et al., 2006; Tourangeau, 2006; Van

den Heede et al., 2009; Yakusheva et al., 2014). Restricted evidence exists that

demonstrates patient outcomes being positively affected by nurses who are certified in

separate specialisations, even though more nurses have started to acquire these

qualifications. According to Fossen (2014) since nursing touches and addresses issues that

relate to the health of individuals, advancing to at least a BSN level gives sufficient insight

into the human physiological, psychological and social functioning that makes it easy to

address health matters that may affect them.

Kendall-Gallagher & Blegen (2009), in conducting a review of 279 adult patient charts in

29 different hospitals, found that a significant decrease in skin breakdown correlated with

higher proportion of nurses certified with a BSN. Another recent cross-sectional study

conducted by Blegen et al., (2013), aimed to examine the effect of registered nurse

education on patient outcomes. Data were collected from 21 University Health System

Consortium (UHSC) hospitals in the US, four quarter from each hospital. The results

concluded that there is a significant association between nursing education and patient

outcomes and that this goes further than considering mortality rates. Hospitals with high

proportions of nurses with a baccalaureate or higher level of education had lower rates of

mortality from CHF, Hospital Acquired Pressure Ulcers (HAPUs), postoperative Deep

Vein Thrombosis (DVT/PE), and reduced length of stay (Mary et al., 2013). However, the

study may be limited to generalisability due to the small sample size. In addition, the data

collected for their study were from 2005, and may not replicate the current level of

patients’ outcomes.

A separate cross-sectional analysis was conducted by Estabrooks et al., (2005) evaluating

the outcome for over 18,000 discharged patients from a total of 49 acute care hospitals in

Alberta, Canada between 1998 and 1999. The aim of the study was to assess the effects

and relevance of nursing education and abilities, together with the continuity of care and

the quality of the workplace environment. Hence, it was feasible to predict the 30-day

mortality possibilities following the adjustment of institutional factors and characteristics

of these individual patients, who were diagnosed with acute myocardial infarction,

congestive heart failure, chronic obstructive pulmonary disease, pneumonia, or stroke.

Overall, 44.2% of the month-mortality variance was explained by patients of a certain age

who suffered from multiple diseases. Subsequently, post-adjustment following the

comprehension of patient co-morbidities and demographics, as well as the defined format

of study and teaching for a fixed-effects model within hospitals, it became possible to

understand the significance of hospital nursing characteristics that assist in predicting 30-

day mortality rates, and how people rate their relevance. On average, higher nursing

education stood at 0.81, a full mix of nursing skills was at 1.26, and improved nurse-

physician relationships was relevant at 0.74. Therefore, in an effort to reduce 30-day

mortality risks for patients, nursing characteristic developments are seen as imperative

within hospitals.

However, certain studies cited in the previous discussion have incorporated factors that

indicate conflicting findings in regards to baccalaureate preparation. Two individual

studies reported positive evidence in the mortality rate, relationship and baccalaureate

attainment levels of nursing staff. It was determined that mortality rates were decidedly

lower when care was delivered by baccalaureate-educated nurses (Estabrooks et al., 2005;

Blegen et al., 2013). Overall, throughout the previous two decades, there has been

increasing attention on how patient mortality and survival rates are impacted by the

nursing care provided within the hospital setting. Nevertheless, inconsistent knowledge

into hospital structures impacts on the quality of patient care and this topic is perhaps

worthy of further investigation.

One specific longitudinal, retrospective, two-stage panel study was designed to incorporate

a cross sectional sample of three sources of data collected between 1999 and 2006

(Kutney-Lee et al., 2013). These data sources were administrative patient discharge

information, a nurse survey and the Annual Survey from the American Hospital

Association. The study examined a possible correlation between patient outcomes and

nursing education within 134 clinical hospitals. It was ascertained that for every 1,000

patients an average 2.12 deaths were reduced as a direct connection to the 10%

advancement in hospitals that employed baccalaureate educated nurses, as well as a

reduction average of 7.47 deaths for a sub-group of patients who had experienced

complications. Consequently, Kutney-Lee et al.'s (2013) research highlighted a progressive

marked decline in fatal surgical outcomes directly correlated to hospitals employing

baccalaureate-qualified nurses. Unfortunately, due to the limitations of the study, namely

being carried out in only one state, the research findings are not generalizable to national

or global situations.

Aiken (2010) examined the connection between registered nurses who possessed specialty

certification and their effect on the risk adjustment outcomes of about 1 million discharged

adults, who received orthopaedic and vascular surgery in non-federal hospitals in

California, Florida, New Jersey, and Pennsylvania. Findings indicated that those who have

speciality certifications were more likely to neutralise risks and enhance adjustments

following this type of surgery. This implies that attaining speciality education can

positively impact on risk adjustment outcomes (Aiken, 2010). Historically, through expert

and collaborative nursing practice, the specialty certification for a registered nurse is

believed to actively advance patient outcomes, as it constitutes a demonstration of defined

clinical knowledge that is acquired through both formal education and experience

(Kendall-Gallagher & Blegen, 2009).

It is eminent that within the modern, complex and rapidly changing healthcare

environment it is imperative to adequately inform nursing officials, educators and

policymakers of the available evidence in order to provide efficient and beneficial

educational strategies. As a consequence of taking such action, a competent nursing

workforce can be instilled, who will have the necessary knowledge and skills to deliver

excellent patient care.

The evidential correlation between nurse educational levels, particularly BSN and above,

and patient health outcomes has been demonstrated by nursing research literature. Reduced

hospital mortality rates, reduction in length of stay, less medication errors and procedural

violations have been shown to be associated with better educated nurses, especially when

they had studied to baccalaureate level (Estabrooks et al., 2005; Tourangeau et al., 2006;

Tourangeau, 2006; Kendall-Gallagher & Blegen, 2009; Kendall-Gallagher et al., 2011;

Aiken et al., 2011; Blegen et al., 2013; Kutney-Lee et al., 2013; Blegen et al., 2013).

Furthermore, these findings were not limited to the USA, but have been found in various

countries and nursing specialties (Estabrooks et al., 2005; Tourangeau, 2006; Friese et al.,

2008; Aiken et al., 2009 ; Van den Heede et al., 2009; Aiken et al., 2014).

Nursing and professionalism

Nursing professionalism is defined as the knowledge, skills, behaviours, and values

required for nurses to be registered (Veenema et al. 2016). According to Tanaka et al.

(2014), professional practice in nursing includes commitment to compassion, caring,

accountability, individual responsibility, collaboration and ethical values and believes.

Nurses have established educational and practical standards and nursing professionalism in

is a great demand within the healthcare system (Tanaka et al., 2014).

However, professionals within healthcare have considered various approaches to rectify

the shortage of nurses educated to deliver a high standard of care. The challenges facing

contemporary nursing are to improve education levels, with the potential for determining

the baccalaureate degree as a prerequisite to practice entry. For instance, the National

Council of State Boards for Nursing in the U.S. has reported that around 66% of associated

degree courses are attended by new nurses, while in Canada it is a requirement for all

nurses to hold a baccalaureate degree. Likewise, advanced collaboration from funding

bodies to university boards has been stated as imperative in the dynamic process of

addressing the issue of educational capacity. This is evident in New Zealand as

Committee on Inter-Institutional Cooperation, as it collaborates to enable the institutions to

share faculties, curriculum, simulation technology, sites for clinical placement, and

application portals (Cleary et al., 2009). Furthermore, scholarships for hospitals and

faculty loans have been procured, together with successful foundation funding partnerships

between organisations and government bodies within the private sector (Cleary et al.,

2009). It is an impetus for policy makerss, nursing boards and HE institutions to come

together to collaborate to ensure nurse education is delivered at degree level.

In western countries, the nursing students are seeking to be professionals by attending

higher education, for example, obtaining a degree and specialisation in their chosen aspect

of nursing; these elements have been reported a priority within research on BSN graduates’

aspirations, career progression and job satisfaction. A study by Park et al. (2007) that

involved a sample of bachelor nursing students graduating between 1994 and 2000, found

a strong focus on getting promotion, gaining experience and further specialisation.

Rambur, McIntosh, Palumbo, and Reinier (2005) claim that BSN nurses have a higher

degree of professionalism than others with a lower level of education; their ‘RN Job

Analysis and Retention Study’ indicated their findings were lined to social return on

educational investment. A large cross-sectional survey was conducted by (Hwang et al.,

2009). The study aimed to compare different factors influencing job satisfaction among

nurses. The study included a sample of 693 Chinese nurses and 593 Korean nurses. The

results indicated a significant correlation between levels of education and levels of

professionalism. Furthermore, Kubsch et al. (2008) compared perceptions of professional

values of 198 registered nurses, according to their level of education and other influential

factors. The study found RN-BSN nursing student demonstrated a higher rate of

professionalism than other students.

Nursing and experience

A number of studies looked at the concept of ‘years of experience’ being a factor in

delivering better health outcomes. For example, this notion could be considered akin to

research on the number of accidents involving inexperienced drivers, compared with those

with a lot of experience. Obviously, experience allows a driver to develop key skills.

However, when it comes to nursing, and nursing experience, the research does not show

such clear results. While studies do concur that inexperienced nurses are less likely to

detect complications (Dellon et al., 2009), it is a common theory that nursing expertise

develops best with continued exposure to experiential learning (Dunton et al., 2007; Bobay

et al., 2009).

Bobay et al. (2009) in a cross sectional analysis of data from 8,611 registered nurses (RN)

that aimed to determine the relationship between nurse experience and education with

other hospital contextual factors with the level of clinical expertise found a significant

correlation between experience as an RN nurse with an initial level of expertise. Another

study conducted by Dunton et al. (2007) aimed to review eight of the total 25 quality

indicators from the National Database of Nursing Quality Indicators (NDNQI). They

identified a decrease in the fall rate by one percent for every increase in year of nurse

experience. Furthermore, the same study highlighted a decrease of hospital acquired

pressure ulcers of 1.9% for each year of nurses’ experience (Dunton et al. 2007).

Research on the impact of experience on nursing practice and medical error generally

considers a nurse to be ‘expert’ after having completed five years of clinical experience

(Orsolini-Hain & Malone, 2007; Dellon et al., 2009). McHugh & Lake (2010) identify

these nurses as those that will stand out among others by being able to make critical

decisions and, at the same time, grasp the nature of a situation as a whole; they are also

able to recognise potential problems and alert the necessary people to them before they

occur. These characteristics mean that less time is wasted and, essentially, the level of

patient care is improved (McHugh & Lake, 2010). Expert nurses also act as educators for

less experienced nurses and are often consulted and relied upon for help.

However, it is important to consider the difference between experience and expertise; these

are two related but entirely different concepts. Experience is necessary to become an

expert, however it is not enough alone to class a nurse as an expert; therefore, not all

experienced nurses will be experts (Christensen & Hewitt-Taylor, 2006; Ericsson, Whyte,

& Ward, 2007). Although, it is clear that the repetition and continuous exposure to practice

that comes with experience is essential for establishing critical thinking and developing an

idea of judgment, we cannot tell exactly how much of an impact this actually has on

patient outcomes. In attempting to define a number of years of practice, related to the

outcomes for patients, a number of factors obscure the results; these include technological

changes, which have resulted in a number of errors. These changes, along with information

updates and organisational demands mean that health care professionals need to be

continuously seeking further education and expanding their knowledge in order to adapt.

For example, research conducted by Kanai-Pak et al. (2008), highlights hospitals where

50% of the nursing workforce were inexperienced (less than 4 years of practice) reported

the probability of job dissatisfaction, poor-to-fair quality of care and staff burn-out to be

twice as high when compared to those with considerably less experience and lower

educational attainment. Most evidence indicates that nurses and midwives with more years

of experience are more skilful and knowledgeable than others.

Nursing and Education

McHugh & Lake, (2010) state that it is theory and principles that give nurses the tools to

know which questions to ask, to easily identify patients’ problems and to provide quality

care by making the right decisions. Although there is little research that looks specifically

at the educational composition of staff in relation to individual clinical nursing expertise, it

is suggested that the level of education of a group of staff would contribute to the

development of expertise in a clinical setting (McHugh & Lake, 2010; Blegen et al., 2013).

Following research results showing the positive effect of higher educational levels on

patient care, the recommendations of the Institute of Medicine (2011) are concerned with

increasing the percentage of staff with a BSN qualification to 80% by 2020. This research,

as discussed earlier, has been highlighted in the literature and can be associated with a

decrease in failure to rescue and mortality rate (Estabrooks et al., 2005; Tourangeau, 2006;

Friese et al., 2008; Van den Heede et al., 2009; Aiken, 2010; Kendall-Gallagher et al.,

2011; Aiken et al., 2014).

This was confirmed in a more recent, cross-sectional study conducted across 21

universities from 84 quarters of quality data that analysed the association between RN

education and patient outcome (Blegen et al., 2013). Further to this, significantly lower

rates of congestive heart failure mortality, deep vein thrombosis, and length of hospital

stay were noted.

Furthermore, a cross-sectional analysis of data collected from 6,611 nurses conducted by

McHugh & Lake (2010). The study revealed that the composition of hospital staff,

concerning the proportion of nurses with a minimum BSN level of education, had a direct

correlation with the number of nurses at a more advanced level of expertise. The results of

this study suggests working in a hospital context can significantly influence clinical

nursing expertise. The generalisability of the results of McHugh & Lake's (2010) study is

subjected to certain limitations. For instance, the data sourced is dated 1999 and only

represents nurses in Pennsylvania; these factors mean that the findings cannot be easily

generalised and it must be considered that the information sourced could be a little

outdated, due to variances over time.

The results of research into the relationship between nursing experience and patient

outcomes were inconsistent. When it comes to studies that considered the effects a nurse’s

level of education had on patient care, there are few identified with the majority of the

research exploring 30-day mortality and failure to resuscitate (Estabrooks et al., 2005;

Tourangeau, 2006; Van den Heede et al., 2009; Aiken, 2010; Aiken et al., 2014). The

research in this area is not only minimal, but also quite specific. For instance, there is only

two study that looks into multiple nurse characteristics to determine their effect on patient

sensitive outcomes (Kendall-Gallagher et al., 2011). This research provides valuable

information on how individual nurse characteristics might influence each other and how

these influences are then transferred to patient care.

In both types of research, concerning the relationship between nurse education or nurse

experience and patient outcomes, studies were conducted in speciality units, such as

oncology or intensive care, and could have been more generalizable had they covered a

broader range of illnesses (Kendall-Gallagher & Blegen, 2009; McHugh & Lake, 2010;

Kendall-Gallagher et al., 2011).

Overall, a significant association between the education of nurses and patient outcomes

was found (Tourangeau, 2006; Tourangeau et al., 2006; Van den Heede et al., 2009; Aiken

et al., 2011; Kendall-Gallagher et al., 2011; Blegen et al., 2013; Aiken et al., 2014).

However, there were two studies contradicting this that concluded that there was no

correlation between BSN education and improved patient care (Sales et al., 2008; Bobay et

al., 2009).

3.4 Summary and Conclusion

In summary, the nursing profession, on a global level, is experiencing a number of

difficulties, most notably being short staffed and this resulting in the employment of under

qualified nurses. In addition, a large number of potential students are not accepted onto

programmes due to strict entry requirements. These concerns present a particular challenge

for SA where the situation is severe and many potential nurses are discouraged by the

social stigma surrounding the profession. The introduction of the BSN as a minimum

requirement has shown positive results but also presents problems considering the time it

will take to ensure that all nurses are educated to this standard.

This chapter has considered the challenges for the nursing profession on an international

level and, more specifically, in SA. The literature review has highlighted a number of key

themes discussed in two sections:

First section; most notably there appears to be some issues related to the nursing workforce

in SA: these have been categorised under educational, system, and social headings.

 Educational issues include the fact that many nursing personnel do not hold a

Bachelor of Science Nursing degree and this lack of education for nursing staff is a

hindrance in providing high quality nursing care to the patients who need an

advanced level of nursing.

 System problems involve reassessing policies and regulations related to nursing

along with the turnover and retention rate of nurses.

 Social issues include the working environment involving the gender ratio, long

working hours, job dissatisfaction and low wages, as these factors are a cause of

the high turnover rate, as well as reinforcing the social image of nursing practice.

The second section of this chapter demonstrated a correlation between the number of BSN

trained nurses and an improved level of patient care. These have been categorised under

the following key themes:

 Nursing education is associated with improved patient outcomes.

 Nursing education is correlated with professionalism and clinical expertise.

 Nursing education promotes career and economic development of nurses.

This literature review has revealed the importance of nursing education and how this

translates into improvements in patient outcomes, for example reducing mortality risk and

complications in hospital settings. Most of the literature reviewed in the present study also

recommends degree education for nurses in order to improve nursing care, promote

professionalism and enhance expertise amongst nurses.

The following chapter will detail the philosophical rationale and methodological approach

for the study, including the sampling criteria, data synthesis, trustworthiness, and ethical

considerations.

Chapter 4 : Methodology

4.1 Introduction

The previous chapter critically reviewed the available evidence related to degree education

as it relates to nurse workforce planning and explored the effectual impact of degree nurse

education on quality of care, presenting the reader with the key themes. This chapter will

introduce the case study method which was used to examine the implications of a degree

as the minimum requirement for nurse practice in Saudi Arabia. First and foremost, an

overview of the philosophical rationale is offered, considering methodological approaches

including a discussion on qualitative and quantitative methods. A justification for the use

of case study methodology as an appropriate choice for this research is provided. The

chapter also includes a description of macro, meso, and micro theory/framework which

were used in this research together with an explanation of the data collection process,

analysis, and ethical considerations; with a particular focus on what the research considers

the implications at all levels, from the MoH to selected members of staff employed in

public hospitals.

4.2 Philosophical Rationale

This section aims to explore the researcher’s perspective of the ontology, epistemology,

and methodology that underpins this study. It is important to consider such philosophical

positions to help answer the research questions of ‘why’ and ‘how’ in order to develop a

strong understanding of the nature of reality and how that reality can be known (Creswell,

2003).

Ontology is the sum of beliefs that reflect an individual’s interpretation about what

constitutes a fact (Phillimore & Goodson, 2004). It is associated with the central question

of whether social entities need to be perceived as objective or subjective. However, my

Islamic cultural background has shaped my personality. The values, beliefs, and education

that I carried inspire me to see reality from a different perspective. This, combined with

my experience as a practising nurse, has underpinned my ontological position and given

me the power to choose the appropriate situation and method. Ontology is explained as the

study of the existence of reality (Hudson & Ozanne, 1988).

Epistemology, on the other hand, explores the interconnection between the researcher and

the existence of facts (Phillimore & Goodson, 2004), or the way in which it is acquired or

established. Epistemology is the study of the fact and scope of existing knowledge

(Reimer-Kirkham et al., 2009). Phillimore and Goodson, (2004) state that the

epistemological stance an individual adopts indicates their beliefs on world knowledge and

how this is acquired. The epistemology of this case study approach is formed in the

context of the argument that “there are multiple realities integrated into the form of

multiple constructs” (Guba & Lincoln, 1994: P. 110).

However, these two key philosophies have different assumptions. Firstly, a reality exists

that is detached from our awareness and on which the basis of our existence is created or

developed, resulting in the term of foundationalism. Secondly, that reality does not exist,

but rather an existence is both indirectly and socially constructed, which is consequently

determined by a specific culture, event, or period in time (Guba & Lincoln, 1994).

Thus, to determine the meaning of individual events, the constructivist approach is used,

which also helps in understanding the events in relation to their reality. According to

Denzin and Lincoln (2011) the constructivist approach provides the researcher with an

opportunity to attain knowledge regarding the reality of the event, and it also provides the

researcher with insight into the possible solutions for the issues (Baxter & Jack, 2008).

This paradigm supports the use of the qualitative method to explore the different views of

participants at three levels of an organisation (macro, meso, and micro). Furthermore, this

approach does not look at the meaning of the event from an outside perspective; instead, it

requires the researcher to gain in-depth knowledge, as understood by the participants

(Rodwell, 1998). Therefore, it is very important for me as a researcher to understand the

multiple realities, relating to the issue under exploration, from the perspective of the

participants. The reality, in context, is degree education as a minimum entry requirement

for nursing practice in SA, which will be analysed by taking a contextualised view of the

existing policy and putting into practice this important decision for the future nursing

workforce.

However, having an appropriate research question is an essential element in selecting the

research methods and methodology (Creswell, 2003). The path the research takes is

prejudiced by the position of the researcher in relation to their philosophy about scientific

knowledge and truth. Therefore, to select an appropriate research method for this study, it

was first necessary to contemplate my own philosophical position in relation to research,

evidence and knowledge. Smith (2001); Polit and Beck (2013) claim that this is imperative

for three reasons. Firstly, it permits the researcher to select the most appropriate

methodology to conduct the investigation; secondly, it permits the evaluation of other

methodologies helping to avoid any incongruous selection and superfluous work; and

finally, it may inspire the researcher to go beyond their aforementioned level of experience

to try new tactics within their research. Procto (1998) supports this opinion by stating that

uniformity between the objectives of the research, the research questions and methods

selected and the philosophy of the researcher is essential to any research project.

The previous discussion provides the philosophical rationale from ‘my view’, on the

ontology and epistemology stance that underpins this study. It is important to consider

such a philosophical perspective to help answer the research question in order to develop a

strong understanding of the situation under study. The following section discusses the

methodological approach in general and the case study in particular.

4.3 Methodological Approach

Research methods are professional techniques that are used to structure, collect and

analyse the data relating to the research question (Polit & Beck, 2013). There are two

different paradigms that have a significant implication for the research method: the

positivist and the relativist paradigms or quantitative and qualitative approaches (Polit &

Beck, 2013). These two paradigms have contrasting worldviews and assumptions about

reality (Creswell, 2013). They are, essentially, the two primary methodological approaches

that are actively seeking researcher recognition (Ellis, 2013). In seeking to identify causal

factors or indeed generate scientific rules, they do not solely allude to the concept of

natural science in their ontological and epistemological theories but utilise an identical

approach a suggested by Phillimore and Goodson (2004).

Ultimately, positivist methodology aims to compile and analyse numerical data, to prove a

single truth. The objective of this methodology is to provide explicit and precise casual

factors, which are indisputable, rather than trying to interpret the data (Polit & Beck,

2013). The main benefits of using this technique are (1) the study can be reproduced

without difficulty and (2) the findings are generalisable (Creswell, 2013). These qualities

are results of the purely statistical nature of the structured method of data collection (Polit

& Beck, 2013). Nevertheless, one of the typical objections cited against positivism is the

lack of clarity in interpreting the findings of, for example, surveys– the main one is

positivism does not take account of human experience and how human beings arbitrate

between their experiences (Creswell, 2013). The question arises as to whether this

criticism is justified, as the key elements of this method are concerned with the patterns of

cause and effect, rather than the significance of these behaviours (Creswell, 2003). While it

is obvious that the methods used when undertaking positivist research are indeed scientific,

the concept of “objectivity” herein is not strictly maintained in this study.

Conversely, qualitative methods are typically used by relativists, interpretivists or

constructivists, in line with the ontological and epistemological stance of the researcher

(Procto 1998). Qualitative methodologies seek to establish the significance of social

conduct, which allows for a wealth of knowledge to be gathered (Ellis, 2013). Based on

the idea that all information requires analysis in order to provide contextual sense,

relativists employ various techniques including interviews, focus groups, case studies and

other methodologies to gain a more comprehensive understanding of the research area

(Yin, 2013). While, according to positivists the findings of qualitative research are not

reliable, valid and/or generaliseable, they do proved a deeper understanding from a human

perspective, as is the case with this study (Park, 1991).

The advantages and disadvantages of qualitative methods and the reason for accepting case

study as an appropriate method for this research are identified in Table 4-1.

Table 4-1: Advantages and Disadvantages of Qualitative Data Collection Methods

Methodological

Approach

(Qualitative)

Advantages of Method Disadvantages of

Method

Reason for

Accepting/Rejection

Method

Ethnography This approach is based on

the observation of an

occurrence. The

researchers study the

phenomenon and interpret

it according to the

participants’ perspectives

(Nurani, 2008). It does

not depend on on people

willingness to provide

information.

Vulnerable to

observe bias.

Hawthorne effect-

participant usually

perform better when

they know they are

being observed.

Does not provide

information to

understand why

people behave the

way they do.

I rejected this approach

because it focused on

the observation of

cultural and social

interaction in daily

lives. In addition, I

have a limited time for

data collection for my

research and this

method tends to take a

longer time to generate

and analyse data than

other methods.

Phenomenology

It studies structures of

conscious experience as

experienced from a

subjective or first person

point of view, along with

its intentionality.

It is challenging to

describe or interpret

phenomenon

according to its

context without bias

(Shi, 2013).

It is a more descriptive

approach. This

approach focuses on

describing the meaning

of phenomenon that all

participants have

experienced by using

in-depth interviews.

Grounded

Theory

Rigorous method that

facilitates theory

development. The

researchers do not make

use of available theories

to make sense of the data,

instead, interpretations

come from the data itself

(Hussein et al., 2014).

It is difficult for

inexperienced

researchers to collect

data based on the

budding theory.

High potential for error.

Researchers may end

up documenting

people’s experiences

without understanding

the social process.

Case Study Explains, describes or

explore phenomena in

everyday contexts (Yin,

2009). Observation of

phenomena occurs in its

natural context (Zainal,

2007).

Difficult to

generalise results due

to sample limitations.

Represent depth of

evidence rather than

breadth.

A case study allows me

to use multiple sources

of evidence that helps

to address a range of

behavioural and

historical issues (Stake,

2003; Baxter & Jack,

2008; Yin, 2013).

This used qualitative case study (constructivist approach) to investigate people’s personal

realities in order to gain insight into the effectiveness of degree nursing being a

requirement in SA and its implications in the reality of contemporary practice (Guba &

Lincoln, 1994; Yin, 2013; Polit & Beck, 2013). This approach is helpful when there is little

information about the research focus, or if it is not possible to distinguish the issues under

consideration from the participants’ context, or where it is important to determine how

issues are dealt with in the context of their surroundings (Park, 1991). Furthermore, this

approach is helpful in circumstances where interaction between the researcher and the

research participant is essential in order to better understand and draw conclusions about

the research focus (Rodwell, 1998).

4.3.1 Research Design

Research design assists in directing or pointing researchers towards the focus of their

studies. According to Joubish et al. (2011), a research design is the paste that glues all of

the components in a research project together. Yin (2009) identifies three conditions to be

considered when determining the appropriate research method:

1. The type of research question posed

2. The extent of control the investigator has over actual behavioural events; and

3. The degree of focus on contemporary as opposed to historical events.

The relationship between the three conditions and the related research methods (as

outlined in Table 4-2 determine the most suitable approach to use.

Table 4-2: Relevant Situations for Different Research Methods (Yin, 2009: P.8).

Method The type of research

question posed

The extent of control

the investigator has

over actual behavioural

events

The degree of focus

on contemporary as

opposed to historical

events

Experiment How, why? Yes Yes

Survey Who, what, where, how

many, how much?

No Yes

Archival

Analysis

Who, what, where, how

many, how much?

No Yes/no

History How, why? No No

Case Study How, why? No Yes

As Table 4-1 indicates, the relationship between the three conditions and the related

research methods determined the most suitable approach to use. In this instance a case

study was the most appropriate method to use with “how” and “why” questions that

require no control of behavioural events and a focus on contemporary events, which made

it a good fit for this study. Yin (2009) pointed out that “how” and “why” are more

explanatory in nature and are more likely to lead to the use of case studies. Furthermore,

Yin (2009) explains that case study survey entails planning, determining the study design,

resource gathering and allocation, data collection, analysis, and reporting. Although each

stage is distinct, it is linked to other stages as the processes are dependent on each other

and all affect or are affected by the research findings.

Yin (2009) makes a comparison between case study and other research methods. He

elaborates that the case study approach provides results showing how and explaining why

certain events happen the way they do. It is also the most applicable research method in

cases where the researcher has no power over the events. Yin (2009) advises the readers to

select data collection and analysis methods before embarking on the project.

Yin (2009) guides the researcher in choosing the most appropriate case study type

depending on the research goals, data gathering, and evaluation methods. After theory

development, the researcher also makes a catalogue of other hypotheses that may explain

the phenomenon. According to Yin (2009), this strengthens the research plan and validity.

The scholar may select holistic, single case, embedded or multiple case designs. Single-

case studies are chosen because they are critical, acute, and representative. During the

determination of the survey design, the author emphasises on the creation of a study pool

protocol as it affects the research findings.

Unlike other literature that only outlines information sources, Yin (2009) explains data

gathering principles such as the use of several sources, database development for future

use, and preserving a series of proof. The ideologies are necessary for research, as they are

associated with quality control. Scholars can increase the reliability of a study through

triangulation of results obtained from different data sources. Regarding reporting, the

author explains that an understanding of the audience determines the report’s language and

tone.

However, the implication of a degree nurse education policy required an in-depth and

extensive description within the context of the social-cultural phenomenon in SA. The case

study methodology, justification, and how it is processed for this thesis will be discussed

further in Section 4.4.

4.4 Case Study Methodology

A case study is a research methodology focused on gaining an in-depth understanding of a

particular phenomenon within a specific time. It is a popular approach among qualitative

researchers Case studies are commonly used in organisational studies, nursing and clinical

sites, across the social sciences and in other fields (Yin, 2013); and there is some

suggestion that the case study method is increasingly being used, with growing confidence,

as a rigorous research strategy in its own right (Stake, 2003). Robson (2002: P.146)

defined a case study as:

“A strategy for doing research which involves an empirical investigation of a

particular contemporary phenomenon within its real-life context using multiple

source of evidence”.

Case studies can also be used to explain, describe or explore phenomena in everyday

contexts (Yin, 2009). According to Yin (2013) a case study is comprised of five

components, and these are followed to structure this research: a study question; its

proposition (if any); its unit of analysis; the logic linking the data to the propositions; and

the criteria for interpreting the findings. In designing the inquiry, these components are

organised and consistent with each other. Extra attention has been given to the fourth and

fifth components focusing on the planning of the data collection and analysis, as

recommended by (Yin, 2009). In relation to these components, the relevant literature

regarding the case under study was reviewed before conducting any data collection

(Section 3.2, 3.3).

Case studies may utilise multiple methods of data collection and do not rely on a single

technique (Ary et al., 2014). Interviewing, observation, reviewing documents, and other

methods may be applied (Ary et al., 2014). Whatever techniques are applied, all are

focused on a single phenomenon or entity and attempt to collect data that can help

comprehend or understand the focus of the study.

Table 4-3 indicates the strengths and weaknesses of the different data collection techniques

for case study research, as identified by Stake (1995) and Yin (2009).

Table 4-3: Type of evidence Yin (2009, P80).

Source of

Evidence

Strengths Weaknesses

Documentation Stable - repeated review

Unobtrusive - exist prior to

case study

Exact - names, etc.

Broad coverage - extended

time span

Retrievability – difficult

Biased selectivity

Reporting bias - reflects author bias

Access - may be blocked

Archival Records Same as above

Precise and quantitative

Same as above

Privacy might inhibit access

Interviews Targeted - focuses on case

study topic

Insightful - provides

perceived causal inferences

Bias due to poor questions

Response bias

Incomplete recollection

Reflexivity - interviewee expresses

what interviewer wants to hear

Direct

Observation Reality - covers events in real

time

Contextual - covers event

context

Time-consuming

Selectivity - might miss facts

Reflexivity - observer’s presence

might cause change

Cost - observers need time

Participant

Observation Same as above

Insightful into interpersonal

behaviour

Same as above

Bias due to investigator’s actions

Physical Artefacts Insightful into cultural

features

Insightful into technical

operations

Selectivity

Availability

Documents are physical materials in which facts or ideas have been recorded and can

reveal a great deal about the people or organisation that produced them and the social

context in which they emerged (Prior, 1974). They can take on different forms Yin (2009);

such as agendas, letters, minutes of meetings, memoranda, or any relevant document that

could add to the database of the case study (Stake, 1995). All are useful and rich sources of

information for a qualitative researcher (Stake, 1995; Creswell, 2003; Yin, 2009). The

documents should be reviewed carefully to ensure validity and to avoid unnecessary data

being included in the database. Documentary review can be used to verify evidence that is

gathered from other sources. Over-reliance on documents can contribute to exploration of

the wrong leads by inexperienced investigators (Yin, 2009). Documentary analysis is a

social research method and an important research tool in its own right; it is an invaluable

part of most schemes of triangulation (Prior, 1974). It refers to the various procedures

involved in analysing and interpreting data generated from the examination of documents

and records relevant to a particular study (Prior, 1974). Archival documents include service

records, charts, maps, lists of names, survey data and others such as personal records and

diaries. The accuracy of the records should be evaluated carefully before using them (Yin,

2013).

The interview is one of the most vital sources of case study information. Yin (2009, P.90)

states that:

"Most commonly, case study interviews are of an open-ended nature, in which you

can ask key respondents about the facts of a matter as well as their opinions about

events.”

Focus groups are another type of interview. Comprising a small group of participants

purposively chosen to fit key criteria and who have similar characteristics, these

discussions aim to provide qualitative data in a focused dialogue (Morgan, 1997). This

dialogue is the ‘interaction element’ that is the key point in understanding how focus

groups can be used to generate a different type of collected data than is possible from a

face-to-face interview (Billson, 2005). Direct observation is a useful technique for

providing additional information about the case being studied (Yin, 2013). Direct

observation occurs when the researcher conducts a field visit to gather data. The

observation could be as simple as casual activities or as formal as measuring and recording

behaviours. In this study, it was not deemed necessary to observe the participants,

considering that the focus was predominantly on their perspectives and, therefore, it was

what they had to say that was important. Participant observation is a special technique of

observation in which the researcher is an active observer in the study. This technique

provides opportunities to perceive reality from the perspective of the observer “inside” the

case rather than externally (Stake, 1995). The last source of evidence is a physical artefact

that includes tools, instruments, artworks, notebooks, computer output and other physical

evidence that can be used during a field visit (Yin, 2013).

Case studies allow researchers to use multiple source of evidence that help to address a

range of behavioural and historical issues (Stake, 2003; Baxter & Jack, 2008; Yin, 2013).

The purpose is to use several sources of data as a triangulation of evidence. Triangulation

increases the reliability of the data collection and is considered a strength within case study

research (Baxter & Jack, 2008). A case study attempts to illustrate the subject’s entire

range of behaviours and the relationship of these behaviours to the subject’s history and

context (Brown, 2008). The researcher goal was to ascertain the influence of degree

education as a minimum entry requirement into nursing practice on the planning and

development of the nursing workforce, based on evidence from multiple resources. In this

study, the researcher did not consider it sufficient to use a single data collection method. It

is important to understand why there are minimum educational requirements and what

factors contribute to this phenomenon by employing a holistic systems-based approach

(macro, meso and micro).

The case methodology approach in this study is a single-case design that required one unit

of analysis, where events are limited to a single phenomenon (Yin, 2013). This allows the

researcher to build theory where little data or theory exists in the current literature (Yin,

2009). In this case, the researcher is able to respond flexibly to the emergent discoveries

made during the data collection process due to the nature of the case study design that

allows for the creation of innovative theory by combining paradoxical evidence from

different levels (macro, meso, and micro) into a unified theory.

In this research, the “case” or the “unit of analysis” is the policy relating to the entry

requirements for nursing and their implementation. At a deeper level, implications of the

way in which this research is conducted are explored and this will entail the consideration

of all aspects that could affect the results, ensuring that the data is analysed precisely and

systematically (Yin, 2013). In order to provide a more inclusive view of which factors

influence the minimum educational requirements for entry-level practice as a registered

nurse in SA, multiple methods of data collection were considered and selected. These

include; document analysis, in-depth interviews with stakeholders and focus groups of a

sample of practising nurses at the meso and micro levels. Each of these data collection

methods was selected to help understand or interpret the focus of the study. Thus, they

required different skills from the researcher.

As previously mentioned the existing research on the case topic is extremely limited; to

my knowledge, there is no existing study that forms a baseline for research on this topic

and it is therefore important that the study is exploratory. The case study needs to be

exploratory because no one has yet explored the implication of degree entry requirements

for professional nurses in Saudi Arabia. For example, this study is about a relatively

unknown issue. Therefore, it is important to determine what is going on, from the

perspectives of people working within the health system and functioning at all three levels,

as a basis for future planning. A case study approach was appropriate for this study since it

allowed the researcher to build evidence where little data or theory existed in the current

literature (Stake, 2003; Baxter & Jack, 2008; Yin, 2013). This approach was also suitable

since it allowed the researcher to respond flexibly to the emerging discoveries made during

the data collection process. For all the reasons given, a qualitative case study design was

deemed appropriate for this research.

4.5 Macro, Meso, and Micro Theory/Framework

Frame analysis is a way to explore occurrences in organised steps and determine what is

exceptional in a given case or experience (Goffman, 1974). A “frame” or framework

defined by Goffman (1974) as a “schemata of interpretation” to explore, perceive, identify

and label events, experience, and their implications. This definition has been expanded by

other researchers to include factors such as utilisation of resources politics, character,

causation and the course of change (Caldwell & Mays, 2012). Based on this initial

“schematic of interpretation”, this study will use Caldwell & Mays' (2012) adaption of

Goffman (1974) theory includes three levels; macro, meso, and micro framework/theory.

macro, meso, and micro framework/theory, as it considers the mechanism of decision

translation from policy idea to a programme in action, and looks at the mechanism of

decision translation from policy development to policy implementation. This is how the

policy idea was presented, when recommended to the MoH by WHO (2009).

This usually includes the organisation and structuring of experiences by an individual’s

perception of background events (Caldwell & Mays, 2012). This will be achieved by

analysis of how the participants, at each level within the organisation (macro, meso and

micro levels), shape their understanding of degree nurse education.

The idea behind selecting the macro, meso and micro levels within the MoH and the wider

health service setting for framework analysis was influenced by the need to understand the

process, direction and influence of degree education policy on multi levels and to study the

interconnection between evidence across different organisational levels (Pope et al., 2006).

In this particular case study, the different organisational levels are evident within the MoH

in Saudi Arabia. Goffman (1974) argued that researchers use their background or

experience to organise their understanding of something and to guide future action. I am

interested in the macro, meso and micro levels of healthcare, and wish to explore the

possible implications of introducing degree education at these levels in order to gain new

knowledge to inform further workforce planning as a whole. According to Caldwell &

Mays' (2012), macro-meso-micro framework/theory is a useful way of exploring the

transition of a policy from a high level of notion to plans in action, as illustrated in Figure

4-1.

Figure 4-1: Macro, Meso and Micro levels of Analysis

Figure 4-1 illustrates the macro, meso, and micro levels of practice in relation to their

influences on graduate entry nursing. Data collection is concerned with the influence of

degree entry nursing from strategy through to operation, capturing the influences at all

levels of practice within the healthcare context. To guide the collection and analysis of

data, it is useful to define each level of organisation in this study.

Macro Level

The macro level is concerned with policy idea development and implementation of degree

education as a minimum requirement for those wishing to qualify as a nurse; this is treated

as an issue requiring “government action” (Caldwell & Mays, 2012: P.3). The employees

working at this level are the decision makers, such as the General Director of Nursing, the

General Director of Personal Affairs and the General Director of Education and

Scholarship. These decision makers are concerned with policy conceptualisation and

planning prior to the implementation phase achieved through in the MoH; this is the

largest governmental sector in the Saudi health system, where the policies explained in

Section 1.3.1 are established.

Meso Level

The meso level concerned a sample of Regional Nursing Directors, from all five parts of

the country (north, east, south, west and centre). This level is where the “policy begins to

take shape” (Caldwell & Mays, 2012: P.3). At this level, the policy translates to a

programme in action, where there is a chance its aims may be misunderstood (Caldwell &

Mays, 2012).

Micro Level

The micro level in this study is the local settings, for example: nurses in clinical areas,

including nurses, managers, and educators. This level is where the “policy operates”

(Caldwell & Mays, 2012: P.3). It is important that the macro level within the MoH

supervises and monitors the practical implications of the policy, in order to confirm its

correct application at this level. The policy is implemented and its impact is followed up

through evaluation within hospitals and primary health settings.

Analysis of the different views of participants at each of the three levels of this framework,

complemented by documentary analysis, will enable the exploration of the impact of

degree entry requirements on nursing workforce planning, and a subsequent interpretation

in terms of its effectiveness. This will also inform future nursing workforce planning and

development in the MoH.

4.6 Methods

Data was collected from participants working at all the three levels (macro, meso, micro)

within the organisational structure of the MoH in SA, explained in Section 4.5. Face-to-

face interviews and focus groups were the chosen methods of data collection for this

research, complemented by documentary analysis.

This approach involved semi-structured interviews/focus groups with a variety of

associated Ministry stakeholders and nurses at the three levels of administration and

practice, as illustrated in Figure 4-2.

Figure 4-2: Data collection elements.

Multi-sectorial input must be gathered in order to best understand the full span of

implications across the board. The primary source of data collection in this research is as

follows:

 Documents

MoH documents that include the meeting documents of the GCC Nursing

Technical Committee related to the decision to have a degree entry requirement for

nursing, and the process for implementation of this policy. Printed documents were

reviewed.

 Semi-structured Interviews

Open semi-structured, face-to-face interviews were implemented to collect in-depth

information from the first level of administration (Macro level). This enabled the

Macro Level: (Central), Documentray Analysis + face-to-

face, semi structure interview/ Decision maker (MoH), Riyadh./ work

office of the decision maker during working hours

Meso Level: (Regional), focus group semistructure discussion/ Regional

Nursing Directors / central auditorium of MoH during working hours.

Micro Level: (Local) focus group semistructure discussion nursing manager, nurse directors and staff

nurses (Diploma & Bachelor)/ conference room, King Saud Medical

City

researcher to explore the participants’ views and experiences related to degree

education and its effects. Merriam (2009) suggests semi-structured interviews are

valuable if the researcher needs to gain more information from key informants, as

semi-structured interviews are guided by the situation being explored.

 Focus group interviews

Focus groups are used to obtain multiple perspectives on the same issue at the same

time (Morgan, 1997). In this research, focus groups were used to collect evidence

from participants working at the meso and micro levels. Each group had eight to

twelve participants as recommended by Barbour (2007).

4.6.1 Sampling Criteria

For each data collection strategy within this research, at each level of the framework

(Section 4.5), purposive sampling was used to recruit people who have a background in the

phenomena under study. This qualitative strategy enables the researcher to select specific

subjects from the target population to meet the criteria being studied (Merriam, 2009). A

purposive sample simplifies the selection of participants who show a specific feature or

characteristic necessary for the research outcomes (Baxter & Jack, 2008). It is a non-

randomised approach that is not concerned with generalizable or reproducible outcomes;

instead it aims to yield a sample that is information-rich (Barbour, 2007). Moreover,

purposive sampling is described by (Morgan, 1997) as the deliberate or conscious choice

of research participants on the basis of their knowledge or expertise. In this way, this form

of sampling enables the provision of information that is relevant to the study’s focus and

research questions (Creswell, 2013).

In addition, Yin (2013) suggests that purposive sampling is suited to case study design. It

contrasts with random sampling where participants are allocated to data collection on a

random basis. Since a qualitative case study is concerned with the in-depth exploration of

a specific phenomenon and there is no desire to determine incidence, prevalence or

statistical significance in the finding (Yin, 2013), a small sample size is considered

acceptable. Miles et al., (2014) discuss that a small sample size is desirable in qualitative

enquiry in order to explore phenomena in adequate depth and detail, provided that the

sample is representative of the population under study and is able to deliver adequately

rich data (Teddlie & Tashakkori, 2010). This type of sample shows different perspectives

of the participants from three levels (macro, meso, and micro) on the situation, processes,

or events that will help the researcher to understand the problem and the research questions

(Creswell, 2013). The inclusion and exclusion criteria for each level of sampling within

this study are illustrated in Table 4-4.

Table 4- 4: The inclusion and exclusion criteria for each level of sampling.

