Nursing: Attitudes, Perceptions and Strategies for Progress in Saudi Arabia
1991; King Faisal Specialist Hospital and Research Centre; Volume: 11; Issue: 4 Linguagem: Inglês
10.5144/0256-4947.1991.452
ISSN0975-4466
AutoresCynthia L. Jackson, Rebecca Gary,
Tópico(s)Cultural Competency in Health Care
ResumoSpecial CommunicationsNursing: Attitudes, Perceptions and Strategies for Progress in Saudi Arabia Cynthia L. Jackson and MSN Rebecca GaryMSN Cynthia L. Jackson Address reprint requests and correspondence to Cynthia Jackson: King Faisal Specialist Hospital and Research Centre, PO Box 3354, Riyadh 11211, Saudi Arabia. From the Department of Nursing Education and Research, King Faisal Specialist Hospital and Research Centre, Riyadh Search for more papers by this author and Rebecca Gary From the Department of Nursing Education and Research, King Faisal Specialist Hospital and Research Centre, Riyadh Search for more papers by this author Published Online:1 Jul 1991https://doi.org/10.5144/0256-4947.1991.452SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractWestern countries are experiencing a nursing shortage which will impact on future nurse manpower supply in Saudi Arabia because the Kingdom is dependent on expatriate nurses. The young people of Saudi Arabia are the Kingdom's most valuable resources but are reluctant to enter nursing. Therefore, a random survey was administered to 1,131 secondary and university students to determine attitudes and general knowledge of Saudi nationals toward the health care system, perceived role of the nurse and recommendations for improving Saudization of the nursing profession. The majority of those surveyed preferred hospitalization within the Kingdom with Saudi nationals delivering the nursing care rather than expatriates. The nurse was perceived as being a caring person who was responsible for giving more than custodial care. Moreover, the role of the nurse was perceived as an extension of the physician with little or no role in disease detection and prevention. The low image and status of nursing, traditional and social values were identified as major inhibiting factors that affect the Saudi nationals' reluctance to enter nursing. Increasing financial rewards, utilizing the media and segregation of hospitals into male and female were the most frequently cited recommendations to promote Saudization of nursing. Data from this study provided insight into the current perception of nursing as a potential career for Saudi nationals and could provide direction for future concerns in the development of nursing in the Kingdom.IntroductionSaudi Arabia, a country of vast economic resources, has traditionally relied on expatriates to provide nursing care for its citizens[1]. The current nursing shortage, particularly in the Western world, has dramatically increased the marketability of available nurses which, in turn, has brought about a proliferation of creative recruitment and retention strategies. The health-care industry in general has responded to this critical shortage of nurses by increasing salaries and benefits, offering flexible work hours and providing tuition-reimbursement plans for those who desire further education[2]. These positive approaches have directly impacted on, and reduced incentives, for Western nurses to consider employment in Saudi Arabia, as well as in other parts of the world. Moreover, despite their advanced knowledge and technological skills, Western nurses are at a disadvantage as care providers for the people of the Kingdom due to language barriers, cultural differences and relatively short-term stay commitments. These factors, along with increased demands for health-care manpower, have necessitated more attention toward attracting Saudi nationals into the nursing profession[3].In 1407H, a health manpower study estimated that 25,000 nurses were employed in the Kingdom. Of this number, only 8.5% were Saudi nationals, while expatriate nurses accounted for 91.5% of the total population[4]. It is projected that nursing manpower requirements will continually increase over the next 20 years as a result of further expansion in health care facilities, specialized services and natural growth of the population (Figure 1).Figure 1. Projected nurse manpower requirements. (From Al-Ammari A. Nursing shortage impact on Saudi Arabia: Strategies for the future. Presented at Fourth Annual Health Care Manpower Development Symposium on Nursing: The Future Career. 