Choosing to Become a Nurse in Saudi Arabia and the Lived Experience of New Graduates: A Mixed Methods Study Submitted by Mohammed Alboliteeh A thesis submitted as the requirement of the Doctor of Philosophy Degree Faculty of Health Sciences School of Nursing February 2015 Table of Contents Table of Contents ............................................................................................................................... ii List of Figures .................................................................................................................................. vii List of Tables .................................................................................................................................. viii Statement ........................................................................................................................................... ix Acknowledgements ............................................................................................................................ x Abstract ............................................................................................................................................. xi Chapter One: Introduction.................................................................................................................. 1 Introduction to the Study ................................................................................................................ 1 Personal Interest in the Research ................................................................................................... 2 The Research .................................................................................................................................. 3 The Research Aim ...................................................................................................................... 3 The Research Questions ............................................................................................................. 3 The Potential Significance of the Research ................................................................................ 3 Structure of the Thesis ................................................................................................................... 4 Chapter Two: Background ................................................................................................................. 6 Saudi Arabia ................................................................................................................................... 6 Economic and Political Background .......................................................................................... 7 Cultural and Gender Issues ........................................................................................................ 9 Saudisation Plan ........................................................................................................................... 11 Healthcare in Saudi Arabia .......................................................................................................... 12 Nursing in Saudi Arabia ............................................................................................................... 14 Nursing Organisations .................................................................................................................. 16 Men in Nursing in Saudi Arabia .................................................................................................. 18 The Current Situation of Men in Nursing ................................................................................ 19 Recruitment and Retention ........................................................................................................... 21 Image of Nursing in Saudi Arabia ............................................................................................... 22 Nursing Education in Saudi Arabia .............................................................................................. 24 Conclusion ................................................................................................................................... 25 Chapter Three: Research Design ...................................................................................................... 28 Introduction .................................................................................................................................. 28 Research Strategy ......................................................................................................................... 29 Research Design ........................................................................................................................... 29 Mixed Methods Research ............................................................................................................. 32 ii Sequence and Priority .............................................................................................................. 34 Integration ................................................................................................................................ 35 Mixed Methods Study Types ....................................................................................................... 36 Convergent Parallel Mixed Methods Design ........................................................................... 36 Sequential Exploratory Mixed Methods Design ...................................................................... 36 Sequential Explanatory Mixed Methods Design ...................................................................... 37 Choice of the Design .................................................................................................................... 37 Conclusion ................................................................................................................................... 40 Chapter Four: Study One ................................................................................................................. 42 Introduction .................................................................................................................................. 42 Background .................................................................................................................................. 42 Recruitment and Retention ....................................................................................................... 43 Motivation to become a Nurse ................................................................................................. 46 Understanding of the Nursing Role .......................................................................................... 48 Gender Balance ........................................................................................................................ 49 Methods ........................................................................................................................................ 50 Description of Research Design ............................................................................................... 50 The Setting of the Study ........................................................................................................... 51 Population and Sample ............................................................................................................. 51 Inclusion/Exclusion Criteria..................................................................................................... 53 Recruitment Strategies ............................................................................................................. 53 Ethical Considerations ............................................................................................................. 54 Development of the Tool ......................................................................................................... 54 Issues of Validity and Reliability ............................................................................................. 56 Expert Panel ............................................................................................................................. 56 Translation ............................................................................................................................... 56 Piloting ..................................................................................................................................... 57 Data Analysis ........................................................................................................................... 57 Results .......................................................................................................................................... 58 Introduction .............................................................................................................................. 58 Demographic Characteristics ................................................................................................... 59 Motivation to Become a Nurse ................................................................................................ 65 Perceptions of Nursing ............................................................................................................. 71 Future Plans .............................................................................................................................. 75 Open-Ended Question .............................................................................................................. 82 Conclusion ................................................................................................................................... 82 iii Discussion of Study One .............................................................................................................. 