The levels of sampling Inclusion criteria Exclusion criteria

1-Macro

level

Phase one:

Documentary

Analysis

The minutes of meetings of the

GCC Nursing Technical

Committee.

Arabic documents (Arabic is the

native and formal language used

in formal meeting for all

ministries in SA).

Paper and electronic

Unrelated documents

such as attached

reports, tables and

.lists

:Phase two

Face –to-face

interview

n=4

Stakeholder who is involved in

the decision to establish the

Bachelor of Science in Nursing

(BSN) as a minimum entry

requirement for nursing practice.

Working as a General Director in

the MoH.

Male and female.

Stakeholder who is

not working in the

MoH and not involved

in nursing decision.

:phase three: Meso level -2

one focus group

n=6

Regional Nursing Directors.

Saudi nationality.

Male and female.

Staff nurses and

Nursing

Directors in hospitals

and primary health

.care centres

:phase fourMicro level: -3

Three focus groups

Group one: n=7

Group two: n =4

Group three: n=4

Total: n=15

Focus group 1

Nurse Manager and Educator in

KSMC.

Saudi and non-Saudi

Male and female

Staff nurses, nursing

directors and nursing

educators from other

hospitals.

Focus group 2

Staff nurses in KSMC

Diploma holder

Male and female

Saudi nationality

English speaking

5 years’ experience

Non-Saudi staff

nurses.

(All will be Saudi staff

throughout, not

expatriates –

important to establish

Saudi views of MoH

‘Saudization’ plan

include plans to have

all Saudi nurses’

administrative levels).

Focus group 3

Staff nurses in KSMC

Bachelor qualified degree nurses

Male and female

Saudi nationality

English speaking

Two years’ experience

Total sample size 25 participants

4.6.2 Study Location

This study took place in Riyadh, the capital and largest city of SA, as well as its financial

and administrative centre. For example, it houses embassies, the government, and the head

offices of international companies, bringing many more expats into the community.

4.6.2.1 Setting

The study was conducted in the MoH setting, located in the capital city, Riyadh, and its

selected hospitals. This setting was selected for the study because the city is linked to other

regions through a modern international airport that makes it accessible for all participants

from different regions (meso level) to participate. The interviews at the macro level were

conducted in the participants’ work office, at the MoH headquarters, during working hours

and the focus group for the selected regional directors was organised in the main

conference room at this location. The focus groups at the micro level were arranged in the

fieldwork setting of King Saud Medical City (KSMC). KSMC has a 1,400-bed capacity,

distributed among the different departments of the City. It is composed of three hospitals: a

General Hospital, Maternity Hospital, and Children's Hospital.

4.7 Data Synthesis

Having sampled suitable participants and collected data from multiple sources and

methods: documentary analysis, interviews, and focus groups; it was necessary to

synthesise the results in order to discuss the implications of the study. Content analysis is a

systemic approach that can be used to analyse data using either a deductive or inductive

approach (Elo & Kyngäs, 2008). Kohlbacher (2006) seeks to encourage the integration of

qualitative content analysis into case study research and considers it an important element

of the process. This involved qualitative content analysis and the use of NVivo software to

organise the data collected within this study. In addition, a reflective field notes were used

to assist in the interpretation of data. This process is commonly used in nursing research

such as mental health, gerontological, and public health studies (Elo & Kyngäs, 2008).

This study used two different approaches to analyse the data:

 First; Prior's (2003) framework (an inductive approach to qualitative content

analysis) was used to analyse the documents as a first phase in order to construct an

understanding of the influence degree education requirements have had on the

nursing workforce. The framework will be discussed further in Section 5.2.3.

 Second; Zhang and Wildemuth (2009) framework involving eight steps, as illustrated in

Figure 4-3, was used to analyse the data collected from the interviews and focus groups.

Figure 4-3: Phases of Content Analysis (Zhang & Wildemuth 2009).

The following are the general steps of qualitative content analysis suggested by Zhang and

Wildemuth (2009) was used in analysing the interviews:

1. Preparing the Data: The interviews/focus groups were audio recorded,

transcribed verbatim for review and uploaded to NVivo, qualitative analysis

software for undertaking content analysis.

2. Defining the Unit of Analysis: The interview transcripts were read and re-read

to familiarise myself with the text and gain a first impression of the content.

3. Developing Categories and a Coding Scheme: During the initial phase of the

content analysis, the researcher developed several categories of response type,

based on the initial read and re-read of the transcripts as well as the literature

reviewed for the study.

4. Testing Your Coding Scheme on a Sample of Text: Using the categories

developed, the coding scheme was tested by coding a section of the micro-level

focus group transcript. The coding scheme served to enable the researcher to

1 • Preparing the Data

2 • Define the Unit of Analysis

3 • Develop Categories and a Coding Scheme

4 • Test Your Coding Scheme on a Sample of Text

5 • Code All the Text

6 • Assess Your Coding Consistency

7 • Draw Conclusions from the Coded Data

8 • Report Your Methods and Findings

effectively categorise the data offered by the participants and was therefore

used in the coding of all the textual data obtained for the study.

5. Coding All the Text: Text was then coded into categories (coding scheme).

Relevant statements/responses offered by participants were coded (highlighted

and labelled) into the various thematic categories, and were assigned a node

(code label) that described the response type. This was done by carefully

analysing each participant’s response/statement within the context of the

discussion and coding and categorising the responses into nodes (descriptive

labels), to reveal commonality of responses. If no category existed in the

coding scheme for the response type, a new category was added to ensure the

capture of all relevant data. NVivo was used to track the type and location of

responses (Hilal & Alabri, 2013).

6. Assessing Your Coding Consistency: The coding categories with response

nodes coded were re-read and evaluated to ensure coding was appropriate to

each category. In addition, the researcher explored the coding for redundancy

and similarities of codes, combining and/or separating coded content as

necessary.

7. Drawing Conclusions from the Coded Data: From the final coded content in

each thematic category, key common themes were identified and discussed,

citing textual examples from the transcripts to support theme development and

in-depth understanding for the reader.

8. Reporting Your Methods and Findings: Data were presented according to

thematic categories using frequency of mention to highlight the key common

themes, tables and textual examples to support conclusions. Conclusions at

each data source level (micro, meso, and macro) were then synthesised and

combined to reveal the overall conclusions of the analysis.

4.8 Trustworthiness of the Study

Any research design embodies a logical set of statements; its quality can be arbitrated

according to certain logical tests. In qualitative research, scientific ‘rigour’ is less

quantifiable, mainly because it merely consists of anecdotal evidence, is biased by the

researcher, and lacks generalisability (Baxter & Jack, 2008). For this reason, the term

‘rigour’ that relates to the quality of a research process is replaced by the term

‘trustworthiness’ for judging ‘naturalistic inquiry’ (Guba & Lincoln, 1994). The

trustworthiness of qualitative research can be assessed by several frameworks/models

(Guba, 1981; Guba & Lincoln, 1994). Guba (1981) developed a significance model of

trustworthiness or “rigour” that offered four strategies, illustrated in Table 4-5, to establish

credibility, transferability, dependability and confirmability (Sandelowski, 1986).

Table 4-5: Four strategies to establish credibility, transferability, dependability and confirmability

Credibility Confidence in the ‘truth’ of the findings

Transferability Showing that the findings have applicability in other contexts

Dependability Showing that the findings are consistent and could be repeated

Confirmability The extent to which the findings of a study are shaped by the

respondents and not the researcher’s motivation or interest

4.8.1 Truth-value/Credibility

Truth-value is an important concept for the qualitative researcher as it enables them to tell

the truth and reflect on the credibility of the study analysis and results. Phases and

constancy were considered throughout the data collection and analysis to ensure that the

findings and interpretations were accurate, which Creswell (2013) refers to as validation.

The accuracy or credibility of the findings of this research were determined through certain

strategies such as member checking or triangulation as suggested by Creswell (2013). The

establishment of operational measures for the concepts of the study ensure construct

validity; for this research multiple sources of evidence were used during the data collection

phase, including: interviews, focus groups, and document review. The validation of this

study was ensured according to the credibility criteria, as described by Merriam (2009).

1. Rigorous fieldwork methods were used to generate and analyse data that was

relevant to the aim of the study.

2. I had appropriate experience and training to undertake this research study. The

presentation of ‘self’ is acknowledged and discussed through the process of

reflexivity.

3. This study underpinned by the philosophical values of qualitative inquiry: methods

that embrace social interaction and interpretation of meaning, purposive sampling,

inductive analysis and holistic thinking.

Other strategies used to enhance the truth-value were peer review, cross-case analysis,

triangulation, member checks and reflexivity. A detailed explanation of these strategies

follows:

Peer review

Yin (2013) suggests that the truth-value of a data collection process can be assessed

through peer review. Also known as peer de-briefing, according to Guba and Lincoln,

(1994: P. 308) peer review includes:

“A process of exposing oneself to a disinterested peer in a manner paralleling an

analytical sessions and for the purpose of exploring aspects of the inquiry that

might otherwise remain only implicit within the inquirer's mind”

The above quote suggests the researcher can gain useful feedback from an outsider, with

an unbiased viewpoint, in order to uncover any issues or perspectives, which may have

been overlooked. This process challenges the researchers’ assumptions; it also assists the

researcher in establishing their interpretation of the data with the opportunity to share and

defend the results of the study to ensure that they are reasonable and plausible. To this end

a draft report was comprehensively reviewed by peers (Section 5.3, 5.4, 5.5).

Cross-level analysis

Within this study, any outlying results or themes were carefully identified and reported on

Section 7.5. Analysis of negative or contrary themes and embedded cases enabled the

researcher to consider and confirm patterns in the data and enhanced the credibility of the

data analysis.

Triangulation

Yin (2013) suggests that triangulation is the hallmark of a case study. Triangulation is the

process of confirming evidence from different individuals, types of data, or methods of

data collection (Creswell, 2013; Yin, 2013; Merriam, 2009; Stake, 1995; Merriam, 2009;

Creswell, 2013; Yin, 2013), similar to peer review. This use of multiple data sources

allows for an in-depth understanding and the uncovering of alternative perspectives

regarding the study findings generated by other data collection methods (Denzin &

Lincoln, 2011). In qualitative research, this is a way of assessing the credibility of a study

by ensuring it is comprehensive and well-developed (Merriam, 2002). For this reason, this

study considered more than a sample of nurses, but chose a variety of participants in

different positions within the hospital setting; nurses, managers, regional directors and

decision makers. In this research, the data collected was triangulated, that is the analysis

resulting from the interviews and focus groups and document review were explored in

relation to each other. Furthermore, the analysis process involved triangulation in that a

sample of cases was selected to be analysed independently by supervisors. This allowed

the researcher’s interpretation of the results to be compared to other viewpoints.

Member checking

Member checking involves sending the transcribed interviews back to the participants for

review and confirmation (Section 5.3, 5.4, 5.5). Despite the criticism that this technique

has received from some researchers, such as Sandelowski (1986), namely because it relies

on the assumption that there is a fixed truth of reality that can be recorded by a researcher

and authenticated by a participant, others believe it to be one of the most important

strategies in establishing credibility (Guba & Lincoln, 1994). The value of member-checks

is in the ability to ensure that the researcher has not misinterpreted what the participant has

said or the participant’s viewpoint. With this in mind, member-checks were involved in

this research process to enhance the credibility of the study. The verbatim transcripts of the

interviews were returned to participants and these, along with the researcher’s study notes,

were used to summarise the key points of each interview.

Reflexivity

Reflexivity is defined by Guba and Lincoln (1994:P. 183) as “the process of reflecting

critically on the self as researcher”. Reflexivity also includes taking action based on my

reflections and it takes account of my involvement in the research process (Section 5.6). A

reflexive researcher is aware that his or her own thoughts and/or attitudes can influence the

research process, such as interpersonal interactions during the data collection process

(Freshwater, 2005); hence, the case study obviously acknowledges the direct position of

the researcher in the study process (Bryar, 2000). This process necessitates the researcher

to inspect and record the impact of self on the research in order to recognise where areas of

bias could be evident, many authors believing this to be unavoidable within any research,

regardless of the paradigm (Freshwater, 2005). In order to address these concerns, a

reflective journal was kept with the aim of limiting bias and an in-depth report on

reflexivity is included within this thesis (Section 5.6 & 8.6). Reflectivity is used in this

study to enrich the quality of the research findings in relation to trustworthiness and

transferability (Guba & Lincoln, 1994).

4.8.2 Applicability/Transferability

The concept of applicability, as suggested by Guba and Lincoln (1994), considers to what

degree research conclusions are relevant to a wider field than simply that specifically

addressed in a piece of research (Anney, 2014). However, the specifics of situating case

studies in real-life settings, and thus making them qualitative, arguably makes them

unsuited to being assessed for their applicability (Sandelowski, 1986). This is supported by

Anney (2014), who suggest the conclusions of case studies are fundamentally unsuited to

being considered relevant on a larger scale. Baxter and Jack (2008) highlight the insularity

of case studies.

Concurrently, it is not always the case that a case study is considered in isolation, but as

part of a larger body of research. Baxter and Jack (2008) suggest that in this eventuality,

the manner in which the research is carried out and later presented is important. An

alternative is proposed by Guba and Lincoln (1994), who discusses the terms ‘fittingness’

or ‘transferability’ as a means of evaluating applicability. However, Yin (2013) states that

the conclusions of case studies are problematic when used to explain phenomena occurring

in a larger setting. However, it can be highly useful in contributing to the creation of

theories. Yin (2013) explains that case studies present opportunities for broadening the

scope of existing theories. In doing so, their findings become relevant on a larger scale.

Sample size is another feature of case studies that can affect their applicability and validity.

For instance, by focusing on a minimal number of participants, the specifics of a situation

potentially take precedence over identifying factual data (Creswell, 2013). Baxter and Jack

(2008) suggested that accepted sampling procedures are often omitted in case studies, thus

making their findings even less applicable or representative. Yin (2009) disputes this,

presenting the idea of ‘deep data’, which comes into existence specifically because of the

concentration on a specific group or individual. Yin (2009) has produced a model for case

studies to address concerns relating to sampling procedures, which is designed to make

case studies more valid and thus, potentially, more applicable. Rather than considering

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random sampling, qualitative researchers must provide a detailed description of the study

process and setting in order for any reader to be able to assess the applicability of the

research results and judge them against studies in other settings (Guba & Lincoln, 1994).

While the more traditional idea of generalisation may not be suitable for a case study, it is

still important to consider how the findings of this research could be transferable to other

contexts and valuable for other studies. This can be achieved by allowing the reader to

fully understand the research process so that they may be able to consider it in relation to

their own work. With this in mind, the following steps were taken in order to make the

study appropriately transferable or ‘fitting’:

1. A detailed account of each level is provided so that the reader can develop their

own understanding of the findings (Merriam, 1997).

2. Participants were selected using purposive sampling to ensure that the study

covered a wide range of contexts and was able to compare and contrast between

different topics concerning the study aims.

3. Three levels (macro, meso, and micro) have participated considered in this research

in order to provide data for within-case and cross-case analysis. This will facilitate

information relating to the specifics of each level and ensure the identification of

interesting and possibly contrasting relationships between levels (Stake, 1995).

4.8.3 Consistency/Dependability

Anney (2014) states that the validity of a study should take into account how consistent the

data gathered is; that is to say whether similar conclusions would be reached if it was

repeated. As Anney (2014) explains, the idea of consistency is closely connected to

dependability. However, it is worth noting that the real-life quality of case studies and

other qualitative research engenders variableness to a strong degree (Guba & Lincoln,

1994). With this in mind, Guba (1981) proposes the idea of ‘dependability’ within which

variability is applied only to certain parts of the study. Guba (1981) describes the use of

audit trails, clear and detailed records of the study, to assess the dependability of data used

in research by means of providing documentary evidence of the exact research process.

This study considered the following audit trail; at each stage of data collection and the

processes documented, as shown in Table 4-6.

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Table 4-6: Audit trail

Category Audit trail

Raw data Tapes, audio files, transcripts, documents, field notes and

copies of electronic records, stored securely. All interview

data were anonymised before storage.

Data reduction and analysis

products

The process of coding individual transcripts and the

collated findings, stored as hard copies and electronically as

Word documents

Data reconstruction and

synthesis products

The development of themes and their inter-related

connections with each other and existing literature, within-

case findings and across-case findings, all stored as Word

documents, electronically.

Notes relating to methods and

procedures

Researcher’s decisions concerning the study, recorded as

field notes.

Materials relating to intentions The research proposal, available upon request; a copy is

held by the MoH & UoS Ethics Committee that approved

this study. Copies of written confirmation of access to the

MoH and its hospitals are included in the appendices.

Instrument development

information

An exhaustive list of all forms and guides is provided in the

appendices.

4.8.4 Neutrality/Confirmability

Following dependability, Guba (1981) also states the importance of neutrality in assessing

the validity of a study. As Guba (1981) Kreftling (1991) explains, neutrality considers the

possibly impact of, for example, researcher bias and pre-held viewpoints on the

conclusions of a study, in opposition to the direct influence of the participants and the

research environment. To this end, neutrality interlinks with confirmability (Anney, 2014).

Triangulation and reflexivity are considered when assessing the neutrality of qualitative

research, as they also are in the instance of truth-value and previous scholarship. Similarly,

Miles, Huberman, and Saldana (2014) states that cost-effectiveness should be evaluated

with regard to case studies. The concept of deep data, as proposed by Yin (2009) is also

relevant here, as case studies offer the opportunity to observe and analyse participants to a

substantial degree.

As Miles et al. (2014) notes, case studies can be both costly and time consuming,

considering that a very limited number of participants are being researched for a given

duration, where other types of study may potentially include a far greater number. Yin

(2009) challenges this with the assertion that this is exactly the method through which

intense observation and research can result in the production of deep data that comparative

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studies with larger sample sizes may potentially miss. This relates to the concept of

conflicting interests (Miles et al., 2014). In order to find a compromise of sorts, steps such

as including participants from a wider variety of educational backgrounds and experiences

would be necessary.

In summary, an audit trail was established in order to document every aspect of this study.

Research is continuously affected to some degree by abundant variables over which there

can be no complete control. Within a quantitative study, researchers attempt to distance

themselves from the research in order to reserve objectivity and provide validity (Creswell,

2003). Within a qualitative study, the influence of the researcher is far more apparent than

in quantitative methods, since there are no attempts on the part of the researcher to be

independent of the findings, mainly when employing ‘close up’ data collection methods

such as fieldwork. Quite the opposite, subjectivity and engagement are incorporated within

qualitative enquiry and are accounted for through the process of reflexivity (Freshwater,

2005).

4.9 Ethical Considerations

A number of ethical considerations are associated with the case study process. According

to Stake (1995) the confidentiality and anonymity of participants are the main points for

ethical consideration within a case study. Firstly, there is the issue of confidentiality

agreements surrounding information given by Ministry officials, because if the case study

is not appropriately designed, it may be possible to identify research participants,

especially those in high positions and in focus groups. The research was conducted in

accordance with the ethical principles published by the Royal College of Nursing (RCN,

2011). One of the most important among these principles is that for data collection and

analysis: all confidential documents should be placed inside a locked cabinet and access

should be allowed only to authorised persons (RCN, 2011). This ensures that documents

are secured and the personal opinions of participants are not exposed or compromised.

The UK Data Protection Act (1998) was applied as the framework to protect the data of

this research. All participant information was coded and anonymised; only the researcher

and supervision team at the UoS had access to anonymised data. However, no names or

personal details were used that could identify places, individuals, or professional roles, and

such data was removed from transcriptions and audio recordings. The study displays two

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forms of data; a hard copy and an electronic copy. Hard copy data was kept in a locked

cabinet accessible only to the researcher. Electronic data was secured on a password

protected external hard disk and connected only to the researcher’s private laptop, the only

person who had access to the saved study data. Furthermore, during the study period, all

data were considered highly confidential and carefully handled with respect to participants’

anonymity and dignity to avoid breach of confidentiality. Besides that, all anonymised

hard and electronic data will be kept for three years following the study, whilst publication

and dissemination take place. The data will then be discarded through confidential

shredding and secure deletion methods.

For the face-to-face interviews, the Code of Ethics (RCN, 2011) recommends that

interviews should be performed after informed consent is given and should ensure the

confidentiality of information disclosed by the participant. Furthermore, the interviewee

should have the right to withdraw at any time without fear of adverse consequences (RCN,

2011). For the focus group stage, there will be special consideration of confidentiality. For

example, all interview participants were assured total anonymity and ensured that they

would not be mentioned by name or position in the final written report. There will be no

disclosures to a third party; only anonymised discussion in my thesis and subsequent

publications and presentations. To address this, coding was used to protect the anonymity

of place, person and role.

For participants in this study the protection of their human rights was assured throughout

the study. Participation in the research was voluntary; and this was reinforced by sending

the consent form, the information sheet, and the interview questions before the interview.

Data collection started after approval was obtained from the Research Ethics Panel of

Salford University and the MoH in Saudi Arabia (Appendix 4.2; 4.3), thereby ensuring the

protection of human subjects involved in this study. The process of obtaining permission to

access the facilities of the MoH is illustrated in Appendix 4.1. Data collection included

adult respondents over the age of 18 years and did not involve any vulnerable populations.

It was a long process to obtain permission from the MoH to gain access to its hospitals,

and make practical arrangements with the three levels of participant. Fortunately, this

process was helped by the Saudi cultural attaché, who provided me with an introductory

letter to the MoH to facilitate access, recruitment of participants and preparation for the

data collection phase. Concurrently, there was a need to visit the MoH in Riyadh to obtain

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ethical approval. This took around four to six weeks. In February 2015, while I was

waiting for the research approval, I contacted my place of work and met the General

Director of Nursing in order to explain the purpose of the study and the research process so

that I would be able to gain access to valuable resources and ultimately data for the study.

The General Director was supportive and provided all the facilities that I needed such as an

office, computer, printer, internet access and telephone.

The research proposal was submitted to both the General Director of Nursing and the

General Director of Research for review and approval at the MoH in SA. Within the MoH,

such ethical approval is equivalent to that granted by any ethical committee in a UK

academic setting. The policy of the University of Salford (UoS) is to obtain ethical

approval from the university in the first instance, followed by approval from the area

where the research is to be conducted; in this case Saudi Arabia. Evidence of the latter then

needs to be passed to the former. The ethical approval was obtained from Rachel

Suttleworth (University of Salford) in February, 2015 (Appendix 4.2). The Saudi ethical

approval from the MoH and its hospitals was obtained in March, 2015 (Appendix 4.3).

4.10 Summary and Conclusion

This chapter has discussed the research methodology for this study, considering the

philosophical perspectives of the research and discussing the most appropriate research

paradigms, with a primary focus on the justification for using a qualitative case study. The

macro, meso, and micro level theory/framework of Caldwell and Mays (2012) was

highlighted, followed by the consideration of the study design, data collection and

analysis. The three levels identified by Caldwell and Mays (2012) macro, meso and micro,

within the MoH context were detailed, along with the four phases of the study design. In

addition, the choice of sampling method was explained, accompanied by the sampling

criteria.

Furthermore, the importance of the trustworthiness of the study has been considered; an in-

depth discussion has been provided on this matter with a particular focus on reflexivity and

the potential of the researcher’s influence on the research. Finally, the ethical

considerations that apply to the conduct of this study were discussed, including the

necessary documents obtained by both the UoS and the MoH that made the study possible.

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The following chapter will highlight the research process and provide an in-depth analysis

of the reality concerning the implications of the study, looking at the effects of the policy

requiring a Bachelor’s degree education as a minimum for entry into the practice of

nursing in SA. This analysis will consider the perspectives of the participants from all

three levels, macro-meso-micro, within the context of the MoH.

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Chapter 5 : Data Collection Phases

5.1 Introduction

The previous chapter explored the methodology of the study, detailing the researcher’s

philosophical position, the research paradigm and its theory/framework. The three levels of

analysis for data collection were explained and data synthesis was considered. Finally, the

importance of the study’s trustworthiness and the ethical considerations were discussed.

This chapter describes the protocol for the data collection in more detail. At the Macro

level (phase one) a documentary analysis was utilised to gain more information about the

rationale and processes followed by the decision makers at the MoH concerning the policy

to introduce degree education as a requirement for qualified nurses. At the Macro level

(phase two) face-to-face interviews took place to understand the perspectives of a sample

of decision makers at the MoH regarding the influence of the degree education policy on

nursing workforce planning and development. In addition, at the Meso level (phase three),

data was also collected through the use of one focus group. Finally, at the Micro level

(phase four) data collection was undertaken within four focus groups and a meticulous

explanation of the data transcription and analysis is given The flow chart in figure 5.1

illustrates progression of how each thesis stage inform the next.

Figure 5-1: The progression of thesis stages

Phase 3: Micro level

This level provided significant information from the nurses who worked directly with patients in hospitals, and those who had been directly affected by the introduction of the policy.

Phase 3: Meso level

This level showed that there is a lack of involvement of Regional Nursing Directors in the descision process and provided rich evedence for asking more questions at the micro level.

Phase 2: Macro level

This level provided more information about the missing parts of orgnisation between the macro, meso, and micro level. The policy for degree education in nursing has been endorsed in a top-down process.

Phase 1 : Documents review Documentary analysis was utilised to gain more information about the rationale and processes followed by the decision makers at the MoH concerning the policy to introduce degree education, this helped me

to identified the gap in knowledge and ask the decision makers more questions at the macro level phase.

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In the following section, the data collection process is explained for each level focusing

on: sampling, data collection procedures and data analysis.

5.2 Macro Level (Phase one): Documentary Analysis

The first phase of this study is the analysis of MoH documents with the purpose of

understanding the influence of degree entry policy and assessing the intended outcomes for

national nursing workforce planning in SA. This process of documentary analysis included

mapping the thematic content analysis and allowed scoping the envisaged requirements of

degree-educated nurses in practice.

5.2.1 Sampling

The documents used for this study were the minutes of the last six meetings conducted by

the GCC Nursing Technical Committee, who introduced the recommendation of degree

education as the minimum entry for nursing practice. The introduction of this new policy

within the Saudi MoH was a suggestion of the WHO, who supported its implementation.

This form of documentation was located in the organisational committee’s files of the

MoH. Since these files are the property of the MoH and are used as data for research

purposes, I came to an agreement with the MoH about how the contents could and could

not be used and how confidentiality would be preserved; these ethical considerations for

the study were discussed in Section 4.9. Specific inclusion criteria for documents were

implemented (Section 4.6.1), which included primary source documents relating only to

policy implementations that were written in the Arabic language, which is the formal

language used in communication for all ministries in SA. Other, unrelated attached reports

and lists were excluded. Documents that included the decision process for degree entry

requirement for nursing practice in Saudi Arabia were subjected to review. The summary

of the sample documents is identified and illustrated in Table 5-1.

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Table 5-1: The summary of the GCC documents

Documents selected No. of

Pages

Date of

meeting

Key findings theme

D1 Meetings of the GCC Nursing Technical

Committee in Jeddah, Kingdom of Saudi

Arabia (KSA), no. 30

18-19

March, 2015

Rationale for change

A Good Decision

D2 Meetings of the GCC Nursing Technical

Committee in Dubai, United Arab Emirates

(UAE) no. 29

14 13-14 April,

2014

Rationale for change

A Good Decision

D3 Meetings of the GCC Nursing Technical

Committee in Bahrain, no. 28

14 5-6 March,

2013

Rationale for change

A Good Decision

D4 Meetings of the GCC Nursing Technical

Committee in Oman, no. 27

20 5-4 March,

2012

Rationale for change

A Good Decision

D5 Meetings of the GCC Nursing Technical

committee in Kuwait, no. 26

14 24-25 April,

2011

Steps toward change

D 6 Meetings of the GCC Nursing Technical

Committee, Abu Dhabi, UAE, no. 25

30-31

March, 2010

Steps toward change

Global direction

D7 Booklet GCC (Challenge and achievement

of nursing in Gulf countries for the period

1993-2013).

79 Published in

2014

Steps toward change

Challenge and achievement of

nursing in Gulf countries for the

period 1993-2013.

Total number of pages 171

5.2.2 Data Collection Procedure

In the first instance, the central office of the MoH in Riyadh was contacted to gain

permission to collect the overall data for this study (Section 4.9). This included the

documents that met the inclusion criteria of the study (Section 4.6.1) that served to build

the evidence about the decision process for the degree entry requirement for qualified

nurses in SA, and to fill the gap in knowledge related to workforce planning and

development. This prepared me, as a researcher, to become more oriented and familiar

with all the processes that had been applied when implementing the decision before

conducting the interview (Prior, 1974).

I accessed the files that contained these documents, which were kept in printed form in a

special folder, and placed in the office of the General Director of Nursing. I conducted a

brief overview of the documents to exclude any unrelated papers. The documents

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comprised 629 pages, with 171 pages containing the exact meeting records being included

and 458 pages including attached reports, tables and lists related to other Gulf countries

that were excluded as illustrated in Figure 5-2.

Figure 5-2: Document searching strategy

All of the included meeting records have the pages numbered consecutively as separate

documents, and the excluded pages were attached in an unorganised manner without page

numbers. I scanned the documents and saved the electronic copies onto my encrypted

computer. I also developed a database on my personal computer that contained secure files

for each phase of the study (documents, macro, meso and, micro level interviews and focus

groups transcripts), to organise and save the large amounts of data that I had collected, as

suggested by Stake (2003) and Yin (2013). Each file contained electronic records of

multiple sources of data that I made, along with my reflective notes.

However, most of the documents are not easily accessible and contain evidence that would

take a researcher a long time and much effort to gather alone. The most important

advantage of using documents in social research is their stability. Unlike other sources of

data, such as interviews or observations, the presence of the researcher does not alter what

is being investigated. According to Merriam (2002) documents in qualitative research are

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objective sources of data unlike other forms, indicating that documents are a good source

for my case study research because they ground my exploration in the context of the

phenomenon being studied and they validated and triangulated evidence from interviews

and field notes (Guba & Lincoln, 1994). Indeed, these documents work as valuable social

facts to confirm the information obtained from other sources (Prior, 1974), and it is very

important to check whether these documents can assure objectivity, consistency and

accuracy. The collected documents for this study are primary sources, which increases

their trustworthiness and credibility. They were used for the purpose of this study only.

5.2.3 Data Analysis

Documentary analysis is mainly applicable to rigorous, qualitative case studies,

constructing rich descriptions of a single phenomenon, event, organisation, or programme

(Stake, 1995; Yin, 2009). The documents for this study were analysed using Prior's (2003)

framework and included careful reading and re-reading as well as annotated commentary

about any important information relevant to the purpose of the study. The initial coding of

the documentary analysis was based on the questions of (Prior, 2003) who has conducted

inclusive work on using documents in social research, which I used as a guideline to

understand and analyse the documents.

Prior's (2003:P.26) provides valuable information about the nature of documents in

organisations as illustrated:

 Documents form a field of research in their own right, and should not be

considered as mere props for action.

 Documents need to be considered as situated products, rather than as fixed and

stable things in the world.

Documents are produced in social settings and are always to be regarded as collective

(social) products.

Determining how documents are consumed and used in organised settings – that is, how

they function – should form an important part of any social scientific research project.

In approaching documents as a field for research, we should always keep in mind the

dynamic involved in the relationships between production, consumption, and content.

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When I entered the fieldwork to collect documents related to degree education policy, I

was challenged with decisions as to which documents were the most relevant to the

situation. I found that (Caulley, 1983: P.23) provided four important rules for choosing

documents that guided me to decide the appropriate documents for my research as

illustrated:

1. Incomplete observation and faulty memory are reasons for the inadequacy of

testimony.

2. The longer the time interval between the incident described and the writing of the

document, the less reliable the document. Therefore, choose the document that is

closer to the event described.

3. Some documents are intended as aids to one’s memory, some are reports to others,

some as apologia, some as propaganda, and so on. Therefore, documents differ as

to their purpose.

The more serious the writer’s intention to make a mere record, the more dependable the

document is. The more confidential the document (for example, the fewer eyes that are

allowed to see it), the more ‘naked” the truth revealed by the document.

The documents comprise seven documents, six meeting records including policy related to

degree nurse education and practice, various Gulf countries’ reports include strategic

planning, action plans, curriculum outlines for different level of nursing programme; the

booklet summarising the overall meeting achievements and challenges. The seven

documents comprising 171 pages meeting the inclusion criteria and were subsequently

analysed, while the unrelated documents were excluded.

Each meeting record commenced with minutes of the meeting, which included the date

and time of the meeting, a list of the meeting members and those unable to attend,

acceptance or corrections/amendments to previous meeting minutes, decisions made about

each agenda item – for example: action agreed, next steps, outcomes, items to be held over

to another meeting, recommendations, and date and time of the next meeting. This meeting

was conducted once or twice per year and the GCC members included two representatives

from each of the six countries of the Council: Saudi Arabia, Kuwait, Bahrain, Oman,

Qatar, and the United Arab Emirates, and 2 from Yemen, whose accession to various GCC

authorities has been approved by the GCC.

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Prior (2003) analysis procedures for analysis began with a complete reading of the meeting

records. I then re-read the documents, making notes in the side margins. A third reading

entailed the actual coding of the sentences/phrases/words of the minutes of the meetings.

To code the document data, I highlighted each relevant statement (irrelevant material was

not coded; this process of determining what data is relevant to the topic under investigation

is termed “data reduction”) (Merriam, 2002). I could not use NVivo to arrange and

organise the data because the documents were written in Arabic, so data was organised

manually to include using notes and memos to document initial thoughts. Memos helped

me to move from an empirical to a conceptual level and to identify the issues that required

further exploration in the data analysis (Caulley, 1983).

However, Mogalakwe (2009) provides quality control criteria to assess documents, these

are authenticity, credibility, comprehensiveness and meaning. As a researcher, I was aware

of the potential risks of being misinformed by evidence when collecting documents and a

number of protective steps were taken. These included: identifying the authenticity of the

document to ensure the source used for analysis was correct, ensuring that the texts within

the document were consistent with the context and that the information was clear, accurate

and consequently from the original version. Some documents are partly in the public

domain because they are published and freely accessible, such as the booklet of the Gulf

Cooperation Council’s (GCC) achievements, whereas other documents may be classified,

confidential or otherwise unavailable to the public, such as the actual minutes of the GCC

meetings, which are not published or accessible even for nurses.

5.3 Macro Level (Phase Two): Face-to-Face Interview

The first phase was documentary analysis and this phase was the second stage of data

collection which involved face-to-face interview analysis. I collected data from

administrative stakeholders to determine the different views at the strategic/macro level of

nursing policy and practice, regarding the influence of degree entry requirements on

nursing workforce planning.

5.3.1 Sample and Recruitment

A purposive sampling technique was used to recruit a sample of decision makers working

at the MoH to participate in face-to-face interviews. These participants were invited by

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email and provided with a Participant Information Sheet (Appendix 5.1) which included

information, an explanation of the study and consent form (Appendix 5.2). To ensure an

adequate sample, the four key informant stakeholders who met the inclusion criteria

(Section 4.6.1) were engaged in the interview. This provided the most meaningful

information in relation to the case study to help the researcher to understand the problem

and the research questions (Creswell, 2013). Semi-structured, in-depth interviews were

used to explore different views of stakeholders regarding degree education and its

influence on nursing workforce planning. Each individual interview was conducted at a

scheduled time set with each participant.

5.3.2 Procedure of Data Collection

Semi-structured face-to-face interviews were utilised for each participant at a scheduled

time they had booked previously. Interviews are the most common source of data

collection (Yin, 2009 ; Stake, 1995).

At the beginning of each interview, I welcomed and thanked the interviewee for their

involvement and introduced myself to them, after which I explained the purpose of the

research study to orientate the interviewees with the research topic.

Each interview was digitally recorded to enable it to be saved on to a computer, with the

consent of the participant, to aid accurate transcription. This allowed me to concentrate on

the conversation of each interviewee. This generated a data trail to which I could refer, as

recommended by Polit and Beck (2013).

I used five combination types of questions as guidelines (Appendix 5.9) in the interviews

as suggested by Krueger and Casey (2015). This combination of questions allowed the

participants to focus on the important points of the research questions as suggested by Polit

and Beck (2013).

The questions moved from general to more specific and from relative to important issues

in the research literature (Krueger & Casey, 2015). During the interviews I took notes to

help me concentrate on the participants’ response, develop probing questions and to

explain the issues in depth or to clarify certain words. I continued to interview and probe

until it was felt no more useful data could be gained (Merriam, 2009).

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At the end of the interview, I debriefed participants by allowing sufficient time for each

participant to raise concerns and to make sure they felt they could contact me if necessary.

All interviews took place within the interviewees’ organisation or workplace and lasted

between 30 to 60 minutes. Each interviewee was assured of anonymity and confidentiality

regarding the information given.

Finally, each of the interviewees was thanked for their contribution and informed that they

would receive a copy of their transcript by email. Following each interview, I immediately

started reflecting on my notes and added any ideas or interpretations for any words related

to the gathered data. Further, I reflected on the process of each interview to note anything

that might have had an effect on the trustworthiness of the collected data or the rigour of

the study to add in the final report. Each interview was conducted separately on different

days.

5.3.3 Data Analysis

I started my transcription of the data by first listening to the recorded interview that was

uploaded to the computer to ensure the accuracy of the recorded sound. The second time I

listened to the whole interview without interruption whilst reading my review notes as

annotated during the interview. This enabled me to remember the details and other nuances

of the participants. For the second step of analysis, I opened a new Microsoft Word page in

the database for the macro level data that included the electronic records of interviews. I

developed one template page for each interview, including date, time, level and given

code, within a table that included questions, answers, and researcher’s comments

(Appendix 5.3). I believed that organising the work from the beginning would help me to

work systematically and smoothly. I was very careful when I did the transcription, and for

this reason I developed certain rules that I would follow, including: selecting a quiet place

that contained an office or table and chair, and turning off my phone and annotating a

hardcopy of the interview with a marker pen.

In addition, I used headphones to listen actively to the recorded interview to capture the

conversation accurately, listening to full sentences before stopping the recorder to write.

Sometimes I listened to sentences many times to capture the exact words by using the

forward and back buttons to repeat the conversation, noting down the exact words and

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including repetition, silence and pauses. All names were removed from the transcript and

indicated by their given code as in Table 5-2.

Table 5-2: Macro-level (Decision-makers)

Position No Nationality Given code

General Director 1 1 Saudi GD1

General Director 2 1 Saudi GD2

General Director 3 1 Saudi GD3

General Director 4 1 Saudi GD4

All the audio-recorded data obtained from the four face-to-face interviews was saved on

the macro level database as an audio file. Each transcript was organised and given space to

add any further notes during analysis. The transcription method was very time consuming;

in order to fully engage in the data collection process, I personally transcribed all the data.

The transcripts had many grammar mistakes because most of the participants didn’t speak

English fluently and English is the second language in SA. However, despite the mistakes

contained, the transcripts were not corrected to avoid changing the meaning of the

interviewees responses. In order to back up the outline themes, quotations from interview

transcripts are provided in original format (Section 7.2, 7.3, 7.4). Furthermore, to avoid

changing the meaning, irrelevant parts of the transcripts have been removed as indicated

by the ellipsis points [….]. An example of one-to-one interview transcript was attached in

Appendix 5.4.

I reviewed the transcriptions with the original records to check the words and spellings and

to correct some work to ensure the accuracy of data as suggested by Zhang and Wildemuth

(2009) and explained in Section 4.7. A one-hour interview could take up to six hours to

transcribe as the data was reviewed several times both by myself and a peer reviewer. In

addition, the transcription report for each interview was sent to the interviewee to validate

the information given. The majority of the participants (3 of 4) replied and agreed that the

transcript reflected what was said in the final interview and one participant did not

respond. A final check was conducted before all data was saved securely on my personal

computer, flash memory, and email drop box.

I started coding any data related to the thematic framework (Section 4.7) by selecting the

statement/words and copying it into another document, under an initial constructed

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heading. For example, a title heading was made for this comment that provides an overall

description of the sentiments described within the illustrated Figure 5-3:

NVivo software was used in a similar process to categorise the data and “drag and drop”

the highlighted statement into a heading within the programme rather than in a separate

document (Hilal & Alabri, 2013). According to Zhang and Wildemuth (2009), the basic

functions are supported by the NVivo programme include text editing, note and memo

taking, coding, text retrieval, and node/category manipulation. It has been suggested that

using the software in data analysis adds rigour to qualitative studies (Greenhalgh, 2014).

For example, I would select the entire section of a quote/statement and paste this comment

under a heading that summarised the idea of that statement (Appendix 5.5). In some cases,

the quote could be put under more than one heading, depending on whether more than one

idea had been noted in the statement. If the quote did not fit into an existing heading, a

new heading was created for it.

A log of the headings and the four participants was kept in either the NVivo programme, if

used, or in an Excel file where qualitative software was not used. This was undertaken

during the coding so that I could easily see the categories and trends, and the frequencies at

the end of the analysis. Each statement was coded using this process, throughout the

I think for us culturally. They respect

more the man than the woman. But

over time we are improving the image

of nurses for the Saudi people. Before

they did not respect even man or

woman. The males or females working

in this career are not respected by

others. Some patient look at the nurse

as a housemaid or chamber maid.

some of the people they see that female

and males are working together, they

thinking that of another way!!. Still

there is some people have this bad

perception”

“The nurse who has good knowledge

and very good skills will gain more

respect.

Images of

Nursing

Images of Nursing

culturally

respect

not respect

housemaid

chamber maid

doing dirty

work together

bad perception.

good knowledge

good skills

Figure 5-3: Example 1 of analysis process

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transcription. More and more headings were built, and termed “categories,” and for

example, coded sections were added to existing headings as illustrated in Figure 5-4.

Once the coding had been completed, headings were revisited to determine whether they

were repetitive and could be combined. After this, headings and their similarity were

reviewed to ascertain which could be grouped or “clustered” together by topic. This

allowed organisation of the headings under several different “themes” of sorts, which

generated the “thematic categories” presented in the write up.

A midmap for each thematic category title was generated, which included the headings –

called constituents – that were grouped under this thematic category, and the number of

participants that mentioned that particular element or constituent. To write up the section in

the analysis report, all the comments made under that thematic category were reviewed

along with the frequency of mentions, how the category was formed and the most frequent

responses related to this category.

Addition of verbatim examples allows the reader to gain a “picture” of the participants’

experiences or thoughts on the topic and more specifically, the thematic category being

presented. Once all the thematic categories had been described and presented, all the

Images of

Nursing

Low status of

profession, cultural

influences, lack of

family support, gender

mixing, negative social

image, low prestige,

Arab media portrayals.

Negative

Images

Gaining respect,

Increased job

opportunities,

financial income,

further education,

good knowledge and

Skills

Positive

Images

Figure 5-4: Example 2 of analysis process

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thematic category results were re-analysed, and high frequency data and extremely

relevant data were noted, taking into consideration the narratives and individual textual

descriptions of each participant. In places, the narratives gave a strong sense of certain

elements that needed to be included in the final analysis. These high frequency and

extremely pertinent data are grouped into overarching themes or composite structural

descriptions that describe the findings representative of the sentiments of the group as a

whole. These results are then analysed in relation to the research question in a discussion

considering the implementation of the new policy requiring nurses to have a minimum of a

Bachelor’s degree education.

5.4 Meso Level (Phase Three): Focus group

This is the third phase of data collection (Section 4.6.1). I collected data from middle

management (meso level), looking at information from the Regional Nursing Directors to

critically assess their experiences regarding degree education as a minimum entry

requirement for the nursing profession.

5.4.1 Sampling and Recruitment

The target sample for this level was selected from the Regional Nursing Directors in order

to assess their views about the influence of nursing degree entry requirements upon career

pathways and nursing roles. There were twenty Regional Nursing Directors working under

the umbrella of the General Nursing Directorate in the MoH. The regions are located under

five geographical zones (north, south, east, west and the central area) and a purposive

strategy was used to recruit six Regional Nursing Directors for the focus group, from

across all of the zones, to reflect the geographic spread and population distribution of the

country. This number is in keeping with good practice for focus groups as recommended

by Barbour (2007). Purposive sampling shows different perspectives on the situation,

process or event that will help the researcher to understand the problem and the research

questions (Creswell, 2013).