3-4 October 1989 at King Faisal Specialist Hospital and Research Centre, Riyadh).)Download FigureNursing has traditionally been an unacceptable career option for Saudi nationals. This is evidenced by the low numbers of Saudi nationals enrolled in existing nursing programs in the Kingdom. In 1395H (1975G), the national health plan projected a need for 5,000 Saudi nurses by 1399H (1979G). To date, this quota has not been met and only 70 baccalaureate prepared nurses have graduated from either King Abdulaziz University in Jeddah or King Saud University in Riyadh. Graduates from the various technical institutes of nursing, equivalent to nursing assistants in the Western world, currently number approximately 1,000[5]. The reasons for this reluctance of Saudi nationals to enter nursing are not well documented in the literature, although it has been suggested that the low image/status of nurses, traditional-social values, and inadequate financial rewards are contributing factors[6,7]. If this trend continues, Saudi Arabia must continue to rely upon expatriate nurses, which may not be in the best future interest of its citizens.Unless specific strategies are developed, Saudi Arabia may suffer from diminishing nurse manpower resources at a time of increasing health care demands. As a step toward the goal of addressing future strategies, this study was conducted at the request of the hospital administration for the Fourth Annual Health Care Manpower Symposium entitled, “Nursing: The Future Career”, held at King Faisal Specialist Hospital and Research Centre, 3–4 October 1989.The Saudi youth are the Kingdom's most valuable resources and are fundamental in reversing current trends. Their attitudes and career choices will determine the nature of the health care delivery system in the future. Therefore, a random survey of secondary and college-aged Saudi nationals was conducted in order to answer the following questions: What is the knowledge, attitude, and perception of Saudi nationals toward the health care system in general and the nursing profession in particular?What current factors influence the entry of Saudi nationals into the nursing profession?Which incentives or rewards would encourage Saudi nationals to enter nursing?MATERIAL AND METHODSA 25-item questionnaire consisting of 21 closed-ended, i.e., selection of an answer and 4 open-ended questions, wherein the respondent could write in an answer, was used as the instrument for this study. The questions were subcategorized into the following groups for analysis purposes: General knowledge of and attitudes toward the health care system and the nursing professionPerceptions of the role of the nurseImage/status of nursingTraditional-social values which affect Saudi nationals' entry into nursingRecommendations for Saudization of nursingThe questionnaire was translated into Arabic and reviewed for content and clarity by a graduate nursing student enrolled at King Saud University and by members of the Human Resources Department (HRD) at King Faisal Specialist Hospital & Research Centre (KFSH&RC).Study PopulationThe questionnaire was randomly distributed to male and female students attending secondary public school systems and to secondary schools sponsored by the Ministry of Defense and Aviation in the Riyadh area. The selection of public schools was designated by members of the Human Resources Department (HRD), based on location of the school and the socioeconomic status of the students served. Every attempt was made by the HRD to equally distribute the sample population in relation to socioeconomic status in order to get a more generalized view of all strata of Saudi citizens. In addition, the male and female campuses of King Saud University in the Riyadh area who were not already committed to a health-related profession were included in the sample.Rationale for SelectionThis target population was selected because these young men and women are the present resources and future leaders of the Kingdom. Second, it was felt that a population not committed to any health care profession might contribute fresh insight into the attitudes, knowledge, and perceptions of the Saudi population in general. Third, due to the fact that Saudi males are the leaders of the nation, as well as the family, the researchers felt that it was particularly important to include males in the target population. Finally, the female researchers' ability to access the female population was far easier to accomplish than accessing the male population, which was not possible without the assistance of male members of the Human Resources Department.Data AnalysisThe data was analyzed using descriptive methods by the Human Resources Department personnel at KFSH&RC.RESULTSThe questionnaires were randomly distributed by the researchers and members of the Human Resources Department at Riyadh area schools and King Saud University. A total of 1131 questionnaires were completed. The sample was categorized according to sex and level of education (Table 1).Table 1. Demographic data for sample population.General Attitudes and KnowledgeSixty two percent (62%) of the respondents had little or no background knowledge of nursing. This was supported by the fact that only 30% of the sample indicated an awareness that a worldwide nursing shortage currently exists.Ninety six percent (96%) of the research sample