84 Introduction .............................................................................................................................. 84 Profile of Saudi Nurses Working in MOH Hospitals in Riyadh .............................................. 85 Motivation for Becoming a Nurse ............................................................................................ 86 Perceptions of Nursing ............................................................................................................. 88 Gender Issues and Nursing ....................................................................................................... 89 Recruitment and Retention ....................................................................................................... 91 Limitations ............................................................................................................................... 94 Conclusion ............................................................................................................................... 94 Chapter Five: Study Two ................................................................................................................. 97 Introduction .................................................................................................................................. 97 Background .................................................................................................................................. 98 Preparation of Nurses in Saudi Arabia ..................................................................................... 98 Transition into Practice ............................................................................................................ 99 Cultural Competence .............................................................................................................. 101 Language and Communication .............................................................................................. 102 The Image of Nursing ............................................................................................................ 104 Methodology .............................................................................................................................. 106 Introduction ............................................................................................................................ 106 Philosophy and Phenomenology ............................................................................................ 107 Emergence of Phenomenology .............................................................................................. 108 Phenomenology of Husserl .................................................................................................... 109 Phenomenology of Heidegger ................................................................................................ 109 Hermeneutic Phenomenology ................................................................................................ 110 Hermeneutic Phenomenology: An Interpretative Approach .................................................. 112 Hermeneutic Phenomenology as a Research Approach for this Study .................................. 113 Methods ...................................................................................................................................... 115 Research Question .................................................................................................................. 115 Research Process .................................................................................................................... 115 Training and Preparation ........................................................................................................ 116 Participant Selection............................................................................................................... 116 The Research Setting.............................................................................................................. 117 Data Collection ...................................................................................................................... 117 Recruitment Process ............................................................................................................... 117 The Interviews ........................................................................................................................ 118 Translation and Language Issues ........................................................................................... 119 iv Data Analyses ........................................................................................................................ 120 Trustworthiness ...................................................................................................................... 121 Conclusion ............................................................................................................................. 123 Findings ...................................................................................................................................... 124 Participants ............................................................................................................................. 124 Maha....................................................................................................................................... 125 Waleed ................................................................................................................................... 125 Mohammad ............................................................................................................................ 125 Wiaam .................................................................................................................................... 126 Dalia ....................................................................................................................................... 126 Norah ...................................................................................................................................... 126 Abdullah ................................................................................................................................. 127 Kholoud .................................................................................................................................. 127 Noor ....................................................................................................................................... 128 Sarah....................................................................................................................................... 128 Mona ...................................................................................................................................... 128 Danah ..................................................................................................................................... 128 Major Themes ........................................................................................................................ 129 Interpretation .............................................................................................................................. 166 Introduction ............................................................................................................................ 166 The Process of Interpretation ................................................................................................. 168 Being a New Saudi Arabian Nurse ........................................................................................ 169 Preparation to Be a Saudi Nurse ............................................................................................ 170 Perceptions of Nursing ........................................................................................................... 174 The Day-to-Day Feelings ....................................................................................................... 184 Wanting to Go Further and Being Part of the Change ........................................................... 187 Conclusion ............................................................................................................................. 194 Chapter Six: Integration ................................................................................................................. 196 Introduction ................................................................................................................................ 196 Integration of Results ................................................................................................................. 196 Drivers of Change ...................................................................................................................... 197 Challenges .................................................................................................................................. 199 Saudisation Program .............................................................................................................. 199 The Saudi Culture .................................................................................................................. 200 Preparation for Practice .......................................................................................................... 202 Attrition .................................................................................................................................. 203 v Opportunities .............................................................................................................................. 204 Conclusion ................................................................................................................................. 