JOB SATISFACTION AND BURNOUT AMONG FOREIGN-TRAINED NURSES IN SAUDI ARABIA: A MIXED-METHOD STUDY by Joan E. Mitchell
A Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Education in Educational Leadership
UNIVERSITY OF PHOENIX January 2009
UMI Number: 3357443 Copyright 2009 by Mitchell, Joan E. All rights reserved
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ABSTRACT The purpose of the study was to explore the relationship between demographic and work environment factors and hospital characteristics (linked to job satisfaction) and burnout among foreign-trained nurses (FTNs) living and working in Saudi Arabia. A mixedmethod study using correlation and triangulation designs explored the associations between demographic factors and work environment factors and the subscales for job satisfaction (Nursing Work Index-Revised and the Practice Environment Scale) and burnout (Maslach Burnout Inventory). Four hundred and fifty-three FTNs participated in the surveys and 25 FTNs participated in focus group sessions. The theoretical framework for the mixed-method study was Herzberg’s motivation-hygiene theory. The results identified that FTNs with a diploma or associate degree, newly registered nurses (after 2001), and FTNs on a married contract had a higher perception of job satisfaction for 4 of 9 subscales. Overall scores indicated higher burnout for emotional exhaustion and depersonalization and an average feeling of burnout for personal accomplishment. Scores also indicated FTNs had neutral feelings of a professional work environment. Triangulated analysis corroborated the qualitative and quantitative findings. Important issues for FTNs included staffing, policies and procedures, status, security, support for nursing, continuing education, and communication. Foreign-trained nurses also raised issues unique to the nature of work in Saudi Arabia as areas of improvement. If the work environment improves, job satisfaction may increase, burnout may decrease, and tenure may improve. Nursing leaders in all sectors must be empowered to effect change in the professional nursing work environment through collaboration, cooperation, and transformational leadership in order to recruit and retain qualified FTNs.
iv DEDICATION Two roads diverged in a wood, and I – I took the one less traveled by, And that has made all the difference. The Road Not Taken, Robert Frost (1920) I dedicate this adventure to my deceased parents (Katherine and Roe), who taught me to live life to its fullest and never wonder, what if. To my husband (Khalid) for his support and love as we walked the road together.
v ACKNOWLEDGMENTS This study would not be a reality without the support and encouragement from many people. The first acknowledgment is to the foreign-trained nurses who live and work in Saudi Arabia and who participated in the study; you were courageous. Thank you to the hospital owners, directors, nursing directors, and quality managers for your openness to engage in uncharted territory. The second acknowledgement is for the expert individuals who stood by me to realize this day. I extend my heartfelt gratitude to Dr Suzanne Richins, my mentor. Your patience, understanding, attention to detail, and commitment to learning encouraged me to go the distance. A warm thank you to Dr Barbara L. Brush and Dr Rick Stewart my committee members. Your contribution to the learning process, your energy, and your encouragement along the way facilitated the completion of this dissertation. To my friend and colleague Dr Kamal Hijjazi, thank you for guiding me through the quantitative process as the expert statistician. Thank you to Mrs. Toni Williams for your expert knowledge of APA, your keen eye in editing the dissertation, and for accommodating tight deadlines. The next acknowledgment is for the individuals who supported and encouraged me in this research. To the first General Directorate of Nursing in the Ministry of Health (MOH), Saudi Arabia, a warm thank you to Mrs. Muneera Al Osaimi. Your support of this research demonstrates your commitment to the nursing profession. A special acknowledgement to my friends and colleagues who contributed their time, expert knowledge, and encouragement during this process: Haydee Mabuhay, Jette Mabrouk, Angela Otvos, Irmgard Rondeau, Leo Daquita, Jeddah Nurses Executive Forum members, and others. Special thanks to Dr. Sean Clarke who reached out to help a student and encouraged me along the way.
vi TABLE OF CONTENTS LIST OF TABLES........................................................................................................... xiv LIST OF FIGURES ...........................................................................................................xv CHAPTER 1: INTRODUCTION ........................................................................................1 Background of the Problem .................................................................................................2 Statement of the Problem.....................................................................................................7 Purpose of the Study ............................................................................................................9 Significance of the Problem...............................................................................................10 Nature of the Study ............................................................................................................12 Research Questions............................................................................................................15 Theoretical Framework......................................................................................................18 Definition of Terms............................................................................................................22 Assumptions.......................................................................................................................25 Limitations .........................................................................................................................27 Delimitations......................................................................................................................29 Summary ............................................................................................................................30 CHAPTER 2: REVIEW OF THE LITERATURE ............................................................32 Documentation...................................................................................................................33 Literature Review...............................................................................................................34 Global Migration History ...........................................................................................34 Push–Pull Factors .......................................................................................................36 Status of Nursing Shortage .........................................................................................43 Saudi Arabia’s Nursing History..................................................................................46
vii Status of Saudi National Nursing ...............................................................................48 Supporting Viewpoints on Nurse Migration...............................................................49 Opposing Viewpoints on Nurse Migration.................................................................53 Job Satisfaction and Burnout .............................................................................................58 Saudi Arabia.......................................................................................................................64 Census Data ................................................................................................................66 Religion.......................................................................................................................69 The Status of Women According to Islam .................................................................71 Education ....................................................................................................................73 Health Care .................................................................................................................77 Saudization .................................................................................................................84 The Role of Women....................................................................................................87 Cultural Diversity .......................................................................................................89 Conclusion .........................................................................................................................92 Summary ............................................................................................................................93 CHAPTER 3: METHOD ...................................................................................................95 Research Design.................................................................................................................96 Appropriateness of Design.................................................................................................98 Research Questions............................................................................................................99 Population ........................................................................................................................102 Informed Consent.............................................................................................................104 Sampling Frame ...............................................................................................................106 Confidentiality .................................................................................................................108
viii Geographic Location........................................................................................................110 Instrumentation ................................................................................................................111 Data Collection ................................................................................................................120 Data Analysis ...................................................................................................................124 Validity and Reliability....................................................................................................128 NWI-R ......................................................................................................................129 PES-NWI ..................................................................................................................131 MBI...........................................................................................................................133 Summary ..........................................................................................................................138 CHAPTER 4: RESULTS.................................................................................................140 Review of Data Collection Procedures ............................................................................141 Preparation for Data Analysis..........................................................................................145 Exploring the Quantitative Data ......................................................................................150 Participant Demographics................................................................................................150 Survey Subscales .............................................................................................................152 Reliability .................................................................................................................152 Validity .....................................................................................................................153 Bivariate Analysis............................................................................................................156 Multiple Regression Analysis ..........................................................................................159 Research Hypotheses .......................................................................................................162 Exploring the Qualitative Data ........................................................................................167 Demographic Information................................................................................................168 Question 1: What Attracted You to Work in Saudi Arabia? ...........................................169
ix Salary ........................................................................................................................169 Religion.....................................................................................................................171 Experience, Knowledge, and Personal Growth ........................................................172 Question 2: What Are the Issues That You Deal With Working in Saudi Arabia?.........173 Work Conditions.......................................................................................................173 Personal Life.............................................................................................................177 Recruitment Practices ...............................................................................................179 Salary ........................................................................................................................180 Company Policy and Administration........................................................................181 Registration and Licensure .......................................................................................182 Questions 3: Describe to Me a Time When You Felt Exceptionally Happy at Work .....183 Recognition...............................................................................................................184 Salary ........................................................................................................................186 Work Itself ................................................................................................................186 Work Conditions.......................................................................................................187 Achievement .............................................................................................................187 Relationship With Peers ...........................................................................................187 Relationship With Supervisors .................................................................................188 Company Policy and Administration........................................................................188 Responsibility ...........................................................................................................188 Question 4: Describe to Me a Time When You Felt Exceptionally Bad at Work...........189 Company Policy and Administration........................................................................189 Work Conditions.......................................................................................................192
x Status.........................................................................................................................195 Relationship With Supervisor...................................................................................196 Security .....................................................................................................................196 Personal Life.............................................................................................................197 Summary ..........................................................................................................................198 CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS...................................200 Findings............................................................................................................................201 Organizational Support and Staffing and Resource Adequacy........................................202 Staffing .....................................................................................................................203 Support for Nursing ..................................................................................................204 Adequate Resources for Staff ...................................................................................206 Adequate Resources for Patients ..............................................................................206 Continuing Education ...............................................................................................207 Opportunities for Advancement ...............................................................................207 Control Over the Practice Setting, Nurse Participation in Hospital Affairs, and Nursing Foundations for Quality of Care ......................................................................................208 Policies and Procedures ............................................................................................209 Recruitment Practices ...............................................................................................210 Orientation and Competency Assessment ................................................................211 Quality Improvement................................................................................................212 Nurse–Physician Relationships and Collegial Nurse–Physician Relationships ..............212 Recognition and Support ..........................................................................................213 Cultural and Value Differences ................................................................................213
xi Autonomy Over Practice and Nurse Manager Ability, Leadership, and Support of Nurses214 Support of Nurses in Practice ...................................................................................214 Language Barriers.....................................................................................................217 Status of Nurses ........................................................................................................218 Research Hypotheses 1 and 2 ...................................................................................219 Research Hypothesis 3..............................................................................................228 Research Hypothesis 4..............................................................................................232 Assumptions.....................................................................................................................234 Limitations .......................................................................................................................235 Delimitations....................................................................................................................236 Implications......................................................................................................................236 Significance of the Study .................................................................................................237 Significance to Leadership...............................................................................................238 Recommendations for Nursing Leaders and Hospital Leaders........................................242 Hygiene Factors ........................................................................................................242 Motivators.................................................................................................................247 Recommendations for Future Research ...........................................................................251 Summary and Conclusion ................................................................................................253 REFERENCES ................................................................................................................258 APPENDIX A: PERMISSION LETTER FROM HEALTH RESOURCES AND SERVICES ADMINISTRATION .............................................................................281 APPENDIX B: HERZBERG’S MOTIVATION–HYGIENE THEORY........................283 APPENDIX C: MINISTRY OF HEALTH LETTER OF SUPPORT .............................284
xii APPENDIX D: TRANSLATED MINISTRY OF HEALTH LETTER OF SUPPORT .285 APPENDIX E: STUDY PROTOCOL.............................................................................286 APPENDIX F: INTRODUCTION LETTER TO STUDY..............................................292 APPENDIX G: LETTER OF COLLABORATION AMONG INSTITUTIONS ...........293 APPENDIX H: INFORMED CONSENT: PERMISSION TO USE PREMISES, NAME, AND/OR SUBJECTS ................................................................................................294 APPENDIX I: INTRODUCTION LETTER TO PARTICIPANTS................................295 APPENDIX J: INFORMED CONSENT FOR PARTICIPANTS 18 YEARS OF AGE AND OLDER.............................................................................................................297 APPENDIX K: THANK YOU LETTER TO MINISTRY OF HEALTH ......................300 APPENDIX L: CONFIDENTIALITY STATEMENTS .................................................301 APPENDIX M: DEMOGRAPHIC SURVEY.................................................................304 APPENDIX N: NURSING WORK INDEX – REVISED ..............................................308 APPENDIX O: PERMISSION LETTER FROM DR AIKEN........................................314 APPENDIX P: THE PRACTICE ENVIRONMENT SCALE OF THE NURSING WORK INDEX..........................................................................................................315 APPENDIX Q: PERMISSION LETTER FROM DR. LAKE.........................................317 APPENDIX R: PERMISSION LETTER FROM CPP, INC ...........................................318 APPENDIX S: FOCUS GROUP SESSIONS..................................................................319 APPENDIX T: HOSPITAL VISITS IN MARCH AND APRIL 2008 ...........................321 APPENDIX U: CONSENT AND SURVEY DISTRIBUTION AND COLLECTION DATA ........................................................................................................................322
xiii APPENDIX V: VARIABLE DESCRIPTION AND CODING AND HOSPITAL INFORMATION........................................................................................................324 APPENDIX W: ORIGINAL FORMAT AND RECODED FORMAT OF STUDY VARIABLES (DESCRIPTIVE STATISTICS).........................................................332 APPENDIX X: DETAILED DESCRIPTIVE STATISTICS ..........................................337 APPENDIX Y: BIVARIATE STATISTICS (T TEST)...................................................339 APPENDIX Z: CORRELATION MATRIX ...................................................................345 APPENDIX AA: MULTIPLE REGRESSION STATISTICS ........................................346 APPENDIX BB: FOCUS GROUP CHARACTERISTICS ............................................351 APPENDIX CC: SUMMARY OF PARTICIPANT STORIES AND NATIONALITIES (QUESTIONS 1 AND 2) ...........................................................................................353 APPENDIX DD: PULL / PUSH FACTORS ..................................................................355 APPENDIX EE: DAILY ISSUES ...................................................................................361 APPENDIX FF: SUMMARY OF PARTICIPANT STORIES AND NATIONALITIES (QUESTIONS 3 AND 4) ...........................................................................................386 APPENDIX GG: EXCEPTIONALLY HAPPY STORIES.............................................388 APPENDIX HH: EXCEPTIONALLY BAD STORIES .................................................397 APPENDIX II: QUALITATIVE DATA .........................................................................421 APPENDIX JJ: HYPOTHESES 1 AND 2: BIVARIATE RESULTS (T TEST)............424 APPENDIX KK: HYPOTHESIS 3: BIVARIATE RESULTS (T TEST) .......................425 APPENDIX LL: HYPOTHESES 1 AND 2: MULITPLE REGRESSION RESULTS...426 APPENDIX MM: HYPOTHESIS 3: MULTIPLE REGRESSION RESULTS ..............427 APPENDIX NN: HYPOTHESIS 4: MULTIPLE REGRESSION RESULTS................428
xiv LIST OF TABLES Table 1 Measures for Dependent and Independent Variables.........................................125 Table 2 Hypotheses Testing Plan.....................................................................................126 Table 3 Survey Subscales.................................................................................................154 Table 4 NWI-R and PES-NWI Pairing and Means..........................................................203
xv LIST OF FIGURES Figure 1. National supply and demand projections for full-time equivalent registered nurses: 2000-2020..........................................................................................................4 Figure 2. Age distribution trend of the registered nurse population ....................................5
1 CHAPTER 1: INTRODUCTION The nursing shortage challenges policy makers in developed and developing nations. According to Pond and McPake (2006, p. 1448), analysts posit the recent rise in immigration of nurses and physicians from low- and middle-income countries to highincome countries will continue to play a major role in the global health-care shortage for decades. As a recipient nation for health-care professionals, Saudi Arabia has depended on foreign-trained nurses (FTNs) since the 1950s (Tumulty, 2001, p. 285). Despite its financial stability, Saudi Arabia is a developing nation that remains dependent on FTNs as it continues to develop its health-care infrastructure for a society of approximately 28.1 million people (Facts About Saudi Arabia, 2008, People section, ¶ 1). Foreign-trained nurses are “nurses trained in other countries” (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004, p. 70). According to the Ministry of Health (MOH; M. Al Osaimi, personal communication, January 9, 2007), 76% of working nurses in all sectors of the health-care arena, including MOH, private, and military institutions, are non-Saudis. The Arab News (“Saudi Nurses,” 2006) reported, “In public hospitals, 77 percent of working nurses are non-Saudis, in the private sector the percentage reaches somewhere near 98 percent” (¶ 11). There is a gradual move to Saudize the nursing workforce, that is, to replace FTNs with nurses prepared domestically. In 1999, 81.4% (or 54,780) of the nurses working in Saudi Arabia were foreign born and trained (MOH, as cited in Al-zayyer, 2003, p. 3). To replace FTNs with national workers challenges many Arab countries, as the countries’ own workforce is reluctant to enroll in a profession that is fraught with family and religious conflicts (Al-Kandari & Lew, 2005, pp. 533-534; Doumato, 2003, p. 240;
2 Tumulty, 2001, p. 288). Saudi Arabia offers recruitment incentives that are attractive for FTNs: higher salaries, improved benefits, travel opportunities, and the opportunity to immigrate to Western countries after gaining experience in modern health-care organizations. The global competition for nurses, the worsening nurse shortage, the lack of tenure in nursing due to job dissatisfaction and burnout, and the inability to supply sufficient numbers of its own nurses to health care facilities places Saudi Arabia in the precarious position of being both dependent on and at risk for being unable to recruit and retain qualified FTNs. Background of the Problem Like many other nations around the world, Saudi Arabia faces the challenge of recruiting and retaining nurses in sufficient supply to provide quality care to its constituents. Unlike other countries such as the United States, Canada, and the United Kingdom, Saudi Arabia’s nursing leadership has insufficient nurse workforce research to guide work force strategies now and in the future. The significance of the nursing shortage in Saudi Arabia is its dependence on FTNs and the lack of sufficient numbers of Saudi nurses to replace the FTNs. Saudi Arabia’s leadership lacks sufficient data to understand the significance of recruiting and retaining issues (M. Al Osaimi, personal communication, January 9, 2007). Nursing shortages worldwide have been cyclical occurrences since the late 1950s (Berliner & Ginzberg, 2002, ¶ 2; Sigma Theta Tau International, 2001, ¶ 3). To counter these cyclical shortages, employers improved wages and benefits and recruited FTNs (Berliner & Ginzberg, ¶ 2; Buerhaus, Staiger, & Auerbach, 2003, ¶ 2). Three indicators make the present nursing shortage different from previous shortages. First, the demand
3 for nurses is increasing, while the supply is decreasing (see Figure 1). The demand for nurses is increasing because of an aging population that requires more complex healthcare services. The term baby boomer describes the aging population, the generation born between 1946 and 1964 (Sigma Theta Tau International, 2001, ¶ 7). Aiken (2006, Linda Aiken, Ph.D. section, ¶ 6) reported by 2012 the United States will need 1 million nurses because of the creation of new jobs and the retirement of nurses. Second, the supply is decreasing as recruiting potential nursing students remains challenging, nurses are leaving the profession for other careers, and many nurses are retiring (Berliner & Ginzberg, 2002, ¶ 4; Sigma Theta Tau International, ¶ 7). The last indicator that identifies the present nursing shortage as different is improved wages and benefits and FTN recruitment will not stay the shortage (Aiken, Linda Aiken, Ph.D. section ¶ 16). Improving wages and benefits and recruiting FTNs is a short-term measure because (a) the aging nurse workforce will retire, leaving a shortage of 500,000 nurses by 2012 (see Figure 2), and (b) because of layoffs during reengineering phases in managed care, 425,000 new jobs are vacant (Aiken, Linda Aiken, Ph.D. section, ¶ 6).. Many factors contributed to the current shortage of nurses. According to Aiken et al. (2004), “Failed policies and underinvestment in nursing” (p. 76) contributed to the worsening nursing shortage in developed countries such as the United States, United Kingdom, Canada, Ireland, Australia, and New Zealand. Cooper and Aiken (2006, p. 68S) noted in 2004, nearly 150,000 applicants were turned away from nursing schools because of capacity limitations (lack of faculty) and an insufficient educational infrastructure. Nurses spend their time on nonnursing tasks that contribute to burnout, dissatisfaction, and higher turnover rates. In 2006, the International Council of Nurses
4 (ICN) and Florence Nightingale International Foundation (FNIF; p. 5) identified several issues contributing to the present nursing shortage across all economies: an aging nurse workforce, aging populations, increased population growth rates, increased chronic and noncommunicable diseases, lack of funding for nurse recruitment, more career choices for women, lack of human resource policies, internal and external migration, high attrition (because of poor working conditions, low salaries, lack of professional satisfaction, and burnout), and increased risk of HIV/AIDS.
Figure 1. National supply and demand projections for full-time equivalent registered nurses: 2000-2020. Note. From Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020 (p. 3), by Health Resources and Services Administration, July 2002, Washington, DC: U.S. Department of Health and Human Services. Copyright 2002 by the U.S. Department of Health and Human Services. Adapted with permission (see Appendix A).
5
Figure 2. Age distribution trend of the registered nurse population. Note. From What Is Behind HRSA’s Projected Supply, Demand, and Shortage of Registered Nurses? (p. 4), by Health Resources and Services Administration, September 2004, Washington, DC: U.S. Department of Health and Human Services. Copyright 2004 by the U.S. Department of Health and Human Services. Adapted with permission (see Appendix A). Predicted nursing vacancies worldwide are staggering and statistics are increasingly consistent in their reflection of the crisis that is unfolding. Both developed and developing countries are now exhibiting similar patterns of increased nurse demand, diminished nurse supply, and a tendency to look across borders to satisfy the imbalance. As the figures for nursing vacancies unfold, the widespread nurse shortfall in virtually all countries across the world will make the international strategy nearly impossible. Survey data from Canadian nurses in 2005 demonstrated that 70% were over the age of 40, with an average age of 44 and that by 2006, 94,000 nurses would have the option of early
6 retirement at age 55 (Keatings, 2006, p. 63S). Data from Sigma Theta Tau International in 2001 (¶ 12) showed early signs that some smaller countries were already suffering the effects of poor nurse production and a weakened job marker. For instance, Poland graduated 10,000 new nurses each year until 1990 and then the number diminished to 3,000 by 2000, while in Chile, only 8,000 of 18,000 nurses were working in the profession in 2000 (Sigma Theta Tau, 2001, ¶ 13). According to Yan (2006, p. 72S), the Caribbean islands had a nursing vacancy rate of 58.4% in 2003. At the same time, the United Kingdom’s National Health Services (NHS) estimated a shortfall of 35,000 nurses in 2004; the effect was that 25% of the nurses working in London were international recruits (Denton, 2006, p. 77S). At the Australian Health Ministers Conference in 2004 (as cited in Buchan, 2006, p. 18S), Australia predicted a shortage of 40,000 nurses by 2010. The greatest impact was in sub-Saharan Africa, where the shortage was at 600,000 nurses (Denton, p. 76S). Malawi, one of the world’s poorest nations, trains only 60 nurses per year, yet the country loses almost 100 nurses per year to international recruitment, half of whom travel to the United Kingdom. Life expectancy in Malawi is 38 years (Denton, p. 78S). Nursing workforce data are not always available everywhere, such as the Western Pacific Region, because of the lack of an infrastructure to monitor trends (World Health Organization [WHO], 1998, ¶ 3). The nursing shortage has created competition among Western developed countries vying for nurses. By 2003, the competition was so great that recruitment practice reverted to offering positions to almost all nurses regardless of experience, training, and competency (Yan, 2006, p. 72S). The new trend in recruitment practice has also been prevalent in Saudi Arabia. While FTNs applying for positions in the MOH and
7 military hospitals in Saudi Arabia ideally have a minimum 2 years of nursing experience in the specialty, recruiting practices, especially in the private sector, deviate from this norm. According to current practice for some hospitals, the nursing shortage is so critical that recruitment now includes new foreign graduates with less than 2 years experience. The new graduates, classified as assistant nurses, must work in the hospital for 2 years under the supervision of a registered nurse to gain experience. After 2 years, the assistant nurses can write the Saudi Council license exam and when they pass, their title and salary reflect the change in status to a registered nurse (H. Mabuhay, personal communication, March 18, 2007). International recruitment is efficacious as nations strategize how to manage all the issues. With the demand for nurses greater than the supply, international recruitment presents an ethical and moral issue for all nations. The nursing shortage in developed countries is partially resolved by recruiting FTNs (Aiken, 2006, Linda Aiken, PH.D. section, ¶ 3). In doing so, developed countries will deplete the resources of developing countries. Statement of the Problem It will take many years to Saudize the nursing profession (M. Al Osaimi, personal communication January 9, 2007), and the country’s dependence on FTNs places Saudi Arabia’s health-care infrastructure in a vulnerable position considering the worsening global shortage of nurses (Al-zayyer, 2003, p. 1). Aiken, Clarke, Sloane, Sochalski, et al. (2001, p. 52) noted that decreased staffing levels resulted in adverse patient outcomes in the United States, Canada, England, Scotland, and Germany. Saudi Arabia is in a unique situation compared to these other developed countries experiencing the nursing shortage.
8 If FTNs are not available for the Saudi market, the country’s public health will be at risk. Organizational leaders hear about the nursing shortage, but fail to realize the significance of the statistics. Nursing directors are in the vulnerable position of ensuring quality patient care and sufficient nurses to perform that care. The reality for Saudi Arabia is a decreasing market overseas for qualified FTNs. An additional factor in Saudi Arabia’s FTN situation is that the country is losing its competitive edge with respect to recruiting and retaining qualified FTNs (I. Rondeau, personal communication, August 24, 2006). Higher salary offers to nurses by competitor nations combined with Saudi Arabia’s lack of married contracts, decreased value of the Saudi riyal (Saudi currency), continued conflict in the Middle East, segregation of men and women, restriction of movement and mobility for females, and limited housing accommodations are creating challenges for the country as well as job dissatisfaction and burnout for FTNs, just when Saudi Arabia most needs nurses (Al-Kandari & Lew, 2005, p. 534; Tumulty, 2001, p. 288). Foreign-trained nurses successfully lured to the country are also leaving for better opportunities and increasing the imbalance between nurse supply and demand. Those who remain are subject to burnout as they attempt to manage heavier workloads with reduced nursing staff assistance. The study involved an exploration of the relationship between demographic and work environment factors on hospital characteristics (linked to job satisfaction) and burnout among FTNs working in Saudi Arabia. The data provided information to assist leaders in developing nurse recruitment and retention strategies. By correlating the data from Aiken and Patrician’s (2000) instrument, Lake’s (2002) instrument, and Maslach and Jackson’s (1981) instrument, work design demonstrated how FTNs cope with or
9 adapt to the challenges of being in a new environment. Such challenges include being away from friends and family, having to understand new languages, working in a different professional environment, and living in a new culture with different customs. The data gathered in the study will provide health-care leaders with information on the factors contributing to job satisfaction, the variables that contribute to burnout, and the nurses’ desire to work in Saudi Arabia. Purpose of the Study The study’s purpose was to examine the relationship between demographic and work environment factors on hospital characteristics (linked to job satisfaction) and burnout among FTNs working in Saudi Arabia. Previous studies focused on the significance of nurses’ job satisfaction and burnout within the context of the nursing shortage. The first phase of the study involved the use of a quantitative research method. Quantitative research describes a phenomenon and/or investigates relationships between variables by using statistical procedures on collected data, typically through surveys (Polit & Beck, 2004, p. 729). Three instruments and a demographic survey measured the variables in the study. The dependent variables were hospital characteristics (linked to job satisfaction) and burnout. Aiken and Patrician’s (2000) Nursing Work Index–Revised (NWI-R), Lake’s (2002) Practice Environment Scale of the Nursing Work Index (PESNWI), and Maslach and Jackson’s (1981) Maslach Burnout Inventory (MBI) scale helped to determine the dimensions of job satisfaction. Due to a potentially low response rate from FTNs, a direct question like “are you satisfied with your job?” was not added to the survey data. The independent variables were a subset of the demographic data and work environment variables.
10 The second phase used a qualitative research method. Qualitative research uses a flexible research design to investigate stories from participants who reveal their lived experiences to explain a phenomenon, typically through interviews or focus group sessions (Polit & Beck, 2004, p. 729). Focus group sessions from all hospital sectors in Jeddah and Makkah provided rich data based on the FTNs’ experiences with life and work in Saudi Arabia. The theoretical framework provided complementary data to the quantitative data. The technique of triangulation involved using “multiple methods to collect and interpret data about a phenomenon, so as to converge on an accurate representation of reality” (Polit & Beck, p. 734). The results describe a complex worldview on FTNs’ work life and experience in Saudi Arabia. Significance of the Problem The study was important because of the scarcity of research studies on FTNs living and working in Saudi Arabia (B. Brush, personal communication, January 28, 2005). Nursing research in Saudi Arabia concentrated on the education and Saudization of the discipline (Doumato, 1999, 2000, 2003; Miller-Rosser, Chapman, & Francis, 2006; Moghadam, 2004; Polt, 2004; “Saudi Nurses,” 2006; Tumulty, 2001). Unlike its oil reserves, Saudi Arabia does not have its own reserve of nurses to meet its needs. Foreigntrained nurses are transient workers with no attachments or investment in the country even though there has been a continuous supply of FTNs over 6 decades. The study might be important to the Saudi health-care leaders and organizations that experience the challenges of recruiting and retaining FTNs. The challenges of recruiting include the cost, getting FTNs to Saudi Arabia in a timely manner, turnover, and the challenge in developing a Saudi nursing workforce (M. Al Osaimi, personal communication, January
11 9, 2007). Since 2005, recruitment trips to foreign countries by nursing directors yielded less qualified applicants (N. Huda, personal communication, September 20, 2007). The study was important because it lays a foundation from which organizational leaders can plan strategic measures to retain FTNs and the study provided a baseline for professional nursing work environments. Nursing directors and organizational leaders cannot retain FTNs if they do not understand the reasons why FTNs leave. Two dissertations examined Saudi and non-Saudi nurses’ quality of work life, recruitment, and retention (Abo Znadh, 1999; Al-zayyer, 2003). The global shortage has added new dimensions since the publication of these studies. The study is important to researchers studying the nurse shortage, the migration habits of FTNs contracted to work in Saudi Arabia, and the push–pull factors that have some variation in Saudi Arabia. The “crisis in human resources” (WHO, 2006, p. xiii) was the most important issue in developing and developed countries. The WHO (pp. 12-15) reported there are more than 59 million health workers (including family caregivers, part-time workers, community workers, volunteers, and patient-provider partners) worldwide with the shortage approaching 4.3 million. The majority of health workers are in more affluent regions where health-care needs are less critical. A decline in available nurses will alter the health-care infrastructure as Saudi Arabia continues to expand its services to meet the population needs. One strategy identified by the WHO (p. xxii) was for countries to manage migration and attrition. Saudi Arabia can implement strategies to minimize the attrition of FTNs and Saudi nurses. Saudi nurses do not migrate from their home country. Foreign-trained nurses are migrant labor and the focus of retention strategies. Although the nursing shortage is affecting all nations, the impact of the shortage affects each nation
12 individually (Buchan, 2006, p. 16S). It is critical that health-care organizations recognize the global nursing shortage and invest in and develop policies to retain their FTN workforce. It is critical to continue research on the global nursing shortage. Nature of the Study The study involved the use of quantitative and qualitative methods that strengthened the findings. There were several reasons to use a mixed-method study in Saudi Arabia. Quantitative and qualitative data were collected, analyzed, and the results interpreted to explore whether the aggregated data supported or conflicted with each other (Creswell, 2002, p. 565). The expressed experiences of FTNs supported the numbers from the data on job satisfaction and burnout. A second reason to use qualitative and quantitative design was participants might have perceived a threat to being open and honest about life and work in Saudi Arabia (S. Jeha, personal communication, September 13, 2006). Many FTNs fear retribution on the job and termination. Other FTNs have short-term goals for working in Saudi Arabia, where involvement in what they see as the politics of the country or hospital is not part of their commitment to the job. Still other FTNs feel no one will listen or implement changes (S. Jeha, personal communication, September 13, 2006). By using quantitative data, results produced trends that described a large number of FTNs. Qualitative data results provided a “complex picture” (Creswell, p. 559) of life and work in Saudi Arabia. The combined data in a mixed-method study provided robust information. Demographic data captured participants’ basic characteristics (i.e., age, nationality, education, current job, marital status, and place of work). To explore job satisfaction, two instruments provided variables that described a professional nursing
13 work environment. The NWI-R (Aiken & Patrician, 2000) measured “values related to job satisfaction and ability to provide quality care” (Background section, ¶ 3) by exploring organizational attributes. The Likert-type questionnaire explored the hospital environment in areas of nurses’ autonomy over practice, control over practice setting, relationships with physicians, and organizational support (Aiken & Patrician, ¶ 8-9). The second instrument was the PES-NWI (Lake, 2002). The participating nurses evaluated their organizational characteristics in the areas of nurse participation in the organization, nursing foundations for quality of care, nurse manager ability, leadership and support of nurses, staffing and resource adequacy, and nurse–physician relations (Lake, p. 178). The MBI scale (Maslach & Jackson, 1981) assesses burnout for people providing human services. A nurse’s self-assessment of burnout was valuable information for identifying other variables that caused burnout, how burnout affected quality care, and reasons for turnover of staff. The MBI questionnaire evaluated burnout through emotional exhaustion, depersonalization, and personal accomplishment (Maslach & Jackson, pp. 102-103). Focus group sessions strengthened and validated the quantitative data from the surveys. Focus group data were useful in extracting participant experiences, meanings, understandings, attitudes, opinions, knowledge, and beliefs as subthemes to the phenomena of living and working in Saudi Arabia as a FTN (Wilkinson, as cited in McLafferty, 2004, p. 188). The goals of conducting focus group sessions in the study included validating the constructs identified in the quantitative data collection and assessing the relationship of constructs to the theoretical framework.