agreed that nursing is essential to any health care system and the majority (89%) agreed that the patients' health improves because of nursing care.Eighty three percent (83%) preferred to be hospitalized within the Kingdom rather than seeking health care abroad, and they preferred that Saudi nationals deliver the nursing care (70%) as compared to expatriate nurses (Table 2). When asked if nursing was a possible career option, 36% of the respondents indicated they would consider nursing in the future as a career.Table 2. Summary: General attitudes and knowledge toward health care system and nursing.Perception of Nursing RoleThis sub-category consisted of nine questions related to various functions considered within the domain of nursing practice. The results are summarized in Table 3. Briefly, the nurse was perceived by the majority of the population as a caring person who is expected to provide more than custodial care. Nursing was not viewed as an autonomous profession, but more as an extension of medicine with the nurse having little or no independent decision making role. Moreover, results indicated that the nurse is perceived as having no role in the detection and/or prevention of disease.Table 3. Summary: The role of nursing as perceived by sample population.The majority of the respondents (27% = 1-2 years; 41% = 2-4 years) indicated that the nurse should have a minimum of 2 years formal education (Figure 2). Knowledge of diseases, religion and culture, provision of emergency care, and adequate preparation in the delivery of technical skills, were all viewed as part of the nurses' responsibility in providing patient care. In regard to health education, the nurse is perceived as being an appropriate source of information regarding practices which will achieve and maintain “good health.” However, they believed that nurses had no role in disease prevention which is somewhat contradictory.Figure 2. Educational requirements to become a nurse as perceived by sample population.Download FigureImage and Status of NursingParticipants were asked to numerically rank a set of occupations according to perceived status (Figure 3).Figure 3. Numerical ranking of occupations according to perceived status.Download FigureIn relation to image and status, teaching, military service and business were ranked as the most attractive occupational choices. Nursing was ranked sixth out of thirteen career choices. When compared with other health professions, nursing was numerically ranked lower than pharmacy, but higher than other health-care occupations such as laboratory and x-ray technicians and dental hygienists. The researchers assumed that physicians would be ranked higher in image and status than nurses; and therefore medical practice was not included as a career choice.In response to the question regarding whether social class should influence the decision as to who should enter the nursing profession, 57% agreed while 43% disagreed. Specific questions aimed at ascertaining which members of what level(s) of society should enter nursing were not addressed by this study.Traditional-Social ValuesCurrent traditional-social values of Saudi society were perceived as important, influencing factors in choosing nursing as a career. Sixty nine percent (69%) of those responding indicated that they would support a family member who chose to enter the nursing profession. Of the 31% who would not, 72% cited “social” reasons as primary inhibiting factors. These reasons included undesirable work hours, traditional roles of women in society and the non-segregated work environment that currently exists in most hospitals. Salary was not indicated as a major factor in lack of support of one's family member in the choice to enter nursing, as only 5% of respondents listed salary as a concern. Segregation of hospitals into male and female divisions would provide one major incentive for Saudi nationals to enter the nursing profession, as 80% (N = 802) of respondents stated that nursing would be a viable career option if this occurred.Since a great deal of emphasis is placed on marriage, a question was asked regarding whether or not the participants would consider marrying a nurse. Sixty four percent (64%) indicated they would not marry a nurse. “Social” reasons were cited as the major deterrent in this choice. The specific social reasons indicated were the same as those listed previously in response to reason for not supporting a family member's choice to become a nurse. Again, only 5% viewed financial incentives as a factor for their response to this question. The reasons for this are not well understood, i.e., lack of knowledge regarding salaries or financial rewards not a concern. Further research on this topic may provide clarification on this matter.Recommendations for Saudization of NursingFifty-nine percent (N = 667) of the sample responded to the question regarding factors that