A focus group discussion was used to collect in-depth information from different

perspectives. A focus group discussion is a more active and dynamic social discussion,

unlike face-to-face interviews, and thus a cumulative understanding of the identified

situation can be achieved (Billson, 2005). Focus groups are small groups of participants

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with particular characteristics and criteria that provide qualitative data in a focused

dialogue (Krueger & Casey, 2015). It is the ‘interaction element’ that is the key point to

understanding how focus groups can be used to generate a different type of collected data

than what is possible from a face-to-face interview (Yin, 2013). The six participants who

met the inclusion criteria (Section 4.6.1) were invited to attend the focus group discussion

and provided with a PIS and consent form (Appendix 5.6 and Appendix 5.7). The practical

arrangements for the focus group, including the place and time, were prepared earlier and

participants were informed of the details in good time.

5.4.2 Data Collection Procedure

At the beginning of the data collection for this level, focus group discussions were

arranged with the Regional Nursing Directors in the main auditorium at the MoH. The

appointment, setting and arrangements were made specifically to coincide with their mid-

year meeting to more easily facilitate their involvement in the focus group. The groups

were directed by two facilitators as suggested by Billson (2005); one as a note taker

(assistant moderator) and my self, the researcher, as a moderator for the group. The

moderator was responsible for planning and facilitating the discussion, building

relationships of trust with the participants and being a good listener, non-judgmental and

flexible (Billson, 2005). The roles of moderator and assistant moderator are summarised in

Table 5-3.

Table 5-3: The roles of moderator (researcher) and assistant moderator (note taker) in focus groups.

Moderator Assistant Moderator (MA)

Set up equipment, arranged refreshments

and organised the interview room.

Welcomed the participants as they arrived

and distributed honorariums.

Supported the Moderator in setting up

equipment and organised the interview

room.

Oversaw data gathering, negotiated with the

AM regarding the level of detail of note-

taking (to supplement and not replace

mechanically-recorded data). Facilitated the

discussion.

During the interview monitored equipment,

welcomed latecomers and resolved

interruptions. Took notes throughout the

discussion for the purpose of debriefing (as

negotiated with the Moderator). Did not

take part in the discussion unless

exceptionally requested.

Thanked participants. Looked through notes and summarised key

points/issues.

Debriefed the session with the AM

immediately after the interview. Transcribed

and analysed interview data.

Contributed to debriefing immediately after

the interview. Supported the ongoing data

analysis process.

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The assistant moderator and I were oriented to the skills and the task for each discussion.

For classification purposes, the participants registered and were provided with a name tag

with a code consisting of the capitalised first letter of their job title to ensure anonymity.

All the consent forms were signed by the participants, the environment was checked to

ensure that the atmosphere was comfortable and coffee was provided. The moderator

adapted seating positioned around a circular table for the focus group as suggested by

Morgan (1997). This arrangement put the moderator in an equal position to the

participants. The digital recorder was placed in the middle of the table to record the sound

clearly. The researcher welcomed and thanked the focus group for their involvement and

introduced herself to them. A PowerPoint presentation was initially given, which included

the purpose of the research study, the participants’ rights and the structure and guidelines

for the focus group to introduce the interviewees to the research process (Appendix 5.8).

The tape recorder was checked before conducting the discussion, and the guidelines for

asking questions were followed (Appendix 5.9). In line with the necessary ethical

precautions, the moderator explained the confidential nature of the data to be recorded and

reassured participants of their anonymity in the final report and other research outputs.

Since anonymity is impossible during focus group discussion, trustworthiness is an

essential element and participants were reminded that what is said inside the meeting room

is shared in a non-judgemental environment, and nothing discussed during the focus group

should be talked about outside the room (Guba & Lincoln, 1994). This is extremely

important, as nothing discussed during the focus group should be talked about outside the

room. Icebreakers/explanations were used to introduce the session. The semi-structured

interview was guided by five prepared combination types of questions (Appendix 5.10), as

suggested by Krueger and Casey (2015). Additionally, the themes that identified in the

literature were used to direct the initial conversation of the focus group.

The group discussion was audio-recorded with the prior consent of the participants. Polit

and Beck (2013) recommended that this would generate a data trail to which the

researchers could refer back. The assistant moderator wrote the contextual interview notes

and entered them into the database for this study. The moderator debriefed participants at

the end of the focus group discussion. It is important to allow sufficient time for

participants to raise concerns and make sure they have the contact details of the researcher.

I concluded the group discussion and summarised the important themes with the

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participants by delivering closing remarks. I respected the rights and dignity of all those

who were involved in the research and thanked them for their participation by distributing

an appreciation certificate.

5.4.3 Data Analysis

All the recorded audio data obtained from the focus groups group working at the meso

level were saved on the computer as audio files. The recorded interviews were transcribed

into printed text using Microsoft Word documents. The oral conversation was transcribed

verbatim to written conversation and included repetition, silence and pauses. For

classification purposes, I gave a code for each participant in the group to ensure anonymity

as illustrated in Table 5-4.

Table 5-4: Meso-level (Regional Nursing Directors)

Position No Nationality Given code

Regional Nursing Director 1 1 Saudi RND1

Regional Nursing Director 2 1 Saudi RND2

Regional Nursing Director 3 1 Saudi RND3

Regional Nursing Director 4 1 Saudi RND4

Regional Nursing Director 5 1 Saudi RND5

Regional Nursing Director 6 1 Saudi RND6

Transcribing the data for focus groups is time consuming; more so than one-to-one

interviews. It took around 6 to 8 hours to transcribe one focus group. The assistant

moderator and me, reviewed the transcribed data many times and sent the transcription

report for each participant in the focus group by email to validate the information given.

The majority of the participants (4 of 6) responded and agreed that the transcript was fine

and reflected what was said. Two group members did not respond. For transcribing and

analysis, I used the same technique as adopted previously with the data gathered from

macro level participants (Section 5.3.3). Finally, I checked all the data for accuracy and

saved it securely on my personal computer, flash stick memory, and email drop box.

5.5 Micro Level (Phase Four): Focus Groups

This was the last phase of data collection (Section 4.6.1). I collected data at the micro

level, looking at information from the nurses who worked directly with patients in

hospitals and PHCs, and those who had been most affected by the introduction of the

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policy (Caldwell & Mays, 2012).

5.5.1 Sampling and Recruitment

Focus group discussions were used to identify constructs of the issue under investigation.

Focus groups reflect the epistemological commitment to a people-centred design that

focuses on the importance of understanding how people think about the world and their

subsequent actions (Morgan, 1997). This epistemology is of relevance to the degree

education policy that requires a bachelor’s degree as a minimum requirement for entry into

practice in relation to the health organisational system. At level, three focus group

discussions were conducted at King Saud Medical City (KSMC) to allow sufficient

exploration of the phenomena. Focus group studies frequently depend on purposive

sampling wherein participants are chosen based on the objectives of the study. By using

purposive sampling, I was able to place them in specific focus groups according to their

professional roles and allied with their individual perspectives to link the points made in

the groups’ discussion as suggested by Krueger & Casey (2015). The use of explicit

placements in specific groups for the purposes of this study enabled a more consistent

group discussion, thus endorsing meaningful deliberations as opposed to heated

discussions (Teddlie & Tashakkori, 2010). Focus groups may comprise eight to twelve

members for each group as recommended by (Billson, 2005). nurses autonomy (Varjus et

al., 2011).

In this phase, three focus group discussions were conducted to allow sufficient exploration

of the research topic. Conducting more than one focus group discussion has the potential to

enhance the reliability of data by detecting a consensus across the different groups

(Morgan, 1997). The first focus group included a purposive sample of three nurse

managers of the three hospitals and one nurse educator. All were invited by email, and

received the PIS and consent form (Appendix 5.11 & Appendix 5.12 respectively). The

second and third focus groups included purposive random sampling of four staff nurses

with bachelor’s degrees and four staff nurses with a Diploma, who were invited to

participate by use of a poster covering the inclusion criteria for the study (Appendix 5.13).

The sample was achieved on a first-come, first-served basis, with a reserve list established

in case anyone withdrew at a later date. The total sample size for this level was twelve

participants divided into three focus groups. Finally, the place, date and time for the three

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focus groups were arranged and the information was given to participants in good time to

enable them to attend.

A purposive strategy was used for all groups. Six nurse managers from three hospitals and

one nurse educator attended the focus group discussion. The second and third groups

included eight participants in total. The purposive random sampling strategy was used

because the staff nurses working in the clinical area of KSMC represented a large number

of healthcare providers with different levels of nursing education and experience. It was

difficult to invite them by their name or job title because they were all staff nurses; the

poster inviting them was placed in each nursing department. This helped the researcher to

focus on a sample of the nursing population, both Diploma and degree educated nurses,

with the inclusion criteria (Section 4.6.1). According to Patton (1990), purposive random

sampling is small in size, which adds credibility to the sample when the potential

purposive sample is large. The eight participants were divided into two focus groups; four

of them were Bachelor’s degree nurses and four were Diploma holders, and involving

them in discussion enabled the participants to talk freely about the topic. Furthermore,

focus group experts commend the use of several different groupings based on

characteristics such as the level of education (Morgan, 1997; Krueger & Casey, 2015).

This number was still in keeping with good practice for focus groups that can work

effectively, with as few as 3 or as many as 14 participants being recommended by Gill et

al. (2008).

5.5.2 Data Collection Procedure

After permission was obtained from the MoH, I contacted the hospital Director of KSMC

to gain their permission to access the hospitals. The Director referred me to the Nursing

Director Office in KSMC with a letter of permission to conduct the interviews and

facilitate the necessary arrangements. The Nursing Director assigned one nurse as

Assistant Moderator (AM) for the researcher and this nurse made the practical

arrangements for conducting the focus group discussions..

The three focus group discussions took place within the interviewees’ working day and

lasted between 90 and 120 minutes. At the beginning of each focus group discussion, the

researcher welcomed and thanked the interviewees for their involvement and introduced

herself to them. The aim of the research study was explained. Each focus group discussion

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was audio-recorded with the consent of the participants to aid accurate transcription. The

audio recorder was placed in the centre of the round table to enable the sound to be

recorded clearly. The confidential nature of data recording was explained in Section 5.4.

Two moderators (See Table 5.3) facilitated the groups. The skills of the moderators are

vital to the effectiveness of focus groups (Billson, 2005). The semi-structured technique

was guided by five prepared combination types of questions (Appendix 5.9) as suggested

by Krueger and Casey (2015). Opening questions were used to enable participants to feel

comfortable and talk freely. For example, at the beginning of the discussion, the

participants were asked to introduce themselves and their background experience. Then,

introductory questions were used to get participants to focus on the topic and to start

thinking. For example, I asked them about their educational pathway as registered nurses.

Transition questions were used to provide links between the previous questions and the

key questions. For example, I asked them about their opinions regarding the minimum

requirement of a degree for entry to practise as a registered nurse. These questions guided

me to the key questions that focused on the major areas of the research study. At the end, I

asked them about any recommendations they would like to add in order to bring the

session to a close. During the data collection process, I was able to explore the rich

description in order to capture strength, direction and the inter-relationships of the

influential elements relating to the research questions. This process provided context to the

participants’ perceptions of how sustainability initiatives impact their engagement

(Creswell 2013). The moderator debriefed participants at the end of the focus group

discussion. It was important to allow sufficient time for participants to raise concerns and

to make sure they had the contact details of the researcher. Again, the session was

concluded and summarised and I thanked them for their participation by distributing an

appreciation letter.

5.5.3 Data Analysis

All the recorded audio data obtained from the three focus groups were saved on my

computer as audio files. The recorded interviews were transcribed into printed text using

Microsoft Word documents. The oral conversation was transcribed verbatim and included

repetition, silence and pauses. For classification purposes, I gave codes for each participant

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within the micro level which matched the inclusion criteria (Section 4.6.1) for each group

as follows:

Group One include Seven participants including senior nurse managers and educators

were given different codes to ensure anonymity as illustrated in Table 5-5.

Table 5-5: Group one (nurse managers and nurse educators).

Position No Nationality Given code

Senior Nurse 1 Saudi SN1

Senior Nurse 1 Saudi SN2

Senior Nurse 1 Non-Saudi SN3

Senior Nurse 1 Saudi SN4

Senior Nurse 1 Non-Saudi SN5

Senior Nurse 1 Non- Saudi SN6

Senior Nurse 1 Saudi SN7

Group Two include four staff nurses with a Bachelor’s degree were given different codes

as illustrated in Table 5-6.

Table 5-6: Group two (staff nurses with Bachelor degrees).

Position No Qualification Given code

Junior Nurse 1 Bachelor’s degree JNB1

Junior Nurse 1 Bachelor’s degree JNB2

Junior Nurse 1 Bachelor’s degree JNB3

Junior Nurse 1 Bachelor’s degree JNB4

Group Three included four staff nurses with Diploma education, and they were given

different codes as illustrated in Table 5-7.

Table 5-7: Group three (staff nurses with Diploma).

Position No Qualification Given code

Junior Nurse 1 Nursing Diploma JND5

Junior Nurse 1 Nursing Diploma JND6

Junior Nurse 1 Nursing Diploma JND7

Junior Nurse 1 Diploma JND8

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Each group included classifications that matched the inclusion criteria for that group.

Moreover, transcriptions for the three focus groups were saved in a micro level database in

an organised manner and uploaded to NVivo qualitative analysis software for content

analysis, which followed the open-coding process (Hilal & Alabri, 2013; Zhang &

Wildemuth, 2009), explained previously in the macro level analysis (Section 5.3.3). The

results and discussion of the interviews and focus groups are presented in Chapter 7.

5.6 Reflexivity

This section presents my experience, beliefs, values, position and perspectives during the

data collection process that may shape or effect the research method. Indeed, these factors

are considered important issues in all research types, but particularly in qualitative

research. To ensure that I am aware of my own influence on the research process I

developed a reflexive journal (Appendix 5.13), a type of personal diary where I made

regular entries during the research process, specifically highlighting those whereby I can

take any necessary action (Guba & Lincoln, 1994). For example, in the documentary

analysis phase, I faced a lot of difficulty in analysing the documents, as the documents

were in the original professional Arabic language that contained certain words with a

broader meaning. I could not use the NVivo programme in this phase because of the

language. Therefore, I tried to search for a framework to analyse the documents. I found

that the documentary analysis guidelines were the best to guide me to reach, select, and

analyse these documents (Prior, 1974). Analysing documents was time consuming, and for

me was the worst stage of this study. I read the documents many times, and every time I

discovered something significant to the research aim. On the other hand, this stage made

me more confident, knowledgeable and oriented to the whole system and process of policy

implementation.

Throughout the data collection process, a number of elements were kept consistent in the

three levels (macro, meso and micro), such as the importance of confidentiality (Section

4.9), achieved through coding, and ensuring that all participants in the interviews and

focus groups for each level were comfortable within the discussion environment. Creswell

(2013) described an insider researcher as one who is part of the social group they are

studying. Being an insider researcher can have several advantages, such as: a greater

understanding of the culture being studied; not altering the flow of social interaction

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unnaturally; promoting a rapport with interviewees, access and ethics; knowing how to ask

for and where to gather data; having empathy for the interviewees’ perspective as

suggested by researchers (Stake, 2003; Merriam, 2009a; Yin, 2009; Creswell, 2013).

However, there are also some disadvantages of the insider role that have the potential to

impact on the trustworthiness of the findings. For example, as an ‘insider researcher’ in the

macro and meso levels, I was aware that decision makers and regional directors may

respond to me in my other roles; as a ‘colleague’ of those participants who were decision

makers at the macro level and as a ‘director’ to the meso level participants. During the

interviews, some participants asked for encouragement that they were saying the right

things and I had to offer them reassurance that I was not looking for a particular answer,

only their opinions on the subject matter. Meso level participants looked uncomfortable

during pauses and expressed their desire to help me as much as possible to obtain the

adequate data.

Participants at the meso level frequently said ‘as you know’ as they knew I was aware of

their issues, which shows the problem of assuming understanding in this situation of

familiarity in the research field. The frequency of this phrase was especially apparent when

I reviewed the verbatim transcripts. (Miles et al., 2014) points out the problem associated

with taken-for-granted perspective and difficulties with critically examining something

that can appear self-evident. I was aware of the need to counteract any assumption made

on my behalf, so I responded to this comment by asking the participant to explain what

they meant. I was very conscious to view the participants’ responses as objectively as

possible by not assuming understanding, questioning phrases and comments, interpreting

the comments correctly and thinking about all the possible interpretations.

In the micro level focus group, I was partly an insider researcher by virtue of my role as a

director, and an outsider researcher as I was not employed in the hospital and did not know

any of the participants (staff nurses with Diplomas and Bachelor’s degrees). This

insider/outsider role was helpful as it allowed the benefits of insider status but the

limitations of the researcher/participant relationship were easier to retain. In this situation,

participants would possibly not have perceived any internal risk to revealing detailed

information about the organisation, even if this was negative. I was able to focus on being

predominantly a researcher in this environment, as I did not have the responsibility of a

director.

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As a confident and organised interviewer, I was able to quickly build a trusting

relationship with the participants and put them at ease, giving them the time and

opportunity to express their views. This is consistent with the interpretivist perspective,

based on the interaction between myself as a researcher and the participant (Polit & Beck,

2013). I was conscious of my influence on this interaction, especially in terms of

influencing the flow of the interview by being interested in some of their comments more

than others, thus leading the interview in a certain direction.

In order to ensure that the participants had the freedom to respond without adverse

influence, the interview schedule began with some introductory questions about their

views on degree education as a minimum requirement to enter practice before asking key

questions. The semi-structured interview allowed the participants to identify and discuss

their response freely while I continued to be aware of the potential for me to direct the

conversation. In addition, I sought confirmation of my interpretations of interview data

throughout the interview, and at the end of the interview, I summarised key points and

asked the interviewees to add any related information. I was open-minded about issues

raised and probed for further information in order to fully understand the significant

information each interviewee possessed.

The interpretation of the data was affected by the connections made between the data

within each level and across levels and involved comparing and contrasting data for

similarities and differences. The differences were delicate and sometimes difficult to

extract, but important information is explained in the findings. For example, the

participants at the micro and meso levels expressed mixed opinions about the importance

of degree education as a minimum requirement to enter practice as a professional nurse.

These could have been negatively influenced considering that some of them were

Diploma-educated nurses and could not take a degree due to many factors such as age,

limited places on the programme, and requirements for high scores in English test (IELTS).

On the other hand, macro level participants, like governors, opposed the views of micro

and meso level participants, claiming that there were no obstacles to join the programmes.

As a researcher, I am aware of the importance of being highly alert to subtle aspects of

data, to make these clear and to adapt to collecting data from different people functioning

at different levels and from different areas of the country in order to portray a holistic view

in the study.

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5.7 Summary and Conclusion

This chapter has discussed the data collection protocol for three levels of the framework

(four phases), detailing the sampling, data collection procedure, and data analysis of each

group within the MoH (macro, meso and micro levels). The documentary analysis (phase

one) has been used to gain more information from the documents of the GCC nursing

committee about the policy to introducing degree education as a requirement for qualified

nurse’s in SA, to critically assess the implications of this policy and to determine a

baseline from which to develop a national nursing strategy for future workforce planning.

The face-to-face interviews with macro level (phase two) participants has been undertaken

with a sample of decision makers at the MoH to understand their perspectives of the

influence of the degree education policy on nursing workforce planning and development.

The meso level data collection (phase three) has been conducted with one focus group to

determine the views of a sample of practising nurses at the middle management/meso

levels of nursing practice, regarding the influence of degree entry requirements on nursing

workforce planning. The micro level data collection (phase four) has been undertaken

within the frontline/micro level people engaged in nursing practice, regarding degree

education as a minimum requirement for entry to the nursing profession and a meticulous

explanation of the data transcription and analysis is given.

Using documentary analysis in combination with interview techniques allowed me, as a

researcher, to gain in-depth and rich information about the situation under study (Creswell,

2013; Merriam, 2009a; Yin, 2009; Stake, 2003). Finally, the chapter concluded with my

personal reflections throughout the data collection process.

The next chapter presents the results of documentary analysis summarised in three

important thematic categories evident across all documents analysed, from which common

sub-themes were revealed in the data related to each category.

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Chapter 6 : Documentary analysis: Results and Discussion

6.1 Introduction

Chapter 5 offered the analytical processes for documentary analysis and analysis of

participant responses to the interview questions and focus group discussions at three levels

(macro, meso, and micro). This chapter is divided into two sections.

The first section presents the results of the documentary analysis, while the second section

offers a discussion of those results. The results of the interviews and focus groups at the

macro, meso, and micro levels will be presented in Chapter 7. The initial coding from the

documentary analysis was based on the research aim, which was to critically assess the

implications of Bachelor’s degree nurse education as a minimum entry requirement for

nursing practice, to determine a baseline from which to develop a national nursing strategy

for workforce planning and development. The objective, pertinent to this section of the

research, was to:

 Review the MoH rationale for nurse education degree entry and assess the intended

outcomes in terms of national workforce planning.

Relevant documents as described in Section 5.2 were analysed comprehensively and

systematically using Prior (2003) framework analysis and these were explained in section

5.2.3. Analysing documents prior to the interviews helped me to gain a rich understanding

of the policy process. The analysis attempted to understand the process and outcomes that

occurred across the case study, to develop a comprehensive description and explanation

(Polit & Beck, 2013). The two sections within the chapter will detail each of the three

identified thematic categories emerging from the reviewed documents (D1, D2, D3, D4,

D5, D6, and D7). Cognitive/mind mapping (Miles et al., 2014) will be used within three

sub-headings to illuminate the analytical and thought processes related to each thematic

category and the documentary analysis as a whole.

Documentary analysis resulted in the generation of three thematic categories evident

across all documents analysed, from which common sub-themes were revealed in the data

related to each category. The interrelated thematic categories emerging from in the

documentary analysis are illustrated in Figure: 6-1.

131

 Theme 1: Rationale for change

 Theme 2: Nursing as an agent for change

 Theme 3: Making the change

6.2 Rationale for Change

This was a significant thematic category identified from the documentary analysis, which

underlined the rationale for change and the need for global standards for the future nursing

workforce in the Gulf countries. This theme included two important subcategory themes,

illustrated in Figure 6-2.

Figure 6-2: The first category in documentary analysis

6.2.1 Recognition of the challenge

The GCC Nursing Technical Committee recognised the importance of change in nursing

education and practice to meet patients’ expectations by focusing on the quality of

healthcare services. The committee was aware of, and knowledgeable about, the health

challenges facing the Gulf population and the reasons for the change in nursing education

Rationale for change Making the change Nursing as an agent

for change

Figure 6-1: The three thematic categories from the documentary analysis

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as stated in D7:

“the initial education of professional nurses has arisen for several reasons such as an

increasingly ageing population, onset of diabetes, obesity, hypertension, etc.” (D7, p.8).

ض السكري، وقد تم تنفيذ الحد األدنى للدخول إلى مهنة التمريض لعدة أسباب مثل زيادة السكان المسنين، ظهور مر“

”ضغط الدم، وغيرهاوالسمنة، وارتفاع

The document also shows the GCC’s recognition of increasing demands for healthcare

services at different levels of service provision, the increase in the number of other health

professionals, besides nurses, and the need to assure the right access to healthcare services.

In addition, there is recognition of the shortages of professional nurses, especially in the

rural and border areas in SA, which includes the north, south, east, and west areas. The

shortage of nurses is an important issue within Gulf countries and it is expected to increase

as health demand grows. This issue was highlighted in D7, p.19 as:

“Shortage of national nursing staff and lack of national nursing leaders is the first issue

that affects the nursing workforce in the Gulf countries”

لقوى ولى التي تؤثر على انقص الكادر التمريضي الوطني نقص في القيادات التمريضية الوطنية هي القضية األ“

”العاملة التمريضية في دول مجلس التعاون الخليجي

The health challenges and issues listed in the documents are examples of the rationale for

change in the initial education for nurses. Expanding health services and increasing health

complexities require high-level skills within the nursing workforce. Analysis of the GCC

document (D7) shows the GCC nursing committee’s awareness of this current situation,

and the need for professional nurses who are capable of dealing with a diverse population

and providing high quality care. In summary, the challenges are presented as a strong

rationale for change to match the future direction of healthcare highlighted by (WHO

2009) and global healthcare organisations.

6.2.2 Changing patterns of health and disease

It was acknowledged from the documents’ analysis that the changing patterns of health and

illness/or disease in the Gulf countries were related to demographic changes. For example,

the GCC technical members in D1 listed some examples of global health challenges that

might influence the quality of healthcare services and nursing workforce planning in Gulf

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countries, as illustrated:

“Population growth rate, equality of healthcare demands and needs, and

emerging health threats” (p.26).

" لناشئةاة بين مطالب الرعاية الصحية واالحتياجات، والتهديدات الصحية معدل النمو السكاني، والمساوا ”

The population of SA increased from 4.0 million in 1960 to 31.5 million people in 2015

(World Population Review, 2016). Recent statistics show that there is a substantial change

in the Saudi age structure related to an increase in life expectancy and decrease in fertility

rate (MoH, 2014). Non-communicable disease accounted for 71% of all deaths in SA, with

cardiovascular disease the leading cause of death due to a high rate of physical inactivity

and unhealthy lifestyle (Mahmoud & Faramawi, 2015). The incidence of diabetes mellitus

has increased globally and locally over the past decade. In SA, 20% of the population over

the age of 20 complained of type 2 diabetes, which is considered the highest rate in the

world (Section 1.2). Many of these issues reinforce and underline not only the need to

promote health and prevent illness, but also highlight the important role of a degree nurse

who can administer unique care in all three stages of healthcare; primary, secondary, and

tertiary (D 6.4).

Health and disease patterns in SA have changed over recent years due to demographic,

socio-economic, and cultural factors as discussed in section 1.2. In addition, D1, D2 and

D6 present some examples of health challenges that illustrate the complexity of health

needs and demands in the Gulf countries. However, from analysing the GCC documents,

the results show that the GCC nursing committee recognised the key factors affecting the

health of individuals, families and populations, which are stated in D1 and reviewed again

in D2 (p.31) as follows:

 Demographic change (ageing population, birth rate)

 الشيخوخة السكانية، ومعدل المواليد -التغير الديمغرافي

The GCC committee recognised demographic change as a major factor affecting health

and disease patterns in Gulf countries. Saudi life expectancy has increased to 74.5 years,

which exceeds the regional average by 6 years and the global average by 4 years (WHO,

2006). This phenomenon can be attributed to other issues, such as variation in birth and

mortality rates. The ageing population in SA is growing at a faster rate than the Middle

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East average (Almalki et al., 2011), which is considered as an important health indicator

for policy makers:

 Changing pattern of health and disease

 تغيير نمط الصحة والمرض

The social life pattern is the second factor identified, and a major control factor impacting

on health and disease in the Gulf countries. Lifestyle-related diseases occurring in Gulf

countries are associated with eating patterns and decreased physical activities (Section

1.2). The risk factors for chronic (non-communicable) diseases such as coronary heart

disease, stroke, obesity and diabetes mellitus are increasingly prevalent in SA. According

to Mahmoud and Faramawi (2015), the most important risk factors for non-communicable

diseases include high blood pressure, high cholesterol, inadequate fruit and vegetable

intake, overweight and obesity, physical inactivity and tobacco use; all of which are major

factors influencing mortality in developing countries. The WHO (2011) report shows that

26.6/1,000 female and 46/1,000 male deaths in SA were associated with non-

communicable diseases. These statistics illustrate health indicators that may predispose the

direction of future health policy (Mahmoud & Faramawi, 2015; WHO (2011). Symposia

have actually taken place in SA for specific health action planning purposes. Moreover, the

health system in SA and the pervading socio-cultural context of life were explained in

Section 1.2 and 1.3: for example, increasingly sedentary lifestyles, and this led to increase

the expectation of the Saudi population as listed in D1:

 Increased expectations of public and health services users

 مستخدمي الخدمات العامة والصحةزيادة التوقعات من

Increased expectations of health services users is the third factor affecting the healthcare

system. The expectations of the Saudi population for quality healthcare services are

expanding (Al-Yousuf et al., 2002). These expectations reflect the transformation in the

quality of healthcare services, such as the use of technology and social media to engage

with their patients (Section 1.3). The Saudi population are becoming more aware and

knowledgeable regarding healthcare services and they expect more services from the

government sectors. Within the interviews and focus group discussions (presented in

Section 7), there was anecdotal evidence of this concern, with some questioning health

policy and planning to match improved public knowledge of health matters, and a related

135

desire for higher levels of service. This finding is in keeping with wider consumerism and

expectations regarding healthcare provision in other contexts. For example, in the UK, the

Patients Association, (2013) is an active body that represents the public regarding health

provision. ‘INVOLVE’ was previously developed in 1996 and aims to support active

involvement of the community in NHS, public health and social care research (Ham et al.,

2015). However, with regard to increasing expectations amongst new generations in SA,

the Saudi health system has undertaken some initial steps aimed at:

 Increased access to and choice in health services

 زيادة الوصول واالختيار على الخدمات الصحية

This aims to increase communities’ direct control over their care. This in itself has

potentially led the community to select and compare between the different levels of

healthcare services (Section 1.3). Most private health sectors provide unique online

services to their patients. They concern themselves with high quality management, placing

emphasis on patients and their families as customers and consumers of health, and have an

attendant focus upon patient satisfaction. For example, the mission of Al Mishari Hospital

states that:

“Dr. Abdul Rahman Al Mishari Hospital is committed to superior quality and

safety in meeting the health care needs of the clients we serve by fostering

advanced and compassionate health care services”

Furthermore, the private sectors also follow the same direction of the MoH, which aims to:

 Shift the delivery of healthcare services to a community setting.

 التحول في تقديم خدمات الرعاية الصحية إلى بيئة مجتمعية.

Moving healthcare services out of hospitals to the community has been a global direction

for many developed countries such as the USA, Canada, and the UK. This is in keeping

with the WHO (2009) recommendations to enhance community services. Some countries,

such as Australia, Norway, and Sweden, are further on in the process of shifting care out of

the hospital to the community (RCN, 2013). This includes delivering care closer to home,

reducing hospital readmission and length of stay, increasing patient choice and

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satisfaction, addressing health needs for elderly people, and early intervention and disease

prevention.

However, despite the GCC nursing committee’s commitment to encourage community

service development, there is limited evidence to show real investment in the community.

The MoH is supportive of moving care closer to patients (Section 1.3.1). For example,

there is a MoH strategy to expand primary healthcare services (Almalki et al., 2011). Yet,

more community investment is needed by the MoH to achieve this shift. That said,

promotion of community health services and increased uptake by the population does

require some public education, as there is a preference for hospital care. For example,

patients present at emergency departments for non-urgent cases rather than attending the

community services provided and this is in keeping with trends in the UK (Brooks &

Rafferty, 2010). Accordingly, the GCC Nursing Technical Committee’s knowledge

regarding the nature of technology playing a pivitol role in delivering health promotion

programmes in the community (D1) is the overall result of shifting healthcare services to

the community, and indicates the importance of using:

 Advanced technology and innovations in the healthcare system.

 التكنولوجيا المتقدمة واالبتكارات في نظام الرعاية الصحية.

The GCC Nursing Technical Committee, policymakers and stakeholders all acknowledge

that technology continues to change at lightning speed, and impacts the way healthcare is

planned and organised. Technology is growing and playing an important role in almost all

healthcare services, from patient registration to discharge and follow up (Black et al.,

2012). New technology provides cost effective services to organisations, patients, families,

and the community. Devices such as iPads, smart phones and tablets are starting to replace

healthcare processes such as recording, reporting, monitoring, transferring, and so on.

Advanced technology contributes to knowledge, practice, services, and consultations that

are now being taken beyond the boundaries of the hospital and integrated with user-

friendly and accessible devices (Black et al., 2012). The MoH has embarked on e-health

strategies with some success, and this service is being extended to rural areas and smaller

hospitals in more remote Saudi regions. Saudi nursing scholarships and study leave

applications are already processed online in the MoH.

All the identified challenges illustrate the need for change in the traditional models of care

and require advanced professional skills in transforming nursing education and practice to

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manage complex healthcare, meet service demand and address patients’ needs. These

challenges have been identified by the GCC nursing technical committee as a rationale for

change within nursing education, namely progression to degree education.

6.3 Nursing as an Agent for Change

While the previous section has illuminated the GCC committee’s rationale for change, this

thematic category presents the role of the nursing profession as an agent for change. It was

identified from the documentary analysis that a key message of the GCC Technical

Committee of Nursing was the emphasis of the role of nursing as an agent for change in

education, practice, and management. The role of the GCC Nursing Technical Committee

was explained in section 2.5. Reviewing the documents shows there is agreement on the

part of GCC members regarding the importance of nurses as agents for change in

transforming healthcare services locally and globally. The GCC committee also

emphasised the importance of preparing the national nursing workforce for a broader role

(D1, D2, D3 & D7). The key theme/question that emerged from the documents is what the

transformed nursing education and practice in Gulf Countries could and should be like,

and what knowledge, skills and attitudes nurses with degree education will need. In

summary, there was consensus within the GCC documents that nursing has the potential to

act as an agent for change, yet there was little accompanying detail as to how to take the

change forward and implement it within nursing education and the wider profession.

Three important subcategories resulted from the thematic category “Nursing as an agent

for change”, and these are summarised in the illustrated mind map in figure 6-3.

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Figure 6-3: The second category in documentary analysis

6.3.1 The Value of Professional Nurses

The value of professional nurses is a subcategory theme identified from the meeting

minutes of GCC. For example, the nursing committee of the GCC provided

recommendations in their meeting in Kuwait (D 5), and highlighted the important role of

professional nurses in transforming nursing education and practice. According to their

discussion documented in the meeting records (D7), nurses in the GCC countries represent

the largest group of healthcare providers, compared with other healthcare team members,

and this adds to their significant contribution to healthcare systems in primary health care,

critical care, and community services.

“Nurses and midwives make up the greater part of the Gulf healthcare workforce”

D7, (p.10)

الصحية الخليجيةنسبة الممرضات والقابالت تشكل الجزء األكبر من القوى العاملة الرعاية

It is argued that the nursing committee also recognised the unique contribution of the

nursing profession to health services, social services and the community as a whole. The

GCC committee in D5 state that the professional nurse is able to:

“Provide a holistic nursing care that is socially and morally acceptable and based on

evidence and scientific research, using critical thinking in decision-making in the provision

of care and upgrading them to reduce risks and control of diseases and assist in the

rehabilitation and respect for the dignity of the patient at death” (D5)

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مستخدما لعلميا والبحثي البراهين على مبنية واخالقيا اجتماعيا مقبولة تكون بحيث الشاملة التمريضية الرعاية تقديم“

االمراض ىعل والسيطرة المخاطر من للتقليل بها واالرتقاء الرعاية تقديم في القرارات اتخاذ في االبداعي التفكير

”الوفاة عند المريض كرامة واحترام التأهيل اعادة في والمساعدة

The fast socio-economic transition period of SA and its implications for high standards of

professional nursing skills to extend programmes of health promotion and prevention, in

response to changing health needs was discussed in sections 2.1 and 2.2. This type of care

can be provided only by highly educated nurses who can readily adapt to global changes

and manage the complexity of healthcare services as recommended by WHO (2009).

By virtue of nurses’ numbers as the largest group of healthcare providers (D7), and their

advanced knowledge, skills and attitude, professional nurses must help to lead the change

in future workforce planning to meet the population’s needs.

According to the Gulf nursing committee (D5, p6);

“Preparing nurses for professional roles is the future direction for all countries; the

curriculum of nursing programmes must focus on professionalism; reflect the patients’

needs and be immediately applicable to the central role of nurses to meet the strategic

goal of the MoH: patient first”

إعداد الممرضات لدور المهني هو االتجاه في المستقبل لجميع البلدان، والمناهج الدراسية لبرامج التمريض

ابلة للتطبيق فورا إلى الدور المركزي يجب أن تركز على المهنية. تعكس احتياجات المرضى وتكون ق

الهدف االستراتيجي من وزارة الصحة: المريض أوالللممرضات لتحقيق

In keeping with professional identity and the development of professional skills for nurses

as advocated by the GCC, there is a need to reflect professional themes within the nursing

curriculum. This is a key point within the MoH policy discussed in section 3.4. This theme

is also revisited within the recommendations resulting from this case study, which will be

discussed in section 8.3. It is interesting to note in the last quote that most of the reviewed

documents in this study have highlighted the unique role of nurses and their contribution to

healthcare services (D1, D2, D3, and D7).

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The GCC actually wishes to harness this role for nurses in the Gulf countries.

Unfortunately, it is argued that while nurses have much influence and professional

potential, they do not use it; they are holding themselves back due to socialisation, and the

societal context of SA has the potential to hold them back (Gazzaz, 2009). For example,

some families feel there is a certain stigma around the nursing profession. It has been

reported that the mother of a male nurse refused to recognise her son as a nurse; instead,

she referred to him as a doctor within the community (Miller-Rosser et al., 2006).

However, by focusing on knowledge as the key to nursing professionalism, and the role

and actions of the individual nurse, it is suggested that one is missing the point (Section

3.3.7). There should also be focus on the superstructures that are the substance of

professional standing and autonomy (Meerabeau et al., 2004). It is therefore essential that

nursing education and services be restructured from the foundations upward, in addition to

supporting the individual nurse to become confident and autonomous. According to

Meerabeau et al. (2004) this gives the opportunity for the community to view power

relations differently; organisation/community, male/female, professional/unprofessional.

This would challenge the current social concepts within the nursing community in SA and

give space to develop a global model to improve the nursing profession’s organisation and

education and build a more positive future career for Saudi nurses (Section 2.4). Within

this framework, it is important to consider the role of nurses at each level of education and

the impact that this has on patient care, with a particular focus on providing a flexible

nursing workforce. Therefore, it is argued that the intellectual expansion of nursing

influence, autonomy and freedom hinges politically on its power relations with other

healthcare providers, such as doctors and social workers. Moreover, it hinges on the

relationship of nursing within the MoH structures (Section 2.2).

6.3.2 Enhanced Leadership Skills

This is another subcategory theme developed from reviewing the GCC documents. The

document D 5 shows that there is a recognised need for nursing leadership skills within the

Gulf countries. The GCC emphasises the role of Saudi nurses as future leaders and the

need to involve them in the national strategic plan for Middle Eastern countries’ crisis and

related national disaster planning,

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“Enable nursing leaders in each of the GCC countries to participate in the national

strategic and operational policies and plans for dealing with disasters and crises" D5.2

دول المجلس من المشاركة في وضع السياسات والخطط االستراتيجية "تمكين القيادات التمريضية في كل دولة من

والتنفيذية للتعامل مع الكوارث واالزمات"

Nurses are at the frontline of care in responding to any situation that might influence the

health and illness status of the population, such as natural disasters or human induced

disaster. For example, during the Hajj season, the population in Makkah (Mecca) increases

from 200,000 to over three million people. The masses of people that arrive in Makkah for

the Hajj pilgrimage, coming from all over the world, create a critical situation and overt

pressure on healthcare services, in which a number of emergencies are reported (Alamri,

2010). This happens for several reasons, such as the heat, overcrowding and breathing

difficulties. SA has recorded an increase in natural disasters; for example, flash floods and

torrents in Jeddah (Sale) and dust storms in central Riyadh and northern cities (Aa’jj).

These, in turn, are causing an increase in the number of accident and emergency cases that

are transferred to hospitals and emergency centres (Alamri, 2010; Almalki, 2012). These

types of sudden crisis require a high level of nursing leadership skill and management in

order to deliver good care in good time.

In keeping with professional practice, the GCC nursing committee in D2 also views

leadership and management as key components of the BSN curriculum. Leadership theory

is currently taught in year 4 of pre-registration nursing programmes. For example, the BSN

programme outline that was developed by the GCC committee sets as one of its objectives

that,

“the bachelor’s degree nursing students will apply leadership and decision making

concepts and skills in the provision of nursing care in different healthcare settings

including hospitals and primary healthcare centres” D2.4.

ومهارات القيادة وصنع القرار في تقديم الرعاية التمريضية "طالب التمريض من درجة البكالوريوس سيطبقون مفاهيم

ومراكز الرعاية الصحية األولية" في مجال الرعاية الصحية المختلفة بما في ذلك المستشفيات

This supports the evidence presented in the Saudi context of nursing education in section

2.3 to involve nurses as leaders within ‘Saudization’ strategies (Section 1.3.1). The scope

of leadership set out in the GCC documents (D2) suggests that leadership skills and

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management are more appropriately taught through practice via continuing education

programmes, in order to prepare nurses to present leadership skills as part of nursing

practice. Strengthening the visibility and the value of the nurse leadership voice is the

major priority that needs investment to shape governance.

In summary, the above analysis indicates that there is GCC recognition of the nursing

leaders’ role at the national level of strategy and planning, and there is commitment to

developing educational programmes to increase the number of national nursing leaders in

order to meet community needs and healthcare demands. In recognition of this, the Saudi

MoH realised the unique value of degree prepared nurses within practice to improve the

quality of care and patient safety. However, other health agencies such as military

hospitals, teaching hospitals, and Magnet hospitals have already implemented this policy

to enhance leadership skills for all nurses, as explained earlier in section 1.3.2. Other

governmental health sectors in SA have already applied the degree requirement for nursing

practice in their system to enhance nursing leadership and raise the standards of the quality

of care. However, the MoH is still progressing slowly and a key finding is that there is

little detail on how to implement the required change.

6.3.3 Fragmentation in GCC Nursing Strategy

The previous subcategory theme illustrated the GCC Nursing Technical Committee’s

views regarding nursing leadership skills and effectiveness in the Gulf countries. This

subcategory theme reveals explains the fragmentation found in nursing education and

practice within the Gulf countries.

Analysis of the documents suggested that there is some variation in the levels of initial

nursing education and the minimum entry level for professional nurses within the Gulf

countries. For example, some Gulf countries such as Kuwait considered initial nurse

education programmes at secondary school level to be sufficient (D7.3), while other

countries such as SA recently specified university-level education as the minimum point of

entry to the health professions for nurses (D7.3).

In addition, nursing education takes place in a number of governmental and private

college/universities (Section 2.3). These settings create considerable fragmentation within

content of nursing education and the resulting practice abilities of nurses. For example, the

governmental nursing colleges provide free education to a limited number of national

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students through a 5-year degree programme, which includes a one-year internship in the

governmental hospitals (Section 2.3).

However, the GCC Nursing Technical Committee proposed national general curriculum

guidelines for nursing education in recognition of the fragmentation across Bachelor

Degree, Diploma, and bridging programmes in order to standardise the curriculum outlines

for nursing education in the Gulf countries. These curriculum guidelines were written in

Arabic in D1, D2, and D3.

The curriculum outlines the three educational pathways to becoming a registered nurse in

the Gulf Countries as follows:

The first pathway is Diploma-nursing education, and the duration of the programme is,

“not less than two and half years and aims to provide direct patient care in

hospitals and primary healthcare centres” (D2, p.3-4)

الصحية ى ومراكز الرعاية ال تقل عن سنتين ونصف وأهدافها توفير الرعاية المباشرة للمريض في المستشف

األولية

The second pathway is Bachelor’s degree nursing education,

“offered in five years, which includes all the content in the Diploma but an in-

depth study of the pathophysiology, nursing research, pharmacology, leadership

and management, community and public health, ethical and educational principles,

and nursing informatics” (D2, p2).

عرضت في خمس سنوات والذي يتضمن كافة المحتوى في الدبلوم ولكن دراسة متعمقة من الفيزيولوجيا

صحة العامة، والمبادئ األخالقية المرضية، والبحوث والتمريض، والصيدلة، والقيادة واإلدارة، والمجتمع وال

والتربوية، والمعلوماتية التمريض

The third pathway is a bridging programme, which

“provides additional education for Diploma holders who want to expand their

knowledge and advance their skills to get the bachelor’s degree” (D2, p.5,6).