14 Three nursing studies in Saudi Arabia explored nursing leadership, job satisfaction, quality of work life, and barriers to recruiting and retaining nurses (AboZnadh, 1999 1, p. 8; Al-zayyer, 2003, p. 2; Omer, 2005, pp. 5-6). The mixed-method studies used surveys, open-ended questions, and interviews (Abo-Znadh, p. 76; Alzayyer, p. 42; Omer, p. 58). The sample was Saudi and non-Saudi staff nurses and middle-level managers employed in tertiary care hospitals in Saudi Arabia. The instruments for quantitative data included the Job Diagnostic Survey (Abo-Znadh, p. 55), a tool developed specifically for the study (Al-zayyer, p. 50), and the Multifactor Leadership Questionnaire (Omer, p. 54). The qualitative data included written openended questions for participants (Abo-Znadh, p. 67; Al-zayyer, p. 42) and one-on-one interviews with nurse managers (Omer, p. 108). The mixed-method study included conducting surveys with and talking to participants who were FTNs. The nature of participants’ work placed them in a unique setting. The hospitals in Jeddah and Makkah were a mixture of government and private hospitals where salary, benefits, and working conditions varied. The mixed-method study used instruments that distinguished the current research from past research. International studies using the NWI-R and MBI instruments explored the nursing shortage, job satisfaction, burnout, and intent to leave the job (Aiken, Clarke, Sloane, Sochalski, et al., 2001; Flynn & Aiken, 2002). The qualitative data added a more comprehensive view of
1
The names Abo-Znadh and Abu-Zinadah refer to the same person. The names are presented in
the study as they appeared in the original publications.
15 FTNs living and working in Saudi Arabia to the quantitative data. The mixed-method study determined job satisfaction and burnout for FTNs working in Saudi Arabia. The mixed-method study also determined the variables that retained nurses. Organizational leaders could build strategies for the recruitment and retention of FTNs based on scientific knowledge specific to the Saudi experience. Research Questions Research questions for the mixed-method study were both quantitative and qualitative. The central question for the study was the following: What demographic and work environment factors influence job satisfaction and burnout among FTNs who live and work in Saudi Arabia? Aiken, Clarke, Sloane, Sochalski, et al. (2001) stated, “Nurses’ job satisfaction and levels of burnout are especially important in the current context of nurse shortages” (p. 45). Two instruments measured job satisfaction by exploring hospital characteristics. The work (NWI-R) and practice (PES-NWI) environment instruments provided researchers with evidence that the nursing practice environment facilitates or constrains job satisfaction based on certain organizational characteristics (Lake, 2002, p. 178). A burnout instrument (MBI) measured FTNs’ level of burnout in the work environment. Other factors that contributed to job satisfaction and burnout were demographic information and the work environment factors that included type of hospital and contract. The first hypothesis was there is an association between the hospital characteristic (job satisfaction) scores among FTNs working in Saudi Arabia and selected demographic and work environment factors. The null hypothesis was there is no association between the hospital characteristic (job satisfaction) scores among FTNs working in Saudi Arabia and
16 selected demographic and work environment factors. The second hypothesis was there is an association between burnout levels among FTNs working in Saudi Arabia and job satisfaction, selected demographic, and work environment factors. The null hypothesis was there is no association between burnout levels among FTNs working in Saudi Arabia and hospital characteristics (job satisfaction), selected demographic factors, and work environment factors. Nurse work-related outcomes, including job satisfaction and burnout were the focus of staffing in the study by Aiken, Clarke, Sloane, Sochalski, and Silber (2002, p. 1988). The Aiken, Clarke, Sloane, Sochalski, et al. (p. 1992) study found job-related burnout and job dissatisfaction was twice as high for nurses with higher patient-to-nurse ratios as for nurses with lower patient-to-nurse ratios. The third hypothesis for the study was there is an association between hospital characteristic (job satisfaction) scores among FTNs working in Saudi Arabia and burnout levels. The null hypothesis was there is no association between hospital characteristic (job satisfaction) scores among FTNs working in Saudi Arabia and burnout levels. Demographic and the work environment factors provided hospital leaders with additional information that measured job satisfaction and burnout. There were variables that affected the living and working conditions for FTNs in Saudi Arabia. A sampling of the variables includes type of hospital, nationality of FTN, salary, marital status, and contract type. The fourth hypothesis was there is an association between selected demographic and work environment factors among FTNs working in Saudi Arabia and hospital characteristics (job satisfaction) and burnout level. The null hypothesis was there is no association between selected demographic and work environment factors among
17 FTNs working in Saudi Arabia and hospital characteristics (job satisfaction) and burnout level. The selected demographic factors included gender, age, nationality, religion, education level, year of registration, years in current hospital, first contract in Kingdom, years working in the Kingdom, stay in Saudi Arabia (consecutive vs. nonconsecutive), marital status, family with nurse, and continuing education status. The selected work environment factors included title, ownership, contract type, and number of nurses per 100 beds. The demographic and work environment factors were important considerations when exploring FTNs in Saudi Arabia. The country is male dominated, yet the majority of nurses are female. There is an assumption that older nurses with more experience tend to stay longer. Older nurses have older children, the salary may be for retirement, and experience assists in job advancement. The factors that pulled FTNs to Saudi Arabia included the FTNs’ nationality and circumstances at home. Saudi Arabia is the home of Islam and many Muslims come to work in Saudi Arabia for that reason (M. Al Osaimi, personal communication, January 9, 2007). Years working in the current job and years working in the Kingdom reflected tenure. Salary and benefits varied from hospital to hospital depending on nationality, experience, and education level. Contracts for FTNs in staff positions (including charge nurse) are for the FTN only, not for the FTN’s family. Married FTNs work in Saudi Arabia to support their family at home. Many married FTNs leave Saudi Arabia because of family pressures, young children, or death of a caregiver (A. Dababneh, personal communication, March 28, 2007).
18 Theoretical Framework Researchers attempt to understand the “importance of leadership” (Bass, 1990, p. 6) by studying job satisfaction. A theoretical framework helps researchers define and put into practice a worldview based on observable phenomena (Polit & Beck, 2004, p. 118). The Herzberg two-factor theory (or motivation–hygiene theory) was the theoretical framework for the study (see Appendix B). Within organizational and management theory, Herzberg (1966, p. 18; 1993, p. 44) maintained that employees were satisfied at work when certain variables were associated with the content of their work or how well they performed. The variables included achievement, recognition for achievement, interesting work, increased responsibility, growth, and advancement. Herzberg (1966, p. 18) maintained that dissatisfiers at work were associated with the context of the employee’s work or the work environment and included such variables as company policy and administration practice, supervision, interpersonal relationships, working conditions, salary, status, and security. In contrast, job satisfiers were motivators that created a positive attitude to job satisfaction (Herzberg, 1966, p. 18), whereas the dissatisfiers were hygiene factors that reflected the circumstances of the work environment (Herzberg, 1966, p. 18). The hygiene factors are not motivators by themselves, but must be present to maintain a “certain level of employee motivation” (Usugami & Park, 2005, p. 281). Herzberg (1966, p. 76) cautioned the opposite of job satisfaction is not job dissatisfaction but rather no job satisfaction and vice versa. Thus, when the dissatisfiers deteriorated below an acceptable level to the employee, no job satisfaction was the outcome. When hygiene factors were acceptable to the employee, no job satisfaction
19 improved, but the employee remained in a neutral zone being neither satisfied nor not satisfied (Wren, 1994, p. 378). From Herzberg’s theory and research, a classic motivation–hygiene profile developed that represented a normal organization. The classic profile identified organizations that differed. Developing the profile required an interview with employees. The interviewer asked the employees to describe “a time when they felt either exceptionally good or exceptionally bad about an event that occurred on their job” (Herzberg, 1966, p. 19). Herzberg maintained that employees revealed a significant motivational pattern when describing a specific event that changed their attitude. After gathering the data from employee accounts, the interviewer ranked the factors by frequency rather than by importance. “This distinction between frequency and importance is one of the most misinterpreted aspects of motivation-hygiene theory” (Herzberg, 1974, p. 19). There is an assumption that nurses travel to work in Saudi Arabia for the salary. For example, Filipino nurses earn 10 times their salary by working in Western hospitals in Saudi Arabia compared to working in the Philippines (A. Otvos, personal communication, April 10, 2005). With the global competition for FTNs, salary is not the only factor to consider. A recent salary increase was awarded to all nurses at a government hospital in Jeddah, Saudi Arabia. Only 4 of 15 FTNs rescinded their resignation when the salary adjustment was announced in October 2006 (I. Rondeau, personal communication, November 7, 2006). One might assume that if salary were the only motivation for FTNs working in Saudi Arabia, then the nurses would stay. Flynn and Aiken’s (2002, p. 68) study found U.S. and international nurses shared common
20 values on the professional nursing practice environment that were important to job satisfaction. A limitation to the study was the number of years the international nurses resided in the U. S., which could influence their assimilation into the culture (Flynn & Aiken, p. 71). Acculturation to nursing practice in Saudi Arabia is fragmented and based on individual hospital orientations, education programs, and standards of practice. Polit and Beck (2004) reported, “A theory is a systematic, abstract explanation of some aspect of reality” (p. 29). The use of Herzberg’s theory in the qualitative phase of the research was twofold. The hygiene and motivator factors correlated with the instruments used in the quantitative phase in understanding job satisfaction and burnout. The second reason to use Herzberg’s theory was to explore salary in the Saudi environment, to hear from participants if salary is a motivating factor to work in Saudi Arabia. Herzberg’s theory continues to be used in job satisfaction research, job enrichment policies, and a variety of settings internationally (Byrne, 2006; Hackman, Oldham, Janson, & Purdy, 1975, Kacel, Miller, & Norris, 2005; Reinardy, 2007; Usugami & Park, 2006). In 2005, the Irish Health Sector reforms required change for all employees (Byrne, 2006, p. 5). Byrne used the motivator–hygiene factors to assess the managers and their ability to motivate employees (p. 9). Byrne concluded managers lacked training as leaders. Managers used hygiene factors to motivate employees to work. Byrne also concluded managers lacked the autonomy to make some decisions. Managers who promoted employees were more successful in cultivating job satisfaction. Kacel et al. (2005, p. 27) studied job satisfaction for 147 nurse practitioners in a Midwestern state and used Herzberg’s theory as a framework for the variables. The
21 quantitative study used the Misener Nurse Practitioner Job Satisfaction Scale. The descriptive correlation cross-sectional survey study found intrinsic (motivators) and extrinsic (hygiene) factors contributed to job satisfaction. Kacel et al. (p. 31) noted improving salaries and compensation (hygiene factors) improved job satisfaction. Reinardy (2007, p. 105) studied job satisfaction among 184 sports editors. The mixed study used the Michigan Organizational Assessment Questionnaire and Perceived Organizational Support survey for quantitative data. Interviews with participants provided qualitative data. Herzberg’s theory provided the framework for the study correlating external issues (such as workload, family conflict, and organizational barriers) with internal issues (such as enjoyment, sense of pride, and accomplishment; Reinardy, p. 116). Usugami and Park (2006, p. 282) developed a qualitative study based on the work of Herzberg. Five Japanese executives expressed their views of Korean employee motivation. From these results, Usugami and Park, using the motivator-hygiene factors as the foundation of the survey, developed a questionnaire. Sixty-nine Korean and Japanese executives responded to the questionnaire. The study concluded Japanese executives had a better understanding of the importance of employee motivation. Second, both groups realized maintenance (hygiene) and improvement of employee satisfaction was required for a successful business. Third, participants identified hygiene factors as motivators in job satisfaction (such as salary, benefits, personal relationships, and communication in the workplace). The differences between the views of the executives were not consistent with Herzberg’s theory. For example, the Korean executives posited job security as a
22 motivator. The reason for this finding was an unstable job market and an inadequate social security system. The Japanese executives felt company policy and job descriptions were strong motivators for employee satisfaction. The reason for this finding was the Japanese business approach of management by objectives. The continued use of Herzberg’s theory demonstrates its usefulness to organizations and researchers. The focus of the discussion was to encourage participants to share their experiences of working and living in Saudi Arabia by answering the main statements of the theory: describe a time when you felt either exceptionally good or exceptionally bad about an event that occurred on the job. The FTNs’ cultural, political, social, and professional practice changes in Saudi Arabia uncovered different motivator– hygiene realities. The qualitative data complemented the quantitative data in providing a worldview of FTN practices in Saudi Arabia. Definition of Terms Autonomy over practice is “independence in making patient care decisions within the scope of nursing practice” (Slater & McCormack, 2006, p. 32). Baby boomer is a term applied to the generation born between 1946 and 1964 (Sigma Theta Tau International, 2001, ¶ 7). Burnout “is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity” (Maslach, Jackson, & Leiter, 1996, p. 4). Charge nurse refers to a registered staff nurse and assumes responsibility for patients and staff in the absence of the unit manager or head nurse. A registered nurse
23 acts as charge nurse based on experience, education, orientation, and competency (A. Otvos, personal communication, May 24, 2007). Collegial nurse–physician relations involves “physicians and nurses have good working relationships” (Friese, 2005, p. 767). Control over the practice environment involves “exerting influence over others to promote high-quality patient care” (Slater & McCormack, 2006, p. 32). Depersonalization is “an unfeeling and impersonal response toward recipients of one’s service, care, treatment, or instruction” (Maslach et al., 1996, p. 4). Donor country is “the sending country” (Aiken et al., 2004, ¶ 3). Emotional exhaustion is “feelings of being emotionally overextended and exhausted by one’s work” (Maslach et al., 1996, p. 4). Foreign-trained nurses are “nurses trained in other countries” (Aiken et al., 2004, ¶ 5). Head nurse or nurse manager is “one with overall responsibility for the supervision of the administrative and clinical aspects of nursing care” (Head Nurse, 2007-2008). Iqama is the Arabic word for stay or residence. Expatriates receive an Iqama that identifies a foreign worker who can legally stay to work for an extended period (K. Hijjazi, personal communication, April 16, 2008). Job satisfaction encompasses three psychological states: experienced meaningfulness, experienced responsibility, and knowledge of results (Hackman et al., 1975, p. 58).
24 Nurse manager ability, leadership, and support of nurses is “a supervisory staff that is supportive of nurses” (Friese, 2005, p. 767). Nurse participation in hospital affairs occurs when “staff nurses have the opportunity to participate on hospital and nursing committees” (Friese, 2005, p. 767). Nurse–physician relationships are “collegial relationships with medical staff” (Slater & McCormack, 2006, p. 32). Nursing foundations for quality of care is “active in-service/continuing education programs for nurses” (Friese, 2005, p. 767). Nursing practice environment is “the organizational characteristics of a work setting that facilitate or constrain professional nursing practice” (Lake, 2002, p. 178). Organizational support is “administrative and managerial support for nursing, including the adequacy of resources, opportunity for nurse advancement, and support for continuing education” (Slater & McCormack, 2006, p. 32). Personal accomplishment is “feelings of competence and successful achievement in one’s work with people” (Maslach et al., 1996, p. 4). Professional nursing practice environment is “professional autonomy, greater control over practice environment, and better relationships with physicians” (Aiken, Smith, & Lake, 1994, p. 332). Pull factors in international migration are “what it is about the other country that makes it more attractive” (Buchan, 2006, p. 21S). Examples included “higher pay (and opportunities for remittances), better working conditions, better resource health systems, career opportunities, provision of post-basic education, aid work, political stability, [and] travel opportunities” (Buchan, p. 21S).
25 Push factors in international migration are “the reasons that will make a nurse think about leaving the country she is in” (Buchan, 2006, p. 20S). Examples included “low pay, poor working conditions, lack of resources to work effectively, limited career opportunities, limited educational opportunities, impact of HIV/AIDS, unstable work environment, and economic instability” (Buchan, p. 21S). Recipient country is “the receiving country” (Aiken et al., 2004, ¶ 3). Saudization refers to “Saudi nationals educated and/or trained in all areas of employment to replace current expatriate workers” (Miller-Rosser et al., 2006, ¶ 4). Shortage of nurses is “generally considered to be an imbalance between demand for employment and the available supply” (Oulton, 2006, p. 34S). Staff nurse is a registered or professional nurse educated at the post-secondary level who meets criteria (often involving a licensing examination) to practice under the title of registered nurse. This category corresponds to code 223 of the ISCO-88 classification ‘Nursing and Midwife Profession’ (International Standard Classification of Occupations, 2006). (Van den Heede, Clarke, Sermeus, Vleugels, & Aiken, 2007, p. 291) Staffing and resource adequacy occurs when there are “enough registered nurses to provide quality patient care” (Friese, 2005, p. 767). Assumptions The study may be most useful for FTNs living and working in Jeddah and Makkah, Saudi Arabia, if the population of FTNs living and working in Jeddah and Makkah was similar to other studies of nursing job satisfaction. The study may be most useful for area hospitals, if the hospitals were similar to other studies of nursing job
26 satisfaction. An assumption about the research was bedside nurses (staff nurse, charge nurse, and head nurse) have a unique perspective of the life and work in Saudi Arabia. A physician hospital director within a bureaucratic and hierarchical system (Tumulty, 2001, p. 287) typically manages hospitals in Saudi Arabia. The accreditation process with Joint Commission International (JCI) and Makkah Region Quality Program (MRQP) assisted nursing directors in developing professional nursing practice environments. MRQP originated as an initial accreditation program for the Western Region (considered Jeddah, Makkah, and Taif). The standards were similar to JCI standards, yet unique to Saudi Arabia and the systems that exist. MRQP evolved into the Central Board of Accreditation for Healthcare Institutions (CBAHI), an accreditation process that includes all regions and all hospitals in Saudi Arabia. CBAHI is a quality program sponsored and supported by the MOH (MRQP, n.d., p. 4). All MOH and private hospitals must achieve the CBAHI standards and pass the accreditation to continue operations (that is, private hospitals) or receive government funding (that is, the MOH; MRQP, p. 4). Military hospitals are applying for JCI accreditation and are exempt from CBAHI, as JCI is considered a higher accreditation standard. The study may be most useful assuming the hospitals have implemented the nursing standards that support a professional nursing practice environment. Each hospital had its own unique human resource policies for contracting FTNs. The differences between hospitals included basic salary and benefits (for example, housing, food allowance, and ticket home). The information obtained from the FTNs reflected the contract they have with the various hospitals. The focus of the study was FTNs who provided direct care to patients. Workplace experiences might be different
27 between the direct caregiver (staff nurse) and the middle- and upper-management nurses. Regardless of hospital sector, middle- and upper-management nurses were not included in the study due to their having different roles and responsibilities in the job and different contracts. Limitations The study included hospitals with accreditation. Accreditation included JCI and MRQP. The accreditation process assumed hospitals were moving toward standards that deliver safe, quality patient care by continuously improving systems and being fiscally responsible (MRQP, n.d., p. 5). The study was limited to nurses who agreed to participate voluntarily. The study was limited to the number of nurses surveyed and the time available to conduct the study. Validity of the study was limited to the reliability of the instruments used. Kramer and Hafner (as cited in Lake, 2002, p. 176) designed the Nursing Work Index (NWI) in the early 1980s. Kramer and Hafner (1989) studied hospitals that were attracting (magnet) and retaining nursing staff despite the nursing shortage of the 1970s. As research continued, the NWI-R and PES-NWI instruments emerged. Saudi Arabia has recently taken an interest in quality improvement and accreditation through MRQP, CBAHI, JCI, and Magnet status. It was uncertain if the NWI-R and PES-NWI instruments would have the same impact on the FTNs in hospitals in Jeddah and Makkah due to the relatively new focus on quality improvement and a professional nurse work environment. The NWI-R instrument is appropriate for studying hospital traits that define a professional nursing practice environment (Aiken & Patrician, 2000, ¶ 5). Aiken and
28 Patrician (¶ 6) posited that nurse satisfaction and retention is dependent on the working environment. The instrument studied organizational traits (autonomy, control over the practice setting, nurse–physician relationships, and organizational support) that provided an environment where nurses were satisfied or dissatisfied in their job. The NWI-R studied job satisfaction and burnout in the practice environment of the hospital setting for FTNs, and the focus group sessions investigated the nurses’ perspective of variables that provided job satisfaction, no job satisfaction, and burnout. The PES-NWI instrument studied the practice environment in nurse and patient outcomes (Lake, 2002, p. 177). Lake (p. 178) posited that hospital work traits either facilitated or constrained the nursing practice environment. According to Tumulty (2001), the nursing department in most facilities in Saudi Arabia reports to a physician hospital director in a “male dominated, bureaucratic, and hierarchical system” (p. 287). The organizational structure of Saudi Arabian hospitals does not advocate a professional practice environment for nurses. The PES-NWI “may have limited capacity to detect or describe bureaucratic settings validly” (Lake, p. 178). Response bias “occurs in survey research when the responses do not accurately reflect the views of the sample and the population” (Creswell, 2002, p. 411). Responses might be overly negative, overly positive, or neutral. Participants may feel there is a right or wrong answer to the questions and discuss the survey with colleagues. Two hospital settings (government and private) in Jeddah and Makkah, Saudi Arabia, participated in the survey. Each of the hospital systems offered different salary and benefit packages based on a nurse’s point of hire, education, nursing school, experience, registration, organizational budgets, and organizational human resource policies. Staff nurses, charge
29 nurses, and other administrative nurses who provide patient care participated in the survey. Delimitations The study proposal defined the study sample as staff nurses and charge nurses in two hospital settings (government and private) in Jeddah and Makkah, Saudi Arabia. When consents were distributed, administrative nurses stated they were providing patient care due to the critical shortage of staff nurses in the hospital. Based on this new information, additional FTNs were included in the consent and survey process. The hospitals had MRQP or JCI accreditation. The study included a focus on the dimensions of job satisfaction and burnout. The investigation involved variables that described positive hospital characteristics or a professional practice environment that contributed to job satisfaction. Foreign-trained nurses providing patient care were included in the study. Several mechanisms of survey distribution occurred to reach the nurses in the hospitals: surveys attached and sent via e-mail, surveys mailed through the postal system, and surveys delivered to nursing administration for distribution. The introduction letter instructed participants to answer all questions and to answer questions honestly, which may have reduced response bias. Wave analysis is a procedure that monitors response bias (Creswell, 2002, p. 411). In wave analysis, the researcher checks the surveys at regular intervals (say weekly) to see if responses are consistent during the survey collection process (Creswell, p. 411). The focus group sessions strengthened and validated the quantitative data.
30 Summary Organizational leaders are experiencing the challenges of recruiting and retaining FTNs. There is also an opportunity for nursing leaders to support the MOH in its Saudization efforts by collaborating as change agents for the profession. Dependence on FTNs in Saudi Arabia poses a threat to the health-care infrastructure of the country (Tumulty, 2001, p. 286). Health-care policy in all sectors must reflect priority measures to retain and recruit FTNs. Saudi Arabia is competing with countries that offer FTNs opportunities for growth and development, a home for their families, higher salaries, and a stable work environment (I. Rondeau, personal communication, August 24, 2006). The study included an investigation into the professional nursing practice environment of two distinct hospital organizations (government and private) to understand the variables that contributed to job satisfaction and burnout. The mixedmethod research used surveys and focus group sessions for data collection and analysis. Surveys explored the practice environment that provided insight into organizational attributes (Aiken & Patrician, 2000; Lake, 2002; Maslach & Jackson, 1981). As an organizational and management theory, Herzberg’s two-factor theory (1974) was the theoretical framework for the study. The theory provided an understanding of the motivators and hygiene factors that contributed to job satisfaction and no job satisfaction of FTNs within the content and context of their workplace. The literature review explores the global challenges to the present nursing shortage and the specific issues that make the challenge more critical for Saudi Arabia. The push–pull factors of nurse migration only partially explain a FTN’s decision to work
31 in Saudi Arabia. With other opportunities available, Saudi Arabia is competing for FTNs in a dwindling market.
32 CHAPTER 2: REVIEW OF THE LITERATURE Saudi Arabia depends on FTNs for its health-care delivery. As Saudi Arabia promotes Saudization of the nursing profession, policies for managing current human resources may assist organizational leaders in effectively managing the migration issue. Understanding the variables that contribute to positive hospital characteristics (a positive professional practice environment linked to job satisfaction) and burnout will assist in organizational policy development. In this chapter, a review of the literature highlights the religious, political, economic, and social aspects of Saudi Arabia. A review of the literature on the global nursing shortage revealed the challenges, especially as nations and organizations scramble to maintain safe patient care through recruitment, retention, and policy development for FTNs. Policy development for FTNs within the historical context of the push–pull factors of nurse migration demonstrates how polar viewpoints supporting and opposing this strategy for the nurse shortage resolution have evolved. A review of the literature identifies the variables of job satisfaction and burnout that demonstrate retention strategies during the nursing shortage crisis, respective to the challenges faced more broadly and to health-care organizations in Saudi Arabia more specifically. The nursing shortage in the 21st century is different from previous episodes in history. Developed nations (such as the United States, Canada, United Kingdom, and Australia) are luring nurses from developing countries (such as South Africa, India, and the Philippines), leaving behind fragmented and inadequate health-care systems. At the same time, nurse migration is not solving the nursing shortage for developed nations. Mejia, Pizurki, and Royston (1979) described push–pull factors as forces “operating at
33 both ends of the migratory axis” (p. 102). Push factors operate at the donor country while pull factors operate at the recipient country. The ICN and FNIF (2006, p. 5) described poor working conditions, low salaries, migration opportunities, and the increased risk of contracting HIV/AIDS in developing countries as push factors. Aiken (2006, Linda Aiken, Ph.D. section, ¶ 10) noted the pull factors of developed countries included higher salaries, improved quality of life, and opportunities for educational and professional advancement. The factors contribute to the underlying cause of nurse migration with a resultant nursing shortage. Documentation The lack of research in Saudi Arabia on nurse migration, on the nursing shortage, and on FTNs supported the need for the study. Challenged by the scarcity of research in Saudi Arabia, the literature review included an exploration of the researchers and organizations with the most knowledge on the issues surrounding nurse migration and the nursing shortage. Despite the dissertation’s strength with studies by Aiken (and her team), Kingma, Buchan, ICN, and WHO, the literature review failed to meet the percentage of citations less than 5 years old. An explanation of the geographical region, population, religion, culture, and social structure of Saudi Arabia is important for the reader in understanding the challenges of working in the country. The lack of current articles and texts on Saudi Arabia contributed to the literature review failing to meet the percentage of citations less than 5 years old. The databases of the University of Phoenix electronic library (for example, ProQuest, EBSCOhost, CINAHL, Sage Full Text Selection) and the World Wide Web (for example, forums, conferences, and government documents from the Agency for
34 Healthcare Research and Quality and the Health Resources and Services Administration, WHO, and ICN) provided the literature review for the study. Search terms included foreign-trained nurses, nursing shortage, nurse migration, and nursing in Saudi Arabia. Literature retrieved from text publications described the global nursing issues (for example, Doumato, Kingma). Personal communications with the General Directorate of Nursing with MOH in Saudi Arabia, working colleagues, and hospital directors of nursing provided current information on the nursing shortage issues in Saudi Arabia. Literature Review Global Migration History Nurse and physician migration was a concern for the WHO in the 1970s. The WHO member countries (such as Germany, Haiti, India, and Australia) recommended an investigation into the reasons behind the health-care migration and a plan to resolve the issue (Mejia et al., 1979, p. ix). Migration of labor was not a new trend. Mejia et al. noted countries developed policies to “prevent or promote migration” (p. 3) with promotion of migration being more successful. The migration of health-care personnel in the 21st century brought changes that were of concern to both developing and developed countries. Migration in the past consisted of mainly the poor or homeless. The change in migration involved the elite from the poorer nations migrating to the richer nations, resulting in the terms “brain drain and brain gain” (Mejia et al., p. 4). The wave of migration resulted in a widening gap between poor and wealthy nations (Mejia et al., p. 4). When countries realized their physicians were the professionals migrating, the countries recommended an investigation by the WHO.
35 Of concern was the lack of human resource planning that eventually affected the future health-care infrastructure of many countries (Mejia, 2004, p. 626). In the multinational study by the WHO, the goals were to “define the characteristics of the migrants and the dimensions, directions, determinants and consequences of the flows” (Mejia, p. 627). Approximately 14,000 nurses per year migrated to pursue opportunities for professional and economic growth. Ninety-one percent of those migrating went to Europe, North America, and the developed areas of the Western Pacific. One thousand nurses went to developing countries including Asia and Africa, with half going to Saudi Arabia (Mejia, p. 627). An in-depth evaluation revealed the health-care migration was only a part of the complex issue. From the investigation, the root cause of the migration problem was the social and economic issues of every country’s health-care system (Mejia et al., 1979, p. ix). The evidence from the report revealed that health-care migration could not be resolved on its own. It would take the commitment of member countries to resolve the more complex issues of the social and economic health-care systems (Mejia et al., p. xi). Data from the participating countries were lacking. The investigation identified the push factors from donor nations and pull factors from recipient nations that influenced health-care migration (Mejia et al., 1979, p. 415). The push factors included oversupply of physicians, poor planning of health-care personnel according to the healthcare system of the country, lack of education and training for the needs of the country, and improper utilization of trained personnel. The pull factors included attractive salaries from rich countries and planned health-care systems that utilized health-care personnel’s expertise.