would most likely increase Saudization of nursing. Improving financial incentives/rewards (31%), use of media to improve the overall image of nursing (29%), and segregating hospitals (22%) were cited most frequently as measures that would promote Saudization of the nursing profession (Figure 4).Figure 4. Strategies for improving the Saudization of nursing as recommended by sample population.Download FigureDISCUSSIONSaudi Arabia currently has “state of the art” medical care and health-care facilities to offer its citizens. There is no longer a need for Saudi citizens to seek health care abroad, and according to this study, hospitalization within the Kingdom is preferred. Moreover, Saudi nationals are in preference to be the nursing care providers as compared with expatriate nurses. This is problematic, however, since nursing is considered a less than acceptable career choice for the majority of Saudi nationals. Enrollment in the Kingdom's established nursing institutes and colleges suggests this trend is not likely to improve in the near future. Unless specific measures are adopted to attract Saudi nationals into nursing, the quality of patient care, as well as the accessibility to health services by the people, could be threatened in the future.The results of this study indicate that nursing is perceived relatively low in status in comparison to other occupational choices. This is somewhat congruent with the image of nursing in the western world, although changing due to the acute shortage. The low image of nursing as a predominantly female occupation has contributed to the existing shortage with females choosing and being recruited into more lucrative occupations, such as business, law, medicine, etc. Reluctance to choose nursing as a career in Saudi Arabia is based on this perception of low image along with current traditional-social values of the society. Financial concerns were not considered a major deterrent for entering nursing, although recommendations for improving Saudization included increasing financial rewards.Limitations of the StudyThe nature of Saudi society prohibits easy access to its citizens. Moreover, the logistics and manpower required to solicit responses outside of the Riyadh area and/or undertake a Kingdom wide survey were not feasible at the time the study was conducted. Any generalizations of this study to the Saudi population, therefore, must be made with caution.Implications and RecommendationsData from this study provided insight into the current perception of nursing as a potential career for Saudi nationals and could provide direction for future concerns in the development of nursing in the Kingdom.First, it is important for the people of Saudi Arabia and leaders of health-care policy to determine if the best interests of the citizens will be served by adopting a western perception of the nursing profession. Levels of practice, educational preparation, licensure and credentialing are issues that should be addressed and appropriately integrated into the health-care expectations of the Saudi citizens. From this, a unified national nursing education policy could emerge that would identify what nurses need to know in order to deliver care within the context of Saudi society.Second, the resources need to be identified that can be utilized to effect change, if change is desired. Religious leaders, leaders of national policy, Arabic media and the school systems are all potential resources toward this effort. In papers presented at the Fourth Annual Health Manpower Symposium, Dr. Nasser from King Abdulaziz University and Major Rashid Aba Alkhail, M.D., from Security Forces Hospital supported that nursing practice is consistent with Islamic teachings. They went on to state that the historical development of nursing could be traced during the early period of Islam. Support by religious leaders for Saudi nationals to enter nursing could promote enthusiasm and reduce the traditional barriers in selecting nursing as a career option.The Arabic media could play a major role in helping to reverse the current negative image of the nursing profession. The nurse portrayed in a manner that is consistent with religious and traditional-social mores of Saudi society would encourage a more positive view of nursing that is consistent within the framework of societal values. Educating the public regarding the expanded role of the nurse in patient care delivery might encourage increased interest in these areas, i.e., nurse practitioner, educator, administrator. The media, particularly television and newspapers, were identified as major resources to promote Saudization by our research sample. For example, the recent location of kidney transplant recipients broadcast over television brought the two young boys rapidly to King Faisal Specialist Hospital and Research Centre when all other communication contact attempts failed. Saudis do watch television