توفر التعليم اإلضافي لحامل الدبلوم الذين يرغبون في توسيع معارفهم وتطوير مهاراتهم للحصول على درجة "

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البكالوريوس

The three levels of nursing education outlined in the GCC Nursing Technical Committee

documents (D1, D2, D3) are summarised in Table 6-1 to identify the similarities and

differences.

Table 6-1: Nursing education pathways in the GCC countries

Nursing programme BSN Diploma Bridging

The aim of the

programme

Prepare nursing

students that are able

to provide holistic

nursing care to

individuals,

communities and

society at all three

levels (primary,

secondary, tertiary) in

accordance with the

approved standards in

order to promote

health and improve

quality of life.

Provide the basic

level of nursing care

to individuals &

society, and work

within healthcare

team in order to

promote health and

improve quality of

life.

Prepare qualified staff

who are able to provide a

holistic nursing care to

individuals, communities

and society at all three

levels (primary,

secondary, tertiary) in

accordance with the

approved standards in

order to promote health

and improve quality of

life.

The duration 4 years, the

programme starts

instruction after

completion of high

school.

2 ½ years, the

programme starts

instruction after

completion of high

school.

The duration of the

programme depends on

the total number of hours

of the previous

programme.

The internship

period

12 months of clinical

practice.

6 months of

consolidated practice.

6 months of consolidated

practice.

The theory part 50% 50% ____________

The practical 50% 50% ____________

Total credit hours

needed for

graduation

125 credit hours

1 credit hour theory=

1 hour/week

1 credit hour lab= 2-3

hours/week

1 credit hour clinical=

4-5 hours/week.

70 credit hours

1 credit hour theory=

1 hour/week

1 credit hour lab= 2-3

hours/week

1 credit hour clinical=

4-5 hours/week.

____________

The nursing

licensure

Licence provided

after passing the

national exam.

Licence provided

after passing the

national exam.

------

Classification Specialist. Technician

(generalist).

Specialist.

Continuing

education and

renewal license

20 hours/year. 10 hours/year. 20 hours/year.

It appears that there are both similarities and differences across the nursing programmes as

noted in Table 6-1. For example, the aims of the BSN and bridging programmes are

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typically the same, whilst the duration of the internship in the bridging programme is

different from the BSN and similar to Diploma nursing education. However, Table 6-1

demonstrates that the GCC still provides the outline curriculum for the three levels of

nursing education, which means there are some Gulf countries that have still not

implemented the degree education policy. Also, the results indicate some fragmentation in

nursing education and practice in the GCC countries and this may relate to demographic

and socio-economic factors (Section 1.2). For example, Kuwait does not implement the

policy of degree nurse education as a minimum requirement for nurses to enter practice,

whereas it is well established in other countries.

Together these results provide important insights into fragmentation of initial education as

a minimum requirement for nursing practice and the value of the professional nurse in the

Gulf countries. The following section, ‘Making the Changes’, will discuss the last theme

of documentary analysis that includes the purpose of the GCC itself and all the outcomes

of introducing degree nurse education in SA.

6.4 Making the Changes

Making the changes is the final thematic category identified from the documentary

analysis. All the reviewed documents suggested that the GCC nursing technical committee

were proposing, developing, and presenting a strategy to make changes within nursing

education and practice, as a result of the changing health context (Section 3.2.2).

This thematic category ‘Making the changes’ comprised two sub-themes: the process of

the GCC itself, and the outcomes of introducing degree education as illustrated in Figure

6-4.

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Figure 6-4: The third category in documentary analysis

6.4.1 Process of the GCC Nursing Technical Committee

The process of GCC working is itself worthy of discussion in relation to nursing workforce

planning and degree education. For example, it could be argued that the GCC committee

worked in comparative isolation, in that nursing, at all levels of strategy and practice in

SA, nurses did not appear to have been involved in GCC working processes. The GCC

technical members of nursing have grappled with issues, limitations and beliefs as they

have considered the need for significant change in nursing education and practice in the

Gulf countries (D7). The GCC Nursing Technical Committee reviewed the outline of the

action plan for each country (D7). For example, an action plan was presented at the GCC

meeting as a checklist (D7), which includes an action plan for nursing strategy for each

country, as illustrated in Table 6-2.

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Table 6-2: Action plan for nursing strategy, the GCC booklet 1993-2013, (2014).

As can be seen, Table 6-2 does not present the process or the measures to implement

degree nurse education; it does not include a timetable to detail how or when actions

should be taken. The Table does not indicate plans for piloting, or programme evaluation

processes. For example, the action plan for 2006-2010 includes different objectives; one of

them is highlighted in Table 6-2, as

“Take the necessary measures to implement the recommendation of the World

Health Organization that required one level only (university degree/ bachelor’s) as

a minimum requirement for entry into practice”. (P.68).

اتخاذ اإلجراءات الالزمة لتنفيذ توصية منظمة الصحة العالمية التي تتطلب مستوى واحد فقط )شهادة جامعية /

واقع عمليالبكالوريوس( كحد أدنى دخول إلى

Therefore, the action plan on Table 6.2 is open to interpretation, and there is a clear lack of

specific guidelines for implementation. The analysed documents do not show who should

take action during the SA implementation process for Bachelor’s degree nursing

education. For example, there is no evidence in the documents that the MoH General

Directorate of Nursing should form a working group and develop an action plan, first

regionally, to pilot and then roll out the education programme. In addition, there is no

consultation period suggested in document D7 to discuss the implementation of degree

level nurse education within SA, within the macro, meso or micro levels of nursing, or

Saudi

Arabia

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with other interested stakeholders such as medical services, patients and others. The

documents added the recommendations of the WHO as one objective of the nursing

strategy in Gulf countries, but the details of how WHO (2009) would implement the policy

were lacking or not included within the documents analysed.

Further to the process of change, and the lack of detail and clarity, it was identified that the

committee members from SA only included two nursing leaders from the macro level. The

nurses from the meso and micro levels (who would implement the degree nurse education

policy) were not involved or informed about the details that were discussed in the meeting.

In contrast, the other Gulf countries have two different members on the committee; one

from the MoH, and the second from higher education at the macro level; so at least there

was some consideration of education and training issues. The third point concerns the

language of the documents analysed and their accessibility. For example, the documents

were not available on the internet, or internal health service web sites. Had the documents

been made available via the MoH website, nurses would have had the opportunity to look

at and consider the new policy.

Furthermore, the documents were written in the Arabic language, whilst English is the

standard professional language for health communication and publication in SA (El-

Sanabary, 1993). As the documents are written in Arabic, expatriate nurse managers, who

would know the content of degree nurse education, and who would have prior experience

of it, would not be able to help or advise with the process of implementing degree nurse

education. For example, in the large hospitals, the Directors of Nursing are British, or

American, and they would have some experience of degree education, and would have

views to offer in support of implementation and rolling out the policy within SA. As it is,

they were not in a position to comment.

In summary, the processes within the GCC Nursing Technical Committee contributed to

working in isolation, without the involvement of nurses from the meso and micro levels.

Additionally, piloting and consultation periods were missing from the process of

implementing degree level nurse education, as evident in the documents analysed. It is

argued that such involvement of nurses at the macro, meso and micro levels of nursing in

SA was crucial in order to successfully take forward the implementation process for degree

nurse education, including preliminary piloting and evaluation, prior to the national

introduction of such programmes of study.

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6.4.2 The intended outcomes of degree education

Whilst the previous sub-category relates to the process of the implementation of degree

nurse education in SA, this category identified the intended outcomes of degree nurse

education. For example, the analysis outlined the outcomes of current issues of the Gulf

health system that were mainly related to nursing shortages and patient outcomes. In this

thematic category, the GCC committee wanted experienced nurses, national independent

leaders, with knowledge and skills to achieve the Saudization plans and to decrease the

dependence on foreign workers (Section 1.3). However, there are factors hindering this

outcome, with issues such as changing health and disease patterns, changing expectations,

shortage of nurses, and nurses with insufficient experience. In addition, there are increases

in patient complaints noted by the GCC.

According to the GCC nursing technical committee in their discussion about nursing care

and patient satisfaction (D5), the total number of patients’ complaints increased with the

current nurse shortage in SA, as regards independent working with different situations.

They state that:

“The nursing care that is provided by nurses is not meeting the patients’ needs due

to the lack of professional nurses with experience” (D5, p:10).

العناية التمريضية التي قدمت من قبل الممرضات لم تلبي حاجة المرضى بسبب نقص الممرضين ذوي

الخبرة

Secondly, the necessary knowledge and skills base for nursing practice has changed and

become more advanced with degree education level, but the curriculum of the nursing

programme has remained the same (D6).

“The expansion of knowledge in the medical field requires a qualified nurse who is

able to work independently and deal with different health situations” D6.4

الفوري مع تتطلب ممرض مؤهل قادر على العمل بشكل مستقل والتعامل توسيع المعرفة في المجال الطبي

الحالة الصحية المختلفة

Lastly, there has been slow progress in developing different job descriptions for nurses

based on their educational level (D 6). This indicates that there is a lack of job description

details for nurses from Bachelor’s or Diploma levels and all nurses are implementing the

same role. There is a need to improve and update the curriculum of nursing programmes to

meet the current and future needs of service users. However, there remain two fundamental

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problems: one being nurses with a diploma, and the other about the disparity among the

curriculum and the variance in quality.

In summary, these sections have presented the findings from an analysis of GCC

documents, detailing three key thematic categories that support the need to change nursing

education, to address the gap between current nursing education, which has remained

relatively static despite societal changes, and current health practice, which has also

changed. The three themes illustrate that the GCC were aware of these issues, but how to

change nursing in the real world was not explored, in terms of action planning,

consultation periods with nurses and others, piloting and evaluation projects prior to the

roll out of degree nurse education in SA. The three major themes identified from analysing

the GCC documents are:

 The rationale for change includes the recognition of the challenges and changes in

health and disease patterns that required advanced professional skills to meet

service demand and patient needs.

 Nursing as an agent for change includes the GCC’s recognition of the value of

professional nurses and enhanced leadership skills necessary for national nursing

leaders to work at a strategic level in order to raise the standards and subsequently

the quality of care. Furthermore, the fragmentation in nursing education and

practice is highlighted within this theme.

 Making the changes includes the process of degree implementation and an

evaluation of the intended outcomes of degree education.

The overall results of the documentary analysis suggest that the GCC Nursing Technical

Committee worked in isolation. To date, the GCC Nursing Technical Committee’s

documented meetings have not been published, and this means nurses do not have access

to the proposed strategy or to the implementation process. Also, piloting and consultation

periods were missing from the implementation process of the degree nurse education

policy. These points are further discussed and critiqued in Section 6.5.

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6.5 Discussion and Critique of Documentary Analysis

Having presented the three thematic categories, this section of the chapter will provide a

discussion and critique of the categories, drawing upon the data from the GCC Nursing

Technical Committee and information within the previous chapters, including the global

literature. As stated at the outset of this chapter, the analysis of documents enabled me to

gain in-depth information and a rich understanding of the policy process intended to

support the implementation of nursing degree education. The key understanding to emerge

from the analytical process relates to the lack of nursing and community involvement

within such plans to introduce nurse degree education as a requirement SA. The critical

implication from this lack of involvement is that potentially nurses at all levels in SA did

not understand why there was a need to introduce degree level education, how it would be

introduced, or what their role would be within the future nursing workforce.

The first of the three thematic categories from the documentary analysis, ‘rationale for

change’, reflects a wider global debate regarding the structure and process of health

services and the role of nurses within them (Section 2.4). Most of the global health system

is facing many health challenges, including workforce development, ageing populations,

nursing shortages, and the quality of healthcare (WHO, 2011; Ham, Baird, Gregory,

Jabbal, & Alderwick, 2015; AACN, 2016). Nursing leaders have highlighted many of the

issues raised by the GCC internationally through global forums such as the ICN and the

WHO. The WHO Nursing and Midwifery progress report (2008-2012) highlights the

changing nature of the global population with a rise in non-communicable diseases and the

need for high quality care from nurses, which can be achieved through better education,

leadership and autonomous roles (WHO, 2013). Similar views were echoed by more local

groups such as the Royal Australian College of Nursing (RACN, 2004), The King’s Fund

(Ham et al., 2015) and the American Association of College of Nurses (AACN, 2016). It

would appear that the GCC Nursing Technical Committee were very aware of the global

health challenges in developed countries, and the need to adapt nursing education and

develop the nursing workforce to respond to changing health needs. However, it would

appear the rationale for change was not discussed anywhere outside the GCC Nursing

Technical Committee.

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Given the global context of nursing and related societal challenges identified by the GCC

Nursing Technical Committee and others, it may be worthwhile for one institute such as

the WHO to initiate and regulate initiatives to harmonise degree nurse education. The

process would have a collaborative input from individual countries such as SA, overseeing

its implementation at the local level to enable the provision of a regional, specific and

appropriate programme.

The WHO World Health Assembly (WHA) already provides a similar mandate, which

develops and strengthens strategies for nursing and midwifery (WHO, 2016); these include

nursing and midwifery workforce capacity by providing support to Member States on

setting targets, action plans and developing interdisciplinary health teams. It is suggested

that such mandates could be further developed to encompass the standardisation of nurse

education within countries so that eventually the education level and training of nurses will

be comparable globally. This is particularly important for SA where a vast number of

nurses are from overseas, owing to the social and cultural stigma associated with the

nursing role (Gazzaz, 2009; AlMakhaita et al., 2014), and as a result the lack of uptake of

the profession by locals.

Making degree education mandatory only in a selected country such as SA may affect the

recruitment of vital staff, therefore affecting service level. The WHO aims to standardise

nursing standards globally and have already highlighted themes, which act as foci to

develop and deliver the mandates. Themes include: education and competency;

management and leadership; and governance. To cover these areas, these could be

developed further to cover the findings of the GCC. Whilst a the positive point of the

WHO driving and overseeing such an initiative is that it has a global oversight and can

therefore see the bigger picture (WHO, 2009), the worry is that, with such a large

organisation with a general outlook, the actions and policies can be diluted, lacking focus

and drive at the implementation level. Unlike the WHO, where policymakers consist of a

wide range of healthcare professionals with different stakeholders, the International

Council of Nursing (ICN) is a network of nurses and it is suggested that it may be better

placed to oversee the implementation of the education programme for nurses globally

(ICN, 2015). The ICN already has an Education Network dealing with policies devoted to

the educational needs of nurses (ICN, 2015), however, this is recent and still under

development. This would be an ideal opportunity to incorporate the issue of degree level

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education as a global requirement for nursing (AACN, 2016), and would cover the Gulf

region. The specialised nature of the organisation would mean that the issue is more likely

to be dealt with. If the WHO and ICN worked together to develop this strategy, there

would be a point of contact globally and locally for nurses to gain help and support, with

the WHO driving and overseeing the global development and ICN taking responsibility for

monitoring local progress through the local nursing network/representatives.

The pattern of health and disease presentation is changing (Section 1.2). There is an

increase in non-communicable diseases such as diabetes and CHD due to urbanisation

affecting the global population (Jadelhack, 2012; Mahmoud & Faramawi, 2015; WHO,

2016), all of which pose different types of nursing problems. As the trend in changing

disease patterns is a global issue, this should make it easier to standardise education and

training due to the common nature of the problem and allow a competent workforce to

shift globally with ease (WHO, 2016). Better healthcare would surely result in a decline in

non-communicable diseases, not only due to sedentary lifestyle and urbanisation, but also

due to the ageing population (Fulton et al., 2014). Whilst an increase in longevity and an

ageing population is a sign of good healthcare, it will become a major challenge for

policymakers in the future (Almalki et al., 2011).

Saudi Arabia will need to consider whether the policies it develops meet the needs of this

future population. In SA, acute coronary disease is one of the biggest killers in the adult

population, accounting for 23% of the total deaths in SA (MoH, 2014). Training and

resources to deal with such issues need to be addressed by the GCC nursing technical

committee to equip nursing staff to appropriately respond at the primary, secondary and

tertiary levels of care (Section 1.3). Preparedness will reduce financial and staff burdens.

The cost to the MoH in treating patients with heart conditions is on average US $10,710,

with an average stay in hospital ranging from eight days, if patients do not have co-

morbidities, to 11 days if they have co-morbidities (Osman et al., 2011).

The rising rate of obesity is likely to add to this problem in the future (Mahmoud &

Faramawi, 2015). The financial impact presented here further strengthens the rationale for

change. Other trends that highlight the need for change include the high expat workforce

and high turnover of nurses in SA (Almalki et al., 2011); the GCC needs to take this into

account to increase local recruits and also improve staff retention, especially as the latter

has been shown to be correlate with quality of care (Collier & Harrington, 2008;

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Schwendimann, 2015). Furthermore, one study shows that primary healthcare staff in SA

were more dissatisfied with their role and the work-life balance due to staff shortages

(Almalki et al., 2011); therefore, this is an area that would need to be addressed in an

agenda of change. Almalki et al. (2011), recommend a revision of nursing education in SA

to bring it in-line with other developed countries in order to tackle some of these issues

highlighted. In particular, the highly multinational workforce also affects the quality of

care due to language and cultural barriers, and therefore an increase in a locally educated

competent workforce is likely to increase standards (Almutairi & McCarthy, 2012).

Saudi Arabia is the largest country in the GCC (Lowe & Altrairi 2014), and plays a special

role in the religion of Islam (Aldossary et al., 2008; Gazzaz, 2009; Lowe & Altrairi, 2014).

SA houses the holy pilgrimage sites of Mecca and Medinah which see millions of visitors

from around the world every year, particularly in the month of Ramadan and during Hajj

(Alamri, 2010). This increases the risk of disasters and the need for medical care

(Veenema et al., 2016). Hajj season sees an increase in the number of visitors to Mecca by

millions and as a result has seen outbreaks of several types of diseases, fires, and

stampedes, posing unique problems for nursing staff (Alamri, 2010). This type of local

problem needs specialist training which must be incorporated into education programmes;

therefore, staff with this specific knowledge are vital on any ICN or WHO education

development committee. As the recruitment of foreign nursing staff in SA is high (AlYami

& Watson, 2014), movement of staff within SA needs continuous improvement

programmes that train nurses on local issues (Almalki et al., 2011). In addition to these

unique issues, SA has seen many sandstorms, floods and earthquakes in recent years and

studies show nurses in government hospitals are not prepared for such disasters or

emergency management care (Jradi et al., 2013; Alamri, 2010). In light of this education

needs to include better training on disaster management and emergency medicine as a way

of responding to contemporary needs and providing better healthcare services (Veenema et

al., 2016).

In relation to the second thematic category, ‘nursing as an agent for change’, it could be

argued that the GCC Nursing Technical Committee endorsed nursing as an agent for

change and advocated the professionalisation of nurses and enhanced nursing leadership

skills. Regardless of what nation or region is analysed, policy and standards for

professionals invariably exist to protect the public and maintain a high level of care and the

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case of the nursing profession and healthcare in general, is no exception to this rule.

Tanaka et al., (2014) proposed that nursing professionals needed two pillars to gain power

and deliver a professional service, autonomy and self-regulation.

Autonomy and empowerment are key factors for nurses to deliver a high standard of care

(Meerabeau et al., 2004), especially in SA, which is currently lagging behind compared

with other areas such as North America. In light of this, there needs to be a drive to change

the current nursing situation in SA. The GCC recommends a change in the education and

training of nurses to deal with the evolving health needs of SA and the Gulf countries and

this includes nursing professionalization and enhanced leadership. The role of degree

education within nursing has been identified and recommended by the WHO, (2009) and

ICN, (2015). One of the drivers for such change is the movement of care from the hospital

to the community; this being a necessary transition to deal with the rise in the ageing

population. Adapting the healthcare system requires well-qualified, skilled nurses who can

take on leadership roles; a degree education being likely to equip Saudi nurses with these

skills (Miller-Rosser et al., 2006). Conversely, it can be argued that delivering care in the

community, especially to the elderly, requires compassion, understanding and experience;

the backbone of nursing, rather than a degree education (RCN, 2013), and the drastic

change in the educational system may not be necessary.

With regard to nursing professionalisation and nursing leadership in SA, it needs to be

acknowledged that these norms are partially born out of domestic factors of culture,

healthcare approach, and ethnicity that are SA and the approach that has developed therein.

For example, whilst the GCC Nursing Technical Committee endorses nursing

development, within nursing education and practice, the nursing profession is still seen by

some individuals as a lowly career option due to poor work-life balance, poor pay, high

workload and lack of autonomy (AlMakhaita et al., 2014). The nursing degree policy

mainly affected females as they were the target group, and males were not offered equal

opportunity for nursing degrees (Gazzaz, 2009). However, as part of the recognition of

nurses as agents of change, master’s degrees in nursing have recently been offered in a few

universities for male nurses in order to widen the field (Almalki et al., 2011). There may

be several reasons why there has been fewer uptakes by men. This could include issues

related to gender perceptions of nursing, and the cultural practice of gender separation for

education (Gazzaz, 2009; AlMakhaita et al., 2014). However, the equity of nursing

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education between males and females remains problematic, and there are still no master’s

courses for men in many cities in SA, limiting the profession to a predominately female-

only profession and reducing the potential for an increase in the local workforce and

increasing gender-specific inequality and imbalance (Alamri, 2011).

The GCC Nursing Technical Committee lean towards professionalising nursing in Gulf

countries in part, by making a degree a minimum requirement for entry into the nursing

profession. In doing this, the belief is that it is more likely to empower graduates and raise

the profile of the nursing profession within the country. Degree educated nurses’ show an

increased set of professional skills and development applicable to primary and tertiary

health care settings, as well as a better level of care delivery (AACN, 2016; Aiken et al.,

2014; Tanaka et al., 2014).

Making degree-level entry a minimum requirement can also pose risks to the nursing

profession. For example, due to the expense associated with obtaining a degree, which is

longer than a Diploma, there is the potential to exacerbate the current shortage of nurses in

SA (Lamadah & Sayed, 2014; Almadani, 2015), where the majority are Diploma educated

(AlMakhaita et al. 2014). Also, there are concerns from some Patient Associations that the

policy may cause a shift from patient-centred care which involves compassion and dignity,

vital to nursing, to a role that is concerned with personal achievement (The Patients

Association, 2013). Graduates are more likely to exhibit problem-solving skills and take

on leadership roles (AACN, 2016). Graduate nurses are more likely to be promoted over

Diploma-educated nurses, and more likely to apply critical thinking and problem-solving

skills in the patient healthcare pathway (AACN, 2016), which is vital in an environment

with evolving health needs. Integral to professionalism, leadership and management, are

considered by the GCC Nursing Technical Committee, as a vital part of effective nursing

care. For this reason, nurses must be involved in the implementation of education and

practice policy in order to improve patient care (Varjus et al., 2011).

At the three levels of organisation in the MoH, there is a lack of recognition of the

importance of nursing leadership in driving future change. In contrast, before the UK made

a nursing degree mandatory, it carried out an extensive consultation with all UK nursing

bodies including the NMC, incorporating the feedback into their recommendations. Such

consultation with frontline staff ensures that a programme that is fit for purpose is

developed. The GCC proposals did not appear to involve frontline nursing staff with local

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experience in the decision making process, which is a major issue as it undermines the

value of professional nurses. Saudi nursing leaders who are confident on the global level

would ensure that the Gulf region is able to learn from international experiences, share

Gulf nursing expertise and be involved in planning, developing, implementing and

coordinating solutions to global nursing challenges (Abualrub & Alghamdi, 2012;

Alghamdi & Urden, 2016).

The GCC report does recognise the challenges facing SA nursing and how leadership from

nurses could help with some of these challenges. However, whilst the report states that

degree education and continuous improvement programmes will help alleviate some of the

issues highlighted above, there is a lack of commitment to engage the community in health

service delivery. This is an area where nursing and consumer leadership could have a

positive impact in care delivery such as those seen in the UK with the Patient Association

and ‘INVOLVE’ (Ham et al., 2015). Furthermore, the report does not cover how and who

will fund these programmes, or how this will affect new nursing recruits. The GCC

document recognises that nurses could be agents of change, but fails to address how or

identify areas of investment to make this happen. Nursing leaders should be prepared for

all levels of health administration and autonomy should be promoted among nurses to

ensure that they have the freedom to work effectively (Donley, S.R. & Flaherty, 2008;

Abualrub & Alghamdi, 2012; Alghamdi & Urden, 2016; Veenema et al., 2016). For

example, frontline nursing staff would have first-hand knowledge of expectations of

patients, any issues with service delivery, and enable a bottom-up process to increase the

chance of developing relevant policies within the context of clinical practice. The

document overlooks the fact that many of the recommendations mentioned with regard to

challenges and leadership do not mention a timescale for implementation to improve these

important issues. There should have been a clear strategy with timelines, as they all affect

quality of care and patient safety, and are therefore important areas of discussion. Nursing

leaders could help with effective implementation of strategies (Alghamdi & Urden, 2016 ;

Veenema et al., 2016). There is little published literature on the role of nursing leaders in

SA, suggesting empowerment of nurses is lagging behind other countries. One recent

study by Bdeir et al. (2014) shows that a nurse-led heart clinic was extremely successful in

demonstrating that nurses, as clinical leaders in the SA, could work just as well as in other

global scenarios.

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In relation to the second category, the fragmentation in the education of nurses in the GCC

was clearly identified. SA offers both Degree and Diploma level education in nursing and

the Saudi MoHE has a policy to deliver high quality education to international standards in

nursing. This has been addressed by significantly increasing the funding of student nurses,

scholarships and encouraging study abroad (Alamri, 2011; Al-Homayan et al., 2013). The

political and social pressure to conform to standards of other developed nations in making

degree education in nursing mandatory has driven the change in SA (Alamri 2011). The

introduction of such is considered a step towards reducing the fragmentation in nursing

education previously seen in SA. Al-Turki (2010) note that up until the latter half of the

20th century, no graduate or postgraduate experience was required in order to become a

nurse. Although educational standards still existed, the fragmented nature of these

standards created a situation by which individual states and regions, not to mention

different universities and colleges/technical schools, all had different standards in North

America and Europe (AACN, 2016).

Having different standards has caused great difficulty within the nursing community. In

Europe, over the last 30 years, there has been a two-phase drive to reform nursing

education (Spitzer & Perrenoud, 2007). Stage one was to unify nursing education, and

stage two involved taking diplomas and on the job training into universities as part of the

standardisation programme. However, due to lack of clarity within the policy, this caused

great diversity in the levels of nursing education, duration of clinical practice, and the

offering of higher qualifications (Spitzer & Perrenoud, 2007). As a result of fragmentation,

Europe has many different levels of nursing qualifications, varying from country to

country, with some still offering diplomas whilst others offer a myriad of Bachelor’s,

Master’s and PhD programmes (Lahtinen et al., 2014). The level and extent to which

growth and further understanding within the nursing profession could be exhibited was

hampered because of multiple standards creating an uneven labour force (Lahtinen et al.,

2014). The inequitable distribution within the labour force and the non-standardised

programmes of education across Europe influenced the nursing profession, giving impetus

for the drive to standardise nursing education and encourage other nations to follow suit

(Aiken et al., 2014).

These findings are indicative of the value of professional nursing and leadership skills has

been highlighted as significant indicators of the rapid socio-economic developments in the

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Saudi context (Abualrub & Alghamdi, 2012; Alghamdi & Urden, 2016). Failure to make

effective use of nursing leaders across three levels of the organisation will limit its

potential. It seems therefore that the GCC nursing technical committee are exclusively

focusing on developing nursing education and practice in the Gulf countries, targeting

government organisations, human resources, nursing education, nursing care, and nursing

research. Within the GCC there is a clear fragmentation in nursing education, with nurses

being exposed to a variety of educational pathways. Only SA has implemented the policy

to make a degree in nursing mandatory, closing all Diploma programmes as a quick

response to the WHO (2009) recommendations. There is no indication that nurses were

involved in the decision making process, which could effectively have an impact on care

delivery. Having made the decision to implement the policy, it needs to be executed with

the aid of the media to reach a wide target audience and ensure its success (Ventola, 2014).

The change from Diploma to degree level entry in nursing may see a shift in the public’s

perception of the profession due to the prestige and accolade that comes with a degree. If

this is the case, it may allow the profession to gain more respect and recognition in a

country where nursing is seen as a low status job (Section 3.2.2). If successfully managed,

there is scope for the policy to shape the future of the country through changes in culture,

education and social perceptions of nursing as a profession.

In relation to the third thematic category, ‘making the changes’, it could be argued that

nurses are an important factor in the change process due to their power and

professionalism in frontline healthcare delivery. As previously suggested, SA recently

made the degree in nursing mandatory without consultation, piloting or sharing the

decision making process with the three organisational levels, including community

feedback. This is in contrast to Lewin’s change theory (1951), which stresses the

importance of giving attention to the right variables to ensure successful change (Kritsonis,

2005). The lack of attention to change management theory, such as Lewin’s theory (1951),

may influence how successful a policy is implemented, and subsequently those it affects;

in this case the nursing workforce. The Saudi Arabian MOH and MOHE did not look at

examples of practice for degree education in other countries, and yet evaluation and

benchmarks exist. For example, the NMC (2010) was slow to recommend Bachelor

education as a standard entry requirement in the UK. The Willis Commission Report found

that despite the concerns of the NMC and patient groups mentioned earlier, degree

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educated nurses have had a positive impact on the quality of care delivered, which is the

primary goal of the nursing profession (Willis, 2012).

Steps towards the change in nursing education in SA, were evidenced by Almalki et al.

(2011), who discussed the standardisation of policy surrounding nursing degree

requirements when it was established in the West. Prior to this, nursing education was

already being reformed following a haphazard start to the profession; the US federal Nurse

Training Act of 1964 recommended the introduction of nursing baccalaureates, advanced

practice and PhD programmes by injecting funds to mobilise the initiative. Following this,

nursing education entered universities in the 1980s in the US (Scheckel, 2009).

The initiation of changing nursing education, was further discussed by Al-Mazrooa (2011)

who showed that the development of standards and policy evidenced in North America,

was a direct result of the private marketplace encouraging stakeholders to seek out

common denominators and core standards that would lead to a more effective workforce

and was specifically useful for the nursing sector. Therefore, the steps towards changes

were more about the private sector being able to give a guarantee concerning minimum

levels of care and standards, through an enhanced higher level of education and training.

The changes in education taking place in SA is a process that has already happened in

many developed countries, or is currently happening in other countries, and therefore the

ad hoc changes taking place in SA are not unique, but typical of many other nations (Al-

Mazrooa, 2011).

Finally, while these documents show in North America it was the private sector who

determined the shift in nursing education, the lessons learned were translated to the Saudi

context and other developing nations. Governments sought to gain rapid parity with

developed nations by implementing these changes within only a few short years, in

comparison to the countries of North America and the UK who had rolled out the changes

over decades (Smith, 2010; Donley, S.R. & Flaherty, 2008). Following in the footsteps of

the UK, USA and Canada, SA and other developing nations, chose to initiate rapid

changes within their own countries using evidence from the countries they were following

in order to be part of a global workforce and culture (Mebrouk, 2008). Although this might

encourage one to believe that the Saudi model of nursing policy and educational standards

focuses its core goal upon matching/copying the West, the MoH, as well as other

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responsible entities, are uniquely interested in specifying and defining the approach, which

SA will take to healthcare within the coming years.

As such, GCC stakeholders within the system seek to implement standards that will be

beneficial to the issues and interpretation of healthcare provision that are currently deemed

to be the most representative of future expectations within Gulf populations. In the steps

towards making the change, the GCC recognises that there are differences between the

West and the Gulf states. The synthesis between Western standards and a unique GCC

model is ultimately, what is helping to construct policy that is exhibited throughout the

entire healthcare sphere, specifically nursing education (Al-Ahmadi, 2014). Even though

globalisation has a powerful impact with regard to improving cultural understanding and

effecting standards in a way that might not be encouraged within another paradigm

(Almutairi et al., 2015), the unique differentials that exist within cultures are not always

something that should be minimised (Suliman et al., 2009). For instance, a specifically

designed system of education can provide the GCC stakeholders with a unique inference

with respect to Gulf healthcare issues. Within such an understanding, the GCC nursing

committee is encouraged to realise that as standards and globalisation encourage unique

policy shifts within institutions and government structures, the need and requirement to

consider the dynamics of a particular region and the unique physical, emotional, spiritual,

and cultural needs that a specific population might require are still relevant (Suliman et al.,

2009).

The GCC healthcare provision is state-funded and requires little if any monetary

contributions from individuals. The overall involvement that the government has in

designing policies and requirements that help to define the nursing profession within Gulf

countries is profound. Whereas this level of control has allowed for the development of the

MoH and other aspects of the GCC in a beneficial way, the net drawback that it exhibits is

that it constricts the overall number of individuals that are willing to pursue an education

and obtain degrees within the nursing profession (Miller-Rosser et al., 2006). Ultimately,

the rapid and sustained changes with respect to the qualifications and requirements have

been illustrated within documentary analysis and have been discussed in this chapter. It is

argued that as career options have extended over the past few years, individuals are no

longer as interested in pursuing nursing as a career path as they might have been

previously. What this has created is a situation in which government control has actually

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reduced the overall incentive for individuals to engage in nursing and pursue a career

within the healthcare industry. This is especially troubling; particularly as the nursing

profession needs to expand significantly over the next few decades. As the current

population continues to age, analysts expect that the overall number of elderly people

within society, and thus individuals most likely to use the healthcare system, will increase

greatly (Al-Ahmadi, 2014).

When applying these changes, policymakers within the government should be mindful of

the fact that remuneration for the nursing profession should match the increase in standards

and policies that are being implemented. SA would need to encourage people to continue

to consider nursing as a viable career path (Gazzaz, 2009). Further, government

involvement in the policy to develop standards should reflect the market and improve upon

the degree (Aboul-Enein, 2002). This is not to say that the Saudi model of economics or

healthcare provision is in any way government controlled. It merely denotes the fact that as

the market continues to grow and expand, the policymaking structures and standards need

to grow commensurately. Change always takes time and effort, which requires a

theoretical frame or well-studied plan for its implementation and evaluation. According to

Lowe and Altrairi, (2014: P.254),

“Nursing in the GCC is undergoing the growing pains Western countries

experienced in the past. The focus on the changing image of nursing, university

education, technology, and increased participation in the business world has all

contributed to nurses remaining in-country to develop the profession.”

The point is not just to change practice, but rather to take heed of past experiences of

others and to initiate examples of good practice such as consultation processes. If the

vision of degree education in the Gulf countries is not a shared collaborative process

involving all stakeholders, no change will occur, and the status quo may continue. In light

of this, another approach is now needed to improve the planning and development of the

future nursing workforce. One weakness of the GCC report is that it does not discuss any

piloting projects, but focuses on the implementation and impact of such a programme in

SA. The West and SA have very different demographics and culture, which could

potentially affect the success of the policy. For example, SA does not have professional

nursing bodies such as those in the UK or US. In these countries, policy development is

supported by such bodies and they are able to steer issues raised towards a more

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favourable outcome for nurses. The lack of professional bodies could hinder the effort to

reach the ‘gold standard’ in nursing in SA (Abualrub & Alghamdi, 2012; Alghamdi &

Urden, 2016). In addition, whilst many of the countries adopting the mandatory degree

programme operate on evidence-based practice (EBP), SA appears to lag behind in the use

of EBP in policy development, which could be a hindrance in trying to develop a

healthcare system similar to that of the UK, USA and Canada.

The key points from the discussion of documentary analysis are:

 The GCC supports the nursing profession and recognises the need for change; that

said, the documents analysed did not provide details about change strategy and

implementation programmes. Without those details, the policy for degree education

in nursing has been endorsed in a top-down manner, using the formal

communication channels between national managers, regional directors, local

nursing managers and nursing staff.

 The need to reform nursing education as the world entered the 21st century drove

the global impetus to reassess old policies and standardise education, address the

diversity of nursing roles and accommodate the global migration of nurses from

one country to another (Almutairi et al., 2015). Furthermore, other health-related

fields were already one-step ahead in offering and making degrees’ mandatory for

practice, for example; physiotherapy, pharmacy and social care, demonstrating that

the nursing field was slow in transforming policies, which could compromise the

quality of patient care (McHugh & Lake, 2010).

 Transforming care from a focus on hospitals to a focus on the community is a

global priority (Al-Mazrooa, 2011). Many countries recognise the need to develop

and expand productivity at the same time as reducing healthcare costs (Aiken et al.

2014). Transferring care from hospitals to the community has created tensions

within the MoH due to nursing shortages and an ageing workforce that is set to

retire over the coming years, especially during the transition phase (Lamadah &

Sayed, 2014). The GCC documents present an argument at the national level to

invest in the workforce (D7), however, the reality is very different. If the MoH are

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to meet the rising challenges and demands of an ageing population with complex

health and social care needs, there needs to be investment in nursing education and

practice. This would strengthen the workforce, especially as there are not enough

newly qualified nurses to replace the experienced nurses, who will retire in the

coming years (Kattuah, 2013).

 Gulf countries and other nations, seek to standardise educational expectations and

requirements, as a means of creating a broader and more differentiated workforce

that is able to integrate the needs of a dynamic and shifting labour market/economy

(Lowe & Altrairi, 2014). Although this dynamic has proven to be untrue in many

different organisations and labour markets, the level of national standardisation that

exists within healthcare systems throughout the globe is more developed than many

other sectors (WHO, 2009; RCN, 2013). The underlying reason for this has to do

with the ongoing research and best practices that developed nations have put

forward. As a means of implementing the policy and standards, it is a necessity for

the educational system to set similar and universal standards for degree

implementation. While standards relating to other sectors of education are

important, the GCC highlights the importance of building a body of knowledge.

Such evidence will provide for the diverse and global workforce of tomorrow,

which will create an inherent demand for nursing students to meet basic

proficiency levels that are exhibited elsewhere throughout the globe (WHO, 2009;

RCN, 2013; AACN, 2016).

 The future process of changing the current healthcare system in SA needs to follow

Lewin’s (1951) change theory, which stresses that change must happen with

attention given to the right variables to conceptualise and observe the current

change (Kritsonis, 2005). In this case, the major variable would be the change from

Diploma to degree as a minimum requirement for entry into nursing. Monitoring

this variable would need input from nurses, as they are the frontline staff with first-

hand experience and the main service providers. The change theory model

proposes unfreezing-changing-refreezing as a three-part process in changing

human systems (Weick & Quinn, 1999). The first step in Lewin’s (1951) process

of the change model is to unfreeze the existing situation. Unfreezing involves the

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removal of forces that resist change – usually initiated by dissatisfaction – to allow

step two of the model to take place (Weick & Quinn, 1999). In this case, the

dissatisfaction would be the level of care and the inability to meet the requirements

of the current and future nursing demands in SA due to changes in the

demographics and evolving health needs of the population. The second step in the

process of change is movement of the target system to a new level of equilibrium

(Kritsonis, 2005). This step required three actions to assist the movement, namely,

encouraging employees to agree that the status quo is not beneficial to them and

persuading them to view the problem from a fresh perspective; working together on

a mission for change; and connecting the views of the group to well-respected,

powerful leaders that also support the change (Kritsonis, 2005). The third step of

the change model is refreezing. This step needs to take place after the change has

been implemented and sustained over time. It is the integration of the new policy

into the community values and traditions as suggested by Kritsonis (2005). This

step aims to stabilise the new equilibrium resulting from the change by balancing

the force of driving and restraining. The GCC showed weakness by not following

Lewin’s change theory model, as the process of change was not clearly identified

or planned appropriately.

 Finally, the mandatory requirement for nursing being an all degree profession is

recent in the GCC countries, with long-term evaluation still ongoing. Therefore,

pilot studies in SA would have been ideal to give a flavour of the likely success and

impact of the policy. Pilot studies are small trials of an ‘intervention’ which can

help identify strengths and weaknesses, providing an opportunity for the latter to be

eliminated when the programme is rolled out (Leon et al., 2012). Pilot studies are

an essential step in implementing policies, interventions or innovative approaches,

and their lack can increase the chance of failure (Leon et al., 2012).

6.6 Summary and Conclusion

This chapter analysed the GCC implementation process on the changes in nursing degree

education policy in SA and how this might impact on service users and the community.

Having critically analysed the GCC policy for the implementation of changes in nursing

education, the above sections reveal that the GCC implementation process appropriately

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identified the need for change, the issues affecting the current and future needs of the SA

healthcare system and also the desire to raise the quality of care standards. However,

within the GCC implementation process, the analysis of the relevant documents has

indicated that there was a clear lack of involvement from Saudi nurses in the process and it

appeared to be a top-down decision-making process. This is a clear failure of what should

have been a more collaborative process, and could impact on the successful

implementation of the policy to introduce the minimum degree requirement for entry into

nursing practice. Furthermore, there was a clear lack of a planning and implementation

strategy and/or pilot studies, as it was a rushed process in order to make immediate

changes based on other nations’ experience. The drive to make changes was based on what

was happening in the UK, the US and Canada, which have significantly different

healthcare demands, demographics and needs. A direct application of another country’s

policy may not work in SA due to the high number of foreign nurses from different

countries, where a nursing degree may not be an option or mandatory, therefore affecting

recruitment further. There were, in part, efforts to tackle issues with the shortage of local

staff with increased funding, scholarships and support, but no details as to actual figures

were given on how many scholarships would be available, for whom and how much

funding was being allocated. The GCC did not discuss what would be done locally to raise

the profile of nurses socially; currently nursing is seen as a ‘low-level’ career option,

explaining the shortage of local nurses. The GCC does mention that the introduction of the

nursing degree should help raise the profile of nursing due to the higher educational award

and the subsequent professionalisation of the role. In conclusion, the results of this

discussion indicate that there was significant effort by the GCC nursing technical

committee to improve the nursing workforce in Gulf countries. The outcomes of degree

education, and the consequences for practice and patient experience, are not clearly

explained in the GCC documents. These were difficult to identify when undertaking the

documentary analysis, and hence it became a significant sub-theme, which will be

explored in more detail within the analysis of participant discussion in chapter 7.

The following chapter will present the findings of the interviews from the participants in

this case study with relevant discussion of these results.

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Chapter 7 : Participant Perception and Experiences: Findings and Discussion

7.1 Introduction

Chapter 6 offered the results of the documentary analysis together with an integrated

critique and discussion within each of the three themes. This chapter presents and

discusses the results of the data that reveal the participants’ perceptions and experiences

relating to the following research objectives:

 Determine the views of key nursing and administrative stakeholders at the

strategic/macro level of nursing policy and practice, regarding the influence of

degree entry requirements on nursing workforce planning.

 Critically appraise the experiences of a sample of practising nurses at the middle

management/meso levels of nursing practice, and those at the frontline/micro levels

of nursing practice, regarding degree education as a minimum requirement for entry

to the nursing profession.

Analysis was undertaken within the macro, meso and micro levels of the nursing within

the organisation of organisation, and results across all three levels are presented in this

case study. The macro level was comprised of one-to-one interviews with four decision

makers (Section 5.3). The meso level comprised one focus group, including six regional

nursing directors (Section 5.4), and the micro level involved three focus groups: group one

included seven nursing managers and educators, group two involved four nurses with BSN

education, and the third group comprised four nurses with Diploma level education

(Section 5.5). This is further explained in section 5.6.1.

In this chapter, the themes identified within each of the three levels are presented, followed

by a synthesis of the results to provide a cross-level analysis. The thematic findings reveal

the perceptions and experiences of all those in the groups as a whole (Baxter & Jack 2008).

The recorded interview and focus group data were analysed using a content analysis

framework (Zhang & Wildemuth 2009), as described further in Section 4.7.

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 The analysis of data was assisted by the use of NVivo, qualitative analysis

software, which provided an organised workspace for the categorisation and

tracking of the coded content (Hilal & Alabri 2013). The process involved the

classification, sorting and arrangement of the data in order to examine relationships

in the data, both within levels and across levels, through analysis of the three

participant levels.