36 Little has changed since Mejia et al.’s (1979) report except that health-care system planning in some countries did not happen, which contributed to a worsening of the health-care worker shortage. Additional challenges facing nations were the increased health needs of the population (for example, demographics, disease burden, and epidemiological burdens), health systems (for example, finances, technology, and consumer preferences), and the background of country policies (for example, globalization, labor and education, and public sector reforms; WHO, 2006, p. xvi). The central point identified by Mejia et al. (p. 423) continues to resonate; the problem of migrating health-care workers is a symptom of underlying national problems that have not been resolved. International organizations called on governments to collaborate in developing policies to address the challenges. The ICN and FNIF (2006) identified five areas of concentration: “(1) macroeconomic and health sector funding policies, (2) workforce policy and planning, including regulation, (3) positive practice environments and organisational performance, (4) recruitment and retention; addressing mal-distribution within countries, and out-migration, and (5) nursing leadership” (¶ 5). Push–Pull Factors The literature is replete with the push–pull factors of nurse migration. The push– pull factors in global categories describe the political, social, economic, legal, historical, and educational issues of the nursing shortage. The push–pull factors of nurse migration have been studied by organizations and individual researchers for some time (Aiken et al., 2004; Bach, 2004; Buchan, Kingma, & Lorenzo, 2005; Buchan & Sochalski, 2004; Hongoro & McPake, 2004; Kingma, 2006; Kline, 2003; Mejia et al.; Spetz & Given,
37 2003; Stilwell et al., 2004). Push factors are forces that drive health-care workers from donor countries, and pull factors are forces that draw health-care workers to recipient countries (Bach, 2004, p. 625; Kline, 2003, p. 108; Mejia et al., 1979, p. 102). The studies noted migration does not occur unless both sets of forces are in unison, that is, push–pull factors create the desire to migrate. Migration from many developing countries occurred because of an oversupply of qualified, skilled workers. Developed countries attracted workers from developing countries with economic, political, and social stability (Leiman, 2004, p. 675). The phenomenon, known as brain drain, is controversial. The term brain drain applied to the migration of professional workers that were productive citizens in their respective country (Leiman, p. 676). For example, more nurses who are Bangladeshi work in the Middle East than in Bangladesh (Kingma, 2006, p. 173). Ghana lost 382 nurses through migration in 1999, which represented 100% of the nurse graduates that year. Since the mid-1980s, two thirds of Jamaican nurses have emigrated. Statistics are not as accurate on how many nurses come back to their country of origin after working overseas. Kingma (2006, p. 199) suggested replacing the term brain drain with the term brain circulation to describe the nurse returning to the source country. In the Caribbean, for example, health-care emigration contributed to the country’s development. Because workers return to their country after gaining personal and professional growth (Kingma, 2006, p. 199), the term circulation was more appropriate than drain to describe the effect on human resources. International health care is providing short-term and long-term opportunities for work overseas. Netcare International (a South African health-care company) provides traveling teams of health-care workers to countries that require service (Kingma, 2006, p.
38 18). Netcare International has contracted with the NHS to provide cataract surgery in several treatment centers in the United Kingdom. The nurses travel to the United Kingdom to work in the centers for 5 weeks to 6 months and then return to South Africa. Developing countries cannot compete with developed countries. In return for sending nurses abroad, remittances provide a strong economic foundation for the source country, as in the Philippines (Martin, Abella, & Midgley, 2004, p. 1556; Buchan, Kingma, et al., 2005, p. 16). The push–pull factors explain migrating nurses in the 21st century. The current study involved an investigation of those forces that motivate FTN tenure in Saudi Arabia. This area of study yielded little research except from personal accounts of FTNs who have worked or are working in the Kingdom. Saudi Arabia is a stepping-stone for many FTNs. The push–pull factors bring the nurse to Saudi Arabia and the push–pull factors send the nurse to other countries or back home (Buchan, Kingma, et al., 2005, p. 3). Saudi Arabia remains the number two destination for Filipinos and South Africans (Buchan, Kingma, et al., 2005, p. 15). Saudi Arabian nurses do not migrate. The culture encourages family, country, and religion. Foreign-trained nurses maintain their passports while working in Saudi Arabia. Saudi Arabia is not a donor country as data reflect migration from the home country, even though recruitment to another country can occur in Saudi Arabia while the FTN is working. The variables in the current study were the push–pull factors identified in the literature. Nurses were pulled to Saudi Arabia for the salary (it is tax-free in some countries) with the goal to save a substantial amount of money. Another pull factor was free furnished housing and utilities. Compounds offer facilities such as a restaurant, dry
39 cleaner, hairdresser, pool, gym, tennis, squash, and small grocery store. Still another pull factor was a free airfare ticket home, depending on whether the nurse signs a 1- or 2-year contract. Additional pull factors included a minimum of 30 vacation days, free health care, travel opportunities, and personal and professional growth. Other pull factors included some families being able to travel and live with the FTN, an end-of-contract bonus (2-week salary paid by the hospital for 1 to 5 years of service and a 1-month salary after 5 years of service), the proximity to the Two Holy Mosques, and the sense of intrigue to live in a country largely unknown in the global community (A. Otvos, personal communication, April 29, 2005). The push factors for FTNs included lack of jobs in their country and lower salaries, unsafe working conditions because of increased staff shortages, increased violence, HIV/AIDS in some developing countries, lack of country stability, lack of respect, lack of autonomy in the job, lack of promotion opportunities, lack of professional development, loss of skills, lack of support from management, loss of quality in health care, and the experience of working abroad (Buchan, Kingma, et al., 2005). Kingma (2006, pp. 15-17) painted a picture of the permanent and temporary migrant nurse and the push–pull variables that caused nurses to leave their country: the economic migrant, the quality-of-life migrant, the career-move migrant, the partner migrant, the adventurer migrant, the survival migrant, and the return migrant. The “contract worker” (Kingma, 2006, p. 17) described the FTN in Saudi Arabia. Contract periods range from 1 to 3 years, with the organization being the sponsor of the FTNs. Performance, attitude, abiding by the regulations of the country, and need determine whether the FTN will receive another contract.
40 Despite the available studies, researchers called for more specific information and data (Buchan, Jobanputra, Gough, & Hutt, 2005, p. 1). Bach (2003, p. 30) advocated improved data collection for source and recipient countries. Bach (2003, p. 30) stated that qualitative research (especially for female migrant nurses) may assist policy makers in determining if employment abroad meets the nurses’ expectations, if migration will be temporary or permanent, and if certain circumstances might influence the nurses’ return home. A newer area of research must include the role of recruiters and the recruitment practice. Recruiting a nurse can cost up to $10,000 and take up to 2 years in processing (Spetz & Given, 2003, ¶ 13). The Philippine Overseas Employment Administration (POEA; 2004) advertised on the Internet, “Things you should know about working in Saudi Arabia.” The POEA was one of three safety mechanisms for Filipino nurses wanting to migrate (Martin et al., 2004, p. 1551). The interested migrating nurse may have to pay processing or finder’s fees. Martin et al. also noted some private recruitment companies take advantage of Filipino nurses who know there are more applicants than positions available abroad. Nurses have paid private recruiters over the maximum fee to secure a position, only to find out the position did not exist or the nurses must wait for a position (Kingma, 2005, p. 14; Martin et al., p. 1551). Msimang (2001) described an area of research in which the ICN warned nurses that developed countries were not paying developing country health-care workers “market-related salaries” (¶ 1). A claim that was unsubstantiated by data accused Saudi Arabia of promising better pay and not following through. Contracts in the Kingdom depended on the nurse’s home country, inflation rate, cost of living, salary, education, training, experience, employer, and other factors (A. Otvos, personal communication,
41 April 18, 2005). There were reports of late payment of salary in some hospitals, but the nurses received their pay eventually (A. Otvos, personal communication, April 29, 2005). The variances in pay were the baseline incentives to provide a nationality and skill mix that complemented the activities of the FTNs in the Kingdom. That is, middle and upper nurse managers are typically Western (in the military and Western hospitals) and they supervise the less skilled nurses. Buchan, Jobanputra, et al. (2005) conducted a research study on FTNs’ motivations, career plans, and reasons for traveling to the United Kingdom for work (p. 1) and concluded financial opportunity was not the only pull for nurses emigrating to the United Kingdom (p. 22). Professional development was a key motivator for nurses to leave their countries. Most of the respondents (60%) in the survey stated they planned to remain in the United Kingdom for 5 years. Sixty-three percent of Filipinos and 40% of South African nurses stated they would move to another country (Buchan, Jobanputra, et al., 2005, p. 15). Buchan, Jobanputra, et al. (2005) noted that recruitment companies were actively seeking other opportunities for these mobile nurses. In many developing nations, the lack of fiscal resources for health-care workers prohibits the government from recruiting nurses to vacant positions (Kingma, 2006, p. 224). Kingma (2006, p. 224) provided examples of this difficulty. Twenty-seven nurse graduates in 2004 in Grenada were unable to obtain jobs because of lack of money in the health-care budget. Zambia extended the retirement age for nurses by 10 years, yet the country is unable to offer work to nurse graduates. Management and financial responsibilities of health-care services shared by international partnerships are developing that will help utilize available health-care workers.
42 Organizations such as WHO and ICN called for national strategies for recruitment and retention planning that included encouraging former nurses to return to work (Bach, 2003, p. 30; Buchan, Kingma, et al., 2005, p. 4; Buchan & Sochalski, 2004, p. 587; Mejia et al., 1979, p. 5; Stilwell et al., 2004, p. 597). Developed countries have the resources to offer wage differentials that will continue to push and pull nurses from developing countries (Stilwell et al., p. 597). Stilwell et al. (p. 597) reported developing countries must be more creative in their retention plans in areas of working conditions and professional development, as they do not have the benefit of improving remuneration. Although the recommendations by WHO and ICN contributed to several policy statements by national governments and nursing organizations, recruitment of a country’s valuable human resources continues unimpeded (Buchan & Sochalski, p. 588). The Kingdom is unable or unwilling to produce enough of its own nurses. The health-care system continues to rely on FTNs who choose to immigrate. As the country invests more money to upgrade and provide more health-care services to its population, its dependence on FTNs deepens. It is a competitive market as the world vies for nurses. The Kingdom’s contracts are not as lucrative as in the past, and the economic stability of many developing countries draws their nurses back home (A. Otvos, personal communication, April 29, 2005). There is no abating the current nursing shortage. The issue will continue to be problematic for policy makers. Nations require intensive health-care needs for their citizens, and nurses are leaving or retiring from the profession (Berliner & Ginzberg, 2002, ¶ 4; Sigma Theta Tau International, 2001). Nurse migration is a complicated issue
43 involving nurses’ socioeconomic status, concern for safety, infrastructure of health-care systems, and diminished prospects for career advancement and education. Status of Nursing Shortage The nursing shortage is affecting all nations in varying levels of crisis. The Joint Learning Initiative defined a workforce shortage as “the minimum desired level of coverage at 80% and partly by the empirical identification of health worker density associated with that level of coverage” (as cited in WHO, 2006, p. 11). The Joint Learning Initiative updated the analysis for the WHO (2006, p. 12) report and determined that countries with fewer than 2.02 to 2.54 health-care professionals (counting only physicians, nurses, and midwives) per 1,000 people face a critical shortage of health-care workers. According to the Joint Learning Initiative’s definition, 57 countries were critically short of health-care workers. Thirty-six of the 57 countries are in sub-Saharan Africa (WHO, 2006, p. 12). The word nursing “has no universal definition of function and no universal standards of education and practice” (ICN, as cited in WHO, 1998, ¶ 5). The scope of nursing care is dependent on the country’s requirements, budget, and cultural system (WHO, 1998, ¶ 6). Nurses provide a wide range of primary health-care services from preventative and curative in both low- and high-income countries. In other countries, nurses are underutilized and their practice restricted and supervised by physicians (WHO, 1998, ¶ 9). Nurses also spend their time on nonnursing tasks that contribute to burnout, dissatisfaction, and higher turnover rates. The U.S. Bureau of Labor Statistics (2006) reported, “Employment of registered nurses is expected to grow much faster than average for all occupations through 2014,
44 and because the occupation is very large, many new jobs will result” (Job Outlook section, ¶ 1). In 2004, registered nurses held 2.4 million jobs in U.S. health-care settings such as inpatient, outpatient, home care, government agencies, and physician offices (U.S. Bureau of Labor Statistics, Employment section, ¶ 1). Between 1998 and 1999, the International Hospital Outcomes Research Consortium conducted a study on staffing, the organizational climate, and patient outcomes in 711 hospitals (Aiken, Clarke, Sloane, Sochalski, et al., 2001, p. 44). The sample included 43,329 nurses working in the United States, Canada, England, Scotland, and Germany (Aiken, Clarke, Sloane, Sochalski, et al., 2001, p. 44). Even in different health-care systems, nurses reported similar concerns over patient safety and quality of care. The increasing elderly population requiring specialized health-care services requires more nurses, thus exacerbating the situation. Nurses are retiring from the profession, so they too become a statistic in the elder population (Berliner & Ginzberg, 2002, Early Retirement section, ¶ 1). According to Aiken et al. (2004), “Failed policies and underinvestment in nursing” (p. 76) contributed to the worsening nursing shortage in developed countries (such as the United States, United Kingdom, Canada, Ireland, Australia, and New Zealand). The capacity limitations in nursing programs in 2003 resulted in the rejection of 11,000 qualified students (Aiken et al., 2004). Results from the National Sample Survey of Registered Nurses (NSSRN; Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000) provided a description of the “personal, professional, and employment characteristics of the almost 2.7 million registered nurses in the country [United States]” (p. 3). According to the NSSRN, 494,727 nurses were not working in the health-care environment: 322,453 were not
45 seeking nursing employment, 35,968 were seeking employment, and 135,696 had gainful employment in other occupations (Spratley et al., p. 68). The total number of nurses working in March 2000 was 2,201,813. Those nurses between the ages of 40 and 44 represented 18.6% of the sample and 18.5% were ages 45 to 49. The average annual earning was $46,782. Thirty-six percent of nurses had an associate degree and 31.5% held a baccalaureate in nursing (Spratley et al., pp. 39-46). In the NSSRN data (Spratley et al., 2000, p. 71), nurses reported seeking another occupation because of the difficulty in finding a position, inconvenient hours in healthcare settings, better salaries elsewhere, safety concerns in health-care settings, and the inability to practice nursing professionally. Aiken et al. (2002, p. 1987) studied job dissatisfaction extensively and concluded higher patient-to-nurse ratios contributed to nursing burnout, exhaustion, and dissatisfaction. Forty-three percent of the nurses surveyed in Aiken et al.’s (2002) study reported feeling dissatisfied, burned out, and an intention to leave their current position within 12 months. An additional 11% stated they were satisfied in their job, were not burned out, but intended to leave their current job. The NSSRN (Spratley et al., p. 3) indicated 67% of nurses were dissatisfied with their current position in the hospital setting. Berliner and Ginzberg (2002, Conclusions section, ¶ 2) advocated a planned long-term strategic approach to the nursing shortage that included recruiting students to the profession, retaining nurses already working in the field, and encouraging nurses to remain in the profession. Despite the support and assistance of the WHO, the nursing shortage continues in developing countries. Contributing factors include lack of nursing involvement in policy and planning, inadequate education, poor working conditions, limited career
46 opportunities, and lack of resources (WHO, 1998, WHO Nursing Activities Since the Alma-Ata Declaration section, ¶ 7). Future goals for the WHO included strengthening the educational system through curriculum development, research, legislation, leadership training, and more (WHO, 1998, Future section, ¶ 2). Saudi Arabia’s Nursing History Mejia et al. (1979) recognized the data from Saudi Arabia were incomplete and confusing. Saudi Arabia was a country of contradictions in the 1970s. The country showed signs of underdevelopment, yet the gross national product was sufficient to provide the benefits of wealth (Mejia et al., p. 387). Saudi Arabia depended on foreigntrained physicians and FTNs to meet the health-care needs of its citizens. The country has improved its own recruiting and training of physicians, although Saudi Arabia continues to buy FTNs (M. Al Osaimi, personal communication, January 9, 2007). Doumato (1999, p. 570) noted nursing is a new profession for Saudis, yet history documents the first Muslim nurse (Rufaidah bint Sa’ad Al Aslamiyyah) during Prophet Muhammad’s (peace be upon him) time (Al Osaimi, 2004, p. 5; Miller-Rosser et al., 2006, ¶ 8; Tumulty, 2001, p. 285). Rufaidah was born in Yathrib (now called Madina) in the 1st century AH (Hijri) or 8th century CE (Gregorian). Rufaidah was a community health nurse and social worker. Rufaidah and her nurses cared for the sick and wounded by providing medicines, food and water, wound care, emotional support, and so forth in a tent that was erected in the Prophet’s (peace be upon him) mosque (Al Osaimi, p. 5). This was the beginning of the nursing profession in the Islamic world (Al Osaimi, p. 6). Al Osaimi noted, “For a long period this profession (nursing) was badly condemned and misunderstood. It was not appreciated because of ignorance and the inequality in labour
47 between men and women” (pp. 38-39). Throughout history, Islam had identified teaching, nursing, dressmaking, and being a caregiver for small children as acceptable areas to work because of the nurturing role of women (Doumato, 2003, p. 248). The first training program for nurses started in 1958 in Riyadh, a collaborative effort between the MOH and the WHO (Tumulty, 2001, p. 285). The program was open to males only as it was culturally acceptable for males to be nurses. Females did not go to school until 1964. Riyadh offered the first female baccalaureate of science in nursing (BSN) program 1976. The master’s of science in nursing (MSN) program followed in 1987. While the university programs were open to females only, diploma programs still existed for male and female students. In the private sector and other government hospitals, schools of nursing were mushrooming to meet the demands of hospitals and to meet the goals of Saudization (Doumato, 1999, p. 571). The 1991 Gulf War created a crisis in human resource management for Saudi Arabia. Hospitals were short-staffed as FTNs left the country to go home (Tumulty, 2001, p. 286). The loss of FTNs made Saudization a priority. “Human resources development can be argued to be a more realistic, reliable and pervasive indicator of development than any other single factor since it is invariably a necessary condition for all kinds of growth” (Alsahlawi & Gardener, 2004, p. 180). Saudi Arabia’s own workforce is reluctant to enroll in a profession that is fraught with family, cultural, and religious conflicts. It is difficult in the hospital setting to segregate unrelated men and women, as is dictated by their cultural orientation. Another cultural practice is women cover their face in the presence of an unrelated male. Working hours for nurses conflict with family obligations and nursing is an undesirable profession. The sudden wealth of the country from oil
48 production created an unrealistic society in the 1970s and 1980s. Students aspired to elite careers such as medicine, architecture, engineering, and business. Lack of planning and long-range calculations contributed to the lack of potential students for the nursing profession (B. Alhaj Hussein, personal communication, May 11, 2005), although attitudes and cultural mind-sets were changing with the influence of the rising unemployment of educated females (Doumato, 1999, p. 568). Status of Saudi National Nursing Saudi female activists are calling for change. The total number of foreign workers in Saudi Arabia constituting one third of the population was an indication that Saudization was not working in many sectors (Doumato, 1999, p. 571). Attempting to attract young men and women into the nursing profession has been and continues to be a challenge. The incentive for Saudization may be economic as the average per capita gross national product fell from $18,800 in 1981 to $6,700 in 1995 (Doumato, 1990, p. 570) and increased to $11,051 in 2004 according to the MOH (1425 H., 2004 G., 2 p. 1). There are two main tracks for nursing education in Saudi Arabia. The programs include technical diploma (health institutes) and university degree (Miller-Rosser et al., Recent History of Nursing Education and the Health Institutes section, ¶ 5 and Professional Development Programs section ¶ 1; Tumulty, 2001, p. 286). According to
2
The source documents were dated using the Hijri (H.) calendar. The Gregorian (G.) date has
been added to facilitate understanding and to place the document in context with other references used in the study.
49 recommendations by the WHO, ICN, and Gulf Cooperation Council Nursing Technical Committee, the minimum entry to practice should be a BSN by 2010 (Abu-Zinadah, 2006, ¶ 11). Two organizations govern the practice of nursing in Saudi Arabia, the Saudi Commission for Health Specialties (SCHS) and the Saudi Council for Health Specialties (SCFHS). A Royal Decree in 1413 H. (1992 G.) initiated the SCHS (SCFHS, n.d., ¶ 1). The commission was the professional licensing board for all health-care practitioners in Saudi Arabia (SCHS, 2006, ¶ 2). Nursing is one of the health specialties governed by the commission. Gainful employment in the Kingdom is dependent on the FTN passing the licensing exam. The exam is available in the Kingdom or at several testing centers in countries such as India, Pakistan, Philippines, Bangladesh, Egypt, Jordan, Lebanon, and Syria (SCHS, Some Countries Addresses Test Centers section, ¶ 1-8). Trade experts posit that the relicensing of migrant nurses protects the nursing profession rather than the patients under the nurses’ care (Kingma, 2006, p. 46). The SCFHS is responsible for formulating, approving, and supervising professional health specialty programs, formulating continuing education programs, accrediting organizations that provide training in specialty areas, and more (Saudi Arabia, 2006, October, ¶ 1). The SCFHS is responsible for the academic side of the professional health specialties and for the registration procedures for nursing. Nurses are required to provide evidence of continuing education every 3 years when renewing their registration (Abu-Zinadah, n.d., ¶ 3). Supporting Viewpoints on Nurse Migration The supporting viewpoint of nurse migration is the right of individuals to make choices in the face of economic and social constraints (ICN, 2007, Freedom of
50 Movement section, ¶ 1, and Regulation of Recruitment section, ¶ 1). Whatever the push for a FTN, the will and ability to travel is the FTN’s right. Issues will not be resolved if governments and organizations coerce nurses to stay home. Internal country issues make migration a solution for many nurses (A. Otvos, personal communication, March 28, 2007). The reasons for migrating include finances, poor working conditions, lack of management, lack of career opportunities, lack of retirement benefits, issues involving the infrastructure of a home health-care system, and a lack of professional respect by the country and the health-care system. A lack of autonomy in the profession, the increasing crime rate, and rise in HIV/AIDS pushed South African nurses to migrate (Buchan, Kingma, et al., 2005, pp. 10-14). Miti (2006, p. 10) noted Zambian government policy dictated government workers (including nurses) retire at the age of 55. Other factors contributing to Zambia’s declining nurse workforce included a lack of government dollars to provide health-care services, the prevalence of HIV/AIDS (approximately 16%), a freeze on hiring government workers (including nurses), and incentive programs aimed only at physicians (Miti, pp. 12-13). The worsening condition of the HIV/AIDS epidemic for both patients and health-care workers is a safety issue. According to Hongoro and McPake (2004, p. 1452), 44 nurses (or 44%) died in Malawi from the disease in 1997 and 185 nurses (or 38%) died in Zambia in 1999. Kingma (2006) stated, “Looking at the whole continent of Africa, HIV/AIDS is estimated to be the cause of between 19 and 53 percent of all deaths of health employees in the public sector” (p. 44). The risk of transmission of the disease is from patient to health-care worker rather than health-care worker to patient. The WHO
51 reported that health-care worker deaths from HIV/AIDS might be as high as the emigration rate (Kingma, 2006, p. 44). According to Kingma (2006, p. 45), the safety issues that push nurses from their countries have not been given enough attention. For example, many countries reported occupational hazards from overwork, burnout, and stress (Slovakia, the United States). Additional issues of quality stem from the lack of professional development or lifelong learning, poor working conditions, and salary (Hongoro & McPake, p. 1452). In countries with the greatest need and least resources, these are constraints in nurse migration. In Canada, government agencies ignored the nursing shortage threat from nurse leaders, saying that nurses invented the shortage initiative (Shamian, 2006, p. 20). To reduce the deficit, the Canadian government created policies that reduced funding to the health-care system and educational system. To reverse the effects of these policies, the provinces, in collaboration with the Canadian government, implemented policies that encouraged self-sufficiency rather than dependence on immigration (Shamian, p. 23). Despite internal policies addressing nursing issues, Canada remains at risk of losing nurses to other countries, especially the United States, where opportunities are diverse. The second supporting viewpoint of nurse migration is the effect of globalization that has made it easier for developed and developing countries to recruit FTNs (Buchan, Kingma, et al., 2005, p. 5). A lack of reliable data plagues the ability to assess the impact of nurse migration (Buchan, Kingma, et al., 2005, p. 3). Migration practice was not just a simple process of moving from donor country to recipient country (Buchan, Kingma, et al., 2005, p. 8). That is, many countries needed to locate and recruit nurses, wherever they were. A nurse may be working in one country and recruited to work in another country.
52 For example, FTNs working in Saudi Arabia can choose to migrate to the United Kingdom, Australia, or the United States through active recruitment processes in those countries. The third supporting viewpoint of nurse migration is a country’s demand and ability to pay for health-care services. Saudi Arabia is a land of mystery and intrigue, although the country’s nursing shortage holds no mystery. Dependent on FTNs, Saudi Arabia understands the need to Saudize the nursing profession. Replacement of FTNs in the Kingdom is unlikely to happen before 2020. Like many nations, Saudi Arabia suffers from the dwindling pool of potential nurses as other countries vie for their services. Retention of FTNs requires strategic planning based on scholarly research. Saudi Arabia is in a manner of speaking a recipient country and a source country for FTNs. Nursing directors experience international recruitment companies luring FTNs away while working in Saudi Arabia (A. Dababneh, personal communication, March 28, 2007). As health-care services expand to meet the growing needs of Saudi Arabia’s population, dependence on FTNs continues and the market widens. In 2001, South African nurses were a new source of FTNs (A. Otvos, personal communication, April 29, 2005). In 2007, China and Bangladesh were new sources for FTNs (M. Al Osaimi, personal communication, January 5, 2007). Recruitment is not only dependent on the nursing standards of care and training in foreign countries but on the available human resources in the donor countries as well. The last supporting viewpoint for nurse migration is a country’s policy to provide a supply of nurses for countries demanding the profession. The Philippine government systematically produces nurses for export, with the United Kingdom, Saudi Arabia,
53 Ireland, and Singapore being the main recipient countries for nurses in 2001 (Buchan, Kingma, et al., 2005, p. 14). The pull of leaving the Philippines is so great that 80% of government physicians trained as nurses from 2003 to 2005 (Navarro, 2006, p. 32). The demand exceeded the supply. Migration out of the Philippines resulted in the closure of 200 hospitals, and 800 hospitals partially closed. Data from 2005 illustrated the nurse-to-patient ratios ranged from 1 nurse for 40 patients to 1 nurse for 60 patients (Navarro, p. 35). The Philippines, a major market for Saudi Arabia, closed 23 recently opened nursing schools in 2005 (Overland, 2005, ¶ 2). The government was concerned about quality in the country’s academic standards and fraud within the nursing board. Academic standards and fraud are not the only challenge facing the Philippines. Socioeconomic factors in the Philippines provide educated citizens the opportunity to work overseas. Not only physicians are entering nursing programs but other professionals, such as dentists, lawyers, and engineers. The nursing shortage also plagues the health-care infrastructure in the Philippines as the government tries to balance the needs of its own people and the needs of the global market. China has also developed an infrastructure to provide nurses for foreign employment (Kingma, 2006, p. 82). The government initiated scholarship programs (Kingma, 2006, p. 82) and negotiated labor agreements with other governments, including Saudi Arabia (M. Al Osaimi, personal communication, January 5, 2007). Opposing Viewpoints on Nurse Migration The opposing viewpoint on nurse migration is the moral and ethical issues of developed nations that lure nurses from developing countries. Luring nurses from their country compromises health care in the developing country (ICN, 2007, Freedom of
54 Movement section, ¶ 1, and Regulation of Recruitment section, ¶ 1). Buchan and Sochalski (2004, p. 588) reported developed countries take advantage of nurses who are able to migrate by positioning themselves as able to pay higher wages, provide career opportunities, provide professional development, and provide safe working environments. The United States provides easy access for FTNs to qualify for nursing employment in the United States. The National Council of State Boards of Nursing, in collaboration with Pearson Virtual University Enterprises (VUE), develops and administers two national nurse licensure examinations, one for registered nurses and the other for practical nurses (Pearson VUE, 2007, p. 2). Twenty-four international testing centers provide a computerized National Council License Exam (NCLEX) exam. Testing centers include American Samoa, Australia, Brazil, Canada, China, France, Germany, Greece, Guam, Hong Kong, India, Israel, Japan, Mexico, Northern Mariana Islands, Puerto Rico, Singapore, Thailand, Turkey, Spain, Taiwan, United Kingdom, United States, and the U.S. Virgin Islands (Pearson VUE, ¶ 7). The top international countries that tested for NCLEX in 2006 included the Philippines, India, South Korea, Canada, and Cuba (NCLEX Statistics From NSCBN, 2006, ¶ 10). Other countries such as the United Kingdom have preemployment screening for FTNs seeking to emigrate that include English proficiency testing and formal training (FAQs for Nurses and Doctors, 2004, ¶ 11). Adevia Health is a recruiter for nurses and physicians for the NHS in the United Kingdom and individual hospitals in the United States. The company assists FTNs through the process of applying for jobs in the United Kingdom and the United States. By law (Department of Health Code of Practice), the United Kingdom advised Adevia Health not to recruit from certain countries (Buchan,
55 Jobanputra, et al., 2005, p. 22). The Web site provided a list of countries excluded from recruiting nurses; Saudi Arabia is on the list (FAQs for Nurses and Doctors, ¶ 16). One can assume the exclusion list means the nurses of that country (that is, Saudi nurses rather than FTNs working in Saudi Arabia). Nursing directors reported FTNs are in frequent contact with recruiters about opportunities overseas (A. Dababneh, personal communication, March 28, 2007). The fact remains, nurses are in demand. No one can deny a person’s right to a better and more profitable existence. There are two levels of discussion on this issue: a personal and a national level. On a personal level, a nurse gains personal and professional growth by migrating to a multicultural environment (ICN, 2007, ¶ 2). Yet at a humanistic level, migrating nurses realize the effect on the health-care system when they decide to leave their country. Growing evidence indicates that nurse exploitation in developed countries is not monitored (ICN, ¶ 4; Kingma, 2006, p. 112; Msimang, 2001, ¶ 1). Kingma (2006, p. 116) noted several countries attempted to implement measures to protect FTNs, although more needs to be done. At the national level, the consequences of nurse migration include whether the nurses’ education was state or privately funded, employment situation (that is, workforce planning), the effect of migration on the nurses left behind, whether leaving was a permanent or temporary situation, and how much was at stake in remittances (Bach, 2003, pp. 14-15). Policy makers must rectify planned, strategic policies to satisfy the personal and national issues of nurse migration that influence the moral and ethical consequences, which is not easy considering the shortage continues to worsen. Policy makers are aware the growing geriatric population requires more health-care services, HIV/AIDS is
56 affecting the health-care needs of more people, and the lack of educators prevents recruitment of new nurses (Sigma Theta Tau International, 2001, ¶ 22). Navarro (2006) reported the Philippine government called for an “ethical framework that will guide recruitment, policies and procedures applicable to countries who recruit from the Philippines” (p. 37). The POEA negotiates agreements with the destination country, reviews the contracts, provides an orientation of the host country, assesses employers (especially the private sector), and more. The U.K. NHS implemented a Code of Practice that governs its recruitment process (Bach, 2003, p. 22). The guidelines included practices such as developing countries should not be the target for recruitment, potential recruits should have the required skills and knowledge, and potential recruits should demonstrate English proficiency. An additional form of managed recruitment involved bilateral agreements between donor country and recipient country, as in the agreements with India, the Philippines, and Spain and the NHS (Bach, 2003, p. 23). The advantages for such agreements include reduced dependence on private recruiting agencies that may have unscrupulous marketing practices and a sharing of human resources. Bach (2003, p. 24) posited a 5-year agreement in which foreign health workers would work in the United Kingdom for 3 years and in the source country for 2 years. The salary for 5 years would be the responsibility of the United Kingdom. The second opposing view was the root cause of nurse migration for leaders. Kingma (2005) stated, “Migration is a symptom of dysfunctional health systems and should be treated as the primary disease” (p. 15). Oulton (as cited in Kingma, 2006, p. 223) posited that health-care infrastructures have faltered due to health-care reforms. The
57 statement indicated nurse migration was a result of failed national policies and a lack of financial resources in health care (Buchan, Parkin, & Sochalski, 2003, p. 3). Kingma (2006, p. 24) noted that in developing nations, economic policies (or public-sector reform) have reduced health system budgets that make it difficult for nurses to have fulfilling careers. The public-sector reform process started in the 1980s with “structural adjustment programs” (Kingma, 2006, p. 25) by the World Bank and the International Monetary Fund. Intended to stimulate a country’s economic and social structure, the programs failed, leaving deteriorating health-care services in many countries. “The failure of structural adjustment has been so dramatic that some critics of the World Bank and International Monetary Fund argue that the policies imposed on African countries were never intended to promote development” (Colgan, as cited in Kingma, 2006, p. 25). Costcontainment initiatives also reduced the nursing workforce in developed countries. In the United States, for example, financial reimbursement from insurance companies and health maintenance organizations guided the practice of health care (Kingma, 2006, p. 32). A misguided prediction that there would be an oversupply of nurses by the end of the 20th century reduced the number of nurses in the workforce. Closure of nursing schools and hospital restructuring contributed to the current nursing shortage crisis (Kingma, 2006, p. 32). The third opposing viewpoint of nurse migration is leadership ignored the predicted nursing shortage and the recommendations made by researchers and policy makers to remedy the problems associated with the shortage (Shamian, 2006, p. 20; Simpson & Thompson, 2003, ¶ 2). Leadership failed to recognize the “three elements of
58 [the] health care manpower development process: planning, production, and management” (Mejia et al., 1979, p. x). Leaders continue to view nurses as supporters of health care rather than directors of health care. When developed nations experienced a crisis, leaders looked to short-term solutions, including recruiting FTNs from available sources. Available sources for the United States in the past have been the United Kingdom, Canada, and the Philippines. The paradigm is shifting as the shortage affects every country. Recruiters are going to South African nations, Europe, India, the Caribbean, Japan, and China. These countries can ill-afford their human resource to leave as their nations face the challenges of meeting global, regional, and national commitments in health care (Buchan, Kingma, et al., 2005, p. 5). Job Satisfaction and Burnout The scholarly research on the Magnet hospitals provided a foundation for a North American system that showed evidence of retaining nurses (Aiken, Havens, & Sloane, 2000; Coile, 2001; Hackman et al., 1975; Havens & Aiken, 1999; Kramer & Schmalenberg, 2003; Upenieks, 2002). Kramer and Hafner (1989) explored variables in hospitals that were retaining nurses, thus the name Magnet. Magnet hospitals developed organizational attributes that were conducive to nurse work satisfaction and tenure. Kramer and Hafner surveyed and interviewed nurses from 46 Magnet hospitals to explore the situation and developed the NWI (p. 173). The attributes included “adequate staffing levels; flexible scheduling; strong, supportive, and visible nurse leadership; recognition for excellence in practice; participative management with open communication; good relationships with physicians; salaried rather than hourly compensation for nurses;
59 professional development; and career advancement opportunities” (Sovie, as cited in Aiken & Patrician, ¶ 12). Key elements of dissatisfaction included work redesign and management. Healthcare cuts and redesign have affected the working nurse, resulting in loss of managerial positions (for example, director of nursing and nurse managers), increased patient load despite rises in patient acuity, and increased responsibility for other personnel on the unit (Aiken, Clarke, Sloane, Sochalski, et al., 2001, pp. 47-48). Nurses reported spending time on nonnursing tasks (such as delivering food trays, transporting patients, and cleaning rooms). Nurses also reported not having time for basic nursing care (such as oral hygiene, skin care, teaching, and support; Aiken, Clarke, Sloane, Sochalski, et al., 2001, p. 49). Reengineering continues to jeopardize the issues facing the profession. Nurse staffing contributed to patient safety issues and dissatisfaction (Clarke, 2003, ¶ 2; Kingma, 2006, p. 212). Aiken et al. (2002, p. 1988) focused on job satisfaction, patient-to-nurse staffing ratios, and the relationship to surgical patient outcomes and retention of nurses in 168 Pennsylvania hospitals and concluded that higher patient-to-nursing ratios contributed to patient mortality and failure-to-rescue within 30 days of admission (Aiken et al., 2002, p. 1990). Aiken et al. (2002) defined failure to rescue as “deaths following complications” (p. 1987). The findings concluded that a staffing ratio of one nurse to six patients resulted in an additional 2.3 deaths per 1,000 patients and 8.7 additional deaths per 1,000 patients with complications (Aiken et al., 2002, p. 1991). Aiken et al. (2002, p. 1992) concluded nursing staff’s availability to assess and reassess a patient’s postoperative status influenced nursing effectiveness that resulted in poor outcomes, including nurse dissatisfaction and intent to leave. According
60 to Kulwicki (2006, p. 396), nurses are the most visible health-care providers and will continue to shape the health-care status of the world’s population. Reengineering, chronic diseases, and nurse-to-patient ratios are issues that affect patient safety and outcomes when discussing the human resource shortages. Patient safety correlated directly to nurse-to-patient ratios in several studies (Kane, Shamliyan, Meuller, Duval, & Wilt, 2007; McCutcheon et al., 2005; Van den Heede et al., 2007). The restructuring of the Canadian health-care system in the 1990s resulted in significant nurse staffing reductions with an aim to improve efficiency and reduce costs (McCutcheon et al., p. 1). Issues similar to those in the United States resulted in a declining workforce that jeopardized patient safety. The issues included replacement of registered nurses with nonregistered nurses, early retirement of experienced nurses, creation of new clinical teams, younger nurses leaving the profession, and increased responsibilities for nurse managers (McCutcheon et al., p. 1). By 2001, Canada’s declining health-care system was a major concern. McCutcheon et al. documented the findings from previous research on nurse staffing and patient safety and described three domains where nurse staffing related to patient safety: nurse staffing and patient outcomes, nurse staffing and staff outcomes, and nurse staffing and system outcomes (p. 2). Patient outcomes included mortality and increased risk of adverse events (such as pressure ulcers). Staff outcomes included job dissatisfaction, burnout, and turnover. System outcomes included increased length of stay and cost. The report concluded nurse staffing is a determinant of patient safety in all three domains (McCutcheon et al., p. 14). Recommendations for improving patient safety included staffing plans based on acuity of patients, education and professional development of
61 nurses, nurse experience calculated in staff planning, and improving the nurse practice environment (such as transformational leadership, collaborative work relationships, autonomy over practice, and use of technology and research to improve patient care; McCutcheon et al., pp. 14-15). Van den Heede et al. (2007) surveyed international experts to assess “their impressions about specific staffing outcomes and outcomes measures in order to develop a comprehensive set of variables for use in future research” (p. 291). The 28 international participants in the study were nurse executives or nurse researchers who were experts in the areas of nurse staffing and quality health care. The participants identified patient-care outcomes sensitive to nursing care related to the number of nursing staff and the skill mix of the nursing staff (Van den Heede et al., p. 293). Skill mix was “the composition of the nursing staff by licensure or educational background” (Van den Heede et al., p. 291). There was high participant consensus regarding measures sensitive to nurse staffing that included nurse-perceived quality of care, patient satisfaction, and pain management. The measures sensitive to nurse skill mix included aspiration pneumonia, postoperative complications, hospital-acquired pneumonia, medical errors, symptom management, pain management, mortality, failure to rescue, and nurse-perceived quality of care. The participants identified additional measures that are sensitive to nurse staffing and nurse skill mix that included pain management and patient and family complaints (Van den Heede et al., p. 295). The study of current research indicated a link to nurse staffing and patient outcomes. Recommendations included continued research in the area and an exploration of additional variables that are sensitive to nurse staffing and nurse skill-mix measures.