and have limited options for programming. A series on nursing could be most effective.The youth of Saudi Arabia are a captive audience when they are enrolled in the elementary and secondary school system. Saudi nurses could be utilized as health educators in the school system as well as in an expanded role capacity such as nurse practitioner. Both of these functions could serve as positive role models for students who may wish to pursue nursing as a future career. The role of the nurse/teacher could be of particular value when health concerns of the adolescent are addressed. Currently, the Kingdom has launched a nationwide campaign to promote a drug-free society. Nurses can make valuable contributions to such efforts because of their psychosocial and physiological knowledge base.Third, one of the primary responsibilities of the male population is to provide support to the family. In order to promote the acceptance of nursing as a career option for men, increasing financial rewards may be necessary. Although financial concerns were not listed as primary reasons for not choosing nursing as a career, it was considered a major strategy for promoting Saudization of nursing. The leaders of national policy could help toward this goal by improving financial incentives to enter nursing. Increased stipends while studying nursing, as well as improved salaries upon graduation, could increase motivation to choose nursing as a field of study.According to the data, segregation of sexes in the work environment is a major incentive that would attract more Saudi nationals into nursing. Practical consideration may need to be given as to how this could be accomplished in order to provide a work environment more reflective of traditional-social norms. It is recognized this would be a major dilemma for the health-care leaders of the Kingdom. Segregation of hospitals would pose enormous financial and administrative challenges. In the long-run, however, it may be more cost-effective for several reasons. Removing traditional-social barriers would attract more Saudi nationals into nursing as our data suggest, thereby reducing the economic constraints of an expatriate work force. In addition, care could be provided by those who are most suitable from a traditional, cultural and religious standpoint. Work hours, a major deterrent for choosing nursing, may not be as problematic if the hospitals were segregated.During the transition period of Saudization in nursing, expatriate nurses could be utilized as consultants, similar to that of the medical profession. Advanced clinical knowledge and expertise could be disseminated through perceptorships and educational programs. Preparation for extended roles such as Administrator, Educator and Practitioner could be facilitated with expatriate nurses currently fulfilling these roles.In conclusion, the nursing shortage is real, and according to predictions, will continue to grow into the next century. Nurses are, and will continue to be, a valued commodity as they become more limited. The costs of recruiting expatriate nurses may become economically prohibitive for Saudi Arabia in the future. Also, the most expensive health-care provider may not be the best or most appropriate for delivering care to the citizens. The challenge that lies ahead, therefore, is to work at developing a unique, cost-effective health-care delivery system that makes the best use of the current and projected resources available.ARTICLE REFERENCES:1. Sebai Z. "Health services in Saudi Arabia. Part 1: an overview" . Saudi Med J. 1987; 8 (6). Google Scholar2. Miller A, Bradburn E. Seeking an Rx for nurses: as shortages grow, hospitals recruit harder. Newsweek. 1989;July10: 32–3. Google Scholar3. Al-Swailem AR. "Assessing health care delivery in Saudi Arabia" . Ann Saudi Med. 1990; 10 (1): 63–8. Google Scholar4. Ministry of Health, Kingdom of Saudi Arabia. Annual Statistical Report. Riyadh (1987, 1407H). Google Scholar5. Brown BJ. Nursing administration in Saudi Arabia. In: Henry (editor). International administration of nursing services. Philadelphia: Charles Press, 1989;59–66. Google Scholar6. Aba-Alkheil R. "Saudization of nursing: difficulties-solutions" . Presented at Fourth Annual Health Care Manpower Development Symposium on Nursing: The Future Career. 3-4 October1989 at King Faisal Specialist Hospital and Research Centre, Riyadh. Google Scholar7. Nasser K. "Social factors and their impact locally on nursing as a profession" . Presented At Fourth Annual Health Care Manpower Development Symposium On Nursing: The Future Career. 3-4 October1989 at King Faisal Specialist Hospital and Research Centre, Riyadh. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 11, Issue 4July 1991 Metrics History Accepted30 August 1990Published online1 July 1991 InformationCopyright © 1991, Annals of Saudi MedicinePDF download
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