The participants offered a unique insight into the problems and difficulties experienced

in Saudi nursing practice with regard to the nursing workforce and its planning. A

cognitive/mind map was utilised to summarise the result of themes and their

relationships across all three levels. The themes were visually organised using a mind

map diagram of the data analysis (Elo & Kyngäs 2008).

7.2 Macro level

The macro-level analysis consisted of face-to-face, one-to-one interviews with four

administrators functioning at the macro level. The arrangements for these interviews and

coding have been previously described in detail in section 5.3. The main goal of

interviewing the key stakeholders at the macro level was to determine their views

regarding the influence of degree entry requirements on nursing workforce planning.

Using a content analysis framework (Section 4.7) resulted in the generation of three main

thematic categories:

 Theme 1: ‘A Good Decision’

 Theme 2: ‘Use of bridging programmes ‘I don’t see that there is any obstacle…’

 Theme 3: ‘Education and experience are important in giving quality care’

Common sub-themes relating to each category were also generated from the data. All

these interrelated thematic categories are illustrated in Figure 7-1.

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Figure 7-1: The thematic categories and subcategories for the macro level

7.2.1 ‘A Good Decision’

This is a significant theme identified from the interviews with participants functioning at

the macro level. Participants shared their perceptions of introducing degree education as a

minimum entry requirement to nursing. This theme generated three important subthemes,

as illustrated in Figure 7-2.

Figure 7-2: The first theme in the macro level analysis

All four of the macro-level interviewees expressed agreement with the requirement for

Bachelor degree education for entry-level nursing practice. One of the Directors (GD2)

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participating in the interviews discussed the requirement as it being a “good decision” in

terms of preparing well-qualified nurses:

“The knowledge and language [of a Diploma graduate] is not as the Bachelor’s.

The Bachelor’s has more knowledge rather than the Diploma. … I think this is a

good decision to prepare well-qualified staff nurses”.

Similarly, another Director (GD1) described the degree requirement as a means of

improving the quality of patient care and supporting the nursing profession by providing

advanced education through bridging programmes, enabling nurses with a Diploma

education to convert their award to degree level:

“A Bachelor’s degree is not a precondition to enter the service, as the nursing

service already exists in the form of technicians and specialists, but following

MOH’s evaluation of the training level throughout the Kingdom, in accordance

with the instructions and regulations issued by WHO to improve health institution

programmes, it was proposed that the minimum should be the Bachelor’s degree,

which was adopted during Dr. Alrabeeah’s time as Minister of Health (1431-

1432/2010); recruitment in the technician category was then stopped, where

Bachelor’s degree was then adopted for the specialist category. The objective

thereof is to promote a nursing profession which the health sector relies on

throughout the hospitals and primary health centres, representing more than 50%

of the total health services within the MoH …”.

Director (GD4) also expressed similar views, suggesting that Bachelor degree education

was best for those starting a nursing career and especially when lacking practice

experience. This director also felt that it was an educational requirement for specialised

nurses, describing the effect on quality of care related to communication, knowledge, and

language skills necessary to provide high quality nursing and fewer medical errors. The

director stated;

“Bachelor’s level is the best for nurses to start work either in a hospital or at

community level or anywhere in the hospitals or community. We found by evidence

that a Bachelor’s degree should be the minimum requirement. If they have a BSN

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degree, they have fewer medical errors, fewer nursing errors and as we know, our

hospitals and the medical services in Saudi Arabia are getting better and better.

And we have new technologies coming for which we need nurses well-equipped

with knowledge and skills….”.

The Director (GD3) also strongly supported degree education for nurses and for other

health care professionals:

“I strongly agree to go with the bachelor’s degree for an entry level to practice

either for nurses or any healthcare professional. There is enough experience,

practice, knowledge, enough time for training”.

In light of the requirement for Bachelor degree education as a minimum entry requirement

for nursing practice, interviewees functioning at the Macro level noted that the decision to

close Diploma level nursing education was influenced by the GCC Nursing Technical

Committee and WHO recommendations. One participant suggested:

“Okay, the level of entry as Bachelor’s degree, it was agreed by the GCC

countries, it is the recommendation of the WHO, which we take into consideration.

Yes, it was the nursing leaders who took the decision in the GCC countries and it

was agreed by all ministries of health in GCC countries. To close all Diploma

nursing schools is different in every GCC country because each country has their

own situation and they have different numbers of nationals going from country to

country. For Saudi Arabia we decided to close the Diploma level because we have

many governmental universities started with the nursing school, we have 28

governmental universities. So we have a good space to occupy nurses. This is only

governmental and if you go to private now we have more than 42 and some more

are going to start around the kingdom. So when we close the Diploma this will not

affect how many nurses will graduate. We just made it better from Diploma level to

bachelor’s level” (GD4).

Analysis of the interviews conducted with those functioning at the macro level identified

sub-category themes highlighting the benefit of degree education as a minimum

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requirement for nurses to enter professional practice, believing this was “a good decision”.

The directors agreed that it would lead to improved care, a broader knowledge base for

practising nurses, and enhanced language and communication skills – all vital components

of quality nursing practice.

7.2.1.1 ‘We Care about the Quality of Care’

The first sub-theme within the theme ‘A Good Decision’ was ‘we care about the quality of

care’. The Director (GD4) expressed the view that quality of care was necessary and that

the Diploma nurse was not adequately educated to provide the level of care that would

meet public expectation at the required standards. For example,

“We have new technologies coming that require nurses well-equipped with

knowledge and skills, so with the Diploma level it is difficult to meet this. The

community also needs well-experienced nurses. People now are changing with all

these technologies around us. People can easily search for their disease; what kind

of care you are giving them and what care they need. Patients are very smart now

and the nurse needs to be smarter. And more skill is needed to give the right care

to the patients. We care about the quality of care”.

The primary benefit related to degree education as a minimum entry requirement for

nursing noted by the macro-level participants was the improved quality of nursing practice,

through offering improved nursing skills and ultimately, quality of nursing care. The

Director (GD2) stated that:

“The first benefit is improved quality of care, and improved staff skills. This will

create a good chance to form staff, that can lead the nurse and build a good

background where the nursing management, or nursing administrator, depends on

these staff to lead the development process, as they have a basic and good clinical

background that can help them improve the quality of care and the quality of the

environment in the hospital”.

Director (GD4) concluded that the benefits of a Bachelor education in nursing would

sustain better patient outcomes, stating:

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“we are going to have a better outcome, better care. People feel satisfied when

they have the necessary care”.

All four directors agreed that the Bachelor degree is a good base for improving the quality

of care within the practice environment. This was evident in the next sub-theme, a

‘broader knowledge base’.

7.2.1.2 ‘Broader Knowledge Base’

One of the ways to achieve quality nursing care described in the previous section is

through obtaining a broader knowledge base, with participants functioning at the macro

level describing Bachelor degree nurses as being able to demonstrate a broader knowledge

base due to more intensive study:

“The knowledge and language [among Diploma nurses] is not as the Bachelor’s

nurses. The subjects being studied are more in the Bachelor’s rather than the

Diploma, as the Bachelor’s has a broader knowledge base than the Diploma”

(GD2).

Another interviewer explained that Bachelor degree nursing education programmes

included a wider knowledge base than Diploma nursing education programmes, for

example:

“In our educational system we have a problem with the curriculum design. The

Diploma graduates from two and ½ years know nothing, not even the basics. If we

go with the Bachelor ’s degree, we can add more to their curriculum about

research, ethics, practice. If it is a Diploma graduate of two years, there is not

enough time to teach them the basics and go to the advanced level” (GD3).

The above quotes suggest two of the decision makers at the macro level (GD2 & GD3)

recognised knowledge as being an important factor in deciding to introduce

Bachelordegree nursing education rather than continuing with nursing education at

Diploma level. As highlighted in the above quote (GD3), Diploma programmes are of two

years’ duration, compared to five years for Bachelor’s degree. Perhaps more importantly,

the directors were able to articulate an important aspect of providing quality nursing care –

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that of language and communication skills – which was identified as a third sub-category

within this theme.

7.2.1.3 ‘Language and communication skills’

Another way to ensure the quality of nursing practice is to enable nurses to develop

enhanced language and communication skills. Participants at the macro level specified the

benefits of degree nurse education in relation to the ability to speak and write in English,

and to be familiar with the language of healthcare practice in SA, both of which would

contribute to enhanced communication skills in practice. The directors believed educating

nurses to degree level would facilitate better communication with patients and doctors

alike. As well as the ability to communicate with other care providers (doctors and

technicians), the directors believed Bachelor degree nursing education contributed to the

nurses’ confidence and professional esteem. One participant stated:

“Our Diploma [nurses] have fewer years of studying their language, not up to the

extent allowing them to read and search for references. They are not at the level to

communicate with the doctors. And they do not have the full confidence in

language and communication skills” (GD4).

In summary, there appeared to be consensus from the participants functioning at the macro

level that the themes and the sub-themes identified above, enhanced quality of care,

nursing knowledge, and language and communication, were the cornerstones of good

nursing practice. These elements of nursing were identified as valuable reasons for degree

education as a minimum entry requirement for nursing practice. There was also a view that

Diploma-educated nurses were no longer adequately prepared to provide the necessary

quality of care or to meet the public’s expectations regarding standards of nursing care.

7.2.2 Bridging programmes, ‘I don’t see any obstacle…’

Using the bridging programme as a national strategy to enable nurses with Diploma level

education to access Bachelor degree nursing education, opportunities, was the second

theme that emerged when the data from participants working at the macro level was

analysed. This theme comprised two sub-themes as illustrated in Figure 7-3.

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Figure 7-3: The second theme in Macro level analysis

Given that the majority of nurses in SA are Diploma graduates, participants functioning at

the macro level believed the introduction of bridging programmes would be the best way

to meet the requirements of the new political agenda for nurses. They believed the

introduction of a bridging programme would help to support the continued education of

Diploma nurses to Bachelor degree level and beyond:

“In MoH, we started from three years ago a national programme known as IFAD

[local scholarship], which allows the nurses to take a bridging course in

governmental college to upgrade them to bachelor’s degree level” (GD3).

The Director (GD4) offered a thorough understanding of the national programme for

bridging these nurses to Bachelor’s level:

“Right now we have a national programme. We have 13 nursing bridging

programmes for males and 17 for females. So we have quite a good number of

bridging programmes. We have a plan to send our staff to get their BSN degree. It

is going quite well. But we need quite a lot of time to cover all those …we have

quite a number of Diploma nurses, we are not in a hurry. This is happening

through the world. We are on the right track. Inshallah, hopefully we can finalise

all those” (GD4).

The standardisation of education was also noted as being critical to supporting GCC

standardisation and the ability to recruit nurses from GCC countries. One Director stated

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the following:

“It is really good. It is the big step we are taking forward. Because all people in

Arab countries will just move freely. It is good for the citizens. You finish the same

programme and curriculum. When you move from one country to another people

are familiar with what you study and you will not face many problems. You will not

face problems like your certificate not being valid. So this is the main idea to allow

the people in Gulf countries move freely and that will make their life easier”

(GD4).

The statement above was supported by another participant, adding that there are no

obstacles for diploma nurses in accessing the bridging programme and nurses also have

opportunities to continue with postgraduate programmes, including Master’s and Doctoral

level education:

“I don’t see that there is any obstacle, as the Ministry efforts are currently directed

towards the bridging programme, with the evidence that increasing numbers have

been sent to universities within the Kingdom and abroad with the ability to

continue in postgraduate programmes such as Master’s & PhD” (GD1).

There appears to be consensus regarding degree education being a good decision for

nursing in SA, and there is agreement that plans to convert Diploma nurses to degree level

are in place. These opportunities for advanced education will help to support raising the

quality of nursing practice throughout SA and Gulf countries. Moreover, most of the

macro participants (GD3, GD4, & GD1) agree that there are no obstacles or difficulties

facing Diploma nurses wishing to convert their education to bachelor degree level.

However, the macro level participants did note educational differences in programmes of

study based on whether these programmes were within private educational institutions or

governmental institutions. This division is explored further in the following sub-themes.

7.2.2.1 Private and Government Conflict? ‘We can’t really evaluate their performance’

The macro level interviewees recognised the differences in nursing programmes/outcomes

between the governmental and private colleges/universities. For example, within SA,

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nursing education is offered in private and public organisations (Section 2.2). Part of the

problem with the private institutions is that they are too new to evaluate. Despite similar

standards, every institution uses a unique curriculum. One Director explained:

“For the private colleges because they are still new, we can’t really evaluate their

performance. For the governmental colleges we have three old colleges, their

graduates are really good graduates, good outcomes. For the rest of the colleges

they are still new, they just started. Of course they do not have the same curriculum

but of the same standard. Like certain hours for the theory and for the practical but

then every college is different as anywhere in the world. The basics are the same,

this is what we care about” (GD4).

This participant perceives old (traditional) colleges to be good and yet realises that new

developments in healthcare lead to changes in education. This point will be discussed

further in Section 7.6. All the institutions have to meet the standards set by the MoHE.

Although these are difficult to assess, they were described by participants as having

differences in the curriculum, such as elective level coursework. However, one Director

(GD3) noted there is a perceived lack of experience and skills among nurses who

graduated from the private institutions in Saudi Arabia:

“I cannot compare but what I know is that the accredited body in private or

government institutions is the Ministry of Education. What I know is that the

curriculum should be the same, and if there is a difference, it is in the elective

courses. That’s all. … but what I faced in my experience in their hospitals, we have

a lack of experience and skills of nurses who graduated from the private

institutions here in Saudi Arabia” (GD3).

When asked why these perceived educational differences between private and government

institutions may exist, one Director suggested:

“The students who graduate from private colleges mainly they did not get the

chance to study in the government university because they have low grades,

especially in their secondary school. First it is in the level of education; second

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money because the private colleges are looking for the money not students; third,

the locations of the clinical because the private college does not have access to

good teaching hospitals for their students and mainly they practice in a low

standard private hospital which has a contract with them to train their students”

(GD2).

In summary, macro level interviewees agree that there are differences between private and

government-nursing colleges/universities, including curriculum design, level of teaching,

and clinical areas for gaining practical experience. In light of this, the macro level

interviewees recognised the need to standardise nursing education for all nursing in SA.

This standardisation would have a number of important implications in terms of nursing

workforce planning, and differences in education and experience. The following sub-

theme discusses the factors affecting completion of study for nurses.

7.2.2.2 Completing study: a ‘passion for education and self-improvement’

The macro-level participants described two primary factors contributing to or hindering

completion of study. One factor was the nurses’ passion for education and self-

improvement, which served to support continued educational progress and degree

completion:

“My passion for education and self-improvement guided me to complete the study.

I believe that to improve myself I need to improve my knowledge. It is good to lead

the development of the career in my country and I think by getting a high education

we can improve our plan for nursing, nursing is a first line, and we can improve

the care to our patients. By widening my knowledge, it is not just helping me, it is

helping the other nurses because I am working as a decision maker in MoH”

(GD1).

The second factor was an inhibitory factor, financial obstacles, which limited nurses’

abilities to fulfil educational goals and needs. One participant discussed bureaucracy in

scholarship and difficulties obtaining funding for educational advancement. In addition,

difficult admission criteria can be limiting for nurses who desire to complete their studies.

Lastly, this participant also noted that acceptance was difficult for nurses who graduate

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from private colleges, as the government universities favour government university

graduates:

“Yes in the beginning I found it was difficult applying for scholarship. It was not

easy. It takes a long time. You know bureaucracy in scholarship. I always depend

on others’ opinions if they allow me or not. It does not depend on you unless you

want to pay for yourself the fees of the scholarship. So I think these days are better

than before. The scholarship process needs to improve to arrive at the point we

want it to be at, and I think ten years ago it was not possible to take a Bachelor’s

degree for men in Saudi Arabia and these days there is a chance. There is a high

number of people who want to complete their studies and they face difficult criteria

for acceptance in universities, and these are the obstacles… for the people who

graduated from private universities who are not the priority to be accepted to

complete their studies in governmental institutions, all the governmental

universities target those who graduated from governmental universities and

colleges” (GD2).

In summary, the above indicates that it seems some informal agreement that plans to

convert Diploma nurses to degree is in hand, but it is a slow process and will take time to

implement effectively. Also there appear to be educational differences in programmes of

study, based on whether these programmes were delivered within private educational

institutions or governmental institutions, and these differences were noted by the macro

level participants. However, three of the macro participants (GD3, GD4, & GD1) agreed

that there were no obstacles to converting Diploma educated nurses to bachelor degree

educated nurses. One director (GD2) stated that certain obstacles did exist for a number of

nurses who wished to complete their studies; such as difficult criteria for university

admission. The following sub-category identified the importance of both experience and

education within nursing practice.

7.2.3 ‘Education and experience are important in giving quality care’

This was the final theme within the analysis of views from participants at the macro, or

strategic level of nursing organisation and delivery within SA. Specific to providing

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quality nursing care, participants also discussed the importance of both education and

experience. Although the requirement for Bachelor degree nursing education was

supported, as illustrated within the previous themes, the participants did not minimise the

importance of experience and the ideal combination of both experience and education in

the provision of quality nursing care. However, it was noted that without education,

experience could still lead to continued levels of quality care, but without career

advancement. The nurse would simply provide care based on what had worked in the past,

as opposed to understanding why decisions were made and/or improving care decisions

based on evidence and informed problem solving. One participant highlighted the

importance of both education and experience to ensure quality practice:

“It makes a difference if a person has a degree with experience rather than a

degree only without experience. If you have a degree and education that means you

know the rationale of the things you do; but if it is only experience you do things

because you see other people doing it or you did it before and it worked; you just

carry on and do it. But if you have the education you know why you do it and can

even do it better. Education and experience are both important in giving quality

care” (GD4).

Although noting the ability of experienced degree nurses to provide a high level of quality

care, this participant also recognised the limitations of a recent graduate lacking

experience, and in the case of Diploma nurses, lacking appropriate education as well:

“Diploma nurses with accumulated experience of 10 to 15 years know how to deal

with cases more than the doctor. But these days it is difficult to recruit Diploma

nurses; if we employ them or recruit them we need at least a minimum of 6 months

of theoretical foundation to build their knowledge and clinical skills to keep in

touch with the patient” (GD2).

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7.2.4 Conclusions from Macro-level data analysis

The following conclusions are derived from the common themes revealed from the macro-

level participants:

 Benefits of nurses having Bachelor degrees included improved quality of nursing

and better patient outcomes, which may be supported by the other noted benefits of

nurses having a broader knowledge base and enhanced language and

communication skills. The macro-level participants described and generally agreed

with the need for the BSN, believing this to be a good decision.

 Noting the use of bridging programmes to support Diploma level nurses to acquire

Bachelor degree status, whilst recognising the differences between private and

government colleges/universities and the quality of education in the private versus

government institutions also saw agreement in the need for national standards for

the nursing curriculum.

 Both education and experiences are seen as important factors in increasing the level

of quality care, but without the latter alone leading to career advancement.

Despite the noted importance of education (having a Bachelor degree), participant

responses contributed to an understanding of factors that affect completion of study. These

were commonly noted to be (a) passion/self-improvement (supporting educational

attainment) and (b) financial obstacles (limiting factor) comprising the second theme

(Theme 2). The final theme (Theme 3) developed from the data was related to the

importance of both education and experience in providing quality nursing care.

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7.3 Meso level

The meso-level content analysis consisted of a single focus group interview with six meso-

level regional nursing directors, each of whom had different levels of qualifications and

experiences. The detailed organisation of these interviews has been explained in Section

5.4. These meso-level participants offered their personal insight into the problems and

difficulties experienced in Saudi nursing practice in different regions. General themes

identified from focus group data at the Meso level were quite similar to those identified

from the micro-level data, which will be explored in Section 7.4.

 Theme 1: ‘Nursing should be BSN’

 Theme 2: Quality of care and educational levels

 Theme 3: Both [experience & education are important]

The themes and sub-themes identified from analysis of the meso level data are illustrated

in Figure 7-4.

Figure 7-4: The three themes and subthemes within analysis of meso level data

Each of these themes are discussed individually with textual examples from the focus

group transcript to support understanding and theme development.

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7.3.1 Nursing should be BSN

This is the most significant theme identified from the meso level participants and includes

three subcategories, illustrated in Figure 7-5.

Figure 7-5: The first theme in Meso level analysis

The meso-level data revealed general agreement with the minimum requirement for a

Bachelor degree for nursing practice. Five regional nursing directors (RND2; RND2;

RND4; RND5; and RND6) acknowledged the decision to create a Bachelor’s degree as the

minimum requirement; for example, the director (RND5) stated that:

“This decision was promulgated during the term of Dr. Rabea, which stipulated

that nursing should be BSN.”

Participants’ considered it vital that nurses remain able and responsible for keeping up with

the complicated and continuously changing nature of nursing practice and that a BSN was

the way to ensure this could happen:

“Personally, I appreciate the decision and personally I like this decision. The

health process in general witnesses remarkable development in this complicated

time. Health work is getting more complicated and in turn we should ensure an

efficient nursing profession to meet and keep abreast of the development and

complexity of the health sector. Indeed, those enrolled in nursing should have

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BSN as a minimum entry which means that they should be bachelor’s degree

holders” (RND5).

The regional director RND3 also noted that increased quality of care and safety of patients

is a basic requirement, suggesting patients require this level of care, and this level of care

requires degree level education:

“Currently, the basic requirements for nursing services are quality and patient

safety. Even patients are requesting better healthcare services, which means that

they know the quality of service and they ask for enhancement. … … Saudi female

nurses should have a Bachelor’s degree as the minimum education requirement”.

Ultimately, participants within the focus group believed the benefits of attaining a

Bachelor’s degree over a Diploma in Nursing supported improved quality of nursing care,

greater patient safety and more positive outcomes. This was noted by (RND1) as follows:

“Based on my experience in the Ministry of Health, with due regard to the fact

that I graduated from a secondary health institute and thereafter studied in a

health sciences college, and was promoted to study the bachelor’s in college, I

noticed the difference in the quality of care between nurses who were studying in

college and those in university. There are remarkable differences in terms of

information, training and dealing with patients” (RND1).

In contrast, one regional director presented a different opinion regarding the decision to

introduce BSN as a minimum requirement to practise nursing. The director stated that:

“I disagree, we need different levels and we still need the Diploma nurses. The

Diploma has a level of skills not just the Diploma title. They have a level of

knowledge, experience, behaviour, and technical skills. The Diploma should have

clear educational pathway within a specific frame such as the bachelor degree. I

need a Diploma to do specific roles. I believe that the Diploma can deliver a good

care if they graduate from government institutions. We must not forget that we

have been trained by Diploma holders” (RND1).

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In summary, these results indicate that most of the participants working at the meso level

support the decision that nurses should be educated to degree level. Only one participant

(RND1) voiced the need for different levels of nursing to provide different levels of care.

The following section presents the sub-categories identified within the overarching theme

‘Nursing should be BSN’. Within the sub-themes, greater proficiency in English language

skills, the acceptance of responsibility and improved opportunity for accessing higher

education are all recognised.

7.3.1.1 ‘Noticed difference in English skills’

One commonly noted benefit of Bachelor versus Diploma level nursing education was in

English language skills:

“English language, we have noticed the difference of education, noticed a

difference in English skills” (RND3).

“English and communication skills is better in Bachelor’s programmes than

Diploma education” (RND5).

The regional nursing director continued to elaborate on the benefits in terms of

communication with non-Arabic speaking doctors:

“I studied in university and all the subjects were teaching in the English language

and when we worked in our hospitals they deal in English, even the

documentation in patient files was in English. We have doctors who are of non-

Arabic origin who only understand English, which is a medicine and nursing

language. In general, I consider the English language is a professional language

and proficiency in it is improved with degree education” (RND5).

7.3.1.2 ‘Able to carry multiple responsibilities’

An additional benefit noted by the meso level participants, was the BSN degree supporting

greater knowledge and the ability to use this knowledge in clinical practice, leading to

nurses being able to carry more responsibility. One participant described the

Bachelordegree nurse as:

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“[an] Accountable person who is able to carry multiple responsibilities and care

for different cultures” (RND3).

Another participant explained this concept in more detail, articulating how advanced

education and knowledge can support skill development and facilitate nurses taking on

more responsibilities:

“For instance, the bachelor’s nurse has a huge academic volume of information.

The academic education prepares the nurse for better understanding and

awareness. For example, we study pharmacology, physiology, psychology,

autonomy, family, growth and development of humans, and how we deal with

patients of different ages. The nurse will graduate having higher cultural skills in

general and in their profession in particular, which special emphasis on the

nursing degree”. (RND5).

7.3.1.3 ‘Opens the door to higher education’

In addition to being able to take on and handle advanced workplace pressure and

responsibilities, the benefit of Bachelor level education can be increased opportunities for

additional advanced education, and ultimately career development. For example, one

participant in the meso level focus group described that:

“This makes her accommodate the work and then start to develop her capabilities

through courses. Thereafter, the bachelor’s degree opens the door to higher

education, which is considered an excellent idea” (RND5).

Some of the participants at the meso level indicated that there were some obstacles to

completing degree education. Not all Diploma nurses can access bridging programmes,

because they are not able to meet the admission criteria. For example, one director lists the

obstacles and states that:

“First is the age. For instance, 40-year-old nurses do not have the right to enrol

in the supplementary programmes. Second, English language is required, such as

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TOEFL. They should open the domain for enrolment without complicated

standards. They should open the field to encourage people to join” (RND4).

Another director shares their own experience regarding joining bridging programmes:

“before two years, I decided to complete the bachelor’s, but it was conditional on

being below 40 years of age. The certificate should not be more than 10 years old

and the TOEFL grade should be 4.75, as well as full dedication to work”

(RND6).

With regard to the above about the benefit of a Bachelor degree, and the obstacles that face

Diploma holders when trying to complete their degree education, the meso level

participants emphasised that these obstacles need to be considered for future nursing

workforce planning. However, the benefit of nursing degree education depends on the

quality of the BSN programme in private vs. government colleges/universities, which may

affect the quality of nurses it produces. This is explained in the following theme.

7.3.2 Quality of care and educational levels

This is the second overarching theme identified from the meso focus group and includes

three unique sub-themes, ‘Government has better graduates’; ‘Nurses should have different

job descriptions’ and ‘I don’t want a bachelor’s nurse to work in PHC centres’. as

illustrated in Figure 7-6.

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Figure 7-6: The second theme in Meso level analysis

7.3.2.1 ‘Government has better graduates’

Participants at the meso level list certain issues that could influence the quality of care and

those that might be associated with educational levels. In addition, the participants

described the differences between education attained at private institutions of higher

education and that attained in government institutions. The perception that government

education maintained quality as compared to private nurse education was in keeping with

views offered within the macro level discussion (Section 7.2). The private institutions

were described, by meso level participants, as not having the same level of education as

that demonstrated at the government institutions. For example, five meso level participants

explained their perceptions of the Bachelor degree at government versus private colleges:

“It should be governmental college. … I say that government has hundred times

better graduates than private” (RND3).

“Currently bachelor’s is granted from private institutions which do not have the

same level. Nevertheless, the level is worse. Private academies provide

Bachelor’s at the same quality of Diploma and the same study” (RND2).

“The regulations should be enforced in the private sector; the government

graduates they do not have problems. Because private colleges are not under

control, it focuses on business” (RND5).

“but it is unfair that you have a Bachelor’s and they do not understand anything”

(RND4).

“Currently the nursing profession witness desertion by Diploma holders. For

instance, male nurses who have a Diploma intend to complete their study in other

careers and now they are health information specialists, working in social

services, hospital management due to the barriers and obstacles that prevent

completion of the Bachelor’s degree in nursing” (RND4).

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These participants highlight that due to a lack of regulation and control over private

institutions, these organisations are able to award Bachelor degrees to nurses even if they

do not have a high level of skill; these decisions being made based on business

development rather than quality of patient care. Many participants at the meso level concur

that graduates from governmental institutions have a better level of education.

7.3.2.2 Nurses should have different job descriptions

As well as recognising a need for regulation across government and private institutions,

the meso level participants also noted the need for a more structured distinction between

job descriptions for nurses based on education levels. Such distinction could be based

around nurse technician, nurse specialist, and senior specialist. These different specialties

in nursing provide the continuum of care. One of the regional nursing directors, who

argued against the decision for nursing education to be all at degree level, and strongly

advocated for other levels of nursing to perform different levels of skill, stated that:

“Nurses should have different job descriptions and nursing practice varies in

terms of nursing care. I need health assistants, I need nursing technicians and I

need specialists and senior specialists, which means that I need each level to

perform different care” (RND2).

“Nursing, technician, bachelor’s, specialist or senior specialist all of them

working together” (RND3).

“There is not any difference in the job description of the nurse with a bachelor’s

or the nurse with a Diploma”, “They are working the same (RND3, RND6)

The participant RND1 calls for the demarcation of nursing roles according to qualification.

“Currently there is a job description for all except health assistant, but in fact

each technician and specialist has the same work, even the master’s holders

working as nurses, they do the same work which means there is no demarcation”.

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Most of the participants in the meso level focus group (RND2; RND3; RND6D, RND1)

agreed that there was a need for job descriptions in order to differentiate between the

nursing roles appropriate to their level of education and the care they can deliver. One

participant believes that these descriptions are already in place, to some extent, but that

they are not implemented and this means that all the nurses with different levels of

education provide the same care because there is a shortage of nurses. This is an important

issue requiring further discussion and concerns many areas of the healthcare sector,

including Primary Healthcare Centres (PHC).

7.3.2.3 “I don’t want a bachelor’s nurse to work in PHC centres

This is an interesting subcategory. Analysing the focus group data for the meso level,

nurses identified that there is a misunderstanding of the role for nurses who work in

primary healthcare or in community centres. For example, it is notable from the focus

group interview that some nursing directors have not recognised the important role of the

PHC nurse and the reason behind the implementation of degree education as a minimum

requirement for entry into practice. They thought that nurses who were working in the

PHC did not need degree education, because the work was perceived as only needing basic

skills. This is a significant finding; given that the future direction of global health

organisations emphasises Bachelor degree education as an important step to meet the

community needs. This was an unexpected finding:

“I don’t want a bachelor’s nurse to work in PHC centres; I need them to work in

hospitals. The Diploma nurse can work there ….it is basic skills” (RND4).

“So, why is there no replacement plan in the hospital? For example, we cover the

shortage with a Diploma holder, then gradually replaced the Diploma with the

bachelor’s degree and shift the Diploma holder to a primary health centre in the

border area. The duties of primary health centres are easy, only basic nursing

skills and there is no workload” (RND1).

Other participants build on this by noting the placement of degree-educated nurses in PHC

centres to be a waste of their skills.

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“This is not a requirement, we discuss here the nursing specialist, once she starts

the work after graduation they recruit or direct her to the health centre. It is

useless. Such health centres are few. I was head nurse in a hospital, it was

impossible for any specialist nurse to work in a primary health centre and we

returned her back to work in the hospital. This is right” (RND4).

“This point drives us to the basic point which is that the requirements in nursing

practice or nursing services is a bachelor’s, either in hospitals or in primary

health centres, but the system does not support us on this point, when you say you

need a bachelor’s now, and the aim is to develop all employees to be bachelor’s

graduate for the services! The hospital is not less important than the health

centre, and the regulation does not support us on this point by saying that the

credentials of a health centre is a bachelor’s, even if we consider that services

will be better due to the bachelor’s holder’s presence. I do not foresee that they

should be directed to basic care as basic care does not require a bachelor’s”

(RND1).

In summary, the above quotations indicate that participants at the meso level have trouble

understanding the decision to send degree educated nurses to work in PHCs while

hospitals are still reliant on Diploma educated nurses. Many directors believe this to be a

waste of resources as they consider that nurses working in PHCs only need a basic skill set

compared to those in hospitals. This is in opposition to the future direction of global health

organisations and the GCC, both of whom emphasise Bachelor degree education as an

important step to meet community needs. As the participants at the meso level were not

included in the consultation process for the implementation of the degree education

requirement policy, regional directors may find it difficult to see the reasoning behind

these decisions. It is therefore important to consider the inclusion of those working at the

meso level in the consultation process, as previously discussed in the findings from the

documentary analysis. While the importance of educational level is emphasised,

participants also expressed the importance of experience and the need for a balance

between experience and education, which is discussed in the following theme.

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7.3.3 Both [experience and education are important]

Another theme emerging from the meso level data, as was found in the previous macro

level group (Section 7.2), was the distinction between experience and education, both

being recognised as important in terms of supporting nursing knowledge, skills, and

quality practice. This issue was described and acknowledged by the participants in the

focus group as follows:

“Both [experience and education are important], because the nursing leader

needs a good background experience in nursing practice” (RND3).

“Both supplement each other, which means I graduated from a bachelor’s but

was trained by a Diploma holder” (RND1).

“I can summarise it, based on my age and experience, experience has a major

role in terms of guidance, performance, personality, punctuality, communication

and skills. Experience is considered as a source of evidence” (RND2).

“Experience is not only a source of evidence; it is considered as a base of

information. The education supports the experience and experience depends on

trials” (RND6).

One of the participants noted that experience supports decision making in practice, as a

nurse will use their background experiences to manage a given situation. This participant

stated:

“Experience supports your decision. For example, you deal with a certain

situation based on your background experiences” (RND5).

Five participants (RND3; RND2; RND1; RND6; RND5) agreed that both experience and

education are important in nursing practice. However, the implementation of the degree

requirement policy means that many very experienced nurses with Diploma education are

not able to obtain higher positions in the healthcare sector, which could impact on the

quality of patient care.

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7.3.4 Conclusions of meso level analysis

The qualitative content analysis of the meso level data obtained for the study resulted in

the identification of several key common themes related to the research questions,

including:

 Meso level participants agreed with the minimum requirement of the Bachelor

Degree in Nursing, considering that ‘nursing should be a BSN’ (Theme 1). Within

this theme, participants discussed the benefits gained by the attainment of a

Bachelor’s degree, including difference in the level of English language and

communication, increased responsibility and the ability to carry out multiple tasks,

and the opportunity for education and career advancement.

 These participants also identified the quality of care and education level (Theme 2)

as a key point; they discussed differences between private and government

institutions in terms of education offered, noting insufficiencies among the private

institutions. This brings into question the need for standardising the curriculum of

degree nurse education in order to avoid discrepancies between private and

governmental institutions, which have arisen due to a lack of regulation.

 The participants also discussed a need for job descriptions to reflect the different

levels of education, as well as the controversy surrounding distribution of degree-

educated nurses. There was a strong belief that bachelor degree nurses should not

work in PHCs, as participants deemed these nurses ‘overqualified’ for the position

and the hospital setting are in more need of their expertise.

 Finally, participants emphasised the importance of experience in addition to

education (Theme 3).

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7.4 Micro frame (phase four)

Micro level participant data was obtained from focus groups with nurses with a Bachelor’s

degree, staff nurses who obtained certification through a Diploma nurse education

programme, and interviews with nurse managers and educators in hospitals. The

qualitative content analysis of the micro level data (previously described in Section 5.4)

resulted in the generation of several themes, from which common themes were revealed in

the data related to each category. The themes were:

 Theme 1: Pathways to nursing.

 Theme 2: General agreement towards the Bachelor Degree.

 Theme 3: ‘We do not have any difference between the BSN and the Diploma

holders’.

 Theme 4: ‘The curriculum in the private colleges is very different from the

government institutions’.

 Theme 5: Images of Nursing.

 Theme 6: Professional scope of responsibility.

 Theme 7: Nurse education versus experience.

The thematic categories identified from analysis of the micro level data are illustrated in

Figure 7-7.

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Figure 7-7: The thematic categories and subcategories within analysis of micro level data

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7.4.1 Pathways to Nursing

The micro-level participants described a variety of pathways into their own nursing careers

in different countries, which included the national board licensure exam, gaining a

Diploma, and sometimes moving on to Bachelor’s or Master’s degree education or beyond.

These educational gains were obtained from both governmental and private colleges. The

following examples demonstrate different paths to nursing:

“I graduated from a high Diploma college (3 years and a half), I work 4 years as

staff nurse…. then complete my study in BSN and graduate from governmental

University” (JN3).

“I was a staff member with a Diploma, after that I went overseas to continue my

studies for a Bachelor’s degree... four years of Bachelor’s degree” (JN1).

Some described continuing education over many years of nursing:

“I am actually going to complete 22 years in my nursing career. I graduated from

university as a general nurse then I got a master’s in nursing” (SN2).

“I graduated from university four years ago and joined up to work as an RN for 3½

years in Cardiothoracic ICU” (SN3).

Different preparation standards were evident in nurses’ training in different countries:

“I am … Korean. I’ve been working in nursing for about 7 years now. We have

different preparation. ..It is made of two categories, one is the Diploma and the

other is the Bachelor’s degree…after they completed their curriculum they both

proceed to the National board licensure exam. Only those who pass the exam may

be a registered nurse. That is the educational pathway in Korea”. (SN7).

“I am a previous dean in the Philippines. What we currently have in our country

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as a minimum requirement is a Bachelor of Science in Nursing. Although we had

like twenty years back a graduate nurse, this is similar to the Diploma graduates,

that we are having here; but this is already being phased out in the Philippines”

(SN5).

A director level nurse described the process of registration and the benefits of different

aspects of nursing education. This shed light on the focus of the quality of the Saudi

national licensure exam provided by SCHS compared with the exam of developed

countries such as the National Council Licensure Examination (NCLEX) in the USA.

“I think in the USA there is an exam called NCLEX. I wish we had the same exam

here because it would be a tough exam that would assess background and give a

good impact; the important thing is the patient. Every person, even without a

certificate, should go through this exam, to be an RN to work with patients. Our

priority is patient safety” (SN1).

All levels of nursing Diploma education have a different type of exam (required to be a

registered nurse) with the same title and the same roles. These statements demonstrate the

variety of participant pathways in nursing education from different countries, cultures and

levels of education, considering the different views and classifications of national licences

that they undertook for entry into nursing practice. This allows for a broad evaluation of

perspectives when considering the implementation of the policy for a Bachelor degree as a

requirement for entry into nursing. Although each participant’s pathway was different, as

in the macro and meso level analysis, there was a general agreement on the topic of the

BSN being an appropriate minimum requirement, and this is discussed in the next section.

7.4.2 General agreement towards Bachelor’s degree

The Bachelor degree as a minimum entry requirement for nursing practice was considered

by macro level participants as an important decision that will have a considerable impact

on future workforce planning and development. At the micro level, participants who were

staff nurses with a Diploma or Bachelor’s degree were asked if they felt a minimum degree

should be acquired and if they did, what that would be. Four participants (JN2, JN4, JN6

and SN7) described that this would be dependent on the individual and their level of

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general knowledge, languages, ethics and commitment, interest and passion, practice, and

specific skill sets:

“Depends on the personality, passion and the background of the person.”(JN2)

“It is related to the personality not the level of degree” (JN4).

“I think this depends on herself, not on the degree, because I saw some nurses in

my practice work well even with Diploma, high Diploma, or a Bachelor’s. If she

has language, ethics, and interest in nursing she will work” (JN6).

“We have other factors that can affect, as I mentioned, could be like commitment,

might be the language, might be the interest or some people may select nursing

because they thought it was an easy job” (SN7).

Three participants from the focus group of Bachelordegree holders (JN1, JN2, and JN4)

also asserted that a Bachelor degree should be required, making the following statements:

“The minimum should be a Bachelor’s degree to improve the quality of nursing

care” (JN1).

“A Bachelor’s should be an ideal candidate for an entry level nursing job” (JN2).

“We prefer the Bachelor’s degree for nursing practice because nurses with a

degree provide holistic care for patients, families, communities and the population

across all ages and genders” (JN4).

In contrast, two participants from the Diploma holders felt that a Diploma was adequate

(JN6 and JN5):

“For me I think it’s okay for a high Diploma. But we need strong subjects and in-

depth knowledge” (JN6).

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“For me a Diploma is okay, if she can understand everything she can do her work”

(JN5).

The majority of the participants that were nursing managers and educators (SN2, SN3,

SN5, SN7, and SN1) acknowledged that a nurse should have Bachelor degree education

and above. For example:

“Yes it should be a Bachelor’s and above” (SN2).

“Yes actually, if we want to improve health services, it must be from Bachelor’s

and above” (SN3).

“I have seen that it is very much needed that nurses who come in as initial

practitioners should have a BSN degree.” (SN5).

“We can clearly see the understanding because they learned English from the

University so they know how to speak, understand and write. This will all have a

huge impact on our nursing care” (SN7).

“The ideal is to have a Bachelor’s degree and I will not accept any nurses to come

to work in this hospital without a BSN degree because of patient safety” (SN1).

This section provided the largest set of significant themes regarding the importance of

degree nurse education in practice and its influences on healthcare services. This section

highlights the BSN degree being considered of higher quality, because it increases the

level of care and patient safety, whilst reducing mistakes and improving the quality of care

and overall health services. Moreover, with five years of education (four years in college

containing theory and clinical practice, and one full year internship in hospitals) delivered

in English, a nursing degree gives them a greater command of the English language, which

improves verbal and written communication. All these factors may have an impact on the

professionalization of nursing. Overall, the participants at the micro level seemed to put a

lot of responsibility on the shoulders of degree nurses, having high expectations, and they

thought that they could do anything when they had a degree education.

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7.4.3 ‘We do not have any difference between the BSN and the Diploma holders’

The majority of micro level participants agreed that the Bachelor degree holder is better

than a Diploma holder in terms of knowledge, skills and attitude, all of which are

considered basic competencies for nurses to provide safe and competent care to patients,

individuals, families, communities and populations. However, there are more specific

competencies that should be obtained from Bachelor degree education, for example:

leadership skills, teaching skills, and assessment skills. Regardless of the development of

specific competencies, some participants stated that all nurses with different qualifications

are undertaking the same type of work and they did not see any differences in the practice

of diploma holders and degree nurses, as illustrated in Figure 7-8.

Figure 7-8: Third theme in micro level

Four participants (SN4, SN1, SN6 and SN5) noted that certain factors are relevant to

degree education and can influence nursing workforce development in Saudi Arabia. For

example, participants believed having a Bachelor degree equated to having greater

knowledge, skills, attitude and communication, with the ability to speak and write in

English and/or Arabic being incredibly valuable. Many of these skills were organised

under the basic competencies, with participants stating as follows:

Knowledge

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“I think one of the important issues with our nurses here is the knowledge…BSN

degree nurses have a general understanding of the theory concept …should have

knowledge, should have a good background about physiology, anatomy, pathology.

Good background about psychology too to deal with patients and pharmacology to

know the side effects and contra indications for each medication.” (SN1).

Skills

“They have advanced clinical skills such as medication calculation, IV

cannulation, catheterisation…. almost all of them have abilities to provide patient

care proficiency” (SN4).

“If we are talking about competency in the nursing assessment, medication

management, calculation and administration, knowing the complications, side

effects of the medication, total patient care, evaluation, therapeutic nursing actions

or interventions: it is really I think that the nurses with a Bachelor’s degree level

will have better competency in these” (SN5).

Attitude

“.. They are more mature, more committed, accountable, confident and... more

prepared” (SN6)

“We are evaluating our nurses based on three things: knowledge, attitude, and

skills. Knowledge is important and I think it is impacting people’s attitudes”

(SN1).

Duties and Responsibilities

"Compared to my place we do not have any difference between the BSN and the

Diploma holders” (SN5).

“We have both of them the Bachelor’s degree and Diploma nurses, they are

providing the same duties and responsibilities to the patient” (SN6).

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“What is different about these nurses is that they have different classifications,

technicians and specialised nurses. Then they come to work as staff nurses

providing the same total patient care” (SN1).

These findings illustrate that participants believe Bachelor Degree nurses are expected to

be accountable and competent professionals, in terms of knowledge, skills and attitude.