62 Kane et al. (2007) compiled evidence from observational studies in the United States and Canada between 1990 and 2006. The focus of the study was to evaluate how nurse patient ratios and nurse work hours related to patient outcomes in acute-care settings. Ninety-six reports were included in the study. Kane et al. (p. 9) noted that a shortage of nurses combined with an increased workload on those who are available, compromises patient quality of care. Studies have shown that inadequate nurse staffing leads to higher rates of adverse events such as hospital-acquired infections, shock, and failure to rescue (Kane et al., p. 9). Kane et al. (2007, p. 13) revealed a complex picture of nurse staffing issues. Multiple factors contributed to patient outcomes (morbidity, adverse events) and length of stay. The factors included staffing (nursing hours per patient day, skill mix), nurse characteristics (education, experience), nurse outcomes (satisfaction, burnout), patient factors (age, primary diagnosis), and hospital factors (size, volume). Kane et al. confirmed that increased nurse staffing leads to improved patient outcomes, “but this association has not been shown to reflect a causal relationship” (p. 4). Other factors such as Magnet status hospitals (a professional nurse work environment), hospital commitment to quality care, and nurse retention strategies led to improved nurse staffing, nurse outcomes, and patient outcomes. Three dissertations from Saudi doctoral students addressed job satisfaction related to nursing leadership styles, recruitment and retention barriers, and quality of life. Omer’s (2005) mixed-method study included an examination of the leadership styles of nurse managers at a military hospital in Saudi Arabia. Nurse managers and staff nurses participated in the quantitative phase of the study by answering questions on the
63 Multifactor Leadership Questionnaire. Nurse managers provided qualitative data in oneon-one interviews with the researcher. Independent variables included the nurse managers’ perception of their leadership style and staff nurses’ perception of their nurse managers’ leadership style (Omer, p. 53). Dependent variables included outcomes correlated with the nurse managers’ leadership style and included job satisfaction of staff nurse, effectiveness of nurse manager, and staff nurse willingness to exert extra effort on the job. Omer’s (2005, p. 99) study results found a positive correlation with job satisfaction and transformational and transactional leadership characteristics and a negative correlation with job satisfaction and management-by-exception and laissez-faire leadership characteristics. Three leadership themes emerged from the qualitative data based on Hermeneutic phenomenology as the theoretical framework. The themes were leadership process, work environment, and work relationships (Omer, p. 108). The themes together shaped the nurse managers’ leadership experience. Al-zayyer (2003) studied nursing administrators in nine tertiary hospitals in Saudi Arabia. Al-zayyer investigated recruitment and retention strategies and the barriers to those strategies and discovered that over a 3-year period, 35% of the hospitals reported increased vacancies, 22% reported a decrease in vacancies, and 40% stated the vacancies remained the same (p. 63). The nursing administrators cited the following reasons for the increased vacancies: “salaries, competitive job markets, increased workload, expansion of services, the political situation in Saudi Arabia, financial instability, lack of support for nursing personnel, the living conditions in Saudi Arabia and personal reasons” (Alzayyer, p. 64). Al-zayyer noted hospitals that worked on job satisfaction strategies
64 reported a decrease in vacancies. The job satisfaction efforts in the hospitals included teamwork, improved working relationships between departments, competitive salaries, a happy work environment, and adequate support for nursing personnel. In the hospitals that reported vacancies remained the same, the following reasons were attributed: “the promotion of staff nurses, salary raises, floating of staff nurses to other departments within the hospital, and rapid and effective recruitment efforts to fill registered nurse (RN) vacancies” (Al-zayyer, p. 65). Abo-Znadh (1999) conducted a study on nurses’ job satisfaction and turnover in two tertiary care hospitals in Riyadh, Saudi Arabia. Abo-Znadh examined surgicalmedical staff nurses’ characteristics, job characteristics, and quality of work life. Staff characteristics included demographics, growth need, and psychological states. Job characteristics included skill variety, task identity, task significance, autonomy, job feedback, agent feedback, and dealing with others at work. These characteristics correlated to quality of work life that examined general and specific job satisfaction and internal motivation (Abo-Znadh, p. 8). Participants in the study included nurses (foreign and Saudi) that provided direct patient care and charge nurses from medical-surgical units. The hospitals demonstrated acceptable levels of general job satisfaction and low internal motivation. Job characteristics and staff characteristics correlated to quality of work life predictors. Saudi Arabia Saudi Arabia is a Muslim Arab monarchy established in 1902 by King Abdulazeez Al Saud (Al-Sadan, 2000, p. 143). In 1932, the Kingdom of Saudi Arabia was born. Desert life and the Islamic Sharia (“the totality of the religious and moral laws of Islam,”
65 Al-Sadan, p. 143) influence the Saudi way of life. These influences reflect the character of the people. Before the discovery of oil, the people of Saudi Arabia were poor and illiterate. Bedouin was the term used for the inhabitants of this harsh environment. They lived on the land, taking care of sheep and camels, and followed the rain to survive. Although there are still some Bedouins living in the desert, most have moved to the main cities with the change in lifestyle brought on by the discovery of oil. Outward appearances indicate Saudi Arabia went from rags to riches (Bremmer, 2004, p. 26). To assist the growing nation, the government organized and implemented a system of development planning in the public services, health, education, and social services (Alsahlawi & Gardener, 2004, p. 176). Wealth changed the Saudi way of life from simple to complex. Education was a necessity in building the labor resources for industry and economy, and skilled and nonskilled Saudi labor continued to be a challenge in many sectors, including health care. The Arab Human Development Report (United Nations Development Programme [UNDP], 2002, p. vii) concluded that Middle Eastern countries must rebuild their societies based on human rights and freedoms, empowerment of women, and merging knowledge with effective utilization. In May 2003, Saudi Arabia formed two Human Rights Committees (Wattad, 2003, ¶ 4). Saudi citizens demanded an independent nongovernment organization to oversee human rights and domestic reforms. Challenges exist for the nongovernment organization. For example, the nongovernment organization was barred access to a human rights trial (B. Alhaj Hussein, personal communication, May 17, 2005). The idea for reform on domestic issues and human rights is on paper but change takes time. The second committee is a government Human Rights group. The chair is the Human Rights
66 Minister, a newly created position (Wattad, ¶ 4). Other members of the committee included university professors, Shura Council members (appointed legislature), lawyers, and other academicians. The article did not document the goals of the government Human Rights committee. Census Data According to Facts About Saudi Arabia (2008, People section, ¶ 1), foreign workers comprised an estimated 5.6 million of an estimated population of 28.1 million in July 2008. The Saudi population was 80.2% and the non-Saudi population was 19.8% (Facts About Saudi Arabia, 2008, People section, ¶ 1). Baby boomer issues are not affecting Saudi Arabia. In July 2008, almost 60% of the population was between the ages of 15 and 64 years with a median age of 21.5 years (Facts About Saudi Arabia, People section, ¶ 2). The population between 0 and 14 years was 38%, while the population over 65 years was 2.4% (Facts About Saudi Arabia, People section, ¶ 2). On average, four children were born for every female, with a population growth rate at 1.95% (Facts About Saudi Arabia, People section, ¶ 4, 11). Infant mortality rate was 11.94 deaths per 1,000 live births, and life expectancy was 76.09 years (Facts About Saudi Arabia, People section, ¶ 9, 10). The estimated literacy rate in 2008 was 78.8% (Facts About Saudi Arabia, People section, ¶ 19). Unemployment estimates for males only in 2004 were 13%, although other estimates ranged as high as 25% (Facts About Saudi Arabia, Economy section, ¶ 9). According to the Bureau of Economic Analysis (2006), gross domestic product (GDP) is “the market value of goods and services produced by labor and property in the United States, regardless of nationality” (¶ 3). The formula for calculating the GDP is
67 consumption + investment + government spending + (exports – imports). In 2007, the estimated GDP for Saudi Arabia was $376 billion, with a GDP growth rate of 4.1% (Facts About Saudi Arabia, 2008, Economy section, ¶ 3, 4). The estimated GDP per capita in 2007 was $23,200 (Facts About Saudi Arabia, Economy section, ¶ 5). In 1980, the average household income was $18,000, citizens were guaranteed a house, free land, free medical care, free schooling, and no taxes (Doumato, 2003, p. 250). The economy has changed and young Saudis “cannot hope to duplicate the financial security experienced by their parents’ generation” (Doumato, 2003, p. 250). The Kingdom faces serious economic challenges (Feld, 2005, ¶ 5) because of high rates of unemployment, the population growth rate (2.4% yearly), and the need for increased government spending. The country’s dependence on oil is beyond question as Saudi Arabia is the largest exporter of petroleum and possesses 25% of the world’s proven reserves (Facts About Saudi Arabia, 2008, Economy section, ¶ 1). To diversify its economy, Saudi Arabia has allowed foreign investors to participate in its telecommunication and power sectors. After many years of negotiation, the World Trade Organization granted membership to Saudi Arabia in December 2005 (Facts About Saudi Arabia, Economy section, ¶ 1). The MOH is responsible for the health-care sector in the Kingdom. According to the most recent statistics (MOH, 1428 H., 2006 G., p. 217), 386 hospitals serviced 13 regions, including 220 hospitals operated by the MOH, 39 operated by other governmental agencies (military), and 127 owned and operated by the private sector. The total number of health-care workers in the Kingdom included 45,589 physicians (including dentists), 8,546 pharmacists, 83,868 nurses (including 22,744 Saudi nurses),
68 and 45,340 allied health personnel (MOH, pp. 217-218). Kingma (2006, p. 174) stated that MOH recruitment representatives might interview 7,000 FTNs in one week. The MOH (p. 218) stated there are 3.54 nurses per 1,000 people. Saudi Arabia hired from countries that are cooperative and at peace with Saudi Arabia (A. Otvos, personal communication, April 29, 2005). For example, from the 1980s to mid-1990s, Saudi Arabia did not hire nurses from Jordan and all Jordanian nurses were sent home (A. Otvos, personal communication, April 29, 2005). The recruitment process varies according to the health-care sector. The MOH sends a recruitment team to various countries and hires the quota needed for all MOH hospitals. The MOH assigns FTNs to hospitals based on needs identified by the MOH. Foreigntrained nurses work on 2-year contracts and are required to fulfill the contract terms (A. Zahrani, personal communication, February 15, 2007). In the military health-care sectors, FTNs must have a visa to enter and work in the country. The Saudi Ministry of the Interior (for example in North America) established visa blocks and determined how many nurses of each gender would be recruited (A. Otvos, personal communication, April 29, 2005). The chief executive officer of a private hospital networks with someone politically in another country, an agreement is established, and a visa block for that country allows the process to begin (A. Otvos, personal communication, April 29, 2005). Foreign-trained nurses hired locally (in all health-care sectors) are usually under their husband’s sponsorship and do not appear in a data bank within the MOH. Individual hospitals do keep figures on the number of nurses hired locally and internationally. Many FTNs recruited in the 21st century do not have the necessary skills to work independently in the new work environment of Saudi Arabia. The necessary skills to
69 work independently include technology (computers, medical equipment), documentation, nursing assessment (head to toe), medication administration, collaboration with physicians, language barrier, and following policies and procedures (A. Zahrani, personal communication, February 15, 2007). It is the responsibility of the nursing education department to train and educate the nurse (Tumulty, 2001, p. 287). Nursing directors and educators expressed frustration in losing FTNs to other countries after they received additional training and gained new skills. Nurses can move to other hospitals that offer competitive benefits, go home, or immigrate to another country (A. Zahrani, personal communication, February 15, 2007). As only anecdotal articles provided insight into FTNs’ perception of working and living in Saudi Arabia, nursing directors were confident FTNs would be interested in participating in the study. Religion One cannot speak about the culture and norms of Saudi Arabia without discussing the religion of the people. The Arabic word Islam means “the submission or surrender of one’s will to the only true God, known in Arabic as Allah. One who submits his will to God is termed in Arabic a Muslim” (Philips, 1998, p. 6). As the Vatican is the home of Roman Catholicism, the Holy Mosque in Makkah, Saudi Arabia, is the birthplace of Islam. According to 2005 data, Islam is the world’s second-largest religion (21%) behind Christianity (33%; Major Religions, 2007). The third holiest place for Muslims is the Dome of the Rock built on Solomon’s Temple in Jerusalem. It signifies that Islam is the final religion in the world (Murad, 1998, p. 12; Philips, p. 8). The Qur’an states, “The last revealed word of God, is the primary source of every Muslim’s faith and practice” (Ibrahim, 1997, p. 54). Muslims believe the real word of
70 Allah is the Qur’an. Muhammad (peace be upon him) “is the last of Allah’s Messengers and Prophets” (Murad, 1998, p. 21). Muslims believe at the age of 40, he was endowed with the prophethood when Allah the Exalted, revealed to him, through the angel Gabriel the first Qur’anic verses, Muhammad, peace be upon him, was asked to preach the belief of the Oneness of Allah and warn people against polytheism. (Murad, p. 21) The Hadith are “reliably transmitted reports by the Prophet Muhammad’s (peace be upon him) companions of what he said, did, or approved of” (Ibrahim, 1997, p. 49). As in all written words, interpretation of language and the contradictions in the Hadith narrations and Qur’an (Doumato, 2003, p. 241) are the keys to understanding the full meaning. Sharia or Islamic law “was originally designed to regulate all aspects of life in Muslim societies, from the behaviour and habits of individuals to the workings of the criminal justice system and financial institutions” (British Broadcasting Corporation World Service, 2007, A Moral Code section, ¶ 2). Legal concepts based on the principles of the Qur’an are areas of discussion and conflict. The Qur’an, Hadith, and Sharia provide guidance to the faithful and for many Muslims they are the final word on how to live one’s life. The five pillars or beliefs of Islam are as follows (Murad, 1998, pp. 25-27): 1. Ash-Shahaada – the profession of faith. This is a phrase recited by someone embracing Islam; there is no God but Allah and He is worshipped according to the teachings of His Messenger Muhammad, peace be upon him. 2. Salat – prayer. Muslims pray five times a day at set times beginning at dawn and finishing at sunset. The faithful precede prayer by washing hands, face,
71 forearms, feet, and wiping over the head. 3. Zakat – donations of money to the poor. Giving to the poor is purification of one’s own wealth. Saudi’s donate the Zakat through yearly deductions from their paychecks or in the form of a tax on certain products, such as beef or food grain. 4. Sawm – fasting. Fasting begins at dawn and ends at sunset during the month of Ramadan (the ninth month of the Muslim calendar year). Fasting includes no eating, drinking, or sexual relations with the spouse during this time. It is an act of worship to attain piety, humbleness, and share the feelings of hunger with the community. At break-fast, families give food to the neighbors and Mosques provide evening meals to the poor. 5. Hajj – pilgrimage. Saudi Arabia and Makkah host pilgrims for Hajj yearly. It is a one-time journey for those Muslims that can afford it. The Status of Women According to Islam In the historical status of women in various cultures, society regarded women as the property of the husband or as bound and protected in some way by the male (Badawi, 1980, pp. 6-7). The Qur’an (7:189) states the following regarding the status of woman: “He (God) it is who did create you from a single soul and therefrom did create his mate that he might dwell with her (in love)” (Badawi, p. 12). According to Islam, men and women have equal opportunity to obtain Allah’s blessings and enter paradise. While on earth, men and women have complimentary yet distinct roles within the family structure. Researchers further explained the woman’s status in society from the spiritual, social, economic, and political perspectives.
72 Women’s status from a spiritual perspective. Men and women are equal in the rights and responsibilities in fulfilling one’s spiritual obligation to God (Badawi, 1980, p. 12). Chanicka (2005, ¶5)) noted it is not gender but faithfulness that determines who is good in Allah’s eyes. There are some occasions when women are exempt from performing some of the pillars of Islam. For example, women do not need to fast during Ramadan if they are pregnant, nursing, or ill. Women’s status from a social perspective. Education, wifehood, and motherhood are the three subcategories within the social perspective. Education is important for Muslim men and women (Badawi, 1980, p. 16). As a wife, the Qur’an specifies “marriage is sharing between the two halves of the society, and that its objectives, beside[s] perpetuating human life, are emotional well-being and spiritual harmony” (Badawi, p. 16). Women are considered biologically the weaker sex and are in need of protection from the man. The leader of the family is the man but leadership does not imply superiority or dictatorship over the wife. A woman has the right to choose her husband and the right to end an unsuccessful marriage (Badawi, pp. 18-19). Motherhood is sacrosanct in the Muslim religion as Badawi (1980) noted, “A famous saying of the Prophet is, Paradise is at the feet of mothers” (p. 21). Prophet Muhammad (peace be upon him) told Muslims they must love their mother three times more than they love their father. Women’s status from an economic perspective. Women have the right to their own money, real estate, or other properties according to Islamic Law (Badawi, 1980, p. 21). This law applies to women before and after marriage, and whatever properties a woman acquires after marriage. The family is the most important role in Islamic society.
73 Islam believes a mother’s role is to be the heart of shaping communities and nations. A mother’s role is to educate children to be productive citizens. Working is not forbidden for women, in positions that suit the nature of female work and where they are needed (Badawi, p. 22). Suitable professions for women include nursing, teaching, and medicine. Financial responsibilities fall on the man; he must provide for his wife, his children, and oftentimes his relatives (especially females). Women’s status from a political perspective. Badawi (1980) noted that Islamic history demonstrated the “woman’s equality with man in what we call today political rights” (pp. 23-24), which included participation in public affairs, election to public office, and the right to vote (Badawi, p. 24). Interpretation of the Qur’an in the Hadith stated women could not hold positions of head of state (Badawi, p. 24). The Prophet Muhammad (peace be upon him) stated it is not the place for a women to lead for society will not flourish (Badawi, p. 24). Again, women’s status refers to a woman’s biological and psychological structure rather than her rights or inferiority. Education Saudi Arabia discovered oil in 1938. In 1946, Saudi Arabia fully developed the oil industry in a joint venture with the United States (Al-Sadan, 2000, p. 144). Saudi Arabia continues to be a major producer of oil, natural gas, and petrochemicals (Facts About Saudi Arabia, 2008, Introduction section, ¶ 1). A system of development planning began in 1970, when the revenue from oil provided the means to improve the Saudis’ economic and social condition (Alsahlawi & Gardener, 2004, p. 176). A broad goal identified at the time was human resource development, which meant improving the educational system to train people for the jobs that would now be available through the
74 development plan (Alsahlawi & Gardener, p. 176). Early schooling offered reading, writing, and reciting the Qur’an. Private schools offered nonreligious subjects as early as the 1920s. The era of modern education began in the 1930s when the state assumed support of the school system. The Ministry of Education, established in 1954, appointed Prince Fahd (the recently deceased monarch) as the first minister. The goals were to expand the national school system and to modernize the system comparable to Western standards (Al-Sadan, 2000, p. 145). Public education for girls started in 1964, despite objections from the conservatives. Growth was slow because of poverty and illiteracy in the country. In the 1970s, the literacy rate for males was 15% and for females 2%. The estimated literacy rate for males was 84.7% and for females was 70.8% in 2003 (Facts About Saudi Arabia, 2008, People section, ¶ 19). The school system continued to expand through resource allocation according to the development plans outlined by the government. The school budget for 2003 was $14.48 billion or 27% of the total budget for the year (Center for Monitoring the Impact of Peace, ¶ 3). The illiteracy rate in the Arab countries is higher than the international average and higher than developing countries (UNDP, 2002, p. 51). Accessibility, gender equity, and quality are key challenges to the educational system in Saudi Arabia. In 2000-2001, higher education institutions were not able to admit 60,000 high school students (Alkhazim, 2003, p. 483). Some students went overseas to study at their own expense or through government support. In 2009, educators predict there will be 243,000 high school graduates and only 160,000 admitted to university or college (Alkhazim, p. 483). The current system does not meet the
75 demands for educating Saudi students. The second challenge, despite the efforts of providing access to free education (within and outside the country) and offering options for learning (technical and university), is Saudi Arabia’s inability to meet its goal of labor independence in some sectors. A constraint to economic growth remains in the shortage of skilled and unskilled native labor and the quality and standard of that workforce (Alkhazim, p. 483; Alsahlawi & Gardener, 2004, p. 180; Rugh, 2002, p. 407). Bremmer (2004, p. 26) noted the education system required major changes to prepare Saudi workers with the skills and knowledge to contribute to the country’s competitive markets. While other Arab countries are making progress for women’s rights, Saudi Arabia lags behind. Illiteracy marginalizes a female’s place in society. In the Arab world, women’s literacy rate increased from 16.6% in 1970 to 52.5% in 2000 (World Bank, 2004, p. 5), which indicates that approximately 50% of Arab women are illiterate. Education affects change. Doumato (2003, p. 243) reported the monarchy of Saudi Arabia was instrumental in the education of women. The connection with the conservatives of the country allows education to be beneficial for both factions. Women are in the middle of the pull of conservativism and the push of globalization (Doumato, 2003, p. 244). The conservatives perpetuate the role of women “as the central emblem of morality and family values to which society as a whole would aspire” (Doumato, 2003, p. 244), yet education as a whole in both the private and the public forum catapulted women’s opportunities for advancement. The secular paradigm changed when women prepared for a profession (Doumato, 2003, p. 250). The Arab Human Development Report (UNDP, 2005, p. 7) advocated that through education and the utilization of that education (that is, a career), women and
76 society in the Arab region would advance. There must be equal opportunity for men and women. “What deprive the region of these gains are its harmful and discriminatory practices that hold women back” (UNDP, 2005, p. 8). Religious considerations limit career opportunities for women in Saudi Arabia (Doumato, 2003, p. 251). Teaching, nursing, and medicine are occupations identified as appropriate for women for cultural and religious reasons (El-Sanabary, 2003, p. 259). Segregation applies easily to the teaching profession, where female and male students take separate classes. Segregation is more problematic in health care. El-Sanabary (p. 256) noted medicine is a prestigious and acceptable career for Muslim women. Men and women view nursing as a low-status occupation, yet the country’s economy necessitates a female workforce to meet the needs of a growing society. The changes in the economy affected the average household income, which in 2003 was one third less than the 1980 figures. Money was lost in remittances from foreign workers, estimated at $17 billion a year. The yearly deficit challenged the Saudi government (Doumato, 2003, p. 250). The religious and cultural barriers include women do not drive, women do not vote, and Saudi women are not to work in places with men. Career selection is limited to education that is sex segregated, hospitals, women-service only businesses, and working in the home (Doumato, 2003, p. 251). Doumato (2000, p. 22) reported the number of female graduates from universities and colleges doubled between 1983 and 1993 and would double again by 2000. Although education is available to all girls in Saudi Arabia, unemployment remains high (Doumato, 2003, p. 250; UNDP, 2005, p. 88; World Bank, 2004, p. 93).