206 Chapter Seven: Conclusion ............................................................................................................ 208 Introduction ................................................................................................................................ 208 Implications and Recommendations .......................................................................................... 208 Nursing Education and Training ................................................................................................ 209 The Work Environment ............................................................................................................. 211 The Image of Nursing ................................................................................................................ 213 Urgent Need for Nursing Research ............................................................................................ 214 Areas of Future Research ........................................................................................................... 216 Limitations of this Research....................................................................................................... 217 Conclusion ................................................................................................................................. 217 References ...................................................................................................................................... 218 Appendices ..................................................................................................................................... 232 Appendix 1: The Questionnaire (English version) ..................................................................... 232 Appendix 2: The Questionnaire (Arabic version) ...................................................................... 239 Appendix 3: Ethical Approval from the University of Adelaide's Human Research Ethics Committee .................................................................................................................................. 245 Appendix 4: Ethical Approval from the Ethics Department of the Ministry of Health in Saudi Arabia ......................................................................................................................................... 250 Appendix 5: Invitation Flyer ...................................................................................................... 251 Appendix 6: Invitation Sheet ..................................................................................................... 252 Appendix 7: Participants’ Information Sheet ............................................................................. 253 Appendix 8: Consent Form in English ....................................................................................... 254 Appendix 9: Consent Form in Arabic ........................................................................................ 255 Appendix 10: Complaint Form .................................................................................................. 256 vi List of Figures Figure 1: Map of the Kingdom of Saudi Arabia showing the bordering countries ............................ 7 Figure 2: Study design using sequential explanatory mixed methods ............................................. 40 Figure 3: Age of respondents ........................................................................................................... 59 Figure 4: Number of dependents ...................................................................................................... 60 Figure 5: Respondents’ province of origin ....................................................................................... 61 Figure 6: Highest qualification in nursing ....................................................................................... 62 Figure 7: Years of experience in nursing ......................................................................................... 63 Figure 8: Type of position held ........................................................................................................ 64 Figure 9: Area of nursing practice ................................................................................................... 65 Figure 10: Motivation to become a nurse – altruism ....................................................................... 66 Figure 11: Motivation to become a nurse – a caring profession ...................................................... 66 Figure 12: Motivation to become a nurse – job security .................................................................. 68 Figure 13: Motivation to become a nurse – a good salary ............................................................... 68 Figure 14: Motivation to become a nurse – family expectation ....................................................... 69 Figure 15: Motivation to become a nurse – advice from a nurse ..................................................... 70 Figure 16: Motivation to become a nurse – personal experience of healthcare ............................... 71 Figure 17: Perceptions – nursing is for women................................................................................ 72 Figure 18: Perceptions – nursing does not require high academic qualifications ............................ 73 Figure 19: Perceptions – nursing is a respected profession ............................................................. 74 Figure 20: Number of days respondents would prefer to work ........................................................ 75 Figure 21: Intention to leave nursing ............................................................................................... 76 Figure 22: Reason to leave nursing – my gender ............................................................................. 77 Figure 23: Reason to leave nursing – dealing with the opposite sex ............................................... 78 Figure 24: Reason to leave nursing – dealing with patients of the opposite sex .............................. 79 Figure 25: Reason to leave nursing – I will become a fulltime student ........................................... 80 Figure 26: Reason to leave nursing – I have to work long hours ..................................................... 81 Figure 27: Reason to leave nursing– difficulty communicating in English ..................................... 81 Figure 28: Interpretation of the experience of being a new graduate Saudi nurse ......................... 170 vii List of Tables Table 1: The provision of healthcare in Saudi Arabia ..................................................................... 13 Table 2: Gender of respondents ....................................................................................................... 58 Table 3: Years of experience in nursing .......................................................................................... 63 Table 4: Changes that would alter the decision to leave nursing ..................................................... 82 Table 5: Examples of the themes and sub-themes ......................................................................... 164 viii Statement This work contains no material which has been accepted for the award of any other degree or diploma in my name, in any university or other tertiary institution and, to the best of my knowledge and belief, contains no material previously published or written by another person, except where due reference has been made in the text. In addition, I certify that no part of this work will, in the future, be used in a submission in my name, for any other degree or diploma in any university or other tertiary institution without the prior approval of the University of Adelaide and where applicable, any partner institution responsible for the joint-award of this degree. I give consent to this copy of my thesis, when deposited in the University Library, being made available for loan and photocopying, subject to the provisions of the Copyright Act 1968. I also give permission for the digital version of my thesis to be made available on the web, via the University’s digital research repository, the Library Search and also through web search engines, unless permission has been granted by the University to restrict access for a period of time. Signature: Date: ix Acknowledgements There are two important groups to whom due acknowledgement needs to be made. The first is formal and the second is informal. It is difficult to know which group is the most important because without either one, this thesis would never have been written and completed. Convention decrees that the formal acknowledgement be made first. To my principle supervisor Associate Professor Judy Magarey, who always supported and encouraged me in every stage of my journey, thank you for your patient supervision during my journey and unwavering faith in my capacity to complete the thesis. To my co- supervisor Dr. Richard Wiechula who gave me valuable, skilled and thoughtful advice, encouragement and guidance. I am thankful for the valuable experience I gained from both of you during the last four years. The informal group is much larger and there are too many to name. However, I wish to acknowledge my friend Mr Fahad Algahtani, for his considerate support and treasured friendship during the difficult and great times. Finally thanks goes to my beloved wife and my daughters Nora, Dalal and Razan, my son Ibrahim, my mother and father, my brothers and sisters for their support, patience and encouragement during my study and stay in Australia. I am also thankful to all participants and to the hospitals and health administration for their participation in this study. Also, I would like to thank my sponsor the University of Ha’il for their valuable sponsorship and support during my study. x