Another important finding relates to there being no differences in the job description of

nurses in the real world, as they often function in the same role. At this stage, these results

initially support the idea of developing a national competency framework to meet patient

and current health system needs and to solve the inconsistencies in nursing standards,

roles, and responsibilities. More specific and diverse competencies are needed for nurses

with a Bachelor degree. Furthermore, job descriptions should be determined for each level

of nursing practice in order to improve the quality of care delivered by the nursing

workforce.

7.4.4 ‘The curriculum in the private colleges is very different from the government’

This is one of the important themes identified from the analysis of the different views of

practising nurses at the micro level. The participants noted that there is a remarkable

difference between the outcomes of nursing in government and private colleges, as

illustrated in Figure 7-9

Figure 7-9: The fourth theme in the micro level

One of the managers discussed other factors related to the quality of the curriculum of

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nursing programmes in private institutions. This included issues such as Bachelor Degree

educated nurses coming in with no experience to replace experienced nurses with

diplomas. Having new nurses with a Bachelor degree, without experience, and Diploma

nurses with experience, might affect nursing practice due to certain factors such as

commitment. Furthermore, the participants in the micro level noted that the quality of the

curriculum offered during attainment of the Bachelor degree plays an important role in

achieving the desired level of competency and to improve the nursing workforce. For

example:

“We have a lot of new staff who have graduated with a Bachelor’s degree from

private colleges but still they cannot really handle the patient and they cannot even

pass the competency; which means there is something different or a problem either

in their curriculum or in their commitment” ( SN1).

Similarly, in the focus group with nurses with Bachelor degrees, one participant noted that:

“The curriculum in the private college is very different from the government… Yes,

very, very weak.” (JN3).

Likewise, the level of competence (knowledge, skills and behaviours) could also be

affected by the quality of education and where they obtained their education, such as from

government or private institutions. Participants commented on the distinct differences in

educational quality and curriculum. One participant stated:

“The majority we have are Diploma educated and also we are talking about two or

three categories. The Diploma is three and a half years and they were from

governmental institutions like the Health Science College… under MoH and we

have the other one from the private institutions. …we saw the difference, with

experience, background information, abilities, performance in practice and

outcomes” (SN2).

Language and communication skills were also identified as key factors for a degree nurse:

“The new Diploma which we have is common now, it’s the private institution

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Diploma…they don’t speak or communicate in English. They do not have the basic

things (skills)… they are weak and we have to train them first to study English…,

the Bachelor’s, sure… with English, with the good background of theory and

practice Also with the respect of the institution where he or she comes from, we

are having some Saudi Bachelor’s nurses who do not even pass with us” (SN2).

Problems regarding the quality of education in private universities was another factor

raised by one manager, as noted in the following statement:

“we have private and government colleges. Actually we are facing problems - most

of the students or staff who graduated from the private colleges are facing

problems with the competencies. Actually some of them we asked ‘where did you do

your competencies’? One answered me in an honest way, the Institute told her just

stay at home, 6 months, then you come and I will give you the certificate!!!! … the

private sector is focused on the money more than the quality, which is really

affecting our staff. But some of them wanted to learn and try their best to learn.

They do not have the basic skills, especially from the private sector” (SN3).

Different educational levels can be a factor that influences quality of patient care. One

participant commented:

“The staff educational level is an important factor that has an effect on the quality

of care. We have different levels of nurses …the ones who graduates from a

Diploma lasting 2 and a half years needs to be focused on bedside nursing rather

than making decisions because they ...don’t have any knowledge. Nobody came

with them for the practice (no clinical instructor or preceptor)” (SN4).

However, some participants noted that commitment of the individual was a critical factor

in the quality of care delivered and that performance depended on the individual’s

personality, regardless of whether they held a Bachelor degree or Diploma qualification.

For example:

“Yes, Bachelor’s degree holders are better than Diploma holders. When it comes to

skills, or some other commitment, however, it completely and purely depends on

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individual commitment. It is not a guarantee if they are a Bachelor’s holder that

they are better in every aspect. ..We have Diploma holders in our Paediatric

Hospital, and their commitment is much better .. They are very dedicated people….

and their performance is better than Bachelor’s nurses. They want to learn, they

have the initiative, they have the interest to learn” (SN3).

“Commitment is something important. Lack of commitment actually affects the

staffing plan and also the working hours. Rather than interfering with nursing

administration once they enter the hospital. …. we really have to look again at the

curriculum and the teaching methods in the schools” (SN1).

In a similar way, participants also felt the quality of nursing practice was related to the

personality and background of the person rather than the level of education.

“It is in the personality not in the level of the degree. It depends on spirituality,

values, beliefs and the cultural background of the person” (JN2).

Together these results support the macro and meso level comments and provide important

insights into the quality of the curriculum framework that was implemented in both private

and governmental colleges. These curricula lacked standardisation, eliciting a need for

evaluation and national standardisation to cope with the current and future complex

healthcare needs of the Saudi population. Few participants thought that having a

Bachelor’s degree would help to advance their career. There were subtle and overt

differences in private and government curricula, as well as the quality of education each

provided. The government colleges provided higher levels of education, whereas at private

colleges this was considered inferior in quality, primarily because private colleges were

financially oriented. However, there was debate regarding what constituted a ‘good nurse’,

some participants believing it was improved knowledge, skills and behaviours attained

through their level of education, while others thought that it was the personality,

commitment and background of the individual that mattered more than the level of

education.

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7.4.5 Images of Nursing

Participants at the micro level described several cultural and social factors influencing the

degree level attained by the nursing staff; and shared their views on focus group

discussion, as reflected by healthcare providers and patients. Notably, social and cultural

influences were discussed in relation to degree level nurses, including family pressures and

professional respect, some of which were associated with perceptions of gender roles.

Some of the positive perceptions included better opportunities for nursing careers and

increased pay, greater knowledge, opportunities for nursing specialisation and further

education. All of these were commonly cited factors thought to influence degree level

education among the micro-level participants. The negative influential factors were related

to cultural and social influences, family pressure, disrespect and the controversy

surrounding gender mixing in the workplace; the latter affecting opportunities for female

nurses in terms of their education as illustrated in Figure 7-10

Figure 7-10: The fifth theme in the micro level

The following subthemes demonstrate how these positive and negative images of nursing

were evident across all groups, nurse mangers and educators, degree and Diploma level

nursing staff, functioning at the micro level.

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7.3.5.1 Positive image

The career and economic advantages of attaining a degree education were associated with

positive images of nursing, such as increased job opportunities, improved financial

income, gaining professional respect, and opportunity for further education. Participants in

the micro level focus groups reported these opportunities as follows:

Increased job opportunities

“I am thinking of my future career for myself, for financial outcome and a good

position. I am thinking, what is the easiest way to get a salary and to have some

respect… I discovered that nursing is the best way to get it, that’s why I became a

nurse” (SN1).

“If you have a Bachelor’s degree you can have good position like a head nurse”

(JN7).

Gaining Professional respect

“The one who has good knowledge and very good skills will gain more respect and

will gain more knowledge and can also work in administration” (JN1).

“Now, I discovered that the senior and consultant physicians, they respect nurses

just now because their education and experiences are improved” (SN1).

Increased financial income

“Yes because of many factors. If you are thinking financially, with a Bachelor’s

degree you will have a good salary instead of the Diploma. ..Gain more

knowledge... it will give you a variety of ways to continue your study” (JN2).

“With a Bachelor’s degree you will have a good salary... Second thing...when you

graduate with a Bachelor’s degree you will have more knowledge. Third thing, the

Bachelor’s degree will give you a variety of ways to continue your study. …it will

give you a link to many different opportunities - unlike a Diploma” (JN4).

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Increased further education opportunity

“[With a] Bachelor’s degree we can gain more knowledge, when compared to a

Diploma. As a Bachelor’s graduate, we can further our studies to a master’s degree

and PhD; we can continue. We can have the chance to go abroad because

nowadays if you see the outside offers are only for the Bachelor’s degree, not the

Diploma. …. You can go to further your studies, and increase your salary” (JN1).

While it is clear from the quotes above that there are numerous positive perceptions of

degree level nursing, participants also noted that, as a whole, nursing is still viewed in a

negative light. Participant’s thoughts regarding this topic are shared in the following

section.

7.3.5.2 Negative image of nursing

According to participants, the negative image of nursing can be linked to certain cultural,

social and family beliefs in SA.

Cultural and social influences

“I can see our culture is important here; as Saudi people we are not expecting a

male person to be a nurse. We think in Saudi Arabia, nursing is a job for females

only and that’s why we don’t have a lot of male nurses who graduate from a

Bachelor’s degree to work with us” (SN1).

“I think for us, socially, they respect more the man than the woman. But at this time

the image of nurses is improving for the Saudi people.” (JN2).

Family pressure

“Some families push their daughters or sons to study nursing only because of the

need for financial gain”. (SN5).

“Some families do not allow their daughters to work in the night shift or in the

male ward” (SN4).

“One female nurse left nursing after marriage because her husband did not allow

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her to work for different reasons” (JN1).

Disrespect

“I am seeing that there is a respect for physicians - why don’t they have respect as

a nurse? There is no respect for nurses” (SN1).

“The male or female working in this career, they are not respected by

others. …some patients are coming to us ...acting like we are housemaids or

chamber maids” (JN2).

Gender mixing

“They see that we are doing dirty work, some of the people they see that females

and males are working together, they are thinking about that in another way! Still

there are some people that have this bad perception” (JN1).

These comments are valuable because they offer an insight into why degree education is

not easily achievable for all nurses, some are pressured to take the quickest route into

employment and some are demoralised and are likely to drop out of their course. It is clear

that some participants see the introduction of the minimum requirement as a way to

combat these negative views, making nursing a more valued profession with better

financial opportunities, especially considering that the Bachelor degree is required in order

to begin a Master’s degree when a nurse wishes to specialise.

7.4.6 Escape from Professional Responsibility

Participants at the micro level discussed some of the professional issues they associated

with diploma educated nurses. These included language barriers, medication errors and

absenteeism as illustrated in Figure 7.11.

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Figure 7-11: The sixth theme in the micro level

Participants felt that obtaining a Bachelor degree offered professional benefits in terms of

gaining a greater knowledge base, improving their general nursing skill set, particularly

communication skills, gaining opportunities for further advancement, being better prepared

and more competent for the work environment, and supporting an increase in patient

safety.

One participant felt that:

“It is very much needed that nurses who come in as initial practitioners should

have a BSN degree... because this would complete the requirement of

professionalism” (SN6).

Many participants from nursing mangers and educators believed that this level of

professionalism was not being met by nurses with a lower level of education. Participants’

believed this is due to a number of different factors which will be illustrated within the

following subthemes. The key issues addressed are absenteeism in hospitals and frequency

of medication errors affecting the quality of patient care. Both of these concerns were

perceived by the participants to be a result of language barriers.

Overcoming absenteeism

One of the significant benefits of employing nurses with a Bachelor degree was the

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increased level of knowledge, which was felt to support nurse confidence, language skills

(and communication), and combat absenteeism. It could argued that the stress of nurses

from the language barrier and medication error might also affect the hospital organisation

in terms of absenteeism and quality of care as suggested by Alsaraireh et al.(2014). Nurses

lacking this level of education were noted to have difficulties understanding the patient’s

situation, as well as using English, which caused confidence issues and absenteeism. This

was described by one manger (SN1) as follows:

“When I talk with most senior nurses, we discuss the biggest issues; we faced

chronic cases of absenteeism and we found that most of them were nurses with a

low level of education. When I investigated them, to understand their situation and

why they were absent regularly, I discovered that they were absent because they

wanted to avoid responsibility”.

One of the managers added some examples from personal experience to support the

reasons for absenteeism, such as:

“one of my staff told me that ‘I did not come on duty because I am afraid to talk in

front of the physician and he might ask me about the patients and I can’t answer

because I don’t understand their situations.’ Also because they don’t speak English,

so they can’t endorse the case to non-Saudi nurses” (SN5).

Likewise, another nursing manger gave an example of an evidence-based study:

“We did a study about absenteeism here in KSMC, the most significant factor is

workload and the second is endorsement. Because they don’t have good English

and they don’t have good knowledge, they are absent from the duty” (SN1).

Medication errors

Micro level participants considered that nurses with a Bachelor degree education were

more professional in communication and medication administration than Diploma nurses.

For example, two participants noted that:

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“Patients were safe when handled by nurses with Bachelor’s degrees - even their

English is good. Because you couldn’t imagine that some of the Diploma nurses

can’t read English, how they interpret physician’s orders and medical orders! We

discovered that some of our patients did not receive medication because the nurse

technician (NT) couldn’t read English” (SN2).

““We discovered that nurses who make a lot of mistakes have a low level of

education. So, if we need safe practice you have to have at least a Bachelor’s

degree” (SN3).

The evidence presented demonstrates that both absenteeism and medical errors are

perceived to be linked to low levels of education and in turn impact patient care. The

participants explained their perceptions regarding an association between nursing

qualifications and quality of nursing practice and a high level of education. For example a

Bachelor degree, was seen as critical to providing excellence in nursing care. This was

discussed by one of the manger:

“I need our patients to be safe and I need safe nursing practice ... I think there is a

good relationship between nursing qualifications and professional nursing

practice. ...I am a member of the committee of central events of mortality and

morbidity and I can say there is a strong relation or correlation between nurses’

qualification and central events. … because usually when we are reviewing the

cases of central events, we discover that people who have a high level of mistakes

have a low level of education. So, if we need safe practice you have to have at least

a Bachelor’s degree” (SN1).

In conclusion, it was felt a Bachelor degree helped to develop professionalism, which in

turn helped to nurture nurse confidence, accountability and language skills (and

communication), and overcome absenteeism. There was a perceived association between

nursing qualifications and quality of nursing practice and professionalism.

7.4.7 Education versus Experience

The perception of the importance of experience and education was identified during the

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focus groups discussion. When asked about the importance of experience versus education,

in terms of professional benefit, participant responses at the micro level were varied, with

some noting education as being critical over experience, some vice versa, and some

suggesting that both were important. For the majority, both were considered important.

For example:

“It’s the same - both Diploma and Bachelors are the same. How they are

performing. For example, if they are doing any procedure. We do it step by step. We

start from…hand washing then explain the theoretical, go to the patient side. We go

for the procedure in the correct manner step by step. Okay. … This is called staff

performance… it is no different between Diploma and Bachelor’s. It’s the same”

(SN2).

“For me both of them are important because without experience you cannot note

how to solve your problems. So if we mix between the new graduates and the

experienced ones, both of them will teach each other, the new have

knowledge…have new research, have more evidence they would teach the

experienced ones. They have the experience how to deal with and solve the

problem. Both of them [experienced nurses and new graduates] are important; they

complement each other” (JN4).

The importance of education was highlighted, specifically in terms of new research or

knowledge that might advance the field or better patient care; with some participants

suggesting if nurses only have practice experience they may not be providing the best care.

“The Diploma nurse will say, for example, (I already have more knowledge than

you from experience). Nurses they know by their practice or their way. These ways

might affect the patient as they will stick to that experience. That’s where there is a

problem. They need first to update their knowledge and to be ready for change.

Because nurses stay a long time in practice. They are not ready to change their

practice. They want to stick with that” (JN3).

Two members of the Diploma nurses focus group, when asked if they needed more

experience than knowledge, stressed the importance of knowledge as well as experience.

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These two nurses (JN6 and JN8) simply stated, “I need knowledge” and “more

knowledge.”

In contrast, another participant, this time in the focus group of nurses with a

Bachelordegree, stressed the importance of skill development (with experience) over

education:

“We begin with theoretical and practical right? Actually…the main important thing

is skills. So how are we performing? For example, if you are... administering an

injection or something. First, we have to be aware of the knowledge about the

actions and everything. We have knowledge but how we perform that is very

important…So skills are more important than knowledge. Knowledge is also

needed; it’s like the first and foremost thing but more than knowledge we have

skills. So what we apply to the patient to prevent error. To improve” (JN1).

What is significant from these comments is that education and experience are

complementary to each other and are perhaps co-dependent in terms of providing quality

nursing care. Two nurses, however, did think that skills were more important than

education, but the majority believed that education and experience went hand in hand.

7.4.8 Conclusions from the micro level analysis

The following conclusions are derived from the common keys themes with sub-themes

revealed from the data presented in the micro-level sections:

 The variety of pathways available for entry into the nursing profession (Theme 1);

the agreement that BSN education is better than a Diploma (Theme 2); the

importance of developing job descriptions for each level of nurse, Diploma and

Bachelor’s degree (Theme 3); the difference in quality of curriculum between

private and government institutions (Theme 4); the positive and negative images of

nursing (Theme 5); the professional scope for the implementation of degree

education as a minimum requirement was highlighted, specifically concerning

absenteeism and medical errors (Theme 6); and the argument of education versus

experience was addressed (Theme 7).

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 It was highlighted that a BSN degree is considered to have more quality because it

increases competency, patient safety, reduces mistakes and improves quality of

care and thereby improves health services. Also, it was noted by the participants

that the curriculum and competency levels lacked standardisation, eliciting a need

for evaluation and national standardisation to cope with the current and future

complex healthcare needs of the Saudi population.

 Consideration was given to the greater proficiency of the English language with

Bachelor nurse education and how this impacted on the professionalisation of

nursing. Along with socio-cultural aspects, the economic advantage of holding a

Bachelor degree was seen in terms of advancing career pathways and more job

opportunities, thereby enhancing the standard of living.

 In short, it was felt that the Bachelor degree helped to develop professionalism and

improve the image of nursing, which in turn helped to support nurse confidence,

accountability and language skills (and communication), and overcome

absenteeism. Furthermore, it was felt that education and experience complemented

each other and shared equity in the provision of quality nursing. The following

section will present the synthesis of findings across macro, meso, and micro data

sources.

7.5 Synthesis of Findings across Micro, Meso, and Macro Data Sources

Combining and analysing the conclusions of each of the three levels (micro, meso, and

macro participant groups) is important, as the data revealed commonality across these

groups, demonstrating significant findings that support cross-case themes. These themes

support the following conclusions drawn from across all three levels of data.

 Theme 1: General acceptance and agreement with the minimum

requirement of BSN for nursing staff to support adequate knowledge and

communication requirements for quality nursing practice. In addition, the

importance of individual qualities and skills was noted. Discrepancies in

education offered through private versus government institutions were

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raised, and the feasibility of using bridge programmes to support continuing

education of Diploma nurses were discussed.

 Theme 2: Factors affecting degree attainment included personal

commitment/passion for self-improvement, private versus government

institution education quality and financial factors (incentives or promotional

opportunities or obstacles) were highlighted.

 Theme 3: Benefits of BSN include knowledge supporting confidence and

decreased absenteeism, broader knowledge base, greater communication

and language skills, enhanced nursing skills and responsibilities,

opportunities for advancement and increased pay, and increased quality of

nursing practice, patient safety and improved outcomes, and quality of care.

 Theme 4: Perceived importance of both education and experience, with a

focus on education, supporting knowledge and patient care through

advancement and in-depth understanding.

 Theme 5: Need for differentiation of distinct nursing job descriptions based

on the education level attained and a focus on the quality of patient care

through education, validation and regulation of standardisation for the BSN,

and adequate supervision.

Only two themes were not discussed across all three levels:

 The impact of social, cultural and family influences on degree attainment

(nursing image), which was only discussed at micro level.

 The belief that degree educated nurses are too qualified to work in PHCs

and that this impacts on patient care in hospitals, which was only identified

at the meso level.

The following section will present an overall discussion of the result of three levels

(macro, meso, and micro) of data identifying several areas where workforce planning and

mobilisation could be affected by the mandatory degree nurse education policy.

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7.6 Discussion of macro, meso and micro levels

Analysis of macro, meso, and micro level data revealed interesting themes and a dilemma

for workforce planning following the implementation of the mandatory degree level

nursing education in SA. In the early part of this chapter, the results of interviews with

macro, meso and micro level participants are presented. Analysis of across all three levels

allowed the identification of several themes, which would otherwise have been missed if a

cross-group analysis had not been undertaken. The following discussion brings these

themes together and identifies several areas where workforce planning and mobilisation

could be affected by the mandatory degree policy.

7.6.1 The degree and its role in healthcare quality

Macro level participants agree that the decision to make a nursing degree mandatory was

good and likely to play a key role in improving the quality of patient care. Participants also

believed that the gap in degree level education among existing staff could be readily

addressed by offering bridging programmes. At the meso level, the majority of participants

agreed that the decision to make a degree mandatory for nurse education was a good idea,

as recommended by global organisations (WHO, 2009; Willis, 2012; RCN, 2013; AACN,

2016). The meso level participants based their opinion on the fact that they noticed degree

educated nurses had better English language skills and were contributing to enhanced

communication skills. They acknowledged that the official language of medicine was

English (El-Sanabary, 1993), therefore making this an essential skill. Micro level nurses

also agreed that English language skills were important in care delivery, but overall their

concerns were slightly different to the meso and macro level participants.

Micro level participants agreed that nurses have various pathways for obtaining their

qualifications and that courses are different. However, they were all ultimately driven by

their desire to care for patients, by delivering good quality care. However, there was less

emphasis on undertaking degree level education and more on a commitment to providing

quality nursing care (Section 7.4.2). There were mixed opinions on whether all nurses

should be required to be educated to degree level. Participants felt that the decision to

study for a degree over a diploma should be based on individual choice, which is likely to

be reliant on their personality, drive and academic ability. They also recognised that within

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society there are differing levels of willingness and ability to study and perform jobs.

Nursing education should not be so specific, but reflect these differences in healthcare

settings by offering people a wider range of opportunities and not limiting them to one

group of people (Almalki et al., 2011). According to Micro level nurses with degrees it

was necessary to obtain degrees whilst diploma holders thought nursing was more to do

with their personal ability commitment and level of skill.

Micro level nursing managers preferred degree educated nurses working in in-patient

wards because they felt this had a positive impact on patient safety. This was not followed

up in a discussion around experience which, for some, is an important aspect of patient car.

However, micro level nursing managers did recognise that commitment is also very

important, and expert diploma educated experienced nurses have shown better

commitment to ensure the delivery of quality care, in some instances more than certain

degree-educated nurses as suggested by other researchers (Orsolini-Hain & Malone, 2007;

Dellon et al., 2009). This important recognition may help with the recruitment of diploma

educated experienced nurses over degree educated nurses, thereby utilising available

resources in the workforce to maximise output (McHugh & Lake, 2010). Furthermore,

micro level staff thought that the commitment of expert nurses was more important for

workforce planning at local level, particularly with regard to delivering quality care. If

nurses are not committed to their work, then planning rotas and offering quality care

becomes difficult (Dunton et al., 2007).

The view at the micro level was that such commitment is not just associated with

education, but is reliant on personality. However, one micro level nursing manger pointed

out that following investigation into absences, a high number of absentees were diploma

educated nurses. One of the reasons for their absences was identified as fear of tackling

difficult clinical situations due to a lack of English language skills and understanding of

the patient’s problem, which caused nurses to avoid such situation. Nurses with a lower

level of education were more likely to make clinical errors (Tourangeau et al., 2006;

Tourangeau, 2006; Kendall-Gallagher et al., 2011; Blegen et al., 2013; Fossen, 2014), this

would of course affect self-confidence and could lead to absence from work, affecting the

team and the care they can provide to patients. In such cases, on-the-job specific training

for staff nurses may help overcome such issues in a quicker and cheaper way, rather than

having to re-educate nurses in universities (Al-Ahmadi, 2014).

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All of this highlights the multifactorial aspect of workforce planning and healthcare quality

that is not just dependent on nurses being degree educated and having the necessary

academic skills, but also recognises the importance of being able to apply such knowledge

and skills. Too much emphasis on degree level education and career progression, as seen

in the macro and meso levels, could negatively impact on the patient-nurse relationship,

thus affecting the safety and quality of care by using a top-down process (Meerabeau et al.,

2004). There have been fears from patient groups that the mandatory degree policy may

make nursing a less compassionate profession (The Patients Association, 2013).

Indeed, interviews at all three levels (especially macro and meso) revealed that those in

favour of the degree placed a lot of emphasis on career development, academic ability and

management of healthcare systems rather than the patient-nurse relationship and

compassion (The Patients Association, 2013). Some micro level participants felt that

nurses were entering the profession to study for a degree and the accolade that comes with

it for financial reasons. For example; a high salary and career development rather than to

look after patients; may actually compromise the quality of care. Whilst this is a valid

concern, in the UK the Willis Commission Report (2012) found that such issues did not

affect the quality of care and therefore the reason for initially entering nursing should not

affect the quality of care. The Willis Commission Report also suggested that the quality

was improving as a result of the uptake of degree education (Willis 2012) .

If more Saudi nationals were to take up nursing due to the professionalization of the

career, the majority of the workforce would not be English speaking; there would be an

increase in Arabic-speaking nurses and less reliance on foreign staff. A high multi-

cultural/national workforce has been linked with reduced quality of care (Al-Ahmadi,

2014). However, as degree education develops and enhances English language skills and

communication, this would not be an issue in workforce planning as there would be less

reliance on foreign staff (Al-Homayan et al., 2013). This should alleviate some of the

issues seen with lack of communication. However, the enhancement of communication

skills should help mobilise the workforce, enable local staff to take up advanced degrees

and qualifications abroad and help develop the healthcare service by providing local staff

with clinical training to international levels (Al Mutair, 2015). To realise this potential,

nursing opportunities need to be publicised through the media to raise their profile

(Ventola, 2014).

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Meso and macro level participants felt that degree educated nurses were more likely to

multi-task and therefore would be more resourceful than diploma educated nurses. The

multi-tasking ability comes from acquisition of broad in-depth knowledge that they are

able to apply more readily in their roles. Furthermore, a degree can open doors for further

specialised education and personal development such as the uptake of master’s and PhD

programmes. The enhanced communication skills of degree educated nurses were also

noted by the macro level participants, who believed this would increase knowledge and

skills. The skills referred to here are medication calculation, IV cannulation,

catheterisation, knowing side effects of medication and signs of illness in patients, among

others.

Macro level participants believed that degree education could make up for the lack of

experience in graduates compared with diploma educated experienced nurses. It was

suggested degree level education would be good for those beginning a career in nursing as

well as for those wanting to specialise, as it offered nurses the opportunity to gain skills

and specialised knowledge that reduced nursing errors and increased quality of care (Aiken

et al., 2014). Macro level participants appreciated experience as an important part of

delivering quality care, but believed the diploma-educated nurses were more likely to

deliver continuous quality care based on processes that have worked in the past, rather than

apply critical thinking and leadership to improve services and innovate. They argued that

these were skills graduates were likely to possess, concurring with the findings of

Veenema et al. (2016).

Nurse-led clinics in SA have already been shown to be successful in demonstrating

leadership skills (Bdeir et al., 2015). As consumers, it would be interesting to to gain the

patients’ view of graduate nurses versus diploma-educated nurses and the quality of care

they receive. Currently, studies in this area are lacking in Saudi literature and need to be

explored in order to gain an overview of the impact of degree education on the nursing

workforce and quality of care in SA.

Macro level participants stated that enhanced communication skills and knowledge were

partly due to nurses being better at using technology, and thus better able to support those

who are in need of care. At the meso level, participants agreed that healthcare delivery was

becoming sophisticated and complicated, and nurses need to keep up with this trend; a

degree education better prepares nurses for this. Advancement in technology and the

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availability of information means patients are knowledgeable about healthcare (Black et

al., 2012). Interestingly, participants at the micro level, whether degree educated or

diploma educated, did not raise this as an issue, suggesting perhaps this was not an area of

concern as the meso and macro level participants were suggesting.

Macro level participants believed that there was a gap in the level of knowledge taught on

diploma and degree courses, but the latter offered a better knowledge-based programme.

This was the main reason for being in favour of the mandatory degree policy. There was a

failure to recognise that degree programmes can be demanding, as shown in many

countries where the policy has been implemented (Brown, Anderson-Johnson, &

McPherson, 2016; Craft, Hudson, Plenderleith, & Gordon, 2016). This may have a

negative impact on successful completion rates compared with diploma programmes, and

thus negatively impact the workforce (Rother & Lavizzo-Mourey, 2009). The MoH and

MoHE would need to look into this when developing standardisation policies (Section,

6.5).

Meso level participants also pointed out an interesting fact that would help develop the

workforce. The nursing profession in SA needs to have more devolved roles with better

job descriptions. Nursing roles need to be specialised into specific roles such as

administrative, technical, or senior nursing (Considine et al., 2007). Definition and clarity

in job roles would allow nurses to home in on their strengths and develop these further by

being able to refer to their job description to improve their career prospects (Almutairi et

al., 2015). It would enable line managers to arrange appropriate training to improve the

quality of service (Hendricks et al., 2012). Different people have different abilities,

different ambitions, and different rates of learning, therefore offering specific roles based

on their level of education that enable nurses to focus on their strengths should help with

job retention, job satisfaction and career progression (Almutairi et al., 2015).

Under a diploma education system, there is no demarcation of roles, resulting in Master’s

level nurses doing the same job as diploma educated nurses. This devalues and undermines

advanced degrees and reduces the attraction of the job due to lack of opportunities in

career progression (Al-Ahmadi, 2014). Jobs where an individual is unlikely to advance,

despite having good academic qualifications, are likely to deter people from taking up

more specialised courses. Meso level nurses highlighted that such job descriptions already

exist, but are not applied in practice due to the shortage of staff. This means the nurses are

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not able to fulfil their specific roles and instead all staff have to help with all roles to fill

the gap created by the staff shortage. Such issues should be reduced by professionalising

the course, which would help increase uptake of the profession, as identified by Rosseter

(2013) which in turn should increase the workforce, as understaffing can lead to excess

pressure which compromises quality of care (Rother & Lavizzo-Mourey, 2009; Almalki,

2012).

Macro and meso level participants concurred that whilst a degree is important in quality

healthcare, experience is also important. Participants in both groups agreed that as the

degree course is a recent addition to the education system in SA, it is obvious that they had

been taught by experienced diploma educated nurses in order to qualify; illustrating

experience is also important and goes hand in hand with education. Experience was

recognised as a strong factor in making decisions and using judgement in clinical

situations, and it also supports education (McHugh & Lake, 2010). This indicates that

experienced diploma educated nurses should be encouraged to stay on in practice in order

to enable the workforce to take advantage of their experience.

7.6.1 Career and healthcare development

Macro and meso level participants believed that degree qualified nurses were more likely

to become nurse managers and progress in roles quicker. Enhanced communication skills

allowing nurses to communicate better in English with patients, doctors and allied

healthcare professionals were thought to contribute to their career advancement (Almalki

et al., 2011; Al-Homayan, 2013). Both levels of participants believed that degree education

opened further gates of opportunity, such as allowing nurses to study for Master’s degrees

and PhDs, further increasing specialised skills, knowledge and career development. At the

macro and meso levels, there is a lot of emphasis on academic ability and career

progression; but at the micro level, there was more discussion on delivering quality care to

patients being the primary role of nurses. There was a mixed response on the value of

degree education over diploma and experience. Micro level participants understood that

both experience and education went hand in hand and that the nursing profession is

constantly changing. It could be argue that to be flexible and acquire new skills for nursing

workforce as and when required, and be open to change in order to provide high quality

care rather than simply focusing on further education and existing experience (Kattuah

2013).

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The macro level interviewees understood that those with a diploma should be given an

opportunity to gain the knowledge degree educated nurses acquire through bridging

programmes. This should allow better workforce planning as a valuable proportion of

experienced nurses would not be excluded from the workforce. This may help increase the

number of nurses in the workforce by encouraging diploma educated nurses and those

already on diploma courses to stay on in the profession despite the sudden change. It

should entice new recruits to take up a professional career.

Micro level diploma educated staff appeared to be unconcerned about rushing to enrol on

bridging programmes to alleviate the apparent gap in their knowledge, and instead spoke

of their commitment and experience as being more important. Those wishing to complete

degrees felt that being degree qualified and more academic earned them respect from

doctors and consultants that would help with promoting the image of nursing in SA (Al-

Malki et al., 2011). This may contribute to increased uptake, as it has been shown that with

increased professionalization comes respect that has previously been lacking (Miller-

Rosser et al., 2006). The stigma comes from the public and patients who view nurses as

maids, as identified by Gazzaz (2009). Professionalization of the profession may help

patients change their view of nurses, which can help nurses to deliver better quality care

(Willis, 2012). In families, there can be a lack of support, for example parents refusing to

acknowledge their children are nurses due to the stigma associated with the profession, as

highlighted by (Meerabeau et al., 2004), which has affected the uptake of nursing as a

career. Professionalisation of nursing may make parents proud and more supportive, thus

encouraging their children towards this career pathway (Al-Malki et al., 2011), which in

turn would have a positive impact on the workforce.

At the micro level, the discussion on career progression was mixed. Micro level

participants were more concerned with the status of the nurses and how this may be

affected. For example, nursing was seen as a low-level job in SA, with much social stigma

attached to it (Miller-Rosser et al., 2006; Gazzaz, 2009 ). Nurse participants thought the

stigma was a result of nursing being a female-only profession, but opening doors for men

to study nursing will help the profession gain more respect, as culturally in SA, men earn

more respect than women (Al-Malki et al., 2011). Changes in such negative images can

only help open the doors of nursing to a wider number of applicants, which would help

with recruiting and educating an appropriately skilled workforce (Al-Malki et al., 2011).

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Micro level participants thought that the mandatory degree policy and professionalization

would be likely to have a positive impact on the image of nursing, so is therefore more

likely to attract more applicants which would in turn help counteract some of the staff

shortages identified by Alyasin & Douglas (2014), It would also provide more local nurses

who can communicate with native patients, and therefore help mitigate the issue seen with

lack of communication due to poor English language skills. Local nurses would better

understand the cultural needs of patients and thus be able to increase service delivery

(Suliman et al., 2009). Poor language and communication skills can affect the quality of

care provided (Al-Ahmadi, 2014). Other positive impacts of professionalization identified

by the micro level participants that would again help mobilise the workforce were better

pay and the ability to progress professionally more quickly than diploma educated nurses.

This echoes the opinions of macro and meso level participants. The opportunity for

promotion, greater responsibility and salary may confirm the fears of some patient groups

that have said that making nursing a degree-only profession may turn it into something that

becomes an accolade rather than a patient-centric role (INVOLVE, 2012). Indeed, one

participant said the reason they entered nursing was because the individual desired a role

in which they obtained respect, a good salary, and was able to progress up the career

ladder. Going for a career that earned an individual respect and appropriate remuneration

should not be a negative thing; it could motivate staff to do well due to appropriate reward.

The Willis Commission Report (2012) already stated that quality of care has improved due

to the introduction of nursing degrees, even if this is due to individuals wishing to pursue a

career in nursing due to its professionalisation.

7.6.2 Nursing education and bridging programmes

Interviews at the micro level revealed many pathways to nursing education; this was partly

due to the multinational workforce arriving from different countries offering different

nursing pathways. However, it was evident that despite the recent decision to make degree

education mandatory, many of the interviewees already had diplomas, as well as a degree

and higher level certificates such as a Master’s degree. This shows that the drive to excel

and progress in a career was already there and is not something that would be driven by

degree education. Therefore, the desire to excel in nursing was not dependent on being

degree educated. Diploma educated nurses already had the drive to continue to pursue

education that would help develop their knowledge and career.

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The meso level participants explained the reason for favouring the degree programme. The

degree curriculum taught in subject areas such as pharmacology, physiology, psychology,

autonomy, and human development was producing more academic nurses than diploma

educated nurses (Almadani, 2015; Al Mutair, 2015). However, this finding from the micro

level nursing participants suggests diploma educated nurses can be just as academic. The

data revealed there are a number of bridging programmes to help male and female students

to convert their diploma to a Bachelor degree (Almadani, 2015). Meso level staff pointed

out that in the past males could not study for a degree in nursing, but this had now changed

and should help with managing the nursing workforce and mobilisation of skills. These

programmes are already offered at private and government colleges (Al Mutair, 2015).

There is also a perception at the macro level that there would be no problems or issues

with the uptake of bridging programmes. The only issue that the macro level interviewees

did recognise was that the private colleges offering nursing degrees are new, and there is

therefore little information regarding the quality of such courses. In contrast, the meso

level nursing professionals agreed that the degrees taught in government institutions are of

excellent quality, which should help develop a well-taught, knowledgeable nursing

workforce. The meso level participants also felt that private institutions did not offer the

quality of teaching seen in government institutions. This means that simply studying for a

degree does not guarantee a higher quality academic education as implied by macro level

participants. Studying for a degree over a diploma has shown that nurses experience higher

burnout, stress and drop-out rates Brown et al. (2016); Craft et al. (2016), which can have

a negative impact on the availability of nursing staff following implementation of the

mandatory degree policy. The interviews highlighted that graduate nurses from private

institutions have been found to lack the competence seen in graduate nurses from

government institutions, which would affect their recruitment/career prospects. This would

affect the workforce through the lack of appropriate candidates despite the availability of

degree ‘qualified’ nurses.

Degree courses need standardisation, monitoring and evaluation in private and government

institutions, especially because of the new policy. Lahtinen et al. (2014) state that the lack

of standardisation can affect the labour market, workforce planning, quality of care and

staff mobilisation. In fact, one meso level participant stated that in private institutions, the

standard and content of the degree programme were akin to those of the diploma

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programme. This would mean that there would be no point in a diploma-educated nurse

with experience going to the extra trouble of acquiring funding, enrolling and going

through the degree programme in private institutions. Furthermore, the interviews revealed

that government hospitals, which are the biggest recruiters of nurses, preferred students

who had graduated from government universities due to the disparity in teaching between

government and private institutions. This means that nurses who graduate from private

institutions would have a harder time getting a job over their government institution

educated counterparts, and this may deter students if they do not get into government

universities (Al Mutair, 2015). This highlights that simply offering a course with the title

‘degree’ does not guarantee quality education and supports the need for tight monitoring

and evaluating as mentioned above. The lack of regulation and oversight of courses in

private institutions means that they are more focused on increasing business rather than

teaching to improve quality of care and develop the future workforce. Such gaps and

inequality in education can undo the good that has been predicted and on the

professionalization of nursing (Omer, 2012) and could be tackled by introducing

professional bodies and gold standards (Abualrub & Alghamdi, 2012; Alghamdi & Urden,

2016).

Although macro level participants stated that there should be no issues with the uptake of

bridging programmes, they admitted that the expenses and bureaucracy associated with

getting on to a course and obtaining scholarships could affect uptake and therefore affect

the workforce negatively (Lamadah & Sayed, 2014; Miller-Rosser et al., 2006).

Conversely, meso level participants thought diploma qualified nurses would face problems

trying to enrol on bridging programmes. Many diploma-educated nurses would be older;

nurses over 40 years old would be unable to enrol on bridging programmes, which would

affect a large number of experienced nurses. To tackle this problem, the MoHE would

need to lift this restriction in order to help increase the number of experienced staff taking

up degrees and bringing their experience back into the healthcare environment, rather than

being excluded by the new regulation. Another issue highlighted was the minimum score

of Test of English as a Foreign Language (TOEFL) or International English Language

Testing System (IELTS) requirement. Some of the diploma-educated nurses may not meet

the minimum requirement and would be excluded from enrolling on bridging programmes,

thus excluding them and removing their experience from the workforce. Experience plays

a vital role in quality of care, with experienced nurses making fewer clinical errors,

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without baccalaureate status having significance in the outcome (Dellon et al., 2009).

Therefore, to attain maximum benefit in workforce planning and skill utilisation, attention

must be paid not only to recruiting graduate nurses but also retaining nurses with

experience in the workforce. Furthermore, access to grants and scholarships should be

made easier for diploma educated nurses and first time students to study for a degree in

nursing.

There is a belief at the macro and meso levels that although the MoHE sets the standard,

the way the courses are taught in the newer private colleges and the older traditional

government colleges is different. At the macro and meso level there appears to be a

consensus that graduates from private institutions are not as well-trained and skilled as

nurses who graduate from government institutions. Such issues can affect the quality of

care. The difference in education is blamed on the lack of focus on the curriculum and too

much focus on finances. Macro level participants anticipate that standardisation would

help diminish some of these issues and alleviate some of the worries that students have

about graduates from private colleges, who are seen as candidates with a lower quality of

education. Indeed, it was the global drive to standardise nursing education that led to the

mandatory degree policy in the first place, as nurses were moving internationally with

varied levels of education, making it difficult for the workforce to maintain quality (WHO,

2009). Standardisation was aimed at reducing issues with recruitment and qualification and

increasing quality (Almutairi et al., 2015). This level of standardisation should be applied

at the local level in SA to make the policy successful; especially as the GCC document

revealed the drive to change the nursing profession was driven by patients’ desire for

quality healthcare (Albejaidi, 2010). Government institutions mostly offer free courses,

whereas attending private institution requires finance; this can affect the number of

students taking up nursing degrees and graduating, especially as more students would have

to arrange finances to fund their studies, which has been highlighted as a problem.

7.6.3 Workforce organisation and mobilisation

Macro level participants believed that the standardisation of nursing education

programmes allowed for better staff movement and workforce mobilisation with the GCC.

Standardisation would reduce the worry of potential employers checking the level of

education and whether it is significant. Standardisation of education and skills would allow

nurses to be more easily recruited internationally and would help alleviate shortages in the

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workforce due to lack of appropriate qualifications as well as perhaps increasing staff

retention (WHO, 2009; Rother & Lavizzo-Mourey, 2009). Whilst this may work well in

the long term, the mandatory degree policy is a recent initiative and there is still a vast

number of diploma-educated experienced nurses in the workforce. The strong opinion at

both the macro and meso level participants for supporting degree education, and from

nursing managers at the micro level, where strong statements such as ‘I will not accept any

nurses to come to work in this hospital without a BSN degree because of patient safety’

(SN1) may actually hinder workforce planning in the short term. This attitude may alienate

experienced diploma-educated nurses in favour of recent graduates with academic abilities,

but who also lack the nursing experience which ultimately may impact on patient care and

safety, thus defeating the object of the degree programme. Furthermore, if

professionalization of nursing as a career increases the number of people wishing to take

up the degree and increases competition for courses in government universities, a higher

number of students may opt to go to private institutions (Ahmad, 2012). As previously

discussed, there is a concern that graduates from private institutions are not sufficiently

competent. This may affect the workforce, as there may be a high number of unemployed

graduates because their degrees are not valued due to the belief that undertaking a degree

at a private institution is similar to a diploma, with new students not having the experience.

One very important theme to emerge which is likely to have a significant impact on

nursing workforce mobilisation and organisation was the belief at the meso level that

diploma- educated nurses had fewer skills and could be placed to work in the community

or Primary Health Centres. Degree-educated nurses were considered overeducated for this

environment and more suited to work in hospitals. In contrast, participants working at the

micro level did not raise this issue, perhaps indicating there was less hierarchical thinking

within this group of participants. This type of thinking at the meso level is indicative of a

top-down process and can affect policies, which ultimately affect the (Meerabeau et al.,

2004). This may be a step backwards as the healthcare needs are changing in the Middle

East (Shuriquie et al., 2008), with healthcare moving from hospitals to the community. It is

envisaged that this move will allow the delivery of a service that is geared towards

preventative medicine, early treatment, healthcare education and lifestyle changes,

especially as longevity in the overall population increases (WHO, 2009; Almalki et al.,

2011; MoH, 2014) . There are plans in SA to implement more PHC policies, which should

help make healthcare more cost-effective (Jadelhack 2012). The change is also in response

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to the increase in non-communicable diseases which account for around 71% of deaths in

SA (Mahmoud & Faramawi, 2015), and thus the face of PHC is changing and needs

appropriate action (Almalki, 2012). If people working at the meso and macro levels

continue to believe the more educated and better skilled nurses should work in the

hospitals, the success of delivering contemporary healthcare within the community will be

compromised.

The idea that degree-educated nurses would be a waste of resources if placed in the

community undermines the value of community nursing and its importance in quality

healthcare delivery. Furthermore, moving diploma educated nurses from the hospital and

confining them to the community, because it is seen as a role of lower responsibility,

undermines all their previous contribution and hard work and will create resentment,

which has been shown to affect staff retention (Schwendimann, 2015).