77 Health Care The focus of the study is the population of FTNs in the hospital sector, and a discussion of all health-care services provided to citizens and foreigners is important for the reader to understand the significance of the role of FTNs in Saudi Arabia. The MOH is the governing agency with responsibility for health policies and planning for the citizens of Saudi Arabia (Mufti, 2000, p. 5). The Five-Year Development Plans initiated in 1970 focused on expanding and improving health care (Alsahlawi & Gardener, 2004, p. 176; Ball, 2004, The Saudi Arabian Market section, ¶ 1; Mufti, p. 5). Mufti (p. 4) explained that prior to the development plans, hospitals and clinics were insufficient to meet the needs of the citizens and traditional forms of health care existed. Each 5-year development plan identified goals and objectives to establish a national health system that would provide preventive health services, primary to tertiary care, home health services, and public health to all citizens. The development plans focused on MOH services: “There is unfortunately little coordination in planning among health agencies” (Mufti, p. 5). The MOH adopted the phrase “prevention is better than cure” (Mufti, 2000, p. 10) when describing the goal of health-care development for Saudi Arabia. Primary health care was a priority for the Kingdom as the MOH adopted the WHO goals of Health for All by the year 2000. The MOH served an estimated 65% of the total health services (Mufti, p. 9). The MOH primary health-care centers (PHCCs) in Saudi Arabia provided the first point of contact with a public health provider, offering laboratory, radiology, dental, and medical services. The PHCCs established connections with general hospitals and tertiary care hospitals. A patient referral system from the general hospital to
78 secondary and tertiary care hospitals maintained control over the utilization of services (Mufti, p. 11). The PHCCs and the patient referral system provided accessibility for all citizens while reducing the costs. Mufti (p. 24) stated all services in the PHCCs and government polyclinics are free of charge. The other government health sectors have polyclinics, although only employees and dependents have access to these services. Foreign workers use the private polyclinics and pay for the services. The PHCCs emphasized health education in immunization, nutrition, smoking, motor vehicle accidents, and other public health issues (Mufti, p. 26). Other providers of health care include organizations such as the National Guard, Saudi Red Crescent Society, King Khalid Eye Specialist Hospital, and private sector. The National Guard serves the employees of the National Guard and their dependents. Patients not employed by the National Guard must obtain a referral or Royal Decree for treatment at a National Guard facility. The Saudi Red Crescent Society establishes over 300 first-aid centers for the pilgrims during Hajj and performs other services according to its responsibilities as a member of the international Red Crescent and Red Cross Societies League (Mufti, 2000, p. 15). The King Khalid Eye Specialist Hospital is strictly a referral center for patients with ophthalmic diseases that require specialized tertiary care. The private sector complements the MOH services. Although the MOH provides free health care for all Saudi citizens, private expatriates are not eligible for health care at MOH facilities except in cases of emergency. The private sector provides health care to Saudi citizens and private expatriates through health insurance plans with the employer (Mufti, p. 17). Medical care is free at MOH facilities, although an increasing trend is occurring in which Saudis are paying for medical treatment at private hospitals (Mufti, p. 106). The
79 development plans initiated by the MOH focused on the MOH’s own services and provided limited coordination in planning among the other health-care agencies (Mufti, p. 5). The first hospitals in Saudi Arabia opened in the 1950s (El-Sanabary, 2003, p. 259; Tumulty, 2001, p. 285). In 1987 there were 149 hospitals, 1,480 dispensaries, more than 4,000 physicians, and more than 30,000 nurses (Tumulty, p. 286). In 1996, there were 57,110 nurses (Saudi and non-Saudi) working in Saudi hospitals. The MOH hospitals employed 33,373 nurses, other government hospitals (such as military) employed 12,485 nurses, and private hospitals employed 11,252 nurses. Of this total, 24.6% were Saudi (Tumulty, p. 286). The expansion of hospitals from 2005 to 2006 was 1.8%: 220 MOH hospitals, 39 other government hospitals (military), and 127 private hospitals with a total bed capacity of 54,724 (MOH, 1427 H., 2006 G., p. 217). The expansion of PHCCs increased 1% between 2005 and 2006: 1,925 PHCCs with an additional 1,057 private dispensaries, 416 private clinics, 586 private polyclinics, and 324 company clinics (MOH, 1427 H., 2006 G., p. 187). The FTN distribution varies widely within each sector. According to Abu-Zinadah (2006, ¶ 11) the MOH employed 68% FTNs, other government agencies employed 85% FTNs, and the private sector employed 98% FTNs. The nursing workforce (both Saudi and foreign) in all health-care sectors was 83,868 (MOH, 1427 H., 2006 G., p. 218). The literature on home care and long-term care in Saudi Arabia is lacking. Home care is limited and available through individual hospitals, such as the military and private sector. The need for long-term care facilities is “determined by cultural and historical factors, as much as availability of suitable facilities” (Mufti, 2000, p. 86). Saudi Arabia is
80 a young society, with only 3.3% of the population 65 years of age and older (Mufti, p. 86). Until the demographics, culture, and demand change, management of long-term care patients is in the home with family or in the acute-care hospitals. There is no incentive for hospitals to be cost-effective or efficient. Escalating health-care costs are likely related to the fact that health services are provided free of charge (Mufti, p. 76). There is a lack of cost-consciousness on the part of administrators, physicians, and patients. This lack of fiscal knowledge leads to an excessive use of resources without justification for patient need or outcome. Fiscal responsibility is a major focus of the government with details following later in this section. The financing of medical care is a challenge for Saudi Arabia. Mufti (2000, pp. 45-48) explained the rising costs in health care in Saudi Arabia have been attributed to the growing population, demographic changes, availability of technology, system of free health care, and method of reimbursement in private sector. Other factors that contribute to the rising health-care costs are reliance on foreign health-care providers, changing health issues (such as diabetes and cardiovascular problems), duplication of health services, and the use of outside companies in hospitals (where companies lack costcontainment incentives). In 1999, the government created an independent body to control utilization of health-care services to non-Saudi residents (Council of Cooperative Health Insurance, 2003, ¶ 2). According to the Arab News (Ghafour, 2005, ¶ 1), health insurance coverage in the Kingdom was effective January 1, 2006. In its first phase, coverage was mandatory for companies with 500 or more expatriate employees and their dependents (Ghafour, ¶ 1, 4, 5). Article 14 of the law stated employers who did not cover and pay the insurance fees of their employees and their dependents by the effective date would be
81 required to pay the unpaid premiums. Employers in violation of the article would not be able to recruit foreign workers (Ghafour, ¶ 5). The second phase of the law stated all companies must cover their workers with health insurance by March 2008 and this requirement would be linked with the Iqama (or resident certificate) renewals (“Kingdom’s Insurance,” 2007, ¶ 5). Additional phases include coverage for all Saudis, estimated at 16 million people (Hassan, 2007, ¶ 11) and domestic helpers (including maids and drivers; Rasooldeen, 2008, ¶ 1). Another challenge to the health-care system in Saudi Arabia is Saudizing health professionals rather than relying on foreign workers (Mufti, 2000, p. 37). Foreign workers have different cultural backgrounds and values. Continuity of health-care providers is a problem as foreign workers tend to stay for short periods. The MOH discovered foreign workers were not as effective as nationals were in implementing and promoting preventative health care in the community (Mufti, p. 37). Mufti noted (p. 37) foreign workers had a limited stake in improving the general health of the population. Despite the challenges of a foreign workforce, experienced, qualified, and competent foreign health professionals provided quality health services to the citizens of Saudi Arabia (Mufti, p. 23). Reliance on foreign workers comes with a price. In the specialized facilities, expert foreign workers receive high salaries and lucrative benefits. Competition for FTNs resulted in hospitals reevaluating the local and international market to entice FTNs to work in Saudi Arabia. Military hospitals reported increases in salaries (J. Hafez, personal communication, May 3, 2007; I. Rondeau, personal communication, November 7, 2006) and more recently a private hospital in the Eastern Region reported salaries and benefits comparable to the military hospitals (J. Hafez, personal communication, October
82 21, 2007). This is a significant change in practice as private hospitals pay less in salary and benefits compared to military hospitals. This human resource practice for the private sector sets a precedent for other hospitals in the Kingdom. The Seventh Five-year Plan (2000-2005) outlined additional challenges for the health care sector: “efficiency in production and use of services, increased effort at Saudization, and alleviation of financial burdens on government” (Mufti, p. 36). The Saudization plans for the nursing workforce included a target of 50% by 2025 with an annual nursing school output of 3,858 nurses (Mufti, p. 40). In a 1979 WHO study by Mejia et al. (p. 384), the chapter on Saudi Arabia was incomplete from a lack of documentation for both migrating physicians and migrating nurses. Mejia et al. investigated the motives for nurses moving to Saudi Arabia for employment. In 1979, Saudi Arabia was developing its health-care infrastructure. According to the report (Mejia et al., p. 387), in the years 1965 to 1973, the gross national product grew at a rate of 10.1% per year. As the country reaped the benefits of its oil production, plans to develop health-care services for a growing population became a priority. Hospitals were able to attract foreigners with high salaries and other benefits. Whether for adventure or for economic and political reasons, salary (tax-free in most countries), opportunity to travel, more vacation time, and an opportunity to see inside Saudi Arabia were the most common reasons for new employees to work in Saudi Arabia (A. Otvos, personal communication, April 18, 2005). Contracts and benefit packages vary from country to country. The nurses’ country of origin and standard of living are the baseline for contract development. For example, two Western nurses (one American and one South African) will have different salaries. All nurses receive free
83 furnished housing (shared if on a single contract), free health insurance, and paid airfare home yearly (depending on the contract). Other benefits include free transportation to and from hospital (because women cannot drive in Saudi Arabia) a 44- to 48-hour workweek (Article 147 of the Labor and Workman Law [dated 1389 H., 1969 G., ¶ 5] prohibits employers from abusing extended workweeks), up to 6 weeks vacation, and free food for lower salaried nurses. Married status includes housing for the family and an educational allowance for a certain number of children. For Filipino nurses, the salary at home ranges from $75 per month in rural areas to $250 per month with experience (Overland, 2005, ¶ 12). Nursing salaries in the United States average $60,000 per year but can go as high as $80,000 per year on the East and West Coasts (Aiken, 2006, Linda Aiken, Ph.D. section, ¶ 7). Mufti (2000, p. 106) stated that dramatic measures for improvement are needed to improve the Saudi health-care system. Saudis are increasingly dissastified with the quality and efficiency of health-care services even though the services are provided without cost. Plans for restructuring the health-care system in Saudi Arabia are underway. The MOH has recommended a model that meets the needs of an improved and more efficient health-care system. The model includes significant change and transformation of the health-care system. The MOH (2006, pp. 314-315) proposed the creation of a hospital National Authority that would be responsible for the management of all MOH hospitals in the Kingdom. The MOH proposed every citizen would have a primary care physician, concentrating on preventive health through the PHCCs. The MOH proposed the implementation of a National Fund for Health Care that would purchase services for constituents that meet the criteria for funding. The National Fund would be nonprofit and
84 managed by the government. The last part of the proposed model was the creation of health-care councils in the 14 regions, whose purpose would be to coordinate care between systems and funding. In 6 decades, Saudi Arabia developed a health-care system comparable to other developed nations. The proposed health-care model and the Five-Year Development Plans promise commitment to safety, quality of patient care, and effective and efficient utilization of resources and labor. Improvement and change is inevitable, with health-care labor being a priority in all sectors. Recruiting and retaining FTNs is a priority parallel to Saudizing the nursing profession. Saudization Skilled labor constitutes 15% of the foreign workers in oil, health care, finance, and trading (Pakkiasamy, 2004, p. 2). Saudization became a reality during the 1980s to the 1990s. Pakkiasamy (p. 3) noted the country accumulated debt because of participation in the 1991 Gulf War. The economy loses money from foreign workers that remit approximately SR 60 billion or $15 billion a year. In 2004, a Philippine government spokesperson stated that overseas workers (including nurses) sent “$8-billion through formal channels and at least 30 percent more under the table” (Overland, 2005, Headhunted Toward Extinction section, ¶ 5). Foreign workers are not reinvesting the money they earn back into the country. The economy shifted when increased security threats in the region caused the exodus of foreign workers. The Shura Council dictated that by 2007, “70 percent of the workforce must be Saudi, with the process accelerated in specified industry sectors” (Bremmer, 2004, p. 26). The economic reality will perhaps be the catalyst for more rapid growth and change. The
85 Kingdom’s population grew at an annual rate of 2.7 percent while the GDP only grew by 1.6 percent between 1990 and 2000 (Bremmer, p. 25). Bremmer (p. 25) continued to present data that were disheartening and troublesome for Saudi Arabia: real unemployment was at 20%, a higher percentage of Saudis were living in poverty, and almost 60% of the population was less than 20 years old. Reform measures introduced in 2003 from the Saudi Manpower Council mandated foreign workers and their families will not exceed 20% of the total population by 2013. The number of workers from any single nationality will not exceed 10% of the total foreign workers (Pakkiasamy, 2004, Reforms section, ¶ 1). The Saudization program was not working (B. Alhaj Hussein, personal communication, May 11, 2005). The reform measures only achieved 5% Saudization between 1998 and 2003 (Pakkiasamy, Reforms section, ¶ 1). Ball (2004, The Saudi Arabian Market section, ¶ 1) contended it is against Saudi interests to Saudize certain areas of the job market. Saudis are not willing to work at the wage of a foreign unskilled or skilled worker. Saudis see low-skilled jobs as unattractive. Saudization continues to be a challenge as organizations hire more foreign workers to fill the gaps in the workforce (Ball, Global Imbalances in the Distribution and Rights of Filipino Nurses section, ¶ 1). The challenges facing Saudization, included worsening unemployment of young Saudis, not enough managerial and professional workers, disorganized salary allocation, and unsuitable labor laws (Alsahlawi & Gardener, p. 185). Saudi administrative practices have slowed the country’s development (Assad, 2002, p. 53). Assad (pp. 53-55) stated that structural and behavioral management problems manifest in ineffective organizations to meet the needs of the organization’s population. The structural problems included such issues as most managers received on-the-job training (rather than from specialized
86 academia), personal relationships was the practice for promotions rather than hard work, and change was difficult due to a bureaucracy that was rigid and obligated to political leaders. Behavior problems included such issues as frequent social calls while at work, social visits to colleagues, lack of follow-through on projects, and lack of enthusiasm and seriousness at work. Assad (p. 57) posited ineffective management training linked to the structural and behavioral issues would mean a change in the management, social, and cultural framework of organizations. The same challenges face nursing leaders in the Kingdom. Empowering the nursing profession at political levels was a key to Saudizing nursing (Al-Kandari & Lew, 2005, p. 535; Khazaal, Dumit, & Aaraj, 2003, p. 37; Miller-Rosser et al., 2006, Nursing Today in Saudi Arabia section, ¶ 3; Tumulty, 2001, p. 286). Saudi Arabia appointed its first General Director of Nursing to the MOH and created a Division of Nursing (Tumulty, p. 286). A professional nursing board was organized “to meet the requirements of membership of the ICN” (Miller-Rosser et al., Nursing Today in Saudi Arabia section, ¶ 3). In 2002, the board came under the direction of the Saudi Council of Health Specialties (Miller-Rosser et al., Nursing Today in Saudi Arabia section, ¶ 3). The societal pressures of the profession prevail. Saudi women face obstacles based on religion and social norms if they choose nursing as a career choice (Miller-Rosser et al., Abstract, ¶ 6). El-Sanabary (2003, p. 266) noted many societies view nursing as a maid’s job that is for uneducated people. There is a general lack of understanding regarding the role of nursing. The Nursing Division in the MOH has developed a 40-year plan to Saudize nursing. Some strategies included increasing the number of nursing colleges, improving
87 salaries, improving the quality of education and training, and providing specialty training (M. Al Osaimi, personal communication, January 9, 2007). The Role of Women Esfandiari (2004) noted, “Women’s roles and rights in each country are the product of its particular history, culture, and political character” (p. 56). A strict interpretation of the Qur’an, Hadith, and Sharia law controls the role of women in Saudi Arabian society (Badawi, 1980, p. 5; Esfandiari, p. 58). The Islamic Arab states differ in their cultural orientation. For example, in Saudi Arabia women do not drive, segregation occurs in school, and women do not vote (as well, four other Arab countries do not allow women to vote). Women wear a loose-fitting garment called an abaya that covers the body and a black headscarf that covers the hair. These examples illustrate the confusion between the religion and the cultural norms. Nabli and Chamlou (2004) described the role of women in Muslim society through the aspects of the traditional gender paradigm: (1) that men and women differ biologically and these biological differences determine their social function, (2) that men and women carry different and complimentary [sic] responsibilities within the family, and (3) that they have different but equitable rights associated with those responsibilities. (p. 93) The gender paradigm is not only specific to Islam. For example in Christianity, the apostles were men. In Catholicism, women cannot be priests. In Eastern Orthodoxy, women cannot set foot around the altar. In Judaism, women are not allowed in places of worship and cannot participate in the service (Doumato, 2000, p. 35).
88 The gender paradigm illustrates the current opinion of large segments of the population within Saudi Arabia. It was likely a woman would marry early and be wife and homemaker for her family. The paradigm illustrates the role of wife and mother as weak and needing protection (World Bank, p. 94). Men were likely the providers for the family, protectors for the family, and decision makers for the family (World Bank, p. 94). Doumato (2000, p. 26) posited that other opinions about the role of women emanate from religious and political forces. Many people believe the role of women is defined according to standards of behavior (Doumato, 2000, p. 26) associated with the ruling Saudi monarchy as the protector of Islam. Doumato (2000, p. 26)) further noted that enforcing women’s behavior and public segregation has turned into a sign of cultural legitimacy and the King’s piety. Doumato (2000, p. 26) posited that women’s separation was facilitated by Saudi society but was not the basis for its continued demand. The main obstacle to the emancipation of women is family law, which is based on the Islamic Sharia and regulates marriage, divorce, child custody, a woman’s right to work, and to choose her place of domicile, and to leave her house, town, or country. (Esfandiari, 2004, p. 59) Saudi women were on their husband’s or father’s identity card until 2002. Even in 2005, a female obtained an exit-reentry visa through her husband or father to leave and return to the country. A male family member must escort the female when leaving the country (the traditional gender paradigm). Esfandiari noted, “In fighting for their own rights, women in the Middle East are broadening the democratic space in society as a whole” (p. 56). The role of women in economic activities is still limited (Alsahlawi & Gardener, 2004, p. 184; Ball, 2004, The Saudi Arabian Market section, ¶ 3; Esfandiari, 2004, p. 62).
89 Nabli and Chamlou (2004, p. 4) noted for the Arab countries the average household earnings would increase by 25 percent if female participation in the workforce increased to their predicted levels (based on education, fertility, and age). Female students constituted 49% of the total number of students in universities in 1995. By 2000, 55% of the total number of students graduating from universities and colleges were women (Doumato, 2003, p. 249). University programs for females are still in the preliminary stages. The programs were not developed (both in quality and quantity) to meet the demands of the growing population (Alkhazim, 2003, p. 479; Alsahlawi & Gardener, 2004, p. 14). Change is slow. The introduction of women into the workforce occurred in small steps. Since 1991, women have entered careers that were unacceptable a generation ago. These careers include advertising, broadcasting, journalism, architecture, women’s shopping malls, banks, some catering and banquet events, teaching, physicians, healthcare technicians, health-care administrators, and nursing (Doumato, 1999, pp. 569-570). The complexities of Saudi Arabian society continue to redefine themselves in the face of government reforms and the woman’s role is in the center of the discussion. Cultural Diversity Customs are restrictive and enforced. A recruitment agency in the Philippines provides some examples of life in Saudi Arabia for nurses contemplating employment. Some of the restrictive customs included practicing only Islam, during Ramadan nonMuslims are not to be eating, drinking, and smoking in public from sunup to sundown, expatriate women can only interact with their husband, father, or brother, married couples must carry their marriage certificate, there are no cinemas or theatres, only Muslims are
90 allowed into Makkah and Madina, expatriate women are requested to wear the abaya when out in public, and using drugs and alcohol is punishable by imprisonment (POEA, 2004, Important Reminders section, ¶ 1-16). Religion is not the only difference shared in this multicultural setting. Whether the health-care worker is from a collectivist or individualist society, there is potential for conflict, prejudice, and misunderstanding. According to Mead (as cited in Bass, 1990, p. 775), collectivist societies share similar characteristics. These characteristics include cooperation and collaboration, attentiveness to the family and relationships with people, lack of attention to deadlines, circular communication, guaranteed protection for loyalty to the in-group, and group success. The individualist is competitive, straightforward, and deadline conscious, and the emphasis is on self (Bass, p. 777). In general, Western countries are individualistic (such as United States, Canada, Europe, Britain, Australia, and South Africa) and non-Western countries are collectivist (Middle East, Asia, India, Philippines, and Latin America). Although nursing involves caring for populations different from one’s own, traveling to a new country may hold surprises for FTNs. Aboul-Enein (2002, p. 228) described his experiences of the nursing profession while working in Riyadh at a large tertiary care hospital where 95% of the nurses were foreign-trained and represented 40 countries. Aboul-Enein described FTNs adapting to the environment by taking Arabic lessons and discussing care practices specific to the Saudi culture with their Arabic colleagues (p. 228). Hospitals provided programs to assist FTNs in understanding the country and the people and provided the tools to provide culturally sensitive nursing care. Aboul-Enein (pp. 229-230) observed Western nurses demonstrating their individualist
91 tendencies. Nursing care focused on individuals, autonomy, and self-care. Nursing care in Saudi Arabia must focus on the family, especially the mother. Priestley (2000), an Australian nurse, described her experience working in Riyadh in 1994. The introduction described the morning call to prayer by the chants of the religious Imam. She stated that nothing prepared her for the reality of living and working in Saudi Arabia. Working and living in Saudi Arabia is an experience that must be lived. Priestley (p. 18) described her motivation for the move as needing a challenge in her life. The assimilation into the culture and norms took 3 months. The most difficult barrier at first was language. Communication was through an interpreter if Arabic is not the first or second language for the nurse. Priestley noted, “Cultural sensitivity is something best learned when residing among the people” (¶ 15). She cautioned that FTNs are guests in the country and one must be flexible and respectful. Her exposure to the life and work in Saudi Arabia changed her life and her perspectives on many issues. It filled the void from working in her home country. Priestley stated she had been working in the same unit for 6 years. It is not clear how long she remained in Saudi Arabia. Nehring (2003) described her work experience in Qatar as a faculty member of the College. Nehring, an American nurse, sought an experience where English was the working language. Qatar is an Arab country that borders Saudi Arabia and shares similarities in religion, culture, customs, and norms. Other similarities include the country’s plan for encouraging students to enter nursing, Westernizing health care, the accreditation process, and the “handmaiden-to-physician and servant-to-hospital tradition” (Nehring, p. 226). In her teaching practice, Nehring (p. 227) described a conflict while discussing human suffering in an ethics class. The discussion entailed
92 various worldviews based on religion, culture, and law. Citing the Qur’an, the students stated suffering is a test from Allah. The students maintained the patient must suffer and not lose faith (Nehring, p. 227). According to Nehring, the students lacked insight to view the issue from different viewpoints. Given the values of each orientation, it is not difficult to imagine the challenge to maintain group and individual values in the workplace. When collectivist and individualist societies come together in Saudi Arabia, professional and personal relationships take on significant meaning. Foreign-trained nurses increase the diversity of the workforce, although cultural competence is a necessity in Saudi Arabia. One must learn tolerance or go home. Conclusion Saudi Arabia is changing because of religious, social, political, and economic challenges. The literature review included an exploration of the global migration issues and Saudi Arabia’s unique nursing shortage position. Religious and social implications are making Saudization efforts difficult for the nursing profession, yet the economic necessity of working is pulling women into the labor market. For the short term, Saudi Arabia is dependent on FTNs. Saudi Arabia must compete with other nations that offer more opportunities as a destination country. Pull factors outweigh the push factors when nurses decide to emigrate. It is not an easy decision to leave one’s country, home, and family. The global community opened its doors to those nurses who decided to leave their home countries. In the middle of Saudi Arabia’s changes, the dependence on FTNs stands out in need of attention. Health-care organizations are expanding services to meet the demands
93 of a growing population. Saudi Arabia has been a destination for FTNs since the 1950s. Since 2005, the Kingdom has noticed a decline in the number and quality of nurses recruited from source countries (M. Al Osaimi, personal communication, January 9, 2007). The health-care infrastructure is at risk of not being able to provide services for its primary, secondary, and tertiary care patients. Additional challenges to the health-care infrastructure include the country’s move toward an accreditation system and insurancebased reimbursement. Identifying the pull factors for FTNs and planning retention strategies around the current study will assist health-care leaders in retaining their FTN workforce. At the same time, active recruitment of Saudi students to nursing schools must be the priority to meet the MOH’s long-term objective of Saudization. Further research will assist nursing leaders in understanding the difficulties that face Saudi Arabia. Summary The nursing shortage presents many challenges for Saudi Arabia. Many organizational leaders are realizing the demand for FTNs surpasses the available supply (M. Al Osaimi, personal communication, January 9, 2007). With developed nations actively and aggressively recruiting FTNs, Saudi Arabia’s approach to the shortage will require effective strategic planning by health-care leaders. The research study identified those push–pull factors that affected a nurse’s decision to travel to Saudi Arabia and the decision to leave. Research studies have identified that salary is not the main decision or push to leave one’s country (Buchan, Jobanputra, et al., 2005). Other factors are also important for FTNs. The literature suggested developing countries look at working conditions and
94 professional development as a pull factor (Stilwell et al., 2004). The current research study included an investigation into those motivators that bring FTNs to Saudi Arabia and those motivators that encourage tenure. The study addressed positive practice environments, recruitment and retention, and nursing leadership. The MOH is aware that given the projected data on the nursing shortage, Saudi Arabia must recruit more students into the nursing profession and retain the nurses already working (M. Al Osaimi, personal communication, January 9, 2007). Chapter 3 includes an exploration of the research method and design, as well as the population, geographical area, and validity and reliability of the data collection instruments.
95 CHAPTER 3: METHOD The study involved an examination of the relationship between demographic and work environment factors on hospital characteristics (job satisfaction) and burnout among FTNs working in Saudi Arabia. The studies in the literature identified the problems surrounding the nursing shortage as an aging population, an aging workforce, insufficient effort to encourage recruitment into the profession, nurse workload not directly related to the profession, increasing patient-care workload, lack of incentives to enter the profession, insufficient resources to train recruits, and lack of policies to retain or encourage nurses to return to the workplace (Aiken, Clarke, Sloane, Sochalski, et al., 2001; Aiken et al., 2002; Berliner & Ginzberg, 2002; Buchan, Kingma, et al., 2005; Buerhaus et al., 2003; Flynn & Aiken, 2002; Sigma Theta Tau International, 2001; Leiman, 2004; Spetz & Given, 2003; Spratley et al., 2000; Staten, Mangalindan, Saylor, & Stuenkel, 2003). An examination of job satisfaction and burnout among FTNs in Saudi Arabia is unique. As noted in chapter 1, FTNs in Saudi Arabia represent 76% of the workforce. With a lack of an internal supply of nurses, Saudi Arabia’s health-care infrastructure depends on FTNs. The focus of chapter 3 is to present the research method and design, the appropriateness of the study, confidentiality and informed consent, the population and geographical area, and the validity and reliability of the data collection instruments for the study. Findings from the study may assist policy makers in developing retention strategies from the personal accounts and viewpoints of FTNs.
96 Research Design The study involved quantitative and qualitative techniques in a mixed design approach to enhance the validity of the research findings. The quantitative phase of the study used surveys (NWI-R, PES-NWI, and MBI) and a demographic data questionnaire. The qualitative phase of the study used focus group interviews with a number of FTNs selected from the pool of respondents. There is a detailed discussion of the two phases later in the chapter. A mixed study rather than a quantitative or qualitative study provided a more thorough understanding of FTNs in Saudi Arabia. Ragin (as cited in Neuman, 2003) noted, The key features common to all qualitative methods can be seen when they are contrasted with quantitative methods. Most quantitative data techniques are data condensers. They condense data in order to see the big picture. . . . Qualitative methods, by contrast, are best understood as data enhancers. When data are enhanced, it is possible to see key aspects of cases more clearly. (p. 16) There were several factors considered in choosing the research design. The mixedmethod study met the goals of the research in the geographical area, with the mix of hospitals, and with the large population sample. The front-line health-care providers in the current study were the FTNs who provided direct patient care in the hospital setting. The quantitative data collection approach yielded a sizeable body of information, but did not yield some of the unique personal experiences of living and working in Saudi Arabia. Only through the qualitative approach, such as focus group sessions, were the data collected. In consideration of the large variations in characteristics of FTNs and hospitals,
97 it was difficult to formulate a quantitative survey that captured the different elements of the nurses’ perceptions and expectations. A worldview of front-line FTNs who worked and lived in Saudi Arabia illustrated an understanding of the implications of recruitment and retention during the nursing shortage. The study involved the use of a combination of other studies on job satisfaction and burnout (Abo-Znadh, 1999; Aiken et al., 2002; Aiken, Clarke, Sloane, Sochalski, et al., 2001; Flynn, Carryer, & Budge, 2005; Omer, 2005). Foreign-trained nurses are guests in Saudi Arabia and work on a contract-to-contract basis. Nursing directors conduct exit interviews with FTNs, and nursing directors stated the data from the interviews are meaningless if FTNs do not provide accurate information (A. Dabebnah, personal communication, January 20, 2007). Multiple sources of data and multiple statistical procedures improved the accuracy of the study with a better understanding of the issues that affect the FTN personally and professionally. The data analysis plan consisted of five phases. The first phase involved identifying the dependent and independent variables. The second phase included using descriptive statistics that “presents information that helps a researcher describe responses to each question in a database and determine both overall trends and the distribution of the data” (Creswell, 2002, p. 231). The demographic survey provided information on the participants and hospitals. The third phase involved bivariate statistics. The NWI-R, the PES-NWI, and the MBI surveys identified variables that described hospital characteristics (linked to job satisfaction), the work environment, and burnout. The data from the three survey instruments determined a correlation or difference between two variables. The fourth phase was multiple regression. Multiple regression “is a statistical
98 procedure for examining the combined relationship of multiple independent variables on a single dependent variable” (Creswell, p. 646). Triangulation was the last phase in the data analysis plan. Triangulation of the quantitative and qualitative data improved the study by confirming data from different sources (Creswell, p. 280) and provided a worldview of FTNs working in Saudi Arabia. The research design provided credible data on hospital characteristics (linked to job satisfaction), burnout, and tenure for FTNs. Appropriateness of Design The strengths and weaknesses of using a mixed method assisted in deciding the appropriateness of the design. The current research study is unlike any formalized research conducted in Saudi Arabia. The first strength of the research design is the quantitative approach provided a wealth of data from a relatively large sample size. Twenty-five hospitals consented to participate in the study. The potential sample size was significant, as there were more than 4,500 FTNs in the 25 hospitals in June 2007. A working opportunity with MRQP, a role as a nurse surveyor for CBAHI, and a position as vice president of Jeddah Nurses Executive Forum provided access to the nursing departments and hospitals in the Western region. The second strength of the study design was the quantitative data elements expanded the data analysis potential. That is, by using different quantitative techniques (bivariate and high-level multivariate techniques) results were more robust. The third strength of the study design was the qualitative approach that captured some of the individualized experiences that were not collectable using straightforward quantitative approaches. The General Directorate of Nursing supported the study and provided valuable information to support the issues (see Appendix C in Arabic and Appendix D
99 translated to English). The nursing directors in the Jeddah and Makkah regions expressed an urgent need for the research. The weaknesses of using the mixed-methodology approach as cited in the literature pertain to the effort needed to complete such studies. Creswell (2002, p. 568) identified these weaknesses as the knowledge and training of the researcher to conduct a mixed design, reviewers who may not be familiar with mixed methodology, audiences who may not be familiar with the mixed-method design, the extent of the data collection effort, and the volume of required resources. To address these threats, coursework from the University of Phoenix program, the dissertation mentor, and the committee members assisted in the preparation of the mixed-method design. Additional collaboration and assistance from the committee mentor and a statistician helped in the preparation of a data analysis plan. Preparation of hospital visits in similar geographical areas assisted in time-management and cost. Nursing colleagues assisted with the quantitative data entry and focus group sessions. Hospitals received sufficient information about the mixedmethod study in order to sign the informed consent to participate. Research Questions Research questions for the mixed-method study were both quantitative and qualitative. The central question for the study was the following: What demographic and work environment factors may influence job satisfaction and burnout among FTNs who live and work in Saudi Arabia? Two instruments measured the dimensions of job satisfaction by exploring the hospital characteristics or professional practice environment. The work (NWI-R) and practice (PES-NWI) environment instruments provided researchers with evidence that the nursing practice environment facilitates or constrains
100 job satisfaction based on certain organizational characteristics (Lake, 2002, p. 178). A burnout instrument (MBI) measured the FTNs’ level of burnout in the work environment. Other factors that contributed to job satisfaction and burnout were demographic information and the work environment (that included type of hospital and contract) factors. From chapter 1, the study hypotheses were as follows: 1. There is no association between selected demographic variables and work environment variables and hospital characteristics (the NWI-R subscale scores) among FTNs working in Saudi Arabia and (null hypothesis). There is an association between selected demographic variables and work environment variables and hospital characteristics (the NWI-R subscale scores) among FTNs working in Saudi Arabia and (directional hypothesis). 2. There is no association between selected demographic variables and work environment variables and hospital characteristics (the PES-NW subscale scores) among FTNs working in Saudi Arabia and (null hypothesis). There is an association between selected demographic variables and work environment variables and hospital characteristics (the PES-NWI subscale scores) among FTNs working in Saudi Arabia and (directional hypothesis). 3. There is no association between selected demographic variables and work environment variables and burnout (MBI subscale scores) among FTNs working in Saudi Arabia and (null hypothesis).