At the micro level, many participants believed that there was not much difference in the

jobs that diploma and degree educated nurses perform. Creating job descriptions that limit

the practice of degree-educated nurses may actually affect the workforce negatively,

especially as there is a belief at the micro level that the care they provide is the same

despite the difference in education. This emphasises support the importance of job roles,

job description, and role demarcation.

7.7 Summary and Conclusion

In summary, this chapter has been derived from the common themes revealed from the

data presented in the macro, meso and micro levels and has identified several areas where

workforce planning and mobilisation could be affected by the mandatory degree policy.

The following conclusions are derived from the common themes revealed from the cross-

group analysis of the three levels of data collection: The degree and its role in healthcare

quality; career and healthcare development; nursing education and bridging programmes;

and workforce organisation and mobilisation.

A degree education should help propel the Saudi nursing workforce on to a global

platform, enabling mobilisation in the GCC and globally. However, in the process of

training the new generation of degree-educated nurses, it is important to take full

advantage of the availability of diploma-educated experienced nurses. These diploma-

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educated nurses have helped develop the healthcare system gain its current status and

should continue to play an important role in the future of healthcare delivery rather than

being excluded out of the workforce. This is recognised at the micro level, but also needs

recognition at the macro and meso levels of nursing.

The following chapter will present the conclusion of this thesis. The research strengths and

limitations of the study will be acknowledged. Following on from this I will identify the

original contribution this thesis makes to existing nursing knowledge and its potential

influence on workforce planning. The chapter will provide recommendations that will

underpin the future development of a five-year SA National Nursing Strategy for Future

Workforce Planning. Finally, the researcher reflects upon the research process to provide

key lessons for future research.

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Chapter 8 : Conclusion and Recommendations to underpin Future Workforce Planning Initiatives in

8.1 Introduction

The previous chapter presented the result of data collected and analysed from participants

working at the macro, meso, and micro levels. The chapter included an integrated critique

across three levels of analysis and this was followed by a discussion based on the findings

of this study and those of the studies critiqued within chapter 3, the literature review. This

concluding chapter is the final chapter of this thesis and is related to the objective:

 To critically analyse the data and make recommendations that will underpin the

future development of a five-year SA National Nursing Strategy for Future

Workforce Planning.

The chapter begins by presenting the strengths and limitations of the study, followed by its

unique contribution to existing knowledge. The major recommendations derived from the

findings of this study for future nursing workforce planning and development in SA are

then highlighted. Finally, the researcher reflects upon the research process and provides

key lessons for future researchers.

8.2 Strengths and Limitations of the Study

This study has many strengths: the nature of the study and its uniqueness in taking account

of the three levels of the MoH (macro/national, meso/regional, and micro/local); the period

of the study aligning with current changes in SA; and the triangulation of data against the

backdrop of an extensive literature review of the history of nursing education and

contemporary trends. All of these aspects have facilitated putting this into context.

This unique study provides a national vision for Saudi workforce planning and

development that reflects the vision of different decision makers and practice nurses in the

field; from the macro, meso and micro levelsl. Furthermore, the perceptions at all three

levels are explored through the current policy of degree education. This study also

investigated the research question within the context of the political, social, and cultural

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background of SA. It also illustrates how the Saudi healthcare system addresses the

international and the GCC requirements and standards. The study coincided with an

important period of time that witnessed many challenges and changes in both the MoH and

the education system in SA, such as the closing of all diploma programmes for nursing.

The findings of this study have contributed new knowledge to the understanding of degree

education and its influence on workforce planning and development.

However, limitations within the study design may restrict the findings to the Saudi

contexts. Case study methodology has been criticised for a lack of transferability, as, by

definition, the uniqueness of the case is often bound by location and time, but also because

a small sample cannot represent a whole population (Merriam, 2009). The utility and

transferability of findings from qualitative case studies should therefore be judged by

criteria congruent with the philosophical values of research. By its very nature, a case

study is an in-depth examination of small samples of events, programmes, people, or

circumstances, with the sample being selected for originality or uniqueness and not for its

representativeness of the target population. As such, the research aim is to study the

sample intensely and thoroughly, to gain better understanding of the phenomenon within a

given context. Yin (2009) argues that a unique case can also be a single example of a

broader class of things. This study did not intend to generate findings that would be

statistically generalizable, but rather sought to provide naturalistic generalisation as

described by (Stake, 2003). However, in-depth description of each level of people working

within the MoH has been provided, together with pertinent documentary analysis, to

enable the readers to draw their own conclusions regarding this case study.

8.3 The research contribution

This thesis has explored and assessed the implications of introducing a nursing degree as a

minimum requirement for qualified nurses in SA. The current study was undertaken

because there is not an established evidence base to consider the implications of degree-

educated nurses in terms of future workforce planning, quality of nursing care and patient

experience. Whilst other developed countries have recommended degree education for all

nurses, in SA, this policy was implemented by the MoH in 2010, with arguably insufficient

planning and no body of evidence regarding the implications of this policy. In light of this,

the findings presented in this thesis provides an unique original contribution by providing

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valuable evidence regarding the implications of Bachelor degree nursing education in SA,

as a baseline from which to develop a national nursing strategy for future workforce

planning and development. This study will contribute to nursing knowledge and workforce

planning in several ways:

 The papers reviewed explored education attainment and its relationship to Saudi

health outcomes (Al-Ahmadi, 2014; Alyasin & Douglas, 2014; Aiken et al., 2014;

Majeed, 2014; Almutairi et al., 2015). There is currently little consideration of

Saudi workforce policy and planning, and implications following the introduction

of degree education as a minimum requirement for nurses.

 Whilst the papers reviewed give a local or regional prospective on the nursing

workforce (Aldossary et al., 2008; Gazzaz, 2009; Almalki et al., 2011; Almalki,

2012; Al-Homayan et al. 2013; AlYami & Watson, 2014; Alyasin & Douglas, 2014;

AlMakhaita et al., 2014; Lamadah & Sayed, 2014), they are small scale studies.

While such research is required to describe and understand the nursing situation.

 This study is the first within the MoH to adopt a consultative approach that

involves key nursing and policy stakeholders at the macro, meso and micro levels

of nursing. In addition, this case study methodology will contribute to the

development of knowledge and understanding about the process of policy

implementation; and stakeholder involvement in developing strategic policies. It is

anticipated that the case study design could be used in other areas of policy

development. The involvement of different stakeholders across the sectors,

Government bodies who are responsible for economic and social policy through to

those delivering care, would facilitate ownership of the plan. This comprehensive

integration of stakeholders will ensure every aspect of the planning is covered and

arranged for nursing future workforce planning and development of a national

strategy in SA.

 The majority of studies conducted in different countries regarding similar or related

topics used the quantitative method. Only one study used mixed methods. This

study will be the first study exploring the implication of degree nurse education by

using the qualitative approach that is giving voice to those that are actively

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involved in the new policy of degree level education being a requirement for all

nurses in SA. This study builds on this evidence and in doing so is in a position to

proposev national strategies and recommendations for workforce planning. The

outcome will be a series of action plans that underpin future evidence-based

workforce requirements.



8.4 Recommendations

This section provides the recommendations from the data identified within this study. It

will start first by presenting the participants’ recommendations at each level of the

organisation, followed by the overall recommendations from all levels together with three

key messages.

The macro level participants’ main recommendations for improvement of nursing care

were:

 Implementation of differentiated nursing job descriptions, based on educational

level.

 The need for adequate supervision, follow-up and accountability for the nursing

workforce.

Participants working at the meso level provided recommendations for improvement of

nursing care:

 Validate the requirement for Bachelor’s level education for all nurses to ensure

training and education that is appropriate and necessary for nursing staff.

 Nurses who are educated to degree level are thought more likely to be able to

promote public awareness about the use of primary healthcare centres, thus

taking the pressure off hospitals.

 It was specifically noted that the regulations are not enforced in the private

sector, implying the need for more standardisation of national regulations.

 To bridge the gender gap through expansion and/or addition of nursing colleges

offering Bachelor degrees for males to increase the education level among this

group of nurses.

Finally, participants working at the micro level offered their recommendations with regard

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to the issue of standards for nursing education. Three major recommendations emerged

from this data supported:

 The creation of job descriptions for nurses that better reflect their level of

education. This is necessary to address the nursing shortage, which was felt to

necessitate a tolerance for lesser qualifications.

 Recommendation for a focus on the quality of education to produce quality

nurses, rather than increasing the number of nursing colleges or increasing the

number of nursing graduates with poor levels of knowledge and/or skills.

 Support for the creation of education opportunities for Diploma holders to join

bridging programmes for conversion to degrees without any obstacles, which

will expand the supply of degree nurses.

Overall, the recommendations suggest two levels of job description, one focusing on the

Bachelor degree nurses and the other on Diploma nurses. The quality of education was

also seen as important for the future nursing workforce development. Furthermore, the

Diploma nurses called for the provision of opportunities for bridging programmes and the

removal of the obstacles hindering their access to and completion of their studies. The

recommendation is to enhance the status of nursing in SA to make it a worthwhile career

and this has to be tackled by first dealing with some of the existing social stigma evident in

SA (Gazzaz, 2009). The Saudi government needs to use the media to help engage with

people and promote a positive image of the nursing profession to help with the shortfall in

the local workforce (Almalki et al., 2011).

Universities need to improve their curricula in order to cope with the changing and

evolving needs of the nursing profession and the people for whom they provide care. This

needs to be reinforced at the macro level by standardisation of a national curriculum, as the

current disparity for the preparation of professional nurses is also a factor affecting the

outcomes of providing quality care. The major nursing strategists need to focus on

combining knowledge with skills training to benefit the nursing profession and to improve

its conditions.

The studies of Park et al. (2007); Ross & Bell (2009); and Spetz and Bates (2013) could be

used when supporting nurses with Diploma in Saudi Arabia who are planning to achieve

advanced degrees. Offering tuition reimbursement for BSN and graduate-level education

236

without any obstacles might help increase the nursing education level in Saudi Arabia.

Since baccalaureate education and Master’s degrees are likely to confer benefits to both

patients and nurses, policies that encourage nurses in Saudi Arabia to pursue further

education should be supported. Saudi Arabia’s healthcare system should also consider the

accessibility of colleges offering baccalaureate degrees or Master’s degree programmes.

Proximity to these educational institutions might increase the total number of nurses with

BSN or advanced degrees.

The Cross-level Recommendations: Three Major Key Messages:

Key Message 1

The Gulf countries have a wealth of information from the global nursing field to refer to in

order to develop their own healthcare system and manage their workforce to make it fit for

the 21st century (WHO, 2009). In future, the GCC nursing committee needs to assess the

opportunity for looking at countries that have already implemented the policy of making

degree level education a minimum requirement for nursing and working with the outcomes

of this to shape their policy. To date, the policy has been implemented directly in a top-

down manner, with people at the meso and micro levels not being involved. In future

policy decisions need to take account of this and involvement from the bottom up should

be standard practice. Additionally, when introducing a new way of working, there should

be an inbuilt pilot study and/or evaluation capturing the challenges and strengths of the

project, thus enabling appropriate action to be taken.

Key Message 2

Diploma nurses and funding for healthcare fall under the authority of the MoH and nurse

education comes under the MOHE. In order to bridge the gap, there needs to be better

communication and links between the two organisations (MoH and the MoHE); or the

policy needs to be transferred to one of the two for coherence, for example the MoHE. In

Switzerland, due to the two main different linguistic communities, the nursing education

model has taken two separate pathways with high variability and inconsistency between

them (Spitzer & Perrenoud, 2007), defeating the goals of organisations such as the WHO

237

and the International Council of Nurses (ICN) in trying to standardise nursing education

globally. SA could learn from the Swiss example in bettering its own nursing education

system by merger or even the creation of a new department to help drive the initiative. In

fact, there is acknowledgement of nursing power in theory, yet even with a degree

education, nurses might lack the means to change and adapt and use their skill set –

possibly, but not exclusively, to the context of the current Saudi health system outlined in

Chapter one, and possibly to do with the theories of managing change in any setting.

Achieving this is dependent on having a robust, standardised curriculum, a faculty that can

deliver education at the right level, and clinical settings that facilitate nurses putting their

learning into practice. The nursing workforce in SA needs strong strategy and national

planning

“to ensure the presence of the right nurse with the right qualification in the right

role, at the right time, in the right place with the proper authority and appropriate

recognition” (Affara & Styles, 1992:P .18).

Key Message 3

Professional development within nursing should be reinforced by evidence, within the

context of a national nursing strategy. The debate about the comparative value of

generalist and specialist nurses is a distraction from the need to support professional

nursing development and effective leadership programmes. This needs to be taken

seriously by the key government bodies in the context of implementation for change and to

address the recommendation for future workforce planning and development. Nurses must

be positive and active in negotiating the limitations of the health services they provide,

recognising the potential contribution of themselves and other healthcare professionals.

All of these recommendation and keys messages will inform the development of a five-

year national nursing workforce plan in Saudi Arabia. The findings of this thesis will

disseminated through the following dissemination plan.

8.5 Dissemination Plan

This thesis has critically analysed the degree education policy as a minimum requirement

for professional nurses to enter practice in SA. The findings will be disseminated through

238

the following steps:

 The recommendations from this study will be submitted to the policy makers in

the governmental bodies in order to implement the national nursing workforce

plan, including improving nursing competencies and considering the future role

of nursing at different levels. The researcher will request a meeting with the

deputy minister and other decision makers, including the general director of

nursing in the MoH in order to discuss the results of this study and to consider

how they can be translated into monthly action plans for the nursing workforce.

 A copy of the results and recommendations will be sent to the key Saudi

government departments such as the MoH, MoHE, SCHS in order to raise

awareness of nurses and other healthcare providers about the value of degree

nurses in the Saudi community.

 An oral presentation with a brief description of the study and its results will be

given to the regional nursing directors during their annual meeting.

 A publication about workforce planning and developments for nursing in SA in

professional peer-reviewed national and global journals, such as the Journal of

Nursing Education (global level) and Journal of Health Specialties (national

level); the latter being the official publication of the Saudi Commission for

Health Specialties (SCFHS).

 Publications: “Using case studies to explore the influences of nursing degree

education on the nursing workforce in SA”; “Degree education as an entry

requirement for qualified nurses in SA: a policy analysis”; and “The perception

of micro level nurses about Bachelor degree as a minimum requirement for

professional nursing practice in SA” will be submitted to the PubMed Journal,

which is a peer-reviewed international journal and has literature from

MEDLINE, life science journals, and online books.

 The findings of this study will be available on the PhD resource website of

University of Salford Library in the UK.

 Participation in international conferences to present the findings of this study;

for example, conferences organised by WHO, ICN, ANA, and NHS.

 Participation in national and local conferences in different cities within SA and

future working groups for regional impact.

239

 An official nursing committee will be established by the General Directorate of

Nursing with seminars being delivered on a quarterly basis in order to provide

up-to-date information regarding job descriptions and nursing roles and to

follow up the degree nurses’ performance in hospitals and PHCs.

 Adding a couple of post doctoral studies – patients’ perspective of the degree level

nurse in SA.

8.6 Personal Reflection on the research process

Being a decision maker at the MoH and a member of the GCC Nursing technical

committee, and now a PhD candidate, has supported my role on my PhD journey. I

became president of the Saudi Society at the University of Salford and I worked as a

volunteer at different social and educational activities such as the Saudi national day,

which helped me to build a good academic communication network. However, studying

abroad in a western country with a different language was inspirational, as I completed my

Master’s degree in the US. Adaption to the weather and environment in the UK was a

significant change in my life. Living with my family in Manchester was a motivating

factor as it provided me with support for my future during the process of my PhD. On the

other hand, it was stressful as my sons are teenagers and I struggled to combine study with

family commitments. I have undertaken this research independently, and have regularly

engaged with my supervisors, colleagues and post-graduate research students to discuss

the research process and to receive their feedback and comments about all phases of the

study, including my role and position. In order to make a clear audit trail of decisions made

throughout this study, I have maintained a reflective diary throughout the research process,

recording a range of activities, such as field notes and schedules, areas of concern and

interest, tutorials, and the rationale for any decisions (Appendix 5. 14) as suggested by

Alvesson & Skoldberg (2009). My multiple roles in this research process have included

researcher, interviewer, interpreter, moderator and facilitator, and my previous roles as a

senior nurse, decision maker, policy maker and successful student nurse must also be

acknowledged. Accordingly, my own characteristics, experience, skills, understandings,

values and motivation have influenced this study. In particular, I was aware of my ‘insider’

researcher role as moderator within the macro, meso and micro levels of data collection

and analysis. I am an experienced interviewer, having been involved in nursing recruitment

throughout my career as a nurse director in the MoH for the past 20 years. My experience

240

as an interviewer facilitated many aspects of the data collection process, such as familiarity

with building interpersonal relationships, confidence in organising the fieldwork needed

for this study, accessing the documents and discerning which were pertinent, and

contacting the participants from different levels.

Researcher motivation is a vital part of the research process (Alvesson & Skoldberg 2009).

Although a relatively inexperienced researcher, I have been highly motivated to undertake

this research and have brought specific skills, knowledge, and experience to my role as a

researcher. As stated in the introduction, the initial idea for this research originated from

my background experience with responsibility for workforce planning and development. I

also had responsibility for contributing to the nursing strategic plan by ensuring that

potential nurses were successful in undertaking bridging programmes. Although originally

driven by issues relating to the minimum requirement criteria for Diploma nurses and the

shortage of staff, it became apparent early in the research process that the findings would

not be limited to aspects of nursing education and practice, but would offer new insights

into other aspects of workforce planning and development, such as the quality of care.

Additionally, I am a highly organised person who completes tasks thoroughly with a high

degree of honesty. This ability to manage complex responsibilities, manage large volumes

of data, and act with honesty and integrity has stood me in good stead to complete this

study to a high standard.

8.7 Summary and Conclusion

The need to reform nursing education as the world entered the 21st century drove the

global impetus to reassess old policies and standardise education powered by the diversity

of nursing roles and the migration of nurses from one country to another. The trends

followed so that as one country made it mandatory to make a degree in nursing the

minimum requirement, soon after others followed. One of the main reasons for this shift

can be attributed to many researchers demonstrating that education of nurses was directly

linked to quality of patient care (Section 2.4). In the Middle East, including GCC

Countries, there is a great shortage of nurses, with the majority of the workforce being

foreigners. In light of this, Middle East countries need to participate in the global nursing

arena, by being seen to provide the same level of care. Gulf countries such as Saudi Arabia

241

have also recently implemented the policy of degree education as a minimum requirement

to entry into nursing practice following trends in developed countries.

The future of access to PHC and nursing education will depend on increasing the number

of the BSN nurses. Achieving this goal will help the Saudi health system to meet patients’

future needs and demands; and improve the future nursing workforce. There is clearly a

need for an improvement in future workforce planning and development in nursing

practice in SA. Major changes in the Saudi healthcare system will require profound

changes in education and practice for nurses before and after they receive their licences.

Appropriate professional education and providing adequate job facilities to nursing staff is

required in order to bring improvements. The universities need to improve their

curriculums in order to cope with the changing and evolving needs of the nursing

profession. The nursing staff promotional hierarchy should be revisited and improved as

that is also a factor affecting the lack of professional nurses. The major nursing strategists

have put their focus into combining knowledge with training to benefit the nursing

profession and to improve its conditions. The issues of nursing staff, like lack of

promotion, need to be carefully considered and resolved. On the job training and education

should be provided in order to keep them up to date with the latest in health technology

and develop their skills as part of their continuing professional development. These form

the backbone of the healthcare sector, and their betterment is an imperative. Degree nurses

will be able to provide the required level of health care and a level of professionalism that

is necessary in providing quality health care

In conclusion, this chapter has highlighted the contribution of this study to existing

knowledge regarding nursing practice, education and policy. It provides recommendations

for policy makers in the key governments bodies (MoH, MoHE, SCHS and MCS). The

recommendations based on the findings of this research highlight the importance of the

differentiation of distinct nursing job descriptions based on the education level attained

together with a focus on improving the quality of patient care through education,

validation and regulation of the standardization of BSN curriculum, together with adequate

supervision. In addition, the dissemination plan for the results is explicated, as well as

some of my own reflections on the research process.

242

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254

List of Appendices

1. Appendix 4.1: The process of obtaining permission to access the facilities of MoH.

2. Appendix 4.2: The ethical approval from the University of Salford.

3. Appendix 4.3: The ethical approval from the Ministry of Health and its hospitals.

4. Appendix 5.1: Participant’s Information Sheet (PIS): For macro level of

administration.

5. Appendix 5.2: Research Participant Consent Form for macro level of

administration in the MoH.

6. Appendix 5.3: The template page for transcript data.

7. Appendix 5.4: Example of categorisation of the data by NVivo at the micro level.

8. Appendix 5.5: Sample of transcript for one-to-one interview and focus group.

9. Appendix 5.6: Participant’s information sheet: For (Meso level) Nursing Regional

Director.

10. Appendix 5.7: Research Participant Consent Form for the (Meso level) Nursing

Regional Director.

11. Appendix 5.8: Structure and guidelines for focus group interviews.

12. Appendix 5.9: Qualitative interview questions guide.

13. Appendix 5.10: Interview questions guidelines.

14. Appendix 5.11: Participant’s information sheet (PIS) for nurses from King Saud

Medical City (Micro level).

15. Appendix 5.12: Research Participant Consent Form for the nurses from King Saud

Medical City (Micro level).

16. Appendix 5.13: Poster for invitation for staff nurses at KSMC.

17. Appendix 5.14: Sample of Reflexive Journal.

255

Appendix 4.1

The process of obtaining permission to access the facilities of MOH

MOH

Ethical Approval + Intro ductory Letter from

Saudi Cultural Attaché +Salford Universi ty

Ethical Approval

Ethical committee to review Research

Proposal

All Documents

Ready?

Proposal reviewed by

MOH

Hospital Director of

Nursing

Regional Director of

Nursing Ethical

Permission

General Director of Nursing

Yes

Delivered Research proposal

256

Appendix 4.2

Ethical approval from Salford Universdity

257

Appendix 4.3

The ethical approval to collect the data from the MoH

258

259

260

Appendix 5.1

Participant’s Information Sheet (PIS): For macro level of administration

Study title: (The Implications of Nursing Degree Education for Future Workforce

Planning in Saudi Arabia: A Case Study).

I am currently completing a research study for my PhD in Nursing at the University of

Salford. I would like to invite you to be part of this research study. Ethical approval has

been obtained from the University of Salford and it is important that you understand both

the purpose of the research and your role as a participant. Please ask any questions if any

part of the information is unclear to you. Finally, it is your decision whether or not to be

part of the study and you may withdraw at any time.

What is the purpose of the study?

This research seeks to investigate the extent of your knowledge regarding workforce

planning and development as a consequence of the introduction of degree entry pre-

registration nurse education.

Why have I been invited?

The main reason for including you in this research is because you have a high level of

knowledge and experience about nursing workforce and entry requirement for qualified

nurses in Saudi Arabia.

Do I have to take part?

It is your choice as to whether you want to participate in this study. This information sheet

will provide details to help you make this decision and you can contact me if you have any

question about the research. If you agree to be part of the study, you will be asked to sign a

consent form. You are free to withdraw at any point while taking part in the study.

What will happen to me if I take part?

 You will be asked for consent to attend a face to face tape recorded interview.

 The face to face interview is intended to explore your knowledge and experience about

the nursing workforce and entry requirement for qualified nurses in Saudi Arabia. You

may also be asked to explain your answers in detail.

261

 The length of the interview will differ depending on the details you would like to offer

in response to the questions asked. However, the interview will take approximately 30-

60 minutes.

 The interview will be held in a quiet and private place in the Ministry of Health during

working hours.

 The interview will be a confidential and stored safely. The study will have two forms

of data, a hard copy, and soft copy. Hard copy data will be kept in a locked locker and

no one will be authorized to use it except the researcher. The soft copy data will be

secured in a password protected external hard disk and will be connected only to

researcher private laptop, only the researcher can access the saved study data. Your

identity will be kept secure by the researcher.

Expenses and payments?

The Ministry of Health will cover any expenses for this research.

What are the possible disadvantages and risks of taking part?

There are no personal risks associated with participation in the study

What are the possible benefits of taking part?

I cannot promise the study will help you but the information I obtain from the study is

intended to help determine future workforce planning and development needs as a

consequence of the introduction of degree entry pre-registration nurse education in Saudi

Arabia.

What if there is a problem?

If you would like to complain about any aspect of the interview, please contact the first

supervisor Dr. Nancy Smith or Dr Karen Staniland in the first instance, or the University of

Salford College of Health and Social Care Research and Innovation Manager –

Dr Nancy Smith [email protected] School of Nursing, Midwifery, Social

Work & Social Sciences Dr Karen Staniland [email protected]

Will my taking part in the study be kept confidential?

The information that you provide will be confidential. No names will appear in the study.

Your identity and personal contact details will be known only to the researcher, the

research assistants, and the research supervisors at the University of Salford. The

mailto:[email protected]

262

researcher will not use your name or any information that could reveal their identity in this

or any future research study, publication, conference presentation or teaching session.

Storage and destruction of data will conform to the Data Protection Act (1998). Any

information about you which leaves the Ministry of Health will have your name and

address removed so that you cannot be recognised.

What will happen if I don’t carry on with the study?

You have the right to withdraw from the study at any point without prejudice and this will

not affect your care in any way. If you withdraw from the study all the information and

data collected from you will be destroyed and your name removed from all the study files.

What will happen to the results of the research study?

The results will be published in a PhD thesis and parts of the study may be published in

health care journals and/or presented at conferences. You have the right to ask for the

results if needed and the choice of seeing the completed transcript following interview.

Who is organising or sponsoring the research?

The University of Salford and Ministry of Health

If there are any further questions regarding this study, you can contact me (by

phone or email) or my supervisors (by email) as follows. If you prefer, we can arrange to

discuss this invitation, face to face, at a mutually convenient place and time.

Thank you for giving your valuable time in reading this letter

Contact Details

Researcher

 Noura Almadani, PhD candidate, School of Nursing, Midwifery, Social Work &

Social Sciences, University of Salford, Salford, Greater Manchester, United

Kingdom, M6 6PU. Tel: +447462662646 or at [email protected],

Supervisors

 Dr Nancy Smith at [email protected]

 Dr Karen Staniland [email protected]

mailto:[email protected]

263

Appendix 5.2

Research Participant Consent Form for macro level of administration in the MoH

Title of Project: The Implications of Nursing Degree Education for Future Workforce

Planning in Saudi Arabia: A Case Study.

Ethics Ref No: HSCR14/119 Name of Researcher: Noura Almadani

 I confirm that I have read and understood the information sheet for the

above study and what my contribution will be.

Yes

 I have been given the opportunity to ask questions through the use of

an interview guide

Yes

 I agree to take part in the interview Yes

 I agree to the interview being tape recorded

Yes

 I understand that my participation is voluntary and that I can withdraw from the research at any time without giving any reason

Yes

 I understand how the researcher will use my responses, who will see

them and how the data will be stored.

Yes

 I agree to take part in the above study

Yes

Name of participant (print) …………………………………………………………………

Signature …………………………………………………………………

Date ……………………………….

Name of researcher taking consent Noura Almadani Researcher’s e-mail address

n.almadani @ edu.salford.ac.uk

264

Appendix 5.3

The template page for transcript data

Level name:

Date:

Time:

Number of participants:

Given code for interviewee (participant):

Given code for interviewer (researcher):

Questions Answer Researcher note

Q1:

265

Appendix 5.4 Example of categorisation of the data by NVivo at the micro

level.

MICRO LEVEL 0 0 8/28/2015 3:39 PM

Demographic information 0 15 8/28/2015 3:40 PM

Methods or educational pathway to nursing 0 0 8/28/2015 3:41 PM

national board licence exam 2 2 8/28/2015 5:36 PM

diploma or Bachelor’s 0 0 8/28/2015 5:36 PM

Bachelor’s degree 2 5 8/28/2015 5:37 PM

governmental college 1 1 8/28/2015 3:42 PM

health institute 1 1 8/28/2015 3:43 PM

private college 1 2 8/28/2015 3:44 PM

college diploma 1 1 8/28/2015 5:40 PM

Difference between diploma and high diploma 0 0 8/28/2015 3:51 PM

Duration 1 1 8/28/2015 3:51 PM

Salary 1 1 8/28/2015 3:51 PM

Same or different license exam 0 0 8/28/2015 3:55 PM

Curriculum 1 6 8/28/2015 3:55 PM

Minimum degree that should be acquired 0 0 8/28/2015 3:56 PM

Dependent on individual qualities 3 9 8/28/2015 3:57 PM

general knowledge 3 3 8/28/2015 4:02 PM

Languages 3 6 8/28/2015 4:02 PM

ethics and commitment 2 3 8/28/2015 4:02 PM

interest or passion 2 4 8/28/2015 4:03 PM

Practice 1 1 8/28/2015 4:02 PM

specific skill sets 1 1 8/28/2015 4:02 PM

Bachelor's 3 7 8/28/2015 5:40 PM

HS diploma 2 0 8/28/2015 3:56 PM

Factors that influence degree levels 0 0 8/28/2015 4:05 PM

social influences and pressures 3 4 8/28/2015 6:24 PM

family pressures 1 2 8/28/2015 6:24 PM

Respect 1 1 8/28/2015 9:10 PM

individual commitment and focus 2 5 8/28/2015 6:00 PM

related to social culture 1 1 8/28/2015 6:01 PM

problems with quality of private universities 2 4 8/28/2015 6:26 PM

attaining financial security or getting promotions 2 5 8/28/2015 7:46 PM

completing the study 1 5 8/28/2015 4:05 PM

governments need stricter rules 1 1 8/28/2015 6:25 PM

Bachelor's degree 1 1 8/28/2015 6:27 PM

differences in licensure 1 1 8/28/2015 6:30 PM

responsibility to patients 1 1 8/28/2015 7:44 PM

ability to advance education 1 2 8/28/2015 9:03 PM

Benefit gained from Bachelor's degree 0 0 8/28/2015 4:12 PM

Greater knowledge base 4 11 8/28/2015 4:17 PM

Improved communication 2 2 8/28/2015 4:18 PM

Improved skillsets 2 2 8/28/2015 4:21 PM

More advancement opportunities 2 4 8/28/2015 4:28 PM

266

Some problems with absenteeism 2 5 8/28/2015 6:50 PM

Better prepared for work environment 1 2 8/28/2015 6:52 PM

Increased patient safety 1 2 8/28/2015 7:40 PM

Importance of experience versus education 0 0 8/28/2015 4:35 PM

Both 2 3 8/28/2015 4:45 PM

Education 2 4 8/28/2015 4:45 PM

Experience 2 3 8/28/2015 4:45 PM

Minimum requirement for entry level to be elevated to

BSN level

0 0 8/28/2015 4:48 PM

Mistakes from diploma 2 6 8/28/2015 4:48 PM

Constant self-improvement 2 4 8/28/2015 4:51 PM

More comprehensive information 1 1 8/28/2015 4:49 PM

Ability to deal with emergencies and critical cases 1 2 8/28/2015 4:50 PM

More benefit from lectures 1 1 8/28/2015 4:50 PM

Quicker registration 1 2 8/28/2015 9:07 PM

Both can benefit from the others 1 1 8/28/2015 9:11 PM

Need for educational advancement 1 3 8/28/2015 9:12 PM

Qualities of ideal nursing candidate 0 0 8/28/2015 5:10 PM

267

Appendix 5.5

Sample of transcripts for one-to-one interview and focus group

Level name: Macro level /Face-to-face interview number 4

Date: Time: 10:00am -10:45am

Total number of participants: 4

Given code for interviewee (participant): GD4

Given code for interviewer (researcher): N

The highlighted areas are the exact quotation used in the main thesis.

Questions Answer Researcher

note

Q1 Hi Good

Morning. Is the

information that I

sent to you about my

study is clear, and do

you have any

questions before we

start?

Can you introduce

yourself e and your

background

experience in

nursing?

GD4 Good morning. Everything was clear thank you to send

me the information prior the interview. This is GD4. aaa I

have a master’s degree in Nursing. ummm I have a long

experience in working, almost about thirty years working. I

work under the MOH this time……[Data removed for

anonymity]

This question

used to get

people talking

and feeling

comfortable.

Q2 In your opinion,

what is the minimum

degree that should be

required for entry-

level practice as a

registered nurse?

GD4 Bachelor degree is should the minimum requirement.

You will end with better quality of patient care, giving care,

another many benefits that we found as the reference said. And

this is what we found from our work. And we know that our

hospital and the medical services in Saudi Arabia is getting

better and better. And We have new technologies coming that

require nurses well-equipped with knowledge and skills, so

with the Diploma level it is difficult to meet this. The

community also needs well-experienced nurses. People now

are changing with all these technologies around us. People can

easily search for their disease; what kind of care you are giving

them and what care they need. Patients are very smart now and

the nurse needs to be smarter. And more skill is needed to give

the right care to the patients. We care about the quality of care.

Quality care needs to be given to patients. The diploma cannot

give this quality care. Our Diploma [nurses] have fewer years

of studying their language, not up to the extent allowing them

to read and search for references. They are not at the level to

communicate with the doctors. And they do not have the full

confidence in language and communication skills. We feel that

the bachelor’s degree should be the minimum requirement

This question

used to get the

participant to

start thinking

about the topic

at hand.

Q3 With this new

policy of the

GD4 Ok, the level of entry to be bachelor’s degree it was

agreed by the GCC countries, it is the recommendation of the

These questions

provide a link

268

minimum

requirement of BSN

as the level of

entry…Do you think

it is necessary to

close the diploma

nursing, and are the

nursing mangers are

involved in the

decision making of

this policy?

WHO, which we take into consideration. Yes it was the

nursing leaders who take the decision in the GCC countries

and agreed by all ministry of health in GCC countries. To close

all diploma nursing school is different in every GCC country

because each country have their own situation and they have

different number of nationals going from country to country.

For Saudi Arabia we decide to close the diploma level because

we have many governmental university started with the

nursing school, we have 28 governmental universities and they

have nursing all. So we have a good space to occupy nurses.

This is only governmental and if you go to private now we

have more than 42 and some are going to start around the

kingdom and you can have nursing program each. So when we

close the diploma this will not affect how many nurses will be

graduated. We just made it better from diploma level to

bachelor level

Can you explain to me the outcomes of Nursing colleges in

SA? and What is the differences between the governmental

and private colleges?

GD4 Bachelor level, I cannot say up to now…I have met some

of these graduates and they are really doing good. They are

doing quite well. The one who graduated from the

governmental and private colleges in BSN level. For the

private colleges because they are still new, we can’t really

evaluate their performance. For the governmental colleges we

have three old colleges, their graduates are really good

graduates, good outcomes. For the rest of the colleges they are

still new, they just started. Of course they do not have the same

curriculum but of the same standard. Like certain hours for the

theory and for the practical but then every college is different

as anywhere in the world. The basics are the same, this is what

we care about it.

Do they have the same curriculum?

GD4 No of course they do not have the same curriculum but of

the same standard. Like certain hours for the theory and for the

practical they do not have to take less than that. But then every

college is different as anywhere in the world. They have

something extra here and something extra there. The basic are

the same this is what we care about.

Is there any direct supervision from the General

Directorate of Nursing?

GD4 No, we are not dealing with education because we deal

with the services. For education it with the Ministry of higher

education so they are the ones dealing with them supervising

all colleges and universities, all the nursing program and other

different programs. We only share with them. Most of the, mot

most, I can say some of our directorate in different region.

Because we have this regional directorate in Riyadh Region

We have 20 other offices in the kingdom, some of the heads of

these offices are members of the committee in the university,

consulting committee in the university so they are giving their

opinion and consulting with them in whatever is needed for the

nursing education

between the

introductory

questions and

the key

Q5 What the benefits GD4 This is what I said previously, that we are going to have a These questions

269

that can be gained by

requiring BSN as the

entry level practice

for qualified nurse?

better outcome, better care. People feel satisfied when they

have the necessary care.

After you close the diploma programme. Do you think the

Job description will remains the same or what?

Of course there should be a difference in job description of

diploma level and bachelor level and there is a competency for

each level. There is a job description for each level. But

believe me this is not what is happening in the real situation

right now. Why, because we do not have enough number of

bachelor’s degree graduates. It is not applicable at this time.

Yes in some other hospital not in MOH it is applicable and

they are working on that because they have enough bachelors

degree. For us it is a bit early now but it’s ready to be applied

whenever we get the right number. At the moment we stop

taking recruiting nurses from outside unless they are BSN

graduates with a certain experience depending on the country

where they graduate from as a requirement of the Saudi

Commission here. For the meantime we carry on the same until

further application for that when it is suitable.

Since the current work force is mostly diploma holder.

What do you think is the good solution to elevate their

degree level?

GD4 We have a plan for all those diploma holder. Before we

are sending them for bridging program all universities in the

world. But right now we have a national programme. We have

13 nursing bridging programmes for males and 17 for females.

So we have quite a good number of bridging programmes. We

have a plan to send our staff to get their BSN degree. It is

going quite well. But we need quite a lot of time to cover all

those …we have quite a number of Diploma nurses, we are not

in a hurry. This is happening through the world. We are on the

right track. Inshallah, hopefully we can finalise all those.

What is the actual number of those diploma who are in

bridging programme?

GD4 It is not a fix number there is variation every year.

Almost like we are sending around 100 – less than 100 each

year but we have more numbers in the national university.

Do you think there are any obstacles for diploma nurses to

going for bridging programme? Kindly explain to me this

point?

GD4 Yes the university does not take the old graduates here.

Some university ask less than 10 years or some five years.

Some universities require less than 40 age. If more than 40

they will not allow. We try our best to work on this policies

and law with the MOH to allow them to proceed with their

bachelor’s degree or at least to allow them to be in private

colleges on their own to allow them to have the degree. This is

the solution we can say as of now. You know it is all over

world when you get certain age you cannot go and that the

ministry will not pay for that. But it should be allow for them

to take the degree they want on their own. Just give chance

from their work to go for exam and their own time even.

Do you think there is a difference in experience and level of

education between nurses? Explaine please?

focus on the

major areas of

concern. The

majority of the

time is devoted

to discussions of

these questions.

270

GD4 Of course there is a difference experience is very go and

it is really needed. It makes a difference if a person has a

degree with experience rather than a degree only without

experience. If you have a degree and education that means you

know the rationale of the things you do; but if it is only

experience you do things because you see other people doing it

or you did it before and it worked; you just carry on and do it.

But if you have the education you know why you do it and can

even do it better. Education and experience are both important

in giving quality care.

Since you are a member of GCC, What do you think is the

standardization of the education program of nursing in the

GCC?

GD4 It is really good. It is the big step we are taking forward.

Because all people in Arab countries will just move freely. It is

good for the citizens. You finish the same programme and

curriculum. When you move from one country to another

people are familiar with what you study and you will not face

many problems. You will not face problems like your

certificate not being valid. So this is the main idea to allow the

people in Gulf countries move freely and that will make their

life easier.

Could you explain to me more when the GCC will start to

standardize the nursing education?

GD4 What happen its just been working; It has long time also

it has been worked. We have two levels. We have the

technical and the bachelor level. Technical level now in Saudi

Arabia is no more and has been stopped. For the bachelor level

is agreed by all MOH but now it is under the Ministry of

higher education. They all know the agreement but then again

it is still a recommendation also. But we are in the right track.

All our program is approved. It is not less than the

requirements. It is going okey right now.

Q6 Over all can you

describe what is your

ideal candidate of the

entry level to nursing

practice.

GD4 As we said before I agree about the bachelors level. I

think it is the level of entry to a job. Of course even if you have

the bachelors you need an experience. So Bachelor’s level is

the best for nurses to start work either in a hospital or at

community level or anywhere in the hospitals or community.

We found by evidence that a Bachelor’s degree should be the

minimum requirement. This is what all the reference says. If

they have a BSN degree, they have fewer medical errors, fewer

nursing errors and as we know, our hospitals and the medical

services in Saudi Arabia are getting better and better. And we

have new technologies coming for which we need nurses well-

equipped with knowledge and skill. Of course if you work in

administrative level this is different completely you need

specialize experience and certificate.

Do you have anything to add?

GD4 Thank you very much I wish you all the luck in your

study.

Ending

questions bring

the interview to

closure.

271

Level name: Micro level /Focus group

Date: Time: 10:00am -12:00am

Total number of participants: 7

Given code for interviewer (researcher): N

Given code for interviewees (participants):

Position No Nationality Given code

Senior Nurse 1 Saudi SN1

Senior Nurse 1 Saudi SN2

Senior Nurse 1 Non-Saudi SN3

Senior Nurse 1 Saudi SN4

Senior Nurse 1 Non-Saudi SN5

Senior Nurse 1 Non- Saudi SN6

Senior Nurse 1 Saudi SN7

Nursing mangers

N – Okey. Good

morning Everybody!

Before we start do you

have any question?

Did you sign the

consent?

Is the information that

I sent to you about my

study is clear, and do

you have any questions

before we start?

How did you become a

registered nurse or

what was the

educational pathway

that led you to your

initial licensure as a

nurse?

Respondents – Good morning!

Respondents – No

Respondents – Yes

Good morning. Everything was clear thank you……..…

SN1- I am executive nursing director of one of a big medical city in

KSA, and I have many years of experiences in nursing practice and

management.

SN2- Assalamu Alaikum WW. I am SN5 I am actually going to

complete 22 years in my nursing career. I graduated from university as

a general nurse then I got a master’s in nursing.

SN3- I graduated from university four years ago and joined up to work

as an RN for 3½ years in Cardiothoracic ICU.

SN4- Assalamu Alaikum aaah my name is SN4 . Graduate from the

College Nursing Health aaah diploma. I am working until now 26

years. My background of the work I am now the Nursing Director in

Maternity Hospital King Saud Medical City. Actually the degree for the

staff to be a registered nurse. I think from my experience is diploma

because we have a different diploma. We have Health Care Assistant 1

½ year and we have also Diploma 2 ½ year and we have also Diploma

from College. I think from College will be the best now to start the

degree because I have a good quality of training and work. They have

full responsibility with work. For the other Diploma they need more

concentrated training to be more …yani… registered as a nurse. And

also of course in the future we need to be Bachelor’s Degree.

SN5- I am a previous dean in the Philippines. What we currently have

in our country as a minimum requirement is a Bachelor of Science in

Nursing. Although we had like twenty years back a graduate nurse, this

is similar to the Diploma graduates, that we are having here; but this is

272

already being phased out in the Philippines. Those graduate nurses way

back were upgraded to BSN through a bridging program. I think we

shall be discussing more on this issue of BSN and diploma later. That

will be all for now in the meantime.

SN6- My name is SN6. I have Master’s degree in education and

communication. Aaaah My actual experience is 9 years. Amm actually

aaah we observe now we have different pathway. Before we observe

like aaah we are accepting from the secondary school and even from

the elementary school. Now a days they have there are changes in the

pathway. Now they are requesting that they have to pass the Bachelors

and they have the reason to use this different pathway.. aaaah base on

the different incident and recommendation that’s why the change the

pathway from previous years to now.

SN7- I am … Korean. I’ve been working in nursing for about 7 years

now. We have different preparation. ..It is made of two categories, one

is the Diploma and the other is the Bachelor’s degree…after they

completed their curriculum they both proceed to the National board

licensure exam. Only those who pass the exam may be a registered

nurse. That is the educational pathway in Korea.

…[Data removed for anonymity]

N- In your opinion, what is the minimum degree that should be

required for entry-level practice as a registered nurse?

SN2- The minimum requirement…based on our experience, based on

the situations we are confronted with. What I have seen that it is very

much needed that nurses who come in as an initial practitioner should

be a BSN degree. Because this would complete the so called

requirement of professionalizing them and make them ready over the

role that they have to play. Because, If we are going to compare to the

situation we are facing here, we have nurses of different types of

nurses, those with two years or three diploma nurses as oppose to those

with bachelors degree. Really those with diploma comes with less

prepared, less mature as compared to those BSN holders; who are more

mature and who comes to us more prepared and who have these

complete preparation of having the general education given them and as

well as the nursing education, as a complete package. Yes it should be

a Bachelor’s and above.

SN3- Yes actually, if we want to improve health services, it must be

from Bachelor’s and above.

Aaah actually we also have to face that is the reality. We cannot also

escape. We have a lot of staff now who is bachelor but still they cannot

really handle the patient and they cannot even pass the competency;

which mean there is something like different or problem in their

curriculum or either in their commitment. Yes I agree to be Bachelor

and above but still I think because before we were working as a

diploma. We were working very well so not really with excuse that

the….Yes the certificate is important updating with the new

information, but the commitment is something important and what still

like a …I think I will talk in my country, in Saudi Arabia, as my

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concern. Yeah, we really have to look again for the curriculum. The

teaching in the schools.

SN7- Yes this is one of the factors, but We have other factors that can

affect, as I mentioned, could be like commitment, might be the

language, might be the interest or some people may select nursing

because they thought it was an easy job.

SN5- I have seen that it is very much needed that nurses who come in

as initial practitioners should have a BSN degree

SN7- We can clearly see the understanding because they learned

English from the University so they know how to speak, understand

and write. This will all have a huge impact on our nursing care.

SN1- The ideal is to have a Bachelor’s degree and I will not accept any

nurses to come to work in this hospital without a BSN degree because

of patient safety. I need our patients to be safe and I need safe nursing

practice ... I think there is a good relationship between nursing

qualifications and professional nursing practice. ...I am a member of

the committee of central events of mortality and morbidity and I can

say there is a strong relation or correlation between nurses’

qualification and central events. … because usually when we are

reviewing the cases of central events, we discover that people who have

a high level of mistakes have a low level of education. So, if we need

safe practice you have to have at least a Bachelor’s degree.

SN4- For us here in MOH a staff they graduated they take to pass the

Saudi Commission in order to take a license and they will apply for

recruitment. After that they enter the hospital. We have our General

Orientation Program and there is Hospital Wide Program after that we

go to the Specific Orientation. aaaah According to the seniority of the

staff and also the competency of the staff; They will be going to the

level after charge nurse aaaah head nurse to go to that pathway. Right

now we will have inn sha Allah a Career Pathway…We are going to

rank the staff according to qualification, experience and how to go all

the way. Either the staff go as a head nurse, for administrative, quality

or education. aaaah Initial education we have diploma and we have

baccalaureate, masters or phd. For diploma we should have also

according to their years in school. 3 and a half years, which is high

diploma and we have 2 and a half; either she be a health care assistant

or a nurse technician with this degree. While BSN is categorize as

specialist aaaah. This is the variation here even between diploma to

diploma. 3 years and a half diploma should be more qualified we can

say and competent rather than the one who come two years.

SN3- I think the pathway that we have is something from one year

diploma up to PhD and we can touch the aaaah the relation between

variation. Even as mentioned by Ms. Dareen we have 2.5 diploma, 3.5

yrs diploma. For every director of nursing I think they will prefer the

3.5 years Diploma in nursing because they received a more maybe

education and their…. This education is actually covering some item,

some topics that are no covered in 2.5 years. And of the again as we

discuss before is the medication management. The aaah if you want to

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ummmm make a test for those two levels for certain medication

calculation you will see that aaaa 3.5 is really better. They are aware of

the side effects of the medication. How to admit to them safely for the

patients. We also have bachelor’s degree, masters degree, PhD aaaah

but the issue here we have all of them from different sections, from

different sectors, from different institutions, we have variations not

only in the qualifications. We have a variation in the level of the

outcome of the providers, of the education institutions.

N – Ok so what do you think is the factor that influence over the

degree preference?

SN2– I have a lot of things to add I agree with her. Actually first of all I

believe in the commitment. Because we have some people who are

HCA and their performance is better than with the Bachelor. They want

to learn, they have the initiative, they have the interest to learn. Really

they would love to continue their study but I think we have like some

limitation. Like a HCA they cannot continue like a bachelor or

something like that. So I think the first and the last thing is the

commitment, and this is depend. I don’t know sometimes may be. We

can observe now most of the nurses are still young and they don’t have

the, they feel that they are already responsible. They feel like they are

not feeling they are working with the life of patient. Anytime they can

be absent, anytime they don’t care. Even they answer us like, “even if

you deduct that from our salary it’s okey!.” Like that they don’t have

that interest to deal with the life of the patient. And it is really the main

problem. If they don’t have this sense hoe they will be working as a

nurse.

SN4 –We have some diploma and HCA is better than the bachelor. It

means it depends on the person himself, their commitment. How they

not how the certificate perform them. Because now we have some

Bachelor nurses will say, “We will not touch patient.” They are looking

only for the certificate while they don’t have any skills in nursing. So

the commitment is number one. Still I think the culture of education is

absent from them. If we will some education or activities. Always they

are absent or they will escape from the activities. “As if like they are

eating our head this information, “ they are thinking like that. They are

not thinking this information will push me to be more competent and I

can deal in good way. Also there are lots of factors also in order to be

more honest. Like the wasta. And I don’t know, I don’t have translation

on this one, but wasta mean we have like some student who came, who

are not competent and while they will go to there… Like we have

internship, I mean…Even if they are not competent from our side they

will go to their college and they will release for them that they are

competent and they will go. Then we will face problem with this staff.

That’s why even if you will evaluate them not competent during their

period still in their college they will let them go and work. So I will

face like problem. We have not only in our hospital, this is I think

become more global problem for us. And they have really to focus on

something before the disaster will happen. We have really a lot of

factors but this are the important things and really we are suffering.

So what do you think

the influence of degree

SN1- I think one of the important issues with our nurses here is the

knowledge…BSN degree nurses have a general understanding of the

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education has on the

nursing workforce?

theory concept …should have knowledge, should have a good

background about physiology, anatomy, pathology. Good background

about psychology too to deal with patients and pharmacology to know

the side effects and contra indications for each medication. We are

evaluating our nurses based on three things: knowledge, attitude, and

skills. Knowledge is important and I think it is impacting people’s

attitudes .aaaaa What is different about these nurses is that they have

different classifications, technicians and specialised nurses. Then they

come to work as staff nurses providing the same total patient care.

SN4- They have advanced clinical skills such as medication

calculation, IV cannulation, catheterisation…. almost all of them have

abilities to provide patient care proficiency.

SN5- If we are talking about competency in the nursing assessment,

medication management, calculation and administration, knowing the

complications, side effects of the medication, total patient care,

evaluation, therapeutic nursing actions or interventions: it is really I

think that the nurses with a Bachelor’s degree level will have better

competency in these. Compared to my place we do not have any

difference between the BSN and the Diploma holders.

SN6- They are more mature, more committed, accountable, confident

and... more prepared. We have both of them the Bachelor’s degree and

Diploma nurses, they are providing the same duties and responsibilities

to the patient.

SN2: Patients were safe when handled by nurses with Bachelor’s

degrees - even their English is good.

N: Why? Could you explain more?

SN7- Because you couldn’t imagine that some of the Diploma nurses

can’t read English, how they interpret physician’s orders and medical

orders! We discovered that some of our patients did not receive

medication because the nurse technician [NT] couldn’t read English

SN3- We discovered that nurses who make a lot of mistakes have a low

level of education. So, if we need safe practice you have to have at least

a Bachelor’s degree

SN1: We have a lot of new staff who have graduated with a Bachelor’s

degree from private colleges but still they cannot really handle the

patient and they cannot even pass the competency; which means there

is something different or a problem either in their curriculum or in their

commitment.

Why do you think the

minimum educational

requirements for

entry-level practice as

a registered nurse have

been elevated to the

baccalaureate level?

SN2- Because the majority we have are Diploma educated and also we

are talking about two or three categories. The Diploma is three and a

half years and they were from governmental institutions like the Health

Science College… under MoH and we have the other one from the

private institutions….. …we saw the difference, with experience,

background information, abilities, performance in practice and

outcomes. The new Diploma which we have is common now, it’s the

private institution Diploma…they don’t speak or communicate in

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English. They do not have the basic things (skills)… they are weak and

we have to train them first to study English…, the Bachelor’s, sure…

with English, with the good background of theory and practice Also

with the respect of the institution where he or she comes from, we are

having some Saudi Bachelor’s nurses who do not even pass with us.

What benefits could be

gained by requiring a

Bachelor’s degree for

entry-level practice as

a registered nurse?

SN1- I am thinking of my future career for myself, for financial

outcome and a good position. I am thinking, what is the easiest way to

get a salary and to have some respect… I discovered that nursing is the

best way to get it, that’s why I became a nurse. Now, I discovered that

the senior and consultant physicians, they respect nurses just now

because their education and experiences are improved. Also, I am

seeing that there is a respect for physicians - why don’t they have

respect as a nurse? There is no respect for nurses I can see our culture is

important here; as Saudi people we are not expecting a male person to

be a nurse. We think in Saudi Arabia, nursing is a job for females only

and that’s why we don’t have a lot of male nurses who graduate from a

Bachelor’s degree to work with us.

SN4- Some families push their daughters or sons to study nursing only

because of the need for financial gain only.

SN2- Given for example here in the kingdom those who come in an

entry level for their education enter with an option. BSN is being

provided, Diploma is being provided. However, the factors that

influence them is more on the idea of quick fix. You know, I can have

it, I can have my job and I can be earning. And there are also social

influences and pressures. Like some family pushes them because of the

need for financial gain. So they push them hard and push them to finish

early and let them earn their living early also. However, we can also

look at how the offerings of this education in the country. Many

unfortunate stories we heard. We have talked to this diploma nurses

who say to us that it is too easy to earn the diploma certificate because

they make them pass when they don’t deserve to pass. And these

institutes who are providing these certificates to them even they don’t

pass, which I think the government should have stricter rules. The

government has to really make sure that they are doing their job.

Actually according to them that they do not really sweat over their

studies. So it was not clearly emphasize to them what is exactly the role

that they have to face when they come to the hospital. That’s why when

they come to us after this two years and one and a half year. They come

too surprise over their responsibilities because when they were at their

school it was not really shown to them what is the real world in

nursing. It might have been what is emphasize to them how much they

will earn. How much they can buy out of my salary. The value was not

in place. Unlike, if I can raise this point on the Philippines, the

curriculum is really emphasizing on the value. That is why up until this

time, with all due respect to other nationalities, they would speak

highly of a Filipino Nurse. Known to be very compassionate, because

in the curriculum itself it is emphasize there that no nurses should

graduate if they are not compassionate, no nurses should even graduate

if they are not God fearing. Because nursing is not a simple job.

Imagine that you are going to be taking care of people that you do not

even know, you have not seen them before so if you do not have all

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these values within you how can you be that effective.

SN1 – Bachelor’s degree should be required for a staff nurse for the

reason that was mentioned before of having shortage for nurses. Aaaa

also, the classification is different so once we have different

classification from the Saudi Commission so what the implementation

of this in our institution. aaaah Logically aaaah if the bachelor’s

degree nurses they are classifies as specialized nurse and nurses of

diploma degree are classified as technician so the critical question is we

cannot easily answer. Will we have the same duties and and

responsibilities when in the health care settings is better? This is the

question. How can we answer only we have our own competency.

Because they have different licensure exams. Well for my point of view

what is different from these nurses they have different classifications,

technicians and specialized nurses. Then what they want to come to

work as staff nurses providing total patient care for a patient. So we

should have the same competencies for them. So the competencies that

we have would be the indicator if they will provide total patient care or

not. But again because of the shortage we are doing this completely,

because of the shortage and also the large numbers. We have large

numbers of aaaah diploma holders. Year by year they graduate as

compared with BSN. I think this should also be a vision here in KSA to

decrease …yani to –form institutions and to support people to go to

universities for BSN. Once this is not really implemented it’s a

challenge. Once the Minister of Health let’s say he has 35, 000 of

Diploma nurses what he will do . He will let them sitting at home not

doing anything. No! they also need to work. It is a challenge even to

the Minister of Health. So it’s a complicated formula but we can but if

we know the root causes we can solve. If we can decrease the number

of diploma holders. The graduates of Diploma holders we can easily

aaaah yani aaah we have a better people joining the hospital, the

KSMC.

N- Is there a difference with the competency of the bachelor’s

degree to a diploma graduate? What about the job description? Or

both of them take the certification work with the same job

description? Clarify for me… SN3- aaaah Compared to my place we do not have any difference

between the BSN and the diploma holders. But here, I depend on

degrees. When I am informed that we have a new employee who is

bachelor’s degree, I am feeling much, kind of trust, even without seeing

or knowing about this nurses’ competency. When I simply see diploma

or transferred from different institution, we started to sigh because

those nurses who graduated from government school were some other

official accredited institution, they now know exactly what to do. What

nursing, what kind of responsibility they should perform here. So even

if they are not very much excellent in their performance. We can

clearly see the understanding because they learned English from the

university so they know how to speak, understand and write. This will

be all of a huge impact on our nursing care. And the other one aaah

because they also go for internship in governmental institution; they

know what is this routine work of the nurses so. I cannot say that they

are always excellent but at least they are clearly aware of their duties

and also their routine works what to do. But diploma holders especially

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from this institute graduates they do not have any single understanding

of the English word so they cannot actually do it in the competency

check off because they cannot understand any of the English instruction

and when it comes to the documentation sample of what they do make

a copy and paste from the previous shift nurse. And assessment literally

have no idea and at the same time they have consider nursing as very

easy thing.

SN 4 - As Sister SN 3 mentioned many of them consider this job just as

a job without a sense of responsibility or a sense of dignity. Either, they

work hard or not, either they are competent or not since ministry is not

going to terminate them so they were simply ignorant of every single

thing. They do not have initiative, no motivation. They do their duties

simply they just stay there and they really present so much of

misbehavior and even affect relatively to those who work so hard. So as

kind of a byproduct or something even those nurses who work so hard

and are present every single day. They are not even coming very often.

N – Is this competency used for both of the diploma and Bachelor’s

holder?

SN7– aaaaaah yeah. And No, but for diploma and bachelor degree

yeas but for HCA they have different scope of service totally. aaaah

this no. 1, before we only have one job description for a nurse. But now

a days I think Nursing Total Quality Management work to have

different job description per specialty. I work in Surgical I have a

surgical nurse job description, orthopedic nurse, ER, OR, ICU nurse job

description. This specified. But we will talked again as they mentioned

the English language. We don’t have. That is why they never read

prescription. They do not know what is actually inside. Whatever you

will give them is for them so their scope of service they will like follow

and even the competency as she mentioned they are not passing

because they do not know what is inside. Aaaah this one from one side.

Then we have like mentioned that not like necessary that bachelor are

good and diploma are bad. Like from the experience we discover

students who correct our staff actually. Like the student are correcting

the staff. You can just imagine how the level of staff sometimes we

have. This one is based on the commitment. If they want to learn they

will learn . If they don’t they will not and many problems for us here. If

as they mentioned administrative action from the ministry it would be

okey. Now we can see for example most of the hospital are divided into

HOP, which they called Hospital Operation Program and Ministry.

People in HOP are more going to the rule and they will not have many

absent because they know there is a labor law. Like if she will not pass

they will like terminate her. Warning letter. But for us as a Ministry

even of we careless it is like she guarantee that nobody can move me.

Nobody can sometimes in one week we have two hundred absenteeism.

In one day you can imagine how they are suffering. Trying to pull out

even not competent nurse from different area to cover only this area. So

this is also from the factor.

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N – what the differences between diploma holder and degree holder

in terms of skills, knowledge, and attitude ? Do you face any

challenge with these two categories?

SN2- It’s the same - both Diploma and Bachelors are the same. How

they are performing. For example, if they are doing any procedure. We

do it step by step. We start from…hand washing then explain the

theoretical, go to the patient side. We go for the procedure in the

correct manner step by step. Okay. … This is called staff

performance… it is no different between Diploma and Bachelor’s. It’s

the same.

SN2: The new Diploma which we have is common now, it’s the private

institution Diploma…they don’t speak or communicate in English.

They do not have the basic things (skills)… they are weak and we have

to train them first to study English…, the Bachelor’s, sure… with

English, with the good background of theory and practice Also with

the respect of the institution where he or she comes from, we are having

some Saudi Bachelor’s nurses who do not even pass with us.

SN3- we have private and government colleges. Actually we are facing

problems - most of the students or staff who graduated from the private

colleges are facing problems with the competencies. Actually some of

them we asked ‘where did you do your competencies’? One answered

me in an honest way, the Institute told her just stay at home, 6 months,

then you come and I will give you the certificate!!!! … the private

sector is focused on the money more than the quality, which is really

affecting our staff. But some of them wanted to learn and try their best

to learn. They do not have the basic skills, especially from the private

sector.

SN4- The staff educational level is an important factor that has an

effect on the quality of care. We have different levels of nurses …the

ones who graduates from a Diploma lasting 2 and a half years needs to

be focused on bedside nursing rather than making decisions because

they ...don’t have any knowledge. Nobody came with them for the

practice (no clinical instructor or preceptor.

SN1- Yeah, thank you for this question, actually from the weakness

point that you asked aaaaa I am sure 100% sure that the ultimate goal

here at KSMC in Nursing Department is to have a nurses with

Bachelor’s Degree as a minimum requirement to be a staff nurse,

bedside nurse taking care of patients, providing total patient care. One

of the barriers not to achieve this objective, before setting this objective

or hitting this objective. We have the huge number of diploma nurses.

The challenge here if you just choose to make the Bachelor’s Degree

nurses so what you will do with the number of diploma nurses. So we

created actually, there was a full proposal to improve the level if those

nurses and was request by our nurse leaders to the CEO to have

bridging courses for them. We have as you know, like any other

institutions, we have been meeting challenges for implementation. Aaa

ummmm so we are, we have both them the Bachelor’s degree and

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Diploma nurses, they are providing the same duties and responsibilities

of the patient but in the unit that I am working NTQM unit we are

checking the compliance of the nurses in providing the standards of

care so we are monitoring them., we are asking them their perceptions,

their awareness and we really, we have a difference especially for those

new nurses. The Bachelor nurses, they have really a better ummm better

information, better skill. But you know once those diploma nurses, they

have experience in KSMC like 3 years, 4 years experience. They

mostly, they became really skillful and knowledgeable by time. But as

mentioned by Miss Sun there is a better chance for the Bachelor’s

degree for may be for promotion. For example aaaah but again our

goal here is to have Bachelor degree nurses providing total quality care.

Again we have previously objective for this, even for the job

description we could not for that time put this because of the huge

number of the diploma nurses in KSMC. I think Ms Dareen she can

describe more of the nurses that we have on the percentage of those so

that the idea can be clear.

SN3- aaah majority we have its diploma and also we are talking about

two or three categories. The Diploma which is three and a half and they

were from governmental institutions like Health Science College.

Nursing under MOH. And we have the other one from the private

institutions. Actually as a benefit from the bridging from the previous

years we saw. We can say one of our product is Ms Amna now that she

has her Master’s Degree. Yes, we saw the difference, with her

experience, there is, what we can say good outcomes from that one. If

we will go to the new diploma which we have, which is common now,

it’s the private institution diploma. Which is they don’t have English.

They do not have the basic things which you have from that point start

teaching them. Actually when we found that they are weak and that

their basic we have to train them. To train them as a language we are

using is English. So we cannot have them unless we have to teach them

by letting them first to study English. So this is our point. So when

BSN will come, the Baccalaureate, sure… You know with English,

aaah with the good background, also with the respect of the institution

where he would come. Because even with Baccalaureate we are having

some Saudi which they did not pass with us even.

SN4 – Regarding the competency for the diploma and the bachelor’s

degree…as a hope that this will be the answer to your question. There

is a diploma or bachelor’s degree… Their key role in nursing, actually

is saying the outcome of those who studied in the university, there is a

difference in the diploma and bachelors degree. Basic principle in

nursing actually saying and also the requirement skills for nurses, in

fact is saying so for those become a difference between bachelor’s

degree and diploma. The competence check off and the second point

those patient so far that we are taking care of they do not depend on our

degree. They are all saying either you have master’s degree or PhD

degree, diploma or simply the BSN. The patient population sees us

helping people they do not negotiate with our degree, and the third we

are tertiary hospital; that means we are suppose to provide great care to

the community. It means again people in our community and also in

our hospital we don’t deal about our degree. We do care about our

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patients based on nurses actual ----, education and train, and knowledge

of what they gained. From the beginning we have curtained

expectations from the staff and they are actually considered, and

supposedly actually capable and competent. When the NSDD launch

this competence check off. We have actually have expectations from

the staff. What they are suppose to know, what they possess within

themselves. Because of this I don’t think there is a need to have

difference between diploma and BSN in competence check off.

SN3- Yes, Bachelor’s degree holders are better than Diploma holders.

When it comes to skills, or some other commitment, however, it

completely and purely depends on individual commitment. It is not a

guarantee if they are a Bachelor’s holder that they are better in every

aspect. ..

SN1- Commitment is something important. Lack of commitment

actually affects the staffing plan and also the working hours. Rather

than interfering with nursing administration once they enter the

hospital. …. we really have to look again at the curriculum and the

teaching methods in the schools.

Overall, describe your

ideal candidate for an

entry-level nursing

job?

SN3- For me it should be Bachelor’s degree. Especially here at least

those graduate from university, nursing medical university who have

BSN and they have general understanding in the theory concept and

almost all of them they have English proficiency. At least when we

speak to them in English we can communicate with them without any

specific issues and at the same time they are much excellent rather than

diploma workers. We have Diploma holders in our Paediatric Hospital,

and their commitment is much better .. They are very dedicated

people…. and their performance is better than Bachelor’s nurses. They

want to learn, they have the initiative, they have the interest to learn.

That is one thing I can say since they have studied the appropriate

curriculums. They in fact have better understanding in nursing for that.

For that I prefer BSN degree for the competencies so and commitment

purely because of this issue.

N – Do you agree with that?

SN2- You know I strongly agree with that because you know the issue

of language in KSMC in aaaa communication, aaaa documentation, so

the English language. The proficiency on this language is really better

of those graduate from universities having bachelor degree. Finally

comparing between the two programs, the nuniversities and the

colleges. I think that we still have enough opportunity if we are talking

about aaaa competency in the nursing assessment, medication

management, and collation of medications. Medication administration,

knowing the complications, side effects of the medication aaaa total

patient car, evaluation, therapeutic nursing actions or interventions. It is

really I think that the nurses with aaaa having Bachelor degree level

have better competency in this.

SN4– If you just allow me I will add something. If you will ask me for

example of the ideal and if I really had to make thing. Actually I would

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like first any new staff will not join to the hospital to work they have to

come with a certificate of English. To prove really that they have

entered English course. Because now we are facing some people are

writing in Arabic that sometimes just I know that they are studying in

their language and everything in their language. For us we are different

we are using English we have to be an Englis. This number 1. Number

2, I know in some country even of the student pass they will make final

exam. They will take fundamental in Nursing, Ethics, Pharmacology

aaaa some like the important topics. Okey. If they will pass I would like

them to provide for any internship. The copy of their exam, the final

exam with the English course. They have to make their internship on

the same place that they are going to work. Like in our allow me to

mention. Like King Faisal, King Fahd City. They will live them to the

internship of their hospital so. If they will do the internship in our

hospital and they will follow our evaluation for one year. If she is pass I

can accept her in our hospital. If not she can go to the other area or

other hospital and perform another internship. I am sure if they will

conduct like this the staff they will be more competent. They will know

the nursing group and the culture of nursing will be changed.

N – Do you have anything to add.

SN3- Agree to improve the educational level of our staff. We are

agreeing about them to have Bachelor’s degree as their entry level. The

degree to enter in the health care team. aaaah But which we have right

now is the percentage more than 50%, I can say that the Bachelor’s

degree and the High Diploma is only 10% of our total staff of the Saudi

National. But if you are talking of the Diploma with higher we need to

improve them.

SN4- I think the government aaah should have stricter rules over the

schools licensed to operate as Nursing Schools. Because after all, I go

back to what SN3 was saying the students that you have now would be

your future nurses and this will be the ones who is going to take care of

you.

SN7- The nursing who graduate from the college, from diploma, and

they are having good experience in the ward they need to improve their

self and they have to take the chance for the government to give

them…yani….more and more excellent to continue.

SN1- If I suggest I really think this study is going to be affecting some

kind of yourself and also for the MOH.

SN2- I just want to complete my ideas in two points. Yes I agree like

we have to have the Bachelor’s degree with passing competency

including English before let them really aaah work as a staff in our

institute. 2nd thing disciplinary service must be implemented system

base on the labor law in their work otherwise

SN6- It is very much needed that nurses who come in as initial

practitioners should have a BSN degree... because this would complete

the requirement of professionalism. We see that trend itself is to have a

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bachelor degree nurse as a minimum requirement. This is the trend here

now in this hospital. And I know it is also outside KSA. ummm the

other issue that I think is my personal belief here. My personal belief its

really difficult based on the challenges we have and the DON they

know better than me of the current statistics of the diploma nurses that

we have. Its really the challenge will become bigger if we will receive

another huge amount of diploma nurses in KSMC. It is against the goal

of this department in KSMC. So this can be accomplished if there is

better coordination between MOH, the hospitals and the civil services.

This is my point.

SN1- We did a study about absenteeism here in KSMC, the most

significant factor is workload and the second is endorsement. Because

they don’t have good English and they don’t have good knowledge,

they are absent from the duty. When I talk with most senior nurses, we

discuss the biggest issues; we faced chronic cases of absenteeism and

we found that most of them were nurses with a low level of education.

When I investigated them, to understand their situation and why they

were absent regularly, I discovered that they were absent because they

wanted to avoid responsibility”.

SN5- one of my staff told me that ‘I did not come on duty because I am

afraid to talk in front of the physician and he might ask me about the

patients and I can’t answer because I don’t understand their situations.’

Also because they don’t speak English, so they can’t endorse the case

to non-Saudi nurses. Likewise, another nursing manger gave an

example of an evidence-based study:

SN4: aaa I have some suggestion. Actual suggestion. I heard about the

Saudization started year 2003 or 4. For the Saudization I have no

objection at all. This is what I say to myself staff, I mean my

supervisors, I have no objection to Saudization. This is your country

where you should be the one who really keep and protect and treasure

for the coming years. It means rather than depending on foreign

expatriates providing and educating Saudi nations in a better way,

organize in systemic way it will be more beneficial for Saudi citizens to

have qualified and also very standardize nursing care so I really hope

your research will inform, some kind of future plan or better kind of

blueprint for Saudization to give Saudi people better workers out to

care.

284

Appendix 5.6

Participant’s information sheet: For (Meso level) Nursing Regional Director

Study title: The Implications of Nursing Degree Education for Future Workforce Planning

in Saudi Arabia: A Case Study.

I am currently completing a research study for my PhD in Nursing at the University of

Salford. I would like to invite you to be part of this research study. Ethical approval has

been obtained from the University of Salford and it is important that you understand both

the purpose of the research and your role as a participant. Please ask any questions if any

part of the information is unclear to you. Finally, it is your decision whether or not to be

part of the study and you may withdraw at any time.

What is the purpose of the study?

This research seeks to investigate the extent of your knowledge regarding workforce

planning and development as a consequence of the introduction of degree entry pre-

registration nurse education.

Why have I been invited?

The main reason for including you in this research is because you have a high level of

knowledge and experience about nursing workforce and entry requirement for qualified

nurses in Saudi Arabia.

Do I have to take part?

It is your choice as to whether you want to participate in this study. This information sheet

will provide details to help you make this decision and you can contact me if you have any

question about the research. If you agree to be part of the study, you will be asked to sign a

consent form. You are free to withdraw at any point while taking part in the study.

What will happen to me if I take part?

You will be asked for consent to attend the focus group which will be tape recorded. The

agenda will include all the activities you may need from the registration time to the debrief

session. As illustrated in the following table

285

Table 1: Time line Agenda for meso level focus group.

Process overview from 12:00pm to 14:00pm

 Registration & welcome participants and thank them for attending,

 Review the purpose of the focus group & introduce facilitators.

 Ask participants to briefly introduce themselves

 Highlight key points for discussion & moderator will begins focus group questions

 Session debrief (to ensure all points have been captured effectively and

comprehensively)

 Close the session and thank participants for their participation & distribute of

appreciation certificate.

 A focus group aims to explore your knowledge and experience about nursing

workforce and entry requirement for qualified nurses in Saudi Arabia. You may also be

asked to explain your answers in detail.

 The actual length of the focus group will range from a one to two hours.

 The focus group will be held in the main auditorium hall in the Ministry of Health.

 The focus group will be a confidential and audio tape recorded. The interview will be a

confidential and stored safely. The study will have two forms of data, a hard copy, and

soft copy. Hard copy data will be kept in a locked locker and no one will be authorized

to use it except the researcher. The soft copy data will be secured in a password

protected external hard disk and will be connected only to researcher private laptop,

only the researcher can access the saved study data. Your identity will be kept secure

by the researcher.

Expenses and payments?

The Ministry of Health will cover any expenses for this research

286

What are the possible disadvantages and risks of taking part?

There are no personal risks associated with participation in the study

What are the possible benefits of taking part?

I cannot promise the study will help you but the information I obtain from the study is

intended to help determine future workforce planning and development needs as a

consequence of the introduction of degree entry pre-registration nurse education in Saudi

Arabia.

What if there is a problem?

If you would like to complain about any aspect, please contact the supervisor Dr. Nancy

Smith or Dr Karen Staniland in the first instance, or the University of Salford, School of

Nursing, Midwifery, Social Work & Social Sciences and Social Care Research and

Innovation Manager -

Dr Nancy Smith [email protected] School of Nursing, Midwifery, Social

Work & Social Sciences Dr Karen Staniland [email protected]

Will my taking part in the study be kept confidential?

The information that you provide will be confidential. No names will appear in the study.

Your identity and personal contact details will be known only to the researcher, the

research assistants, and the research supervisors at the University of Salford. The

researcher will not use your name or any information that could reveal their identity in this

or any future research study, publication, conference presentation or teaching session.

Storage and destruction of data will conform to the Data Protection Act (1998). Any

information about you which leaves the Ministry of Health will have your name and

address removed so that you cannot be recognised.

What will happen if I don’t carry on with the study?

You have the right to withdraw from the study at any point without prejudice and this will

not affect your care in any way. If you withdraw from the study all the information and

data collected from you will be destroyed and your name removed from all the study files.

mailto:[email protected]

287

What will happen to the results of the research study?

The results will be published in a PhD thesis and parts of the study may be published in

health care journals and/or presented at conferences. You have the right to ask for the

results if needed and the choice of seeing the completed transcript following interview.

Who is organising or sponsoring the research?

The University of Salford and Ministry of Health.

If there are any further questions regarding this study, you can contact me (by phone or

email) or my supervisors (by email) as follows. If you prefer, we can arrange to discuss

this invitation, face to face, at a mutually convenient place and time.

Contact Details

Researcher

 Noura Almadani, PhD candidate. School of Nursing, Midwifery, Social Work & Social

Sciences, University of Salford, Salford, Greater Manchester, United Kingdom, M6

6PU

Tel: +447462662646 or at [email protected],

Supervisors

 Dr Nancy Smith [email protected]

 Dr Karen Staniland [email protected]

mailto:[email protected]

288

Appendix 5.7

Research Participant Consent Form for the (Meso level) Nursing Regional Director

Title of Project: The Implications of Nursing Degree Education for Future Workforce

Planning in Saudi Arabia: A Case Study.

Ethics Ref No: HSCR14/119 Name of Researcher: Noura Almadani

 I confirm that I have read and understood the information sheet for the

above study and what my contribution will be.

Yes

 I have been given the opportunity to ask questions through the use of

the participation information sheet.

Yes

 I agree to take part in the focus group Yes

 I agree to the focus group activities being tape recorded

Yes

 I understand that my participation is voluntary and that I can

withdraw from the research at any time without giving any reason

Yes

 I understand how the researcher will use my responses, who will see

them and how the data will be stored.

 I understand the confidential nature of the focus group and I will not

repeat what has been discussed in the group with anyone outside of

the group.

Yes

 I agree to take part in the above study

Yes

Name of participant (print)

…………………………………………………………………

Signature …………………………………………………………………

Date

………………………………………………………

289

Appendix 5.8

Structure and guidelines for focus group interviews

Introduction:

Focus groups explore topics that may not be easy to explore in one-to-one interviews, and

data are generated and collected in a group setting as a meeting at which a group of people

engage in intensive discussion and activity on a particular subject or project.

Objectives:

The main objective of using focus groups is to use the interaction data generated during

discussion between the participants to gather information from members of a clearly

defined target audience that will increase the depth of the enquiry and reveal aspects of the

phenomenon assumed to be otherwise less accessible.

The expected outcomes from the focus group:

1. The participants will be able to communicate and interact with each other

effectively.

2. The participants will be able to summarise each topic and organise them into

different themes.

3. The moderator will be able to control the group discussion by emphasising free

discussion, and then move toward a more structured discussion of specific

questions.

4. The note taker will be able to capture all the data effectively and comprehensively.

General Guiding information:

1. The focus group will run from 12:00 p.m. to 14:10 p.m.

2. Your contribution in the focus group is vital to achieve the purpose of the study.

3. It is important to accept other opinions and viewpoints among the group.

4. It is a discussion session and everyone who has an opinion will be heard and all

points will be discussed.

5. There will be an assistant who will be responsible for writing the minutes of the

focus group.

6. Your travel to and from the focus group will be paid.

290

7. There will be a lunch provided for the participants.

8. A tape recorder will be used after gaining written permission from the participants.

However, there will be a note-taker who will be responsible for writing down the

details of the focus group.

9. The study has been approved by the College of Health and Social Care Research

Ethics at University of Salford and the Ethics Committee at the Ministry of Health

(General Directorate of Nursing in Saudi Arabia).

Guiding Roles for Focus Group:

It is very important to establish some ground rules prior to the focus group.

Participants will therefore be asked to:

 Turn off their phones.

 Let one person talk at a time.

 Assure maintenance of confidentiality. “What is shared in the room stays in the

room.”

 Hear everyone’s ideas and opinions, as they are all valuable.

 Hear all sides of an issue – both the positive and the negative.

These guidelines will be presented to the group, and displayed throughout the discussion,

on a flip chart page in a clearly visible location. Participants will establish their own

guiding principles for the discussion, which the note-taker will add to the flip chart page.

291

Appendix 5.9

QUALITATIVE INTERVIEW QUESTIONS GUIDE

Questions (Guiding) Response Follow-up (Probing

Questions)

1. How did you become a registered

nurse or what was the educational

pathway that led you to your initial

licensure as a nurse?

2. In your opinion, what is the minimum

degree that should be required for

entry-level practice as a registered

nurse?

3. What influence do you think degree

education has on the nursing

workforce?

Rationale?

4. What benefits could be gained by

requiring a Bachelor’s degree for

entry-level practice as a registered

nurse?

5. Why do you think the minimum

educational requirements for entry-

level practice as a registered nurse

have been elevated to the

baccalaureate level?

Rationale?

6. Overall, describe your ideal candidate

for an entry-level nursing job.

292

Appendix 5.10

Interview questions guidelines

There are five general types of questions that will be used as a guideline in the

interviews as suggested by Krueger and Casey (2000).

• Opening questions are used to get people talking and feeling comfortable.

• Introductory questions are used to get the group to start thinking about the topic at hand.

They help focus the conversation.

• Transition questions provide a link between the introductory questions and the key

questions.

• Key questions focus on the major areas of concern. The majority of the time is devoted to

discussions of these questions.

• Ending questions bring the session to closure.

The following themes from the Literature Review of this study will be used to guide

the interview:

Education challenge

 Different approaches of nursing education

 Impact of degree education on nursing workforce

o Skills

o Knowledge

o Attitude

System challenge

 Nursing policy & regulation

 Saudization Plan

 Nursing turnover & retention

 Working condition

Social challenge

 Ageing

 Women and society

 Cultural diversity

293

Appendix 5.11

Participants’ information sheet (PIS)

For nurses from King Saud Medical City (Micro level)

Study title: The Implications of Nursing Degree Education for Future Workforce Planning

in Saudi Arabia: A Case Study.

I am currently completing a research study for my PhD in Nursing at the University of

Salford. I would like to invite you to be part of this research study. Ethical approval has

been obtained from the University of Salford and it is important that you understand both

the purpose of the research and your role as a participant. Please ask any questions if any

part of the information is unclear to you. Finally, it is your decision whether or not to be

part of the study and you may withdraw at any time.

What is the purpose of the study?

This research seeks to investigate the extent of your knowledge regarding workforce

planning and development as a consequence of the introduction of degree entry pre-

registration nurse education.

Why have I been invited?

The main reason for including you in this research is because you have a high level of

knowledge and experience about nursing workforce and entry requirement for qualified

nurses in Saudi Arabia.

Do I have to take part?

It is your choice as to whether you want to participate in this study. This information sheet

will provide details to help you make this decision and you can contact me if you have any

question about the research. If you agree to be part of the study, you will be asked to sign a

consent form. You are free to withdraw at any point while taking part in the study.

What will happen to me if I take part?

You will be asked for consent to attend the focus group which will be tape recorded. The

agenda will include all the activities you may need from the registration time to the debrief

session. The following is the time-line agenda:

294

Process overview from 9am to 12pm

 Registration & welcome participants and thank them for attending,

 Review the purpose of the focus group & introduce facilitators.

 Ask participants to briefly introduce themselves

 Highlight key points for discussion & moderator will begins focus group questions

 Session debrief (to ensure all points have been captured effectively and comprehensively)

 Close the session and thank participants for their participation & distribute of appreciation

certificate.

 A focus group aims to explore your knowledge and experience about nursing

workforce and entry requirement for qualified nurses in Saudi Arabia. You may also be

asked to explain your answers in detail.

 The actual length of the focus group and transcriptions will range about one to two and

half hours, this the time where the data will be recorded.

 The focus group will be held in the main auditorium hall in King Saud Medical City,

which is easily accessible for all and it is well prepared with all educational supplies

and audio-visual equipment’s to allow more sound quality that will help in

transcription of audio-taped interviews (Asbury, 1995).

 The focus group will be a confidential and audio tape recorded. The researcher will

explain the confidential nature of data recorded and inform subjects of the maintained

anonymity of their identities. The researcher will request that everyone states their

agreement to the confidentiality and non-judgmental response to whatever is said in

this room. This is extremely important as nothing that is discussed here should be

talked about outside the room. The interview will be a confidential and stored safely.

The study will have two forms of data, a hard copy, and soft copy. Hard copy data will

be kept in a locked locker and no one will be authorized to use it except the researcher.

The soft copy data will be secured in a password protected external hard disk and will

295

be connected only to researcher private laptop, only the researcher can access the saved

study data. Your identity will be kept secure by the researcher.

Expenses and payments?

The Ministry of Health will be covered any expenses or payments for this research

What are the possible disadvantages and risks of taking part?

There are no personal risks associated with participation in the study

What are the possible benefits of taking part?

I cannot promise the study will help you but the information I obtain from the study is

intended to help determine future workforce planning and development needs as a

consequence of the introduction of degree entry pre-registration nurse education in Saudi

Arabia.

What if there is a problem?

If you would like to complain about any aspect, please contact the supervisor Dr. Nancy

Smith or Dr Karen Staniland in the first instance, or the University of Salford, School of

Nursing, Midwifery, Social Work & Social Sciences and Social Care Research and

Innovation Manager –

Dr Nancy Smith [email protected] School of Nursing, Midwifery, Social

Work & Social Sciences Dr Karen Staniland [email protected]

Will my taking part in the study be kept confidential?

The information that you provide will be confidential. No names will appear in the study.

Your identity and personal contact details will be known only to the researcher, the

research assistants, and the research supervisors at the University of Salford. The

researcher will not use your name or any information that could reveal their identity in this

or any future research study, publication, conference presentation or teaching session.

Storage and destruction of data will conform to the Data Protection Act (1998). Any

information about you which leaves the Ministry of Health will have your name and

address removed so that you cannot be recognised.

mailto:[email protected]

296

What will happen if I don’t carry on with the study?

You have the right to withdraw from the study at any point without prejudice and this will

not affect your care in any way. If you withdraw from the study all the information and

data collected from you will be destroyed and your name removed from all the study files.

What will happen to the results of the research study?

The results will be published in a PhD thesis and parts of the study may be published in

health care journals and/or presented at conferences. You have the right to ask for the

results if needed and the choice of seeing the completed transcript following interview.

Who is organising or sponsoring the research?

The University of Salford and Ministry of Health.

If there are any further questions regarding this study, you can contact me (by phone or

email) or my supervisors (by email) as follows. If you prefer, we can arrange to discuss

this invitation, face to face, at a mutually convenient place and time.

Thank you for giving your valuable time in reading this letter.

Regards.

Noura Almadani

PhD candidate, School of Nursing, Midwifery, Social Work & Social Sciences

University of Salford, Salford, Greater Manchester, United Kingdom, M6 6PU.

Contact Details

 Researcher

Noura Almadani

Tel: +447462662646 or at [email protected],

 Supervisors

Dr Nancy Smith at [email protected] ,

Dr Karen Staniland [email protected] ,

mailto:[email protected]

297

Appendix 5.12

Research Participant Consent Form for the nurses from King Saud Medical City

(Micro level)

Title of Project: The Implications of Nursing Degree Education for Future Workforce

Planning in Saudi Arabia: A Case Study.

Ethics Ref No: HSCR14/119 Name of Researcher: Noura Almadani

 I confirm that I have read and understood the information sheet for the

above study and what my contribution will be.

Yes

 I have been given the opportunity to ask questions through the use of

the participation information sheet.

Yes

 I agree to take part in the focus group Yes

 I agree to the focus group activities being tape recorded

Yes

 I understand that my participation is voluntary and that I can

withdraw from the research at any time without giving any reason

Yes

 I understand how the researcher will use my responses, who will see

them and how the data will be stored.

 I understand the confidential nature of the focus group and I will not

repeat what has been discussed in the group with anyone outside of

the group.

Yes

 I agree to take part in the above study

Yes

Name of participant (print)

…………………………………………………………………

Signature …………………………………………………………………

Date

………………………………………………………

298

Appendix 5.13

Poster for invitation for staff nurses at KSMC

299

Appendix 5.14

Sample of Reflexive Journal

Date: 7th March, 2015

Phase 1: documentary analysis

I accessed the files that contained these documents, which were kept in printed form in a

special folder, and placed in the office of the General Director of Nursing. I conducted a

brief overview of the documents to exclude any unrelated papers. However, most of the

documents are not easily accessible and contain evidence that would take a researcher a

long time and much effort to gather alone. The documents were in the original professional

Arabic language that contained certain words with a broader meaning. I could not use the

NVivo programme in this phase because of the language. I set myself 2-3 hours/day during

works hours to review documents. However, it took far longer and I had to spend this time

for 4weeks+ due to the mass of information and the language was written in Arabic.

I scanned the documents and saved the electronic copies onto my encrypted computer; I also

developed a database on my personal computer that contained secure files for each phase of the

study to organise and save the large amounts of data that I had collected.

Analysing documents was time consuming, and for me was the worst stage of this study. I read the

documents many times, and every time I discovered some information significant to the research

aim and objectives. On the other hand, this stage made me more confident, knowledgeable and

oriented to the whole system and process of policy implementation.

Throughout the data collection process, a number of elements were kept consistent in the three

levels (macro, meso and micro), such as the importance of confidentiality, achieved through

coding. When I entered the fieldwork to collect documents related to nursing degree education, I

was challenged with decisions as to which documents were the most relevant to this

situation.

I could not use NVivo to arrange and organise the data because the documents were written in

Arabic, so data was organised manually to include using notes and memos to document initial

thoughts. Memos helped me to move from an empirical to a conceptual level and to identify the

issues that required further exploration in the data analysis.