101 There is an association between selected demographic variables and work environment variables and burnout (MBI subscale scores) among FTNs working in Saudi Arabia and (directional hypothesis). 4. There is no association between selected demographic variables, work environment variables, hospital characteristics (the NWI-R subscale scores and PES-NWI subscale scores) and burnout (MBI subscale scores) among FTNs working in Saudi Arabia (null hypothesis). There is an association between selected demographic variables, work environment variables, hospital characteristics (the NWI-R subscale scores and PES-NWI subscale scores) and burnout (MBI subscale scores) among FTNs working in Saudi Arabia (directional hypothesis). The selected demographic factors included gender, age, nationality, religion, education level, year of registration, years in current hospital, first contract in Kingdom, years working in the Kingdom, stay in Saudi Arabia (consecutive vs. nonconsecutive), marital status, family with nurse, and continuing education status. The selected work environment factors included type of hospital, title, contract type, and number of nurses per 100 beds. The demographic and work environment factors were important considerations when exploring FTNs in Saudi Arabia. The country is male dominated, yet the majority of nurses are female. There is an assumption older nurses with more experience tend to stay longer. Older nurses have older children, the salary may be for retirement, and experience assists in job advancement. The factors that pull FTNs to Saudi Arabia included the FTNs’ nationality and circumstances at home. Saudi Arabia is the home of Islam and many Muslims come to Saudi Arabia to work for that reason (M.
102 Al Osaimi, personal communication, January 9, 2007). Years working in the current job and years working in the Kingdom reflected tenure. Salary and benefits varied from hospital to hospital depending on nationality, experience, and education level. Contracts for FTNs in staff positions (including charge nurse) were for the FTN only, not for the FTN’s family. Married FTNs work to support their family at home. Many married FTNs leave because of family pressures, young children, or death of a caregiver (A. Dababneh, personal communication, March 28, 2007). As no reliable data exist, nursing directors assume that an FTN with family in Saudi Arabia will work longer in the Kingdom. Population The study population was FTNs working at hospitals in the Jeddah and Makkah region of Saudi Arabia. There are approximately 40 hospitals in this area, ranging from a 25- to a 1,000-bed capacity. A FTN is a registered and licensed nurse who received education and training in a country other than Saudi Arabia. Registration is a process whereby a nurse must pass a formal nursing education program and pass a national examination that qualifies him or her to work as a licensed nurse. Administrators of 25 hospitals out of a possible 28 hospitals agreed to participate in the study. The sample hospitals included 5 government hospitals (4 with MRQP accreditation and 1 with JCI accreditation) and 20 private hospitals (2 JCI accredited and 18 MRQP accredited). The survey distribution took place at each hospital on designated days arranged with the hospital representative. Surveys were not given to Saudi nurses, nonlicensed nurses (such as nurse aides, patient-care assistants, and midwives without registration), and administrative nurses. Foreign-trained nurses indicated on the informed consent form their willingness to participate with the surveys and attend a focus group
103 session. The plan was to have 8 FTNs per session for four sessions (McLafferty, 2004, p. 190). Country representation included FTNs from North America, European Union, Middle East, Far East, Africa, and Asia. A single hospital in Saudi Arabia may employ over 40 nationalities (I. Rondeau, personal communication, December 13, 2006). The nursing diversity makes credentialing a difficult task for nursing administrators. For effective and safe health-care delivery, it is imperative the multicultural environments be competent in their practice. Nurses recruited from around the world must meet the human resource requirements for employment. Employment requirements include licensure, training, education, experience, and specialty. All potential employees must pass a full medical examination. A potential employee who has Hepatitis B or HIV/AIDS will fail the medical exam. A potential employee with a chronic condition might pass the medical exam, depending on the extent of required health care or anticipated sick time. The potential employee must pass an English test and verify nursing credentials (A. Otvos, personal communication, April 29, 2005). Since January 2005, the Saudi Nursing Directorate has required all nurses to have a Saudi license (S. Abu Saleh, personal communication, April 29, 2004). In the first installment, the directorate has been converting MOH and private hospital nurses. The nurse schedules a time to take the examination to qualify for a Saudi license. The new registration and licensing system will be inclusive of all nurses working in the health-care system. The ICN has been researching trends and policy implications of international nurse migration for some time. Saudi Arabia is a destination country for FTNs. Hospitals in the Kingdom are feeling the effects of the nursing shortage, as the country becomes a
104 source country for foreign recruiters. Foreign-trained nurses working in Saudi Arabia represent a transient population. In 1991, the average nursing and physician turnover rate at a hospital in Riyadh was 2.3 years (Berhie, as cited in Ball, 2004, The Saudi Arabian Market section, ¶ 1). Many FTNs and physicians have made a life in Saudi Arabia. The nursing director at a MOH hospital in Makkah stated she has been in the Kingdom 27 years (S. Ali, personal communication, January 2005). It is difficult for foreign workers to obtain Saudi nationality. A child born in Saudi Arabia to foreign parents will only get nationality if one of the parents is Saudi. Nurses and physicians can obtain nationality depending on their specialty and time in the Kingdom (N. Matasief, personal communication, March 13, 2007). Informed Consent Administrators of 25 hospitals submitted written agreements to participate in the study. Conducting research in the international setting posed several challenges. The research must abide by the local laws and regulations. Consents from proper government or other authorities were required. Above all, the research must protect the rights and welfare of the participants (Collaborative Institutional Training Initiative, 2006, ¶ 6). The general directorate of nursing at the MOH provided a letter of support for the study. Affiliation with the Jeddah Nurses Executive Forum and CBAHI (formerly, MRQP) in Jeddah led to further collaboration and support from the nursing directors in the government and private hospital sectors. Several of the hospitals have a hospital research and ethics committee in place that reviewed the protocol for the study. The Collaborative Institutional Training Initiative (2006, Informed Consent section, ¶ 2-5) discussed several issues for obtaining consents in a non-U.S. setting.
105 Obtaining consent in Saudi Arabia depended on who signs the consent according to customs and culture. The FTNs signed the informed consent and indicated their willingness to participate in the study. The second factor in obtaining consent was the language used for oral and written communication. It was necessary for the participants to communicate in English to participate in the surveys and focus group sessions. A third factor was the need for an interpreter. Interpretation of the surveys or use of an interpreter was not an option for the study. A fourth factor was the age of majority for consent. The age of consent for the study was 18 years and older. The last factor was adding a local contact number for participants to call in case they had questions or concerns regarding the research. Foreign-trained nurses could contact the university mentor by e-mail if they required further clarification. Foreign-trained nurses were free not to participate in the study if the culture, religion, or customs prohibited them from consenting to the study. There was no coercion from the research student or hospital administration. The hospitals in the study achieved accreditation through an international organization (JCI) or the Saudi accreditation program (MRQP). Hospitals that had accreditation limited the variances from hospitals that did not have accreditation. An assumption about accredited hospitals was that implemented standards promote an autonomous nursing department and a higher perception of job satisfaction and healthier hospital characteristics. The nursing standards with JCI and MRQP addressed three main functions for an organization: (a) administration structure, (b) practice, and (c) education. Inherent in the standards is a nursing department that demonstrates autonomy and control over its practice within the organization.
106 The initial contact to request hospital administrators’ participation in the study was by telephone. To encourage participation, hospital representatives reviewed the study protocol (see Appendix E), introduction letter (see Appendix F), instruments, MOH supporting letter, and hospital consent forms. Hospital administrators could e-mail, telephone, or request a meeting in person to clarify additional concerns. The University of Phoenix provided two consent forms for the participating hospitals: the letter of collaboration among institutions (see Appendix G) and an informed consent for permission to use premises, name, and/or subjects (see Appendix H). The hospitals signed the consent giving permission for the study. To participate in the study, FTNs signed the University of Phoenix informed consent for participants 18 years of age and older. Failure to sign the consent signified nonparticipation in the study. Sampling Frame Based on documentation from the nursing directors, an estimate of the number of FTNs employed in the 25 hospitals was 4,531 (excluding 10% for administrative staff). Using the sample error formula (Creswell, 2002, p. 634), the sample size for the quantitative data was 356 (with confidence level at 95% and the confidence interval at 4%). Additional participants added validity to the study. The limit set for the surveys was 1,000 and 2 additional focus group sessions, if needed. Hospital representatives assisted in setting a date and time to meet FTNs. Advertisements posted in the hospitals informed participants about the research and the scheduled visits. Many nursing directors had already communicated the purpose of the study with their nursing staff (A. Dababneh, personal communication, February 18, 2007). Simple random sampling is “the most basic type of probability sampling, wherein
107 a sampling frame is created by enumerating all members of a population of interest and then selecting a sample from the sampling frame through completely random procedures” (Polit & Beck, 2004, p. 732). To ensure the random sampling design and a lack of bias, distribution of informed consents and surveys was a two-step process. The first step was the distribution of the introduction letter to participants (see Appendix I) and the distribution of informed consent for participants 18 years of age and older (see Appendix J) enclosed in a plain envelope to all FTNs in the hospital. The participants dropped the plain envelope containing the informed consent into a secure, locked box in nursing administration or quality management office. Cooperation and collaboration with hospital administration and nursing administration ensured the box was in a secure place. The next step involved picking up the informed consent forms and distributing the surveys to the FTNs according to their choice of distribution method. Foreign-trained nurses who consented to participate in the focus group sessions signed the informed consent and follow-up involved a telephone call. The distribution and pick-up schedules were flexible and included all nursing shifts and days off work. Survey pick-up was frequent to ensure the required sample size. The inclusion criteria for participants included working in an accredited organization, being a registered FTN (Staff Nurse I, Staff Nurse II, or charge nurse), being a willing volunteer to participate, being 18 years old or older, and having an understanding of verbal and written English. Exclusion criteria included hospitals that did not have accreditation, Saudi registered nurses, nonnursing personnel (midwives without registration, nursing aides, Staff Nurse IIIs), and administrative staff (head nurses, directors, supervisors, quality management, and infection control).
108 Confidentiality Participation was voluntary. Anonymity of participants and hospitals was mandatory for the research. The study activities established a point of survey distribution and collection in collaboration with the hospital representative. All FTNs meeting the study criteria received the invitation to participate and signed the informed consent. The FTNs placed the informed consent in a plain envelope and dropped it into the secure, locked collection box in nursing administration or quality management office. The offices were secure areas away from administrative offices and patient-care areas, staffed by hospital personnel daily, accessible to all staff during the day, and offices locked when staff not present. The consenting FTNs received the surveys by the method chosen by the FTNs (interoffice mail, hand delivered, or e-mail). The methods of distribution allowed flexibility for the FTNs and attempted to allay any fears the FTNs might have regarding participating in the study. The FTNs placed the completed surveys in a plain envelope and dropped them in the locked box the designated office. Envelopes and surveys did not display identification from the hospital or participants. All forms and surveys had a letter (A, B, C, etc.) placed in the corner of the paper to identify the hospital. In the final submission of the research study, participants and hospitals are anonymous. The general directorate of nursing for MOH (see Appendix K) received a personal letter ensuring hospitals and participants would remain confidential. The confidentiality of the research followed the requirements of the Academic Review Board and the Institutional Review Board of the University of Phoenix. Several colleagues assisted in the study, including a statistician, the assistant for the focus group sessions, and the assistant for data entry. All assistants had access to the data regarding
109 the participants and hospitals. The assistants signed a confidentiality statement (see Appendix L). The regulations required signed participant authorization informing the participant of the following: 1) comprehensive explanation of the research, 2) expected duration of the participation by the subject, 3) description of the risks, 4) description of the benefits, 5) statement of confidentiality, 6) contact information for questions, and 7) a statement that the participation is strictly voluntary and there is no penalty for withdrawing. (University of Phoenix, 2003, p. 16) The FTNs’ nationality and hospital characteristics (government and private) were of interest for the focus group sessions. The participants were heterogeneous, that is, from a combination of nationalities and hospitals. Participants signed the informed consent forms distributed in the first step of distribution. During the focus group interviews, audio tape-recorded conversations allowed the moderator to listen to the dialogue and ask questions and the assistant to make notes on nonverbal communication. A verbal account as well as the signed consent assisted participants to understand the confidentiality and anonymity of the focus group information. Participants received information regarding the process of destroying the research evidence at the completion of the study. Retaining and destroying the records and data from the research study were important ethical aspects of confidentiality in research. It was important that hospitals and participants felt confident that data from the study were exclusive. Retention of all records for the proposal process, dissertation process, approval of the dissertation, and through the completion of the research is a requirement by the university. Completion of the research includes publication of the research in a peer-reviewed journal and 3 years
110 after the date of acceptance of the dissertation. Electronic records were stored in an external hard-drive with fingerprint security access and a back-up copy on a flash drive. The electronic and hard copy records (including informed consent forms and surveys) are stored in a locked cupboard in a residential home. The home is located in a secure area of Jeddah with two residents in the home. In the presence of a witness, all evidence of the study will be shredded and destroyed at the completion of the study. Geographic Location Jeddah and Makkah, Saudi Arabia, were the geographical locations for the study. Jeddah is the second largest city in Saudi Arabia, situated in the Western Region next to the Red Sea. In 2004, Jeddah’s population was approximately 3 million. Although Riyadh is the capital of the Kingdom, Jeddah is the principal seaport. A recruitment feature to work in Saudi Arabia is scuba diving in the Red Sea, which attracts many foreign workers. Saudi Arabia is a Muslim country with Arabic as the official language. Riyadh is the government city where King Abdullah spends most of his time. Inherently it is a stricter environment, while Jeddah is more cosmopolitan and has more relaxed cultures and norms. The health-care sector in Saudi Arabia consists of government hospitals (that is, MOH), other government hospitals (that is, military) and private (that is, under the umbrella of MOH). The MOH is the largest employer and responsible for health care, including hospitals, primary health-care clinics, private dispensaries, private clinics, private polyclinics, first aid centers, and first aid ambulances (Mufti, 2000, p. 3). Government hospitals provide free health care to all Saudi nationals. Foreign workers or expatriates have health insurance through their employer, who contract with facilities for
111 health-care services (Council of Cooperative Health Insurance, 2003, ¶ 2). With all citizens covered by insurance, insurance companies expect quality and safety for their customers (MRQP, n.d., p. 4). Quality management is not a new concept to Saudi Arabia, although hospital accreditation is. Since 2002, three private hospitals, a semigovernment hospital, and a military hospital have achieved JCI accreditation. From 2005 to 2006, 25 hospitals achieved MRQP accreditation. MRQP was so successful in the Western Region that CBAHI was established. National standards now exist based on the MRQP standards. All hospitals, excluding military and semigovernment, are required to have the national accreditation. Inspired by the success of achieving the MRQP accreditation, several MOH and private hospitals are preparing for a JCI survey and accreditation. In its commitment to ensuring quality and safe care, Saudi Arabia has embarked on an accreditation process that sets a standard for the Middle East (M. Khoshim, personal communication, June 20, 2008). Instrumentation A cover letter explaining the research supplemented the informed consent packet in the first step of the distribution process. All FTNs received an invitation to participate in the nursing research study. The introduction letter to the research described general global nursing issues, outlined the focus of the surveys and focus group sessions, identified the support and commitment from hospital leadership, explained confidentiality and anonymity, described the benefits for the FTNs, outlined inclusion criteria for participants, and estimated the time to complete the surveys and focus group participation.
112 The demographic survey for the study (see Appendix M) captured pertinent data specific to Saudi Arabia. Aiken and Patrician’s (2000) NWI-R instrument (see Appendix N) explored organizational attributes that contributed to nurse satisfaction and tenure. Dr. Aiken provided written permission to use the instrument (see Appendix O). The NWI-R instrument originated from Kramer and Hafner’s (1989) research on Magnet hospitals during a national nursing shortage. Kramer and Hafner noted that some hospitals were not having problems attracting and retaining nurses to work and used the term Magnet to describe these institutions (Aiken & Patrician, 2000, ¶ 12). The 65 items on the NWI measured hospital attributes that promoted job satisfaction and the nurses’ ability to provide quality care (Aiken & Patrician, ¶ 14). Aiken’s team adapted the scale to investigate a series of factors that described a hospital or unit, as reported by the nurses in the hospital or unit (Aiken & Patrician, Instrument Modification section, ¶ 1). The revised instrument (NWI-R) had 57 items and a single statement, ‘This factor is present in my current job situation” (Aiken & Patrician, Instrument Modification section, ¶ 1). The quantitative 4-point Likert-type questionnaire ranging from 4 (strongly agree) to 1 (strongly disagree) explored a hospital’s environment in terms of autonomy over practice, control over the practice setting, nurse–physician relationships, and organizational support (Aiken & Patrician, ¶ 8-9). To assess reliability of the instrument, Aiken and Patrician (2000) noted, “The overall Cronbach’s alpha for the entire NWI-R was 0.96. The alpha for individual level data for each subscale was 0.75 for autonomy, 0.79 for control, and 0.76 for relationships with physicians” (Instrument Evaluation, Reliability section, ¶ 4). Aiken and Patrician demonstrated validity of the instrument by “the origin of the instrument, its ability to
113 differentiate nurses who worked within a professional practice environment from those who did not, and its ability to explain differences in nurse burnout” (¶ 4). Aiken and Patrician (2000, Discussion section, ¶ 3) developed the NWI-R to investigate the organizational climate in hospitals that have established professional nursing practice models. Nurses reported the traits that described their hospitals. The instrument was useful for the study on FTN job satisfaction in Saudi Arabia. The participating hospitals for the study implemented standards that met accreditation guidelines. The change had infused a degree of professional practice and job satisfaction for the nursing departments (A. Dababneh, personal communication, January 18, 2007). As the change in professional practice and job satisfaction was anecdotal only, the study provided baseline data for FTN job satisfaction through an exploration of hospital characteristics and burnout in accredited hospitals in the Western Region. The study may be useful for later research and for hospital leaders as they move toward Magnet status accreditation (Wagner, 2004, ¶ 10). The PES-NWI instrument (see Appendix P) developed by Lake (2002) provided quantitative data on the practice environment. Dr. E. Lake provided written permission to use the PES-NWI (see Appendix Q). Lake (p. 177) developed the PES from the NWI. Lake was looking for a measure that would be more psychometrically sound, easily administered, and for subscales that would generate scientific knowledge. Lake’s (p. 177) intent was to determine how the practice environment contributed to nurse and patient outcomes. Lake (p. 181) defined the practice environment as nurse participation in hospital affairs; nursing foundations for quality of care; nurse manager ability, leadership, and support of nurses; staffing and resource adequacy; and collegial nurse–physician
114 relationships. Lake posited benchmarking the data with Magnet hospitals helped nursing leaders to focus on improvements in the nurses’ practice environment and to measure the characteristics and extent of the improvements (Lake, p. 177). The instrument had 31 items using a 4-point Likert-type questionnaire that ranged from 1 (strongly agree) to 4 (strongly disagree). The main question was the participants’ extent of agreement to the item and if the item was present in the participants’ current job. Lake (2002) reported, “Internal consistency reliability at the nurse level was judged by Cronbach’s alpha using a criterion of .80” (p. 180). Two features evaluated the hospital-level reliability (Lake, p. 180): interitem correlations (.64-.91) and intraclass correlations (.88-.97). In other words, “there must be a sufficient number of raters and sufficient agreement among them to measure reliability. Both the average interitem correlation and the intraclass correlation should exceed .6 to justify aggregation” (Glick, as cited in Lake, p. 180). Lake noted, “Construct validity was supported by higher scores of nurses in magnet versus nonmagnet hospitals” (p. 176). The PES-NWI investigated the state of health in the nursing practice environment with newly accredited hospitals in the Western Region. The data illustrated how the changes influenced nurse outcomes. The study provided benchmark research on Magnet status hospitals as the Saudi nursing leadership move toward that goal (Wagner, 2004, ¶ 10). The goal for nursing leaders is to improve or sustain a practice environment that provides quality patient care and improves outcomes for nurses and patients. Recent research (Cummings, Hayduk, & Estabrooks, 2006; Li et al., 2007; Slater & McCormack, 2007) suggested continued research of the NWI-R and PES-NWI as instruments that define the practice environment. The researchers questioned the stability
115 of the four-factor structure of the NWI-R (Slater & McCormack), the validity (Cummings et al.), and the generalizability (Li et al.). Slater and McCormack (p. 37) extracted 15 items that measured the four-factor structure of the NWI-R and found statistical evidence for a three-factor structure that identified physician–nurse relationships, nursing management, and adequate staffing levels. Cummings et al. (p. 93) reported that when the three instruments (NWI-R, PES-NWI, and the one-factor model developed by Estabrooks et al., 2002) were factor analyzed, all three instruments failed to measure and explain the nursing practice environment. In a Veteran Health Administration study, Li et al. (p. 42) noted organizational culture, social climate, a more racially and ethnically diverse workforce, more baccalaureate nurses, and more FTNs could account for the variances found in their study and previous studies in the private sector. Li et al. recommended further research to examine the findings and results. The MBI (developed by Maslach and Jackson (1981), investigated those factors that contributed to burnout as identified by the participant. CPP, Inc. provided written permission to use the MBI instrument (see Appendix R). Maslach and Jackson (p. 99) described burnout in three related aspects. The first aspect was emotional exhaustion, where the professional staff in a human service institution can no longer give of themselves psychologically. The second aspect was negative, cynical attitudes toward patients. The last aspect was negative feelings about oneself and one’s accomplishments on the job. Maslach and Jackson (p. 100) noted there were several consequences to staff burnout: compromised quality of care to the patients, absenteeism, low morale, turnover of staff, and personal problems (including insomnia, physical exhaustion, increased use of alcohol and drugs, and marital and family problems).
116 Three subscales were developed: 1) . . . emotional exhaustion (feelings of being emotionally extended and exhausted by one’s work), 2) depersonalization (unfeeling and impersonal response towards recipients of one’s care of service, and 3) personal accomplishment (feelings of competence and successful achievement in one’s work with people). (Maslach & Jackson, p. 101) The answers from participants on how often the statement occurred tested the frequency and intensity of the subscales. The 7-point Likert-type scale ranges from 0 (never) to 6 (every day). The higher the mean scores on emotional exhaustion and depersonalization, the higher the measure of “experienced burnout” (Maslach & Jackson, p. 101). Lower mean scores on personal accomplishment indicated a higher measure of burnout experiences. The personal accomplishment subscale is independent of the other two subscales. Maslach and Jackson (1981) reported, “Internal consistency was estimated by Cronbach’s coefficient alpha, which yielded reliability coefficients of 0.83 (frequency) and 0.84 (intensity) for the 25-item scale” (p. 105). Maslach and Jackson demonstrated convergent validity by correlating the participants’ scores with a behavioral rating made by a person close to the participant (family member). Job characteristics expected to contribute to burnout and other measures predicted to cause burnout correlated with the MBI and demonstrated convergent validity (Maslach & Jackson, p. 105). One other test to determine validity entailed differentiating burnout from job dissatisfaction (Malsach & Jackson, p. 109). Researchers determined burnout is not synonymous with job dissastisfaction after testing other instruments with MBI.
117 The MBI was useful for the study. Feelings of burnout and stress contribute to increased turnover. Maslach and Jackson (1981, pp. 109-112) used demographic surveys to study burnout according to the participants’ sex, race, age, marital status, and education. Of interest were the findings suggesting, “burnout is likely to occur within the first few years of one’s career” (Maslach & Jackson, p. 111). Foreign-trained nurses in Saudi Arabia with less than 2 years experience are at risk of burnout where support systems are lacking. Several considerations guided the planned use of the NWI-R, PES-NWI, and MBI for the study. The first consideration was the use of the NWI-R and MBI instruments in a research study that won acclaim around the world and implemented change in staffing ratios in California, United States (Aiken et al., 2002). Aiken and her team are experts on the nursing shortage. Her research team found what troubles hospitals “knows no country boundaries” (Aiken, as cited in Smith, 2002, p. 59). Aiken’s research using the NWI-R and MBI has documented those variables that contributed to nurse job satisfaction, tenure, and burnout. The nursing community values Aiken’s research and by using the NWI-R variables the study in Saudi Arabia contributed to her ongoing research on the global problem of the nursing shortage. The PES-NWI instrument, used in conjunction with the NWI-R, added additional data to the FTNs’ perception of the work environment and nurse and patient outcomes. The second consideration was the instruments explored FTNs’ attitudes about the work environment and professional nursing models in the U.S. hospital setting (Flynn & Aiken, 2002, p. 68). The studies on Magnet hospitals demonstrated job satisfaction and improved patient outcomes with a professional nursing practice environment (Flynn &
118 Aiken, p. 68). Flynn and Aiken investigated the FTNs’ values of professional nursing practice in the U.S. environment using the NWI-R and MBI instruments and concluded and supported “the transcultural nature of nursing” (p. 72). The third consideration in the instrument selection was the use of the instruments since the 1980s to test validity and reliability. Multiple studies (for example, Aiken et al., 2002; Flynn, 2005; Flynn et al., 2005; Friese, 2005; Halm et al., 2005) found the scores “stable and consistently reliable” (Creswell, 2002, p. 183). The results of the studies demonstrated useful “inferences (or generalizations) from the scores—their validity” (Creswell, p. 183). The last consideration in the instrument selection was the use of the instruments to investigate organizational characteristics in Magnet hospitals. The organizational characteristics of a hospital attracted and retained nurses, which is valuable information for nursing leaders in Saudi Arabia. Nursing leaders are the change agents in implementing cultural and organizational characteristics. As the quality management movement continues in Saudi Arabia, nursing and organizational leaders are looking forward to Magnet status recognition. One hospital in Jeddah is preparing for the accreditation. The current study provided valuable information and a baseline for nursing directors as these instruments assessed organizational readiness of Magnet recognition. The focus group interviews (see Appendix S) provided a rich, personal account of FTNs’ experience of living and working in Saudi Arabia. A focus group is “a semistructured group session, moderated by a group leader, held in an informal setting, with the purpose of collecting information on a designated topic” (Carey, as cited in McLafferty, 2004, p. 187). Focus group sessions gather information on the “social realities of a cultural group” (McLafferty, p. 189).
119 A second consideration to use focus group data was to corroborate or validate the quantitative data and assess the relationship of constructs to the theoretical framework. The questions for the focus group were derived from Herzberg’s research (1966, p. 19). Herzberg (1966) posited that because participants discussed a significant event, the responses might reflect organizational traits according to frequency rather than importance. The last consideration for using focus groups was the 20-year history of qualitative research using focus groups (McLafferty, 2004, p. 187). Khowaja, Merchant, and Hirani (2005, p. 32) used focus group sessions to study job satisfaction among 45 nurses at a large tertiary care hospital in Pakistan. The qualitative study explored the reasons for nurses leaving the hospital, the nurses’ expectations of management, and factors influencing retention. Khowaja concluded the nurses were dissatisfied with their jobs because of staffing ratios; burnout; lack of respect, recognition, and support from nursing management; and lack of nurse physician collaboration (Khowaja et al., p. 35). Job satisfiers included a safe working environment, opportunities for professional and personal growth, technology, and positive feedback from patients (Khowaja et al., p. 37). Moyle, Skinner, Rowe, and Gork (2003, p. 168) conducted focus group interviews with 27 nurses and nursing assistants who worked in two long-term care facilities. The research explored job satisfaction in relation to work environment and the personal characteristics of the participant. Job satisfaction included contact with the residents, appreciation from residents, flexible schedules, and teamwork. Job dissatisfaction included decreased time spent with residents (such as documentation and staffing ratios), management not recognizing pressures at work, and overtime (Moyle et al., p. 171).
120 Hanratty et al. (2006, p. 493) explored physician perceptions on the care of dying patients with heart failure. Thirty-six physicians from different specialties participated in focus group sessions. The findings demonstrated the lack of knowledge regarding the role of the palliative specialist. There was an understanding of palliative care with cancer patients, but not with other terminal patients. Some physicians felt the role was better suited to nurses rather than physicians because of time constraints with other patients. Some physicians stated they would not accept failure, which was a reflection on their view of dying. The study concluded physicians required education to encourage behavior changes toward palliative care (Hanratty et al., p. 497). Foreign-trained nurses are guests in Saudi Arabia. It is difficult for the nurse to speak his or her mind, as there is always the threat of retribution in some organizations (S. Jeha, personal communication, September 13, 2006). Conflict of interest was not an issue for the focus group sessions, as the two moderators had no affiliation with the hospitals during the research study. The venue for the focus groups sessions was a neutral setting away from the hospitals. Data Collection Data collection is the process of gathering information from different sources to answer research questions (Creswell, 2002, p. 11). Multiple sources of data explained the complexity of the FTNs’ situation in Saudi Arabia. The data included a demographic survey, two instruments on hospital characteristics (job satisfaction), one instrument on burnout, and focus group sessions that focused on job satisfaction. The population identified as FTNs worked in the Western Region of Saudi Arabia in two hospital sectors. Hospital administrators provided written permission to use their
121 premises, name, and subjects. Collaboration for implementation of the study was through a hospital representative. Distribution of a sealed envelope containing the introduction letter and informed consent occurred over 1 month, depending on the number of FTNs in the hospital. Distribution of the letter included all FTNs meeting the criteria for the study. The introduction letter described the surveys and focus group sessions and requested the FTN to sign the informed consent. The FTN indicated on the signed consent how he or she wanted to receive the surveys and put his or her phone number for focus group participation. The FTN dropped the sealed plain envelope with the informed consent into the secure, locked box in the nursing administration or quality management office. Survey distribution followed the informed consent process. Survey distribution occurred by e-mail, distribution through nursing office, or postal mail. When the surveys were completed, the FTN placed them in a plain envelope and dropped the envelope in the locked box in the designated office or e-mailed them back to a safe e-mail address. Additional visits to the hospital ensured the sample size was sufficient and accommodated the FTNs’ work schedule. Participants could withdraw from the study at any time. The focus group sessions started during the survey collection time. There were four focus group interview sessions. Random sampling (heterogeneous sample) identified participants. Stratified random sampling (homogeneous sample) identified the hospital types (that is, government or private). A heterogeneous group of nationalities yielded a more fruitful discussion of satisfiers and dissatisfiers within and among the organizations.
122 The moderator or facilitator of the focus group session recorded and made notes as participants described the event in detail. The events classified into subthemes and factors provided a profile of the FTN in Saudi Arabia. The stories told by the FTNs provided the data on satisfying and dissatisfying days at work. Herzberg’s theory collated the identified factors from interviews by frequency, not importance (Herzberg, 1966, p. 19). Several hypotheses explained in multiple ways tested the theory’s validity. The process of obtaining informed consent, distributing and retrieving the surveys, and conducting focus group sessions was the most reliable method for the study. The objective was to survey all FTNs (random and nonbiased). The Internet was problematic as not all staffs have access to Internet services. The postal service in Saudi Arabia is not reliable, but was an option for the FTN to feel confident regarding anonymity and confidentiality. Mail for staffs go to the hospital mailroom or nursing office, as some staffs live on hospital compounds in close proximity to the hospitals. It was impossible to find addresses for those FTNs who live in the community, although they do receive mail in the hospital. A convenience sample of FTNs might have participated by receiving informed consents and surveys in a designated room or during an in-service in the hospital, but would have resulted in bias and was not suitable for the research. Obtaining a list of all FTNs in the hospital and distributing informed consents and surveys by systematic sampling would have been problematic. Not all hospitals would share a human resource list of employees with outsiders. The hospital site was the only efficacious method. The study involved a four-phase statistical process. In the first phase, descriptive statistics described the participants and hospitals. In the second phase, bivariate statistics
123 correlated the independent variables that shared a relationship with the dependent variables. The third phase was multiple regression statistics that examined the relationship between multiple independent variables and the dependent variables. The last phase of the study was triangulation. The process portrayed the quantitative and qualitative data in a robust worldview of job satisfaction, the work environment, burnout, and tenure for FTNs working in Saudi Arabia. The four-phase process facilitated the management of the data and complexity of the study. The NWI-R, PES-NWI, and MBI instruments reflected the perceptions and attitudes of hospital characteristics (job satisfaction), work environment, and burnout of FTNs in Saudi Arabia. Data reflected current variables in the hospital environment that explained tenure of FTNs. Additional demographic analyses correlated dependent variables with the independent variables, such as the relationship between tenure and hospitals or the relationship between tenure and nationalities. The instruments provided “measurable and observable data on variables” (Creswell, 2002, p. 54). The instruments reflected those push and pull factors developed in the literature (Aiken et al., 2004; Bach, 2004; Buchan, Kingma, et al., 2005, Buchan & Sochalski, 2004; Hongoro & McPake, 2004; Kline, 2003; Mejia et al., 1979, p. 104; Spetz & Given, 2003; Stilwell et al., 2004). The purpose of obtaining qualitative data (focus group interviews) was to corroborate the quantitative data and ensure credibility in the information provided by the FTNs. The second purpose of using qualitative data was to add to the literature on Herzberg’s (1974) theory. Foreign-trained nurses elicited themes of motivation and hygiene variables from Herzberg’s theory. The motivation and hygiene variables are comparable to the job satisfaction variables in the study instruments (NWI-R, PES-NWI,
124 and MBI). Herzberg’s (1974, p. 19) theory focused on organizational profiles of job satisfaction and job dissatisfaction rather than on individual profiles. The focus groups provided a profile on the organizational attributes and commonalities among FTNs working in Saudi Arabia. Data Analysis The study involved the implementation of quantitative and qualitative data analysis methods to analyze the data. The dependent variables were hospital characteristics (job satisfaction) and burnout. The independent variables included a subset of demographic data and work environment variables. Table 1 contains the list of dependent and independent variables. The Statistical Package for the Social Sciences (SPSS) software program analyzed the quantitative data. Descriptive statistics detailed the study sample and enabled the performance of necessary data diagnostics before proceeding to the multivariate data analysis techniques. The frequency distribution determined categorical and ordinal data elements. The mean and standard deviation determined interval-level data. Parametric statistics “are statistical tests based on the premise that the population from which samples are obtained follows a normal distribution and the parameters of interest to the researcher are the population mean and standard deviation” (Creswell, 2002, p. 237). Bivariate correlation statistics described the relationship between the dependent variables and independent variables using t tests, analysis of variance (ANOVA), and Pearson’s r² correlation test. Multivariate techniques (multiple regression) examined the relationship between multiple independent variables and each of the dependent variables while controlling for the effect of other variables To test the
125 hypotheses using survey data, both bivariate and multiple regression were used. Table 2 illustrates a summary of the approach to test the hypotheses. Table 1 outlines the independent and dependent variables used in the hypotheses testing. Table 1 Measures for Dependent and Independent Variables Variables
Measure Dependent variables
Job satisfaction
Score from NWI-R (autonomy over practice, control over practice setting, nurse–physician relationships, and organizational support) Score from PES-NWI (nurse participation in hospital affairs; nursing foundations for quality of care; nurse manager ability, leadership, and support of nurses; staffing and resource adequacy; and collegial nurse–physician relationships)
Burnout
Score from MBI (emotional exhaustion, depersonalization, and personal accomplishment) Independent variables
Demographic
Gender, age, nationality, religion, educational level, year qualified as nurse, number of years of work at current hospital, worked in Kingdom prior to current contract, first contract in Saudi Arabia, number of years working in the Kingdom, stay in Saudi Arabia, married, family with nurse in Kingdom, currently pursuing a degree
Work environment
Title, ownership, number of beds per 100 nurses, contract type
126 Table 2 Hypotheses Testing Plan
Hypotheses 1, 2, 3
Dependent
Independent
variables
variables
Interval
Categorical
Statistics t test
(2 groups)
Purpose To test the difference between the means of two related groups or sets of scores.
1, 2, 3, 4
Interval
Categorical
ANOVA
(3 + groups)
To test the difference among the means of three or more independent groups, or of more than one independent variable.
4
Interval
Interval
Pearson r²
To test that a correlation is
correlation different from zero (i.e., that a relationship exists)
Qualitative coding entails “segmenting and labeling text” (Creswell, 2002, p. 266) to identify thoughts or themes. The moderators analyzed the tape recordings and written notes taken during the focus group sessions. The following steps outline the segmenting and coding of the discussion themes: 1. Review the notes and tape recordings for each session to get a sense of the general picture.
127 2. Take one session at a time, review the notes, listen to the tape, and make notes regarding common issues or subthemes identified by participants. 3. Compare the common subthemes between the sessions. 4. For any outliers (those issues that come up that are specific for a minority of participants), make a note as potential additional variables. Triangulation of the quantitative and qualitative data yielded a logical pattern of relationships and meaning between and among variables to understand the complexity of job satisfaction, organizational characteristics, and burnout in hospitals in Saudi Arabia. Themes and relationships developed based on the findings from both the quantitative and the qualitative data. A central purpose for using the NWI-R, PES-NWI, and MBI was to continue the research on Magnet and non-Magnet hospitals. The instruments explored and compared the nursing practice environment and job satisfaction that affected different organizational outcomes. Organization outcomes included job satisfaction and retention (Aiken et al., 2002; Friese, 2005; Halm et al., 2005; Kramer & Hafner, 1989), burnout (Aiken et al., 2002; Flynn & Aiken, 2002; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004; Halm et al.), nurses’ health status (Budge, Carryer, & Wood, 2003), productivity (Kramer & Hafner), perceptions of empowerment (Laschinger, Almost, & Tuer-Hodes, 2003; Manojlovich & Laschinger, 2007), executive nurse leadership style (Upenieks, 2002), patient satisfaction (Vahey et al.), patient morbidity and mortality (Aiken, Clarke, & Sloane, 2001; Aiken et al., 2002; Halm et al.), work design (Aiken, Clarke, & Sloane, 2001; Aiken, Clarke, Sloane, Sochalski, et al., 2001), nursing work values across cultures (Flynn & Aiken), and nursing work values across settings (Flynn, 2005; Flynn et al.,
128 2005). Herzberg’s (1974) theory assisted in developing job enrichment strategies by studying job satisfaction and no job satisfaction. The theory helped investigate job satisfaction in higher education in Uganda (Ssesanga & Garrett, 2005), job satisfaction in recruiting and retaining government employees (Tamosaitis & Schwenker, 2002), nurse manager qualifications (Timmreck, 2001), manager perceptions of employee satisfaction (Byrne, 2006; Usugami & Park, 2006), work redesign (Hackman et al., 1975), job satisfaction among nurse practitioners (Kacel et al., 2005), and job satisfaction among sports editors (Reinardy, 2007). Nursing researchers studied Magnet and non-Magnet hospitals internationally using the NWI-R, PES-NWI, and MBI instruments. The data from the NWI-R, PESNWI, MBI, and focus group interviews using a mixed-method research design will provide organizational leaders with insight into the perceptions of the FTNs’ work environment, job satisfaction, job dissatisfaction, and feelings of burnout and whether these variables affect FTNs’ tenure in Saudi Arabia. The data identified motivation– hygiene profiles and job-enrichment strategies that will lead to improved tenure. Validity and Reliability Validity is “the extent to which scores on a measure relate to scores on other measures” (Cone & Foster, 2003, p. 156). Different categories of validity (such as construct and convergent) depend on the subject matter under investigation. Creswell (2002) noted, “Reliability means that individual scores from an instrument should be nearly the same or stable on repeated administrations of the instrument, they should be free from sources of measurement error, and they should be consistent” (p. 180). A
129 discussion follows on the validity and reliability for the NWI-R, PES-NWI, and MBI instruments. NWI-R Aiken and Patrician (2000, Instrumentation Evaluation, Validity section, ¶ 1) noted the NWI-R is a valid instrument for measuring organizational characteristics that nurses find important and that lead to improved patient, nurse, and organizational outcomes. The NWI-R demonstrated content, criterion-related, and construct validity. According to Polit and Beck (2004), content validity is “the degree to which the items in an instrument adequately represent the universe of content for the concept being measured” (p. 714). The NWI-R, developed from the NWI, described the characteristics of Magnet organizations. Data gathered from a national AIDS care study obtained an 86% response rate (Aiken & Patrician, ¶ 3; Cummings et al., 2006, p. 83). Three methods developed the content validity for the NWI. The first method captured characteristics from Magnet hospitals. The second method was extensive research over a 25-year period on job satisfaction and work value instruments. The last method was to use three of the four original Magnet hospital researchers to analyze the instrument (Kramer & Hafner, 1989, p. 173). The NWI-R established content validity by securing the elements of professional practice models from the NWI instrument (Aiken & Patrician, Instrumentation Evaluation, Validity section, ¶ 2). Criterion-related validity is “the degree to which scores on an instrument are correlated with some external criterion” (Polit & Beck, 2004, p. 715). According to Aiken and Patrician (2000, Instrumentation Evaluation, Validity section, ¶ 3), the NWI-R correlated organizational characteristics with better outcomes. Aiken and Patrician
130 validated the instrument by demonstrating higher subscales on the NWI-R in Magnet hospitals and dedicated AIDS units. There was a correlation with Magnet hospitals and dedicated AIDS units as demonstrated by higher patient satisfaction, decreased mortality, lower nurse emotional exhaustion and burnout, and lower incidence of needlestick injury (Aiken & Patrician, Instrumentation Evaluation, Validity section, ¶ 3). Construct validity is “the degree to which an instrument measures the construct under investigation” (Polit & Beck, 2004, p. 714). The construct under investigation is the outcome resulting from determined subscales that describe professional practice in Magnet hospitals. The subscales are autonomy over practice, control over the practice setting, nurse–physician relationships, and organizational support (Aiken & Patrician, 2000, ¶ 8-9). Aiken and Patrician referred to Magnet hospitals as the “known group” (Instrumentation Evaluation, Validity section, ¶ 6). Research correlating outcomes between Magnet hospitals and non-Magnet hospitals demonstrated higher mean scores. The NWI-R contained a combination of attributes specific to the unit and to the hospital. Aiken and Patrician explained there may be differences between unit attributes but units in a given hospital would not differ in organizational attributes (Aiken & Patrician, Instrumentation Evaluation, Validity section, ¶ 8). Aiken and Patrician (2000) supported reliability by the representativeness of the sample. The sample included 40 units in 20 hospitals. The researchers surveyed all nurses who worked more than 16 hours per week on dedicated AIDS units with an overall response rate of 86% (Aiken & Patrician, Instrumentation Evaluation, Reliability section, ¶ 1). A second method to support reliability was to account for the heterogeneity of respondents. The researchers used hierarchical linear modeling to control value-laden
131 responses based on race, sex, education, and so forth (Aiken & Patrician, Instrumentation Evaluation, Reliability section, ¶ 2). Another source to support reliability is through studies over time that demonstrate stability in the findings (Aiken & Patrician, Instrumentation Evaluation, Reliability section, ¶ 3). The last instance of reliability was the results from the instrument (Aiken & Patrician, Instrumentation Evaluation, Reliability section, ¶ 4). The Cronbach’s alpha for the NWI-R was .96. The individual (nurse) level internal consistency reliability coefficient was .85 for autonomy, .91 for control, .84 for relationships with physicians, and .84 for organizational support (Aiken & Patrician, Instrumentation Evaluation, Reliability section, ¶ 4). PES-NWI Lake (2002, p. 177) developed the PES from the NWI. Lake (p. 178) tested the PES instrument by using data from two sources: (a) the original research from Kramer and Hafner in 1985-1986 testing Magnet and non-Magnet hospitals with a response rate of 98% and (b) the data collected from the Aiken et al. study in Pennsylvania in 19981999 with a 52% response rate. Lake followed five stages in developing and testing the instrument. The first step was to select 48 items from the NWI that defined the nursing practice environment. The second step was to use explanatory factor analysis to develop five subscales from the items selected that measured the nursing practice environment. Lake (2002) noted, “The most robust subscale structure was selected for reliability, validity, and generalizability testing” (p. 179). At the second step, “a mean was chosen rather than a sum to aid interpretation of scores, in which 2.5 is the neutral point on the 4-point response set, as well as to facilitate comparisons across subscales” (Lake, p. 179). The
132 next step entailed an examination of reliability of the subscales between individual (nurse), hospital, and composite scores. Nurse-level internal consistency reliability was “judged by Cronbach’s alpha using a criterion of .80” (Lake, p. 180) to ensure that future use of the instrument would produce robust results for sampling size and variability. Varimax for the orthogonal rotation (uncorrelated subscales) in Step 2 yielded five uncorrelated subscales for the instrument (Cummings et al., 2006, p. 83; Lake, p. 180). Thirty-one items from the 48 remained across the subscales. All subscales and composites (except for the collegial nurse–physician relations subscale) for the nurse demonstrated an internal consistency reliability of α ≥ .80. Collegial nurse–physician relations demonstrated an α of .71, which Lake considered moderate (p. 182). Two indicators measured the hospital-level internal consistency reliability (Lake, p. 180): (a) interitem correlations (consistency of responses aggregated to hospital level) and (b) interclass correlation (mean rater reliability from an adequate number of nurse respondents and adequate agreement among them). The average interitem correlation and average interclass correlation should “exceed .6 to justify aggregation” (Glick, as cited in Lake, p. 180). The hospital-level internal consistency reliability was .64-.91 for interim correlation and .88-.97 for interclass correlation (Lake, p. 182). In the fourth step, the construct validity of the subscales examined the composite measures of the nursing practice environment and compared the scores from the Magnet hospitals and non-Magnet hospitals. The mean scores from the subscale and composite measures demonstrated higher scores for nurses working in Magnet hospitals compared to non-Magnet hospitals with p < .001 (Lake, 2002, p. 182). The difference in the scores
133 for all subscales between Magnet and non-Magnet hospitals ranged from standard deviation (SD) of .33 to .66 and SD of .75 for the composite (Lake, p. 182). In the last step, “the generalizability of the selected subscale structure was evaluated by an oblique multiple-group principal-components cluster analysis” (Lake, 2002, p. 180). Using the data from a Pennsylvania study, Lake found that 1 item from the 31 moved to another subscale because of the change in terminology of nursing administrator to nursing manager. In turn, the change shifted the item from a hospital perspective to a nursing unit perspective (Lake, p. 184). MBI Two studies captured the items or variables for the MBI instrument. The first study included 605 respondents from various health and service occupations. Forty-seven items illustrated frequency and intensity of attitudes and feelings characterized by burnout (Maslach & Jackson, 1981, p. 100). Factor analysis examined the data “using principal factoring with iteration and an orthogonal (varimax) rotation” (Maslach & Jackson, p. 101), which reduced the items to 25. The items were retained if they met the following criteria: “a factor loading of > 0.40 on only one of the four factors, a large range of subject response, a relatively low percentage of subjects checking the ‘never’ response, and a high item-total correlation” (Maslach & Jackson, p. 101). The second study used the 25-item scale. Four hundred twenty respondents participated in the study from various health and service occupations. The results were similar so Maslach and Jackson combined the two studies for a sample size of n = 1,025. Maslach and Jackson (1981) explained, “The correlations between the frequency and intensity dimensions across items ranged from 0.35 to 0.73, with a mean of 0.56” (p.
134 104). Maslach and Jackson noted the results demonstrated a moderate relationship and explained the result by noting the two dimensions “sometimes reveal different patterns of correlations with situational and personality variables” (p. 104) and respondents noted they liked the two-dimensional structure as it allowed them to differentiate their responses. The two-dimensional aspect remained with the 25 items. The second study calculated reliability coefficients. Cronbach’s coefficient alpha demonstrated .83 for frequency and .84 for intensity for internal consistency on the 25item scale (Maslach & Jackson, 1981, p. 105). The reliability coefficients for the subscales included emotional exhaustion—.89 (frequency) and .86 (intensity); personal accomplishment—.74 (frequency) and .74 (intensity); depersonalization—.77 (frequency) and .72 (intensity), and involvement—.59 (frequency) and .57 (intensity) (Maslach & Jackson, p. 105). A test–retest study demonstrated the following: emotional exhaustion—.82 (frequency) and .53 (intensity); personal accomplishment—.80 (frequency) and .68 (intensity); depersonalization—.60 (frequency) and .69 (intensity); and involvement—.64 (frequency) and .65 (intensity). Maslach and Jackson reported these “coefficients are significant beyond the 0.001 level” (p. 105). External validation of personal experience, dimensions of the job experience, and personal outcomes established convergent validity (Maslach & Jackson, 1981, pp. 105107). Maslach and Jackson sampled coworkers and the spouses of respondents who had completed the MBI. Forty participants evaluated their MBI respondent coworker to corroborate the respondent’s self-assessment of burnout. The question asked how emotionally drained the person was and how the person reacted with clients. Emotionally drained correlated highly with emotional exhaustion (r = .41, p < .01) and
135 depersonalization (r =.57, p < .001; Maslach & Jackson, p. 106). Appearing physically fatigued correlated highly with emotional exhaustion, frequency only (r = .42, p < .01), and depersonalization (r = .50, p < .01). How the person reacted to clients was highly correlated with depersonalization (r = .33, p < .05; Maslach & Jackson, p. 106). Maslach and Jackson (1981) surveyed 142 police officers and their wives to validate the MBI. The wives discussed behaviors that related to emotional exhaustion and personal accomplishment but not depersonalization. Depersonalization is behaviors related to the work environment. The police officers who rated themselves high on emotional exhaustion were reported as upset and angry (r = .34, p < .001), tense or anxious (r = .25, p < .001), physically exhausted (r = .15, p < .05), and complaining about problems at work (r = .29, p < .001) by their wives (Maslach & Jackson, p. 106). The police officers who rated themselves high on personal accomplishment were reported as being in a happy or cheerful mood, frequency only (r = .20, p < .05), and having feelings that work was a source of pride and prestige for the family (r = .25, p < .01; Maslach & Jackson, p. 106). Maslach and Jackson (1981, p. 106) validated the instrument by exploring the dimensions of the job experience and relationships between job characteristics and burnout. Ninety-one social service and mental health workers answered the MBI and the Job Diagnostic Survey (JDS; developed by Hackman & Oldham, as cited in Maslach & Jackson, p. 107). The JDS was a personal assessment of “basic job dimensions” (Maslach & Jackson, p. 107). One job dimension, feedback from the job itself, correlated highly with the lower scores on emotional exhaustion (r = -.38, p < .001) and depersonalization (r = -.38, ρ < .001) and with higher scores on personal accomplishment (r = .29, p < .01).
136 The second job dimension, dealing with others, correlated highly with high scores on involvement (r = .23, p < .001). The dimension did not correlate well with emotional exhaustion, frequency only (r = .15, p < .10). The last job dimension, task significance, correlated highly with high scores on personal accomplishment, intensity only (r = .18, p < .05; Maslach & Jackson, pp. 106-107). The last measure of convergent validity, personal outcomes, described the relationship between burnout and various outcomes (Maslach & Jackson, 1981, p. 107). Maslach and Jackson (pp. 107-109) described the results from the JDS and MBI instruments in measuring the following outcomes. Low scores on JDS for growth satisfaction when negatively correlated with emotional exhaustion (r = -.26, p < .001) and depersonalization (r = -.39, p < .001) and positively correlated with personal accomplishment (r = .29, p < .001, where n = 180). Low scores on JDS for experienced meaningfulness of the work correlated to higher scores on depersonalization (r = -.1, p < .05) and lower of personal accomplishment (r = .19, p < .05). The correlation with emotional exhaustion lacked statistical significance (r = -.16, p < .10, where n = 91). Low scores on JDS for knowledge of results correlated with high scores on emotional exhaustion (r = -.21, p < .05) and depersonalization (r = -.28, p < .01) and with low scores on personal accomplishment, frequency only (r = .20, p < .05, where n = 91). MBI scores on intention to leave one’s job were highly predictive (R (6,135) = .68, p < .001, where n = 142). MBI scores on staff who took more breaks correlated highly with emotional exhaustion, intensity only (r = .29, p < .04), and scores on absenteeism correlated highly with depersonalization (r = .30, p < .04, where n = 40). MBI scores on staff wanting to get away from people (work and social) correlated highly with emotional
137 exhaustion (r = .27, p < .05, where n = 43); scores from coworkers on evaluating their clients more negatively over time correlated highly with emotional exhaustion, intensity only (r = .33, p < .05, where n = 40); low scores on JDS peer and co-worker satisfaction correlated highly with emotional exhaustion (r = -.19, p < .01) and depersonalization (r = -.36, p < .001) and had a low correlation on personal accomplishment (r = .32, p < .001, where n = 180). High scores on gets angry with wife or children correlated highly with depersonalization (r = .28, p < .001) and emotional exhaustion (r = .26, p < .001, where n = 142); high scores on wanting to be left alone correlated highly with emotional exhaustion (r = .19, p < .02, where n = 142); high scores on perceived distance with children correlated highly with depersonalization (r = .24, p < .01) and personal accomplishment (r = -.39, p < .001, where n = 142); high scores reported by wife on husband did not share his feelings with her and did not care as much about her correlated highly with depersonalization, intensity only (r = .19, p < .02) and (r = .17, p < .03), respectively; high scores on was absent from family celebrations correlated highly with depersonalization (r = .21, p < .01); high scores on fewer friends correlated highly with depersonalization (r = .20, p < .05); and a wife’s report on she and husband did not share same friends correlated highly with depersonalization (r = .24, p < .01). As reported by the wife, problems with insomnia correlated highly with emotional exhaustion (r = .24, p < .01); dealing with stress by taking a drink correlated highly with emotional exhaustion (r = .24, p < .01); and taking tranquilizers correlated highly with emotional exhaustion (r = .21, p < .01) and correlated with low scores on personal accomplishment (r = .33, p < .001).
138 Maslach and Jackson (1981, p. 109) tested whether the experience of job dissatisfaction is the same as burnout. Ninety-one respondents tested the JDS and MBI instruments. General job satisfaction had a moderate negative correlation with emotional exhaustion (r = -.23, p < .05) and depersonalization, frequency only (r = -.22, p < .02), and a slightly positive correlation to personal accomplishment, frequency only (r = .17, p < .06). Maslach and Jackson concluded burnout does not hold the same meaning as job dissatisfaction (p. 109). Further, Maslach and Jackson noted, “scores on MBI are subject to distortion by a social desirability response set, since many of the items describe feelings that are to professional ideals” (p. 109). Maslach and Jackson used the MBI and the Social Desirability Scale (developed by Crowne & Marlowe, as cited in Maslach & Jackson, p. 109). The results from the MBI demonstrated there was no correlation with the Social Desirability Scale (at the .05 significance level; Maslach & Jackson, p. 109). Summary This chapter included a discussion on the mixed-method research, the research design, the appropriateness of the study, the sample population, the geographical area, the instruments, the focus group interviews, and instrument validity and reliability. The international setting requires special consideration for consent to participate and confidentiality. The study’s replication and generalizability corroborated with numerous international studies using a mixed-method design and the instruments. The uniqueness of the study is the population and the setting. Aiken and Patrician (2000) noted that nurses are suitably situated to report on organizational traits that are important in their work (Discussion section, ¶ 1). The study identified an “inference that the findings can be generalized from the sample to the population” (Polit & Beck, 2004, p. 719). Chapter 4
139 discusses the findings and results of the mixed-method research study.
140 CHAPTER 4: RESULTS The purpose of chapter 4 is to report in sufficient detail the results of the research discussed in chapter 3. Chapter 4 reviews the purpose of the research study, research hypotheses, and research questions, as well as the data collection procedures, preparation for data analysis, data analysis procedures and explores the quantitative and qualitative data. The mixed-method study addressed the relationship between demographic and work environment factors on hospital characteristics (job satisfaction) and burnout among FTNs working in Saudi Arabia. The purpose of the triangulated mixed-method study was to validate both quantitative and qualitative data. Survey data measured the relationship between demographic and work environment variables and hospital characteristics (job satisfaction) and burnout. Concurrent with the quantitative data collection, qualitative focus group sessions explored job satisfaction and no job satisfaction for FTNs working in Saudi Arabia. The reason for collecting both quantitative and qualitative data was to bring together the strengths of both forms of research to validate the results. Previous studies focused on the significance of nurses’ job satisfaction and burnout within the context of the nursing shortage. Saudi Arabia’s dependence on FTNs places its health-care infrastructure in a vulnerable position. With insufficient numbers of Saudi nurses and competition from other countries for a FTN workforce, retention strategies are of significant importance. The first phase of the study involved a quantitative research method with 453 participants. Three instruments and a demographic survey measured the variables in the study. The dependent variables were hospital characteristics (job satisfaction) and burnout. Job satisfaction was determined by using Aiken and Patrician’s NWI-R (2000)
141 and Lake’s PES-NWI (2002). Burnout was determined by using Maslach and Jackson’s MBI scale (1981). The independent variables were a subset of the demographic data and work environment variables. The second phase of the study used a qualitative research method with 25 participants. Focus group sessions from different hospital sectors in Jeddah and Makkah provided rich data based on the FTNs’ experiences with life and work in Saudi Arabia. The theoretical framework provided complementary data to the quantitative data. The results described a complex worldview on FTNs’ work life and experience in Saudi Arabia. Review of Data Collection Procedures To determine how long it would take a FTN to complete the surveys, a focused pilot study occurred prior to distribution of the surveys and the demographic questionnaire. Five FTNs completed both the survey and the questionnaire and agreed they spent an average of 15 minutes overall. The intent of the pilot was only to obtain a timeline so that participants would not be overwhelmed with filling in three surveys and a questionnaire. The quantitative and qualitative data collection processes occurred concurrently. The analysis plan focused on one goal: “to validate one form of data (typically quantitative) through the other forms (typically qualitative data)” (Creswell & Clark, 2007, p. 119). Participant selection occurred with signed consent forms. Participant characteristics included that individuals were FTNs from accredited hospitals (either MRQP or JCI accreditation) holding licensure and registration in their home country;
142 were working as a staff nurse, charge nurse, or other nurse performing bedside care; participated voluntarily in the study; and were able to speak, read, and write English. Twenty-eight hospitals meeting the criteria of MRQP and JCI accreditation received the study protocol and informed consents requesting their participation in the study. Twenty-five hospital administrators signed the consent forms during the months of January, February, and July 2007. By September 2007, the nursing directors confirmed an approximate number of 4,423 FTNs working in the 25 participating hospitals. After receiving approval for the study by the Institutional Review Board of the University of Phoenix, meetings with the nursing directors took place to discuss the study. Objectives of the meeting included outlining the benefits of the study, gaining support from nursing administration, providing written information on the study to answer any questions the FTNs might have, and distributing the participation letter and informed consent form to the FTNs in each hospital. The nursing directors assisted in the distribution of the participation letter and consent form to ensure all FTNs received the invitation to participate. Foreign-trained nurses were encouraged to participate, sign the informed consent, and place the form in the collection box in nursing administration or the quality management office. The participation letter and consent form distribution began November 24, 2007, and finished January 8, 2008. The consent form pick-up began December 24, 2007, and finished February 9, 2008. Nine hundred forty-four FTNs signed consents. Participants chose the method of receiving the surveys: e-mail, mailed through the postal system, or hand delivered to the unit through the nursing office. The intent for providing three choices was to allow the participant to make the decision regarding the
143 security of the confidentiality of the study. Upon completion of the surveys, the FTNs emailed the surveys back to a safe e-mail address, used the self-addressed envelope and mailed the survey to a personal post office address, or placed a self-addressed envelope in the locked collection box in the nursing or quality management office. Survey distribution began January 21, 2008 and pick-up began February 10, 2008. Initial returns were disappointing and several activities followed to enhance survey return. A colorful flyer posted in the hospitals reminded FTNs to finish the surveys and put them in the collection box. Two-hour visits to the hospitals between March 19, 2008, and April 2, 2008, to meet with FTNs helped stress the importance of the study. The goals of the visit were to review the study purpose, the importance of FTNs’ participation, and the benefit of the study for the FTNs and to answer any questions or address concerns they had (see Appendix T for the schedule of hospital visits). The last activity to encourage survey return occurred at the Jeddah Nurses Executive Forum monthly symposium on April 8, 2008. The average monthly attendance to a symposium is 350 to 400 nurses. Foreign-trained nurses who indicated a willingness to participate received the informed consent form and surveys at the registration desk. The FTNs were encouraged to complete the surveys that evening and place the completed surveys in the collection box. By April 29, 2008, survey return was 453 (see Appendix U for survey distribution and collection data). Each FTN communicated his or her interest in the focus group sessions by providing a contact phone number on the informed consent form. Several challenges occurred in the scheduling of the focus groups including finding FTNs to participate and transportation. Foreign-trained nurses did not understand that providing their phone
144 number was the permission to call and schedule a focus group session. The telephone discussion reiterated the purpose of the session to ensure informed consent. The FTNs agreed, refused, or hung up the telephone. Foreign-trained nurses did not want to attend if it was their day off. Many FTNs work overtime on a day off and were not available. One government hospital requested that someone pick up the FTNs as the hospital would not allow the FTNs to travel with a driver who was not a hospital driver. Transportation included providing three to four drivers traveling to different hospitals to pick up the participants for each focus group session. Hospital administrators consented and allowed the FTNs to go off the compound to attend the focus group session in a safe venue. The administrators of four hospitals refused to give the FTNs permission to leave the compound for the focus group sessions due to security or staffing issues. Participants attended the focus group sessions based on availability, permission to leave the compound premises, or permission from their husbands to attend. The focus group sessions occurred during the survey distribution and survey pick-up. The sessions began on February 15, 2008, and finished on April 11, 2008. Twenty-five FTNs participated in four focus group sessions. A colleague assisted in the focus group sessions and recorded observations from FTNs during the discussion. Questions and answers focused on the issues of working and living in Saudi Arabia as presented by the participants. Facilitation and clarification of the issues provided an in-depth worldview of the participants. An audio tape-recorder assisted in recording the discussions to ensure accuracy of the common subthemes and hygiene-motivator factors that emerged and the accuracy of the FTNs’ quotes. Several meetings with the focus group facilitator took place to compare notes, review the data,
145 discuss the common subthemes, and identify additional factors from the discussions. The next section includes a description of the methods used to capture and prepare the raw quantitative and qualitative data for analysis. Preparation for Data Analysis Preliminary procedures assisted in the preparation of the quantitative data for analysis. Excel spreadsheets were used to enter the raw data from the quantitative surveys and demographic questionnaire. The subscales for the NWI-R included autonomy over practice (Questions 4, 6, 17, 24, and 35), control over practice setting (Questions 1, 11, 12, 13, 16, 46, and 48), nurse–physician relationships (Questions 2, 27, and 39), and organizational support (Questions 1, 2, 6, 11, 12, 13, 17, 24, 27, and 48). Data collection for the subscales included 15 of the 25 questions. The remaining 10 questions have been stored in a separate Excel spreadsheet for future research. The subscales for the PES-NWI included nurse participation in hospital affairs (Questions 5, 6, 11, 15, 17, 21, 23, 27, and 28); nursing foundations for quality of care (Questions 4, 14, 18, 19, 22, 25, 26, 29, 30, and 31); nurse manager ability, leadership, and support of nurses (Questions 3, 7, 10, 13, and 20); staffing and resource adequacy (Questions 1, 8, 9, and 12); and collegial nurse–physician relationships (Questions 2, 16, and 24). The subscales for the MBI included emotional exhaustion (Questions 1, 2, 3, 6, 8, 13, 14, 16, and 20), depersonalization (Questions 5, 10, 11, 15, and 22), and personal accomplishments (Questions 4, 7, 9, 12, 17, 18, 19, and 21). See Appendix V for a summary. Two people performed the raw data entry to increase the accuracy of the data key entry method. One person looked at the surveys and demographic questionnaire and
146 instructed the other person, who was entering the data into the Excel spreadsheet, on the answer from the surveys. A blank in the spreadsheet indicated missing data. Missing data were random and did not factor into significant changes in the data. Sometimes data are missing because participants skip questions or refuse to answer sensitive questions (Creswell, 2002, p. 229). Participants in the current study did not understand some words (example in the MBI, the word callous and the phrase the end of my rope; H. Mabuhay, personal communication, July 5, 2008). Participants also may not have noticed the printed surveys were on both sides of the paper (that is, printed back-to-back). Some participants filled out either the NWI-R or the PES-NWI but not both. Li et al. (2007, p. 34) identified survey fatigue for the missing data in their study. In the current study, participants may have had survey fatigue with the number of documents, as the MBI survey returns were lower than the other surveys. The returned surveys and questionnaires totaled 453, whereas the study required 356. Because 10 FTNs returned only the demographic questionnaires with no accompanying surveys, the demographic questionnaires were not included in the study. Where two answers appeared on one question, the data entry team agreed on one answer that reflected the participant’s thoughts in other questions. The next step was to convert the raw data into a form useful for analysis. In order for the NWI-R and PES-NWI data to be useful for scoring, the computer program reversed the coding. For example, answers for strongly agree (1) became strongly disagree (4). The reason was to “have higher scores correspond to more favorable practice environments” (S. Clarke, personal communication, June 30, 2008). SPSS 12.0 was the software program used to perform the steps in the data analysis. There are three files in the SPSS program that include a data file (or
147 spreadsheet), syntax file (for computer commands), and output file (the results). The first step in the data analysis was to convert the Excel spreadsheet to the data file in SPSS. The program recoded and computed the raw data from the Excel spreadsheet. The program then performed reverse coding on responses from the NWI-R and PES-NWI per the instructions from the researchers who developed the surveys. After the recoding and labeling was completed, verification of the data occurred by checking hard-copy surveys with data key entry. The percentage of errors was low, compared to well structured or managed surveys (e.g., national surveys; K. Hijjazi, personal communication, July 4, 2008). The second step was to code the variables. Appendix W outlines the original format and the recoded format for variable testing. To perform statistical tests, variables needed a number (for example, for gender, 0 = male and 1 = female). The next step included identifying variables with short and long labels for the command file (K. Hijjazi, personal communication, June 11, 2008). The short label is typically eight characters long and the long label can be longer than eight characters. The short label writes the commands (K. Hijjazi, personal communication, June 11, 2008). For example, the short label for age was age and the long label was age in years. For the MBI scales, MBI1 was the short label and the long label was Question 1 in the MBI survey (see Appendix V for variable description and coding). The lowest level of measurement for the variables was categorical, “a variable with discrete values (e.g., gender) rather than values along a continuum” (Polit & Beck, 2004, p. 712). The highest level of measurement for the variables was interval, “a level of measurement in which an attribute of a variable is rank ordered on a scale that has equal distances between points on that scale (e.g., Fahrenheit
148 degrees; Polit & Beck, p. 721). The data were ready for the descriptive, bivariate, and multiple regression statistics (see Table 2 for summary of hypotheses testing plan). The focus group participants met at a safe venue that provided a comfortable ambience and privacy away from the hospitals. At the beginning of the session, participants identified themselves, their country of origin, the hospital where they worked, the unit where they worked, length of time in the Kingdom, whether their work length of time was consecutive or nonconsecutive time, and whether their plans included working in another country. The following questions elicited and captured the nurses’ work and life experience in the Kingdom. 1. What attracted you to come to work in Saudi Arabia? 2. What issues do you face working in Saudi Arabia? 3. Describe to me a time when you felt exceptionally happy at work. 4. Describe to me a time when you felt exceptionally bad at work. 5. Tell me three areas of improvement that would retain nurses in Saudi Arabia. Each focus group session averaged 2.5 hours and was audio tape-recorded. An assistant recorded incidentals that illustrated body language, emotions, group dynamics, and peer pressure. A matrix for each focus group session identified the participants by a number, the country of origin, the type of hospital, area of work, length of time in the Kingdom and whether the time was consecutive or nonconsecutive, and plans to migrate to another country to work. One column in the matrix identified the question and the other column was for the participant’s quotes. The questions generated a lot of discussion for FTNs who needed to talk. Thus, all the comments during the focus group sessions were significant and were included in the matrix.
149 During the review of the focus group sessions, a further breakdown of the comments developed a sequence of thought units (subthemes that connect to the main theme) and the main themes (based on the hygiene or motivator factors). For example, in Question 1 (What attracted you to come to work in Saudi Arabia?), Participant 23 stated she spent money in the Philippines applying to the United States for work. Participant 23 is married and left two children in the Philippines to work and earn money in Saudi Arabia. The thought unit is contract and benefits and the main theme is salary. Unlike other countries that recruit FTNs, the benefits and contract of Saudi Arabia provide more than just a salary (the main theme). Vacation time, accommodation, health care, and transportation are some of the added incentives to work in Saudi Arabia. The hygiene factors and motivator factors of Herzberg’s (1966) two-factor theory provided the foundation of the main theme. Hygiene factors are the variables that explain the job context: status, security, relationship with subordinates, personal life, relationship with peers, salary, work conditions, relationship with supervisor, company policy and administration, and supervision. Motivator factors explain the job content: personal growth, advancement, responsibility, work itself, recognition, and achievement (Herzberg, p.18). A matrix helped in identifying the theme, the thought unit within that theme, and the participant quotes or comments. The general discussion identified hygiene factors present, hygiene factors not present, motivators present, and missing components that illustrated other variables of job satisfiers and job dissatisfiers not identified in Herzberg’s theory. The final task was to identify a profile. Herzberg’s research developed profiles of companies based on interviews with employees from that company. The current study
150 developed a profile on FTNs working and living experiences in Saudi Arabia and correlated the profile to the government and private organizations. The focus group sessions involved interviewing a heterogeneous group from different hospitals, different nationalities, different areas of work, different number of years in the Kingdom, and different years of experience in nursing. In analyzing the profiles of FTNs, the factors were ranked by frequency rather than importance, as developed in Herzberg’s theory. (Herzberg, 1974, p. 9). The matrices reflected the reordered frequency of factors or variables. The next section includes an exploration of the quantitative and qualitative data. Exploring the Quantitative Data The quantitative data analysis procedures involved three steps: (a) present descriptive statistics and analysis, (b) present bivariate statistics and analysis, and (c) describe the multiple regression procedure. In the first step, participant demographic descriptive analysis identified the variables and the description, code, sample size, and percentage (excluding the missing values). The following data provided a description of the survey (NWI-R, PES-NWI, and MBI) subscales: total sample size, minimum and maximum scores for statements, and the mean and standard deviation of the survey subscales. The next section includes a description of the sample demographic characteristics and survey subscales. Participant Demographics This section details the demographic characteristics of the participating FTNs. There was a 48% response rate based on 944 consents received and 453 surveys returned. The sample size (453) met the criteria for the study using Raosoft, Inc.’s online sample
151 size calculator with a confidence level of 95% and a 5% margin of error. Female FTNs were the largest group at 94.9%. Foreign-trained nurses in Saudi Arabia are younger than the average age of 45 years in North America (60.9% of participants were up to 35 years of age). A significant number of participants originated from Southeast Asia (92%). The Southeast Asian group consisted of participants from the Philippines, India, Indonesia, China, Pakistan, Bangladesh, and Malaysia. There are fewer Western nationalities in Saudi Arabia due to competition at home. Over 32% of the participants were Muslim. The majority of participants had a bachelor degree or higher (65.8%), which was consistent with the large number of Filipino participants. All nursing programs in the Philippines are baccalaureate level. Over 73% of the participants were registered nurses in their country of origin prior to 2001, which indicates Saudi Arabia is able to recruit experienced staff. Staff nurses accounted for 75.7% of participants. Charge nurses, supervisors, and head nurses comprised 24.3% of the participants, indicating they were taking patient assignments at the time of the study. Over 56% of the participants were from the private sector and over 43% of the participants were from the government sector Fifty-five percent of the participants had tenure in their current hospital up to 3 years, and over 44% of participants had tenure more than 3 years in their current hospital. Retention strategies should focus on the FTNs’ tenure. The percentage of participants on their first contract in Saudi Arabia was significant at 64.2%, which indicates individual hospitals are not doing enough to retain FTNs. Participants whose total length of time in Saudi Arabia was more than 3 years was significant at 55.7%, which indicated participant mobility between hospitals and jobs in Saudi Arabia. Foreign-trained nurses come back
152 to Saudi Arabia to work for many reasons, including a new contract at a new hospital, lack of jobs in home country, salaries in home country cannot provide for FTN and family, and family or friends in the Kingdom. Married participants made up 66.0% of the participants. Over 67% of participants were on a single contract, indicating married FTNs were on single contracts because of benefits and salary. Continuing education is a challenge for FTNs in Saudi Arabia. Hospitals do not provide reimbursement, foreign workers can only attend private universities, and FTNs have limited time to pursue an education when working 12-hour shifts and overtime. Over 83% of the participants were not pursuing a degree (see Appendix W for descriptive statistics and Appendix X for detailed descriptive statistics of interest in the study, including age, year qualified as a registered nurse, and nationality). Survey Subscales Reliability Aiken and Patrician (2000, Instrumentation Evaluation, Reliability section, ¶ 4) noted reliability for the NWI-R was Cronbach’s alpha .96. Budge et al.’s (2003, p. 262) study explored the nursing work environment in non-Magnet hospitals in New Zealand. Budge et al. used three of the four NWI-R subscales with reported Cronbach’s alpha of autonomy over practice .72, control over the practice setting .76, and nurse-physician relationships .83. Vahey et al. (2004, p. 11-59) explored nurses’ job satisfaction working in AIDS units in the United States. Vahey et al. used a composite measure from three NWI-R subscales and reported Cronbach’s alpha reliability as .96 for staffing adequacy, .88 for administrative support, and .87 for nurse-physician relationships. Cronbach’s alpha coefficient for the current study was .98.
153 Lake (2002, p. 180) adjudicated the PES-NWI instrument at Cronbach’s alpha .80 for hospital nurses. Gardner, Thomas-Hawkins, Fogg, and Latham (2007, p. 275) noted Cronbach’s alpha reliability ranged from .85 to .96 for nephrology nurses. Friese (2005, p. 767) studied oncology and nononcology nurses in Magnet and non-Magnet hospitals where the Cronbach’s alpha ranged from .79 to .84. The Cronbach’s alpha for the current study was .96. Maslach and Jackson (1981, p. 105) noted reliability for the instrument was .83 for frequency and .84 for intensity. Flynn and Aiken (2002, p. 70) explored the values and emotional exhaustion between collectivist and individualist nurses working in the United States. The Cronbach’s alpha reliability for emotional exhaustion was .89. Vahey et al. (2004, p. 11-59) investigated burnout for nurses working in AIDS units in the United States. The Cronbach’s alpha reliability coefficients for the MBI included emotional exhaustion .89, depersonalization .73, and personal accomplishment .76. Cronbach’s alpha for the current study was .86. Validity Table 3 presents means and standard deviations for the subscales of NWI-R, PESNWI, and MBI. The mean scores for autonomy over practice, control over practice setting, nurse–physician relationships, and organizational support ranged from M = 8.69, SD = 2.20 to M = 27.66, SD = 5.95. Nurse–physician relationships scored the highest mean of all the subscales at M = 8.69, SD = 2.20. The current study demonstrated validity when compared to the study by Budge et al. (2003). Budge et al. (p. 263) compared NWIR scores from a general hospital in New Zealand to NWI-R scores from Magnet and nonMagnet hospitals in the United States. The New Zealand data showed evidence of similar
154 scores compared to Magnet hospitals in the United States, with nurse–physician relationships scoring higher in the Budge et al. (p. 263) study. The autonomy over practice scores, control over practice setting, and nurse–physician relationships were similar to those reported by Budge et al. (p. 263) and the current study (M = 13.1, SD = 3.1; M = 17.3, SD = 4.4; and M = 8.7, SD = 2.1, respectively). Table 3 Survey Subscales N Min. Max.
M
SD
NWI Autonomy over practice
446
5
20 13.95 3.283
Control over practice setting
447
7
28 18.17 4.696
Nurse–physician relationships
447
3
12
Organizational support
446 10
40 27.66 5.946
Nurse participation in hospital affairs
438
9
36 22.99 6.099
Nursing foundations for quality of care
426 10
40 29.05 5.339
8.69 2.200
PES
Nurse manager ability, leadership, and support of nurses 439
5
20 13.48 3.263
Staffing and resource adequacy
440
4
16
9.78 2.885
Collegial nurse–physician relationships
440
3
12
8.61 1.992
Emotional exhaustion
384
9
54 26.82 10.849
Depersonalization
305
5
30 11.39 5.074
Personal accomplishments
417
8
48 33.81 8.809
MBI
155 The mean scores for nurse participation in hospital affairs; nurse manager ability, leadership, and support of nurses; and staffing and resource adequacy ranged from M = 8.61, SD = 1.99 to M = 29.05, SD = 5.34. Nursing foundations for quality of care and collegial nurse–physician relationships demonstrated higher mean scores at M = 29.05, SD = 5.34 and M = 8.61, SD = 1.99, respectively. The current study validated the data by comparing the results to Gardner et al.’s (2007) study. Gardner et al. (pp. 271-276) studied 199 nephrology nurses’ perception of Magnet qualities in 56 freestanding dialysis units using the PES-NWI survey. Nursing foundations for quality care; nurse manager ability, leadership, and support; and collegial nurse–physician relationships data resulted in significantly higher mean scores than the current study (M = 3.26, M = 3.28, and M = 3.22, respectively; the study reported the results of M by using the 1-4 on Likert scale). Nurses from both studies perceived that nursing foundation for quality of care and collegial nurse–physician relationships were evident in their workplace. The range of burnout in the MBI sores follows the range identified by Maslach et al. (1996, p. 6). The mean score for emotional exhaustion (M = 26.82, SD = 10.85) and depersonalization (M = 11.39, SD = 5.07) indicated the high range for burnout (≥27 and ≥10, respectively). The mean for personal accomplishment (M = 33.81, SD = 8.81) was on the border of high (≤33) to average (39-34) range for burnout. The results of the current study can be validated by Aiken, Clarke, Sloane, Sochalski, et al.’s (2001, p. 46) study. Nurses from four countries perceived high levels of burnout (29-43%) and German nurses perceived a low level of burnout (15%). Vahey et al. (2004, p. 11-62) discovered nurses perceived higher levels of burnout (emotional exhaustion and depersonalization) in poor work environment units (adjusted odds ratio .59 and .68, respectively) compared
156 to nurses who reported lower levels of burnout in better work environment units (adjusted odds ratio emotional exhaustion .35 and depersonalization .46). Burnout is a significant factor for FTNs working in Saudi Arabia. The next section describes Step 2 in the data analysis plan. Using inferential statistics, the next step included an exploration of relationships between the dependent variables and the independent variables. Bivariate Analysis Bivariate analysis using the t test examined the differences in the subscale scores among the different study groups. The study sample was grouped according to gender, age, nationality, religion, educational level, year registered, title, ownership, length of work at current hospital, first contract in Saudi Arabia, length of time in Saudi Arabia, worked in Kingdom prior to current contract, stay in Saudi Arabia (consecutive vs. nonconsecutive), married, contract type, family with nurse in Kingdom, and pursuing a degree. Appendix Y presents the bivariate statistics and t test to illustrate the significant differences between independent variables and dependent variables. For the purpose of the study, the significance threshold is set at p < .05 and p < .01. Newly registered nurses, those registered since 2001, reported a higher perception of autonomy over practice, control over the practice setting, and organizational support (M = 14.45 and p = .036, M = 19.15 and p = .005, and M = 28.74 and p = .012, respectively). Diploma or associate degree participants reported a higher perception of control over practice setting, nurse–physician relationships, and organizational support (M = 18.89 and p = .016, M = 9.03 and p = .016, and M = 28.77 and p = .003, respectively). Participants on a married contract identified a favorable perception of control over practice setting and organizational support (M = 18.95 and p = .024 and M =
157 28.61 and p = .034, respectively). This result indicated that newly registered nurses, FTNs with a diploma or associate degree, and FTNs on a married contract reported a higher perception of job satisfaction for the dependent variables in the NWI-R. Nurses pursuing a degree reported higher scores for nurse participation in hospital affairs and nurse manager ability, leadership, and support of nurses (M = 24.64 and p = .016 and M = 14.19 and p = .037, respectively). Government participants, nurses newly registered since 2001, and diploma and associate degree nurses had higher scores for nurse manager ability, leadership, and support of nurses (M = 13.88 and p = .024, M = 13.97 and p = .043, and M = 14.04 and p = .008, respectively). Diploma and associate degree nurses reported a higher perception of nursing foundations for quality of care and collegial nurse–physician relationships (M = 29.75 and p = .050 and M = 8.88 and p = .041, respectively). Overall, newly registered nurses, FTNs with a diploma or associate degree, FTNs who work in the government sector, and FTNs pursuing a degree reported a higher perception of job satisfaction for the dependent variables in the PES-NWI. Newly registered nurses and FTNs with a diploma or associate degree share a similar high perception of job satisfaction between the study’s two dependent variables. A high degree of FTNs with baccalaureate degree or higher were associated with emotional exhaustion (M = 27.63 and p = .014). Foreign-trained nurses working in the private and government sectors were associated with a high degree of depersonalization (M = 11.91 and 10.76, respectively, and p = .049). Muslim FTNs, FTNs with diploma or associate degrees, staff nurses, and FTNs pursing a degree had low scores on personal accomplishment (M = 32.43 and p = .032, M = 32.24 and p = .014, and M = 30.40 and p < .001, respectively), indicating a high degree of burnout.
158 Appendix Z is a correlations matrix that illustrates the relationship between the NWI-R, PES-NWI, and MBI subscales. The correlation findings at the two-tailed p < .01 and p < .05 significance levels illustrated the strongest correlation was between control over practice setting and organizational support (r = .898). This result indicated 81% of the participants who reported more control over their practice setting had a more favorable perception of organizational support. This finding is in keeping with the bivariate results where newly registered nurses, FTNs with a diploma or associate degree, and FTNs on a married contract reported a higher perception of job satisfaction in the dependent variables of control over the practice setting and organizational support. Similarly, participants who reported more autonomy over practice and nurse–physician relationships had a more favorable perception of organizational support (r = .867, r² = 75%, and r = .764, r² = 58%, respectively). Fifty-seven percent of the participants reported satisfaction in nurse participation in hospital affairs when correlated to nursing foundations of quality care and nurse manager ability, leadership, and support of nurses (r = .760 and r = .754, respectively). This result corresponds to the bivariate analysis in which FTNs pursuing a degree had a higher perception of job satisfaction in the dependent variables nurse participation in hospital affairs and nurse manager ability, leadership, and support of nurses. Participants reported job satisfaction in control over the practice setting when correlated to staffing and resource adequacy (r = .768, r² = 59%). The finding indicated that when staffing resource adequacy increase, so does control over the practice setting. Foreign-trained nurses on a married contract reported a higher perception of job satisfaction for control over the practice setting and staffing and resource adequacy in the bivariate and multiple
159 regression analysis. Participants reported a correlation between nurse–physician relationships and collegial nurse–physician relationships (r = .717, r² = 51%). This result indicated that when nurse–physician relationships were positive, the collegiality between the team was also positive. There was a slight negative relationship between staffing resource and adequacy and emotional exhaustion (r = -.300). This finding is of little value in predicting any causal effect. The next section describes the results from the multiple regression analysis. Multiple Regression Analysis The third step in the data analysis plan was multiple regression statistics. Multiple regression using ANOVA examined the effects of demographic data and work environment factors on the NWI-R, PES-NWI (job satisfaction), and MBI subscales (burnout). The SPSS 12.0 software program performed backward stepwise multiple regressions that selected “the combination of independent variables with the most predictive power” (Polit & Beck, p. 519), or a p value less than .10. The data produced by multiple regression examined the association or relationship between the independent variables on the dependent variable, the direction of the difference, and the size of the difference (or predication). Appendix V illustrates the coding of the variables used in the multiple regression analysis. The statistical method used the variables coded as 1. The independent demographic variables were gender (female), age (up to 35 years), nationality (SE Asian), religion (Muslim), education level (baccalaureate degree or higher), year registered (2001 and after), years in current hospital (up to 3 years), first contract in Kingdom (yes), years working in the Kingdom (up to 3 years), stay in Saudi Arabia
160 (consecutive), married (yes), family with nurse (yes), and continuing education status (yes). The independent work environment factors for analysis were title (staff nurse), ownership (private), contract type (married), and number of nurses per 100 beds. The dependent variables for hospital characteristics (job satisfaction) included autonomy over practice; control over practice setting; nurse–physician relationships; organizational support; nurse participation in hospital affairs; nursing foundations of quality care; nurse manager ability, leadership, and support of nurses; staffing and resource adequacy; and collegial nurse–physician relationships. The dependent variables for burnout were emotional exhaustion, depersonalization, and personal accomplishment. Multiple regression using correlation statistics examined burnout associated with the demographic factors, the work environment factors, and the subscales of the NWI-R and PES-NWI (variables linked to job satisfaction). The results in Appendix AA demonstrated that the regression models using demographic and work environment variables had a wide range of prediction power for job satisfaction (.07 to 7.3%). Foreign-trained nurses newly registered after 2001 had a positive impact on the following dependent variables: control over the practice setting, nurse–physician relationships, organizational support, and staffing and resource adequacy. This finding is in keeping with the bivariate analysis of newly registered FTNs reporting a higher perception of job satisfaction in control over practice setting and organizational support. Foreign-trained nurses currently pursuing a degree had a positive relationship with nurse participation in hospital affairs. This result is consistent with the bivariate analysis. Foreign-trained nurses working on a married contract reported a
161 positive relationship with staffing and resource adequacy. This finding is in line with the bivariate analysis. Foreign-trained nurses’ length of work at current hospital up to 3 years had a negative impact on nurse–physician relationships. Foreign-trained nurses with a baccalaureate degree or higher had a negative impact on control over the practice setting, nurse–physician relationships, and organizational support. The bivariate analysis supported this finding. The result indicates a positive correlation between higher education and job dissatisfaction for control over the practice setting, nurse–physician relationships, and organizational support. Foreign-trained nurses with a baccalaureate degree or higher predicted the absence of nurse manager ability, leadership, and support of nurses. This finding was not significant in the bivariate analysis. Foreign-trained nurses working in the private sector had a negative relationship with nursing foundations for quality of care; nurse manager ability, leadership, and support of nurses; and staffing and resource adequacy. Foreign-trained nurses working in the private sector was an indicator for the lack of nursing foundations for quality of care; nurse manager ability, leadership, and support of nurses; and staffing and resource adequacy. The number of nurses per 100 beds had a negative impact on autonomy of practice; control over the practice setting; organizational support; nurse participation in hospital affairs; and nurse manager ability, leadership, and support of nurses. The results in Appendix AA demonstrate that the regression models using demographic and work environment variables had a wide range of prediction power for burnout (2.2 to 7.5%). Female FTNs with a baccalaureate degree or higher reported a positive impact on the dependent variable emotional exhaustion. Foreign-trained nurses
162 working in the private sector had a positive relationship with depersonalization. Foreigntrained nurses with a baccalaureate degree or higher reported a positive relationship with personal accomplishment, whereas FTNs currently pursuing a degree reported a negative relationship with personal accomplishment. Foreign-trained nurses pursuing a degree indicated lower feelings of competence and lack of achievement and success in their work, and a high degree of burnout. This finding is in keeping with the bivariate analysis. For the effect of job satisfaction variables (NWI-R and PES-NWI subscales) on burnout, further regression models produced data that had a wide range of prediction power for burnout (5.9 to 18.1%). There was a negative relationship between autonomy and emotional exhaustion. There was a negative relationship between organizational support and depersonalization. There was a positive relationship between nurse participation in hospital affairs and emotional exhaustion. There was a negative relationship between staffing and resource adequacy and emotional exhaustion. The next section includes an examination of the research hypotheses. Research Hypotheses To view the significance of the survey data and to test the hypotheses, Appendixes CC and DD present a schematic of the significant findings from the bivariate analysis and multiple regression analysis. This section provides a summary of the findings in order to test the hypotheses. Nine subscales (NWI-R and PES-NWI) that described the dimensions of a professional work environment explored the hospital characteristics (job satisfaction) for FTNs living and working in Saudi Arabia. Three subscales from the MBI instrument explored burnout of FTNs in Saudi Arabia. The hypotheses were as follows:
163 1. There is no association between selected demographic variables and work environment variables and the NWI-R subscale scores among FTNs working in Saudi Arabia. (Null hypothesis) There is an association between selected demographic variables and work environment variables and NWI-R subscale scores among FTNs working in Saudi Arabia. (Directional hypothesis) 2. There is no association between selected demographic variables and work environment variables and the PES-NWI subscale scores among FTNs working in Saudi Arabia. (Null hypothesis) There is an association between selected demographic variables and work environment variables and PES-NWI subscale scores among FTNs working in Saudi Arabia. (Directional hypothesis) 3. There is no association between selected demographic variables and work environment variables and MBI subscale scores among FTNs working in Saudi Arabia. (Null hypothesis) There is an association between selected demographic variables and work environment variables and MBI subscale scores among FTNs working in Saudi Arabia. (Directional hypothesis) Education level was associated with six subscales out of nine in hospital characteristics and two subscales out of three for burnout. Year registered was associated with six subscales in hospital characteristics. The number of nurses per 100 beds was associated with five subscales in hospital characteristics. Ownership was associated with three subscales in hospital characteristics and one subscale for burnout. Foreign-trained
164 nurses pursuing a degree were associated with three subscales in hospital characteristics and one out of three subscales for burnout. Contract type was associated with three subscales in hospital characteristics and one subscale for burnout. Title was associated with two subscales out of nine in hospital characteristics and one subscale for burnout. Work in Saudi Arabia prior to current contract was associated with one subscale for hospital characteristics. Religion was associated with one subscale for hospital characteristics and one subscale for burnout. Gender and age were associated with two out of three subscales for burnout. Length of work at current hospital was associated with one subscale in hospital characteristics and one subscale for burnout. Stay in Saudi Arabia was associated with one subscale out of nine subscales in hospital characteristics and one subscale out of three for burnout. These results indicated an association between selected demographic variables and work environment variables and the NWI-R, PESNWI, and MBI subscale scores. The null hypotheses are rejected and the directional hypotheses are accepted. 4. There is no association between selected demographic variables, work environment variables, NWI-R subscale scores, and PES-NWI subscale scores and MBI subscale scores among FTNs working in Saudi Arabia. (Null hypothesis) There is an association between selected demographic variables, work environment variables, NWI-R subscale scores, and PES-NWI subscale scores and MBI subscale scores among FTNs working in Saudi Arabia. (Directional hypothesis) The following variables were associated with two out of three subscales for burnout: education, ownership, and worked in Saudi Arabia prior to this contract. The following variables were associated with one out of three subscales for burnout: gender,
165 title, length of work at current hospital, and currently pursuing a degree. Autonomy over practice, organizational support, nurse participation in hospital affairs, nursing foundations for quality of care, and staffing and resource adequacy were associated to two out of three subscales for burnout. The results indicated as association between selected demographic variables, work environment variables, the NWI-R subscale scores, and the PES-NWI subscale scores and MBI subscale scores. The null hypothesis is rejected and the directional hypothesis is accepted. The purpose of the study was to examine the demographic variables, work environment variables, hospital characteristics (linked to job satisfaction), and burnout among FTNs living and working in Saudi Arabia. The significant findings at p < .01 included the following: 1. Foreign-trained nurses with a diploma or associate degree had a higher perception of job satisfaction for organizational support and nurse manager ability, leadership, and support of nurses (bivariate analysis). 2. Foreign-trained nurses registered after 2001 scored higher for job satisfaction on control over the practice setting (bivariate and regression analysis). 3. Foreign-trained nurses on a married contract had a higher perception of job satisfaction for staffing and resource adequacy (regression analysis). 4. Foreign-trained nurses with baccalaureate and higher degrees had a lower perception of job satisfaction for nurse–physician relationships and organizational support (regression analysis). 5. Foreign-trained staff nurses had a lower perception of job satisfaction for nurse manager ability, leadership, and support of nurses (regression).
166 6. The number of nurses per 100 beds (staffing levels) indicated a lower perception of job satisfaction with autonomy over practice, control over the practice setting, and organizational support. 7. Foreign-trained nurses with a baccalaureate and higher degree had higher scores for emotional exhaustion (regression analysis). 8. Foreign-trained nurses with baccalaureate and higher degrees had feelings of personal accomplishment (regression analysis). 9. Foreign-trained nurses who worked in the Kingdom prior to the current contract reported lower emotional exhaustion (regression analysis). 10. Foreign-trained nurses pursuing a degree had a lower degree of personal accomplishment (bivariate and regression analysis). 11. Foreign-trained nurses had higher scores for burnout in the following hospital environment variables: autonomy over practice, organizational support, and staffing and resource adequacy (regression analysis). 12. Foreign-trained nurses who scored higher on autonomy over practice, control over the practice setting, and nurse-physician relationship had a more favorable perception of organizational support (correlation analysis). 13. Foreign-trained nurses who scored higher on nurse participation in hospital affairs had a more favorable perception of nursing foundations for quality of care and nurse manager ability, leadership, and support of nurses (correlation analysis). 14. Foreign-trained nurses who scored higher on control over the practice setting had a more favorable perception of staffing and resource adequacy (correlation analysis).
167 Appendixes JJ, KK, LL, MM, and NN provide a brief summary that identified the significant relationships between independent and dependent variables as part of the hypotheses testing. See Appendixes Y, Z, and AA for detailed numeric statistical values for the hypotheses testing. The next section includes an exploration of the qualitative findings. Exploring the Qualitative Data With the nursing shortage high on Saudi Arabia’s priority list, retention of FTNs is a logical solution. The current nursing shortage is unprecedented. Countries have solved previous shortages by hiring foreign workers or increasing enrollment in universities. As discussed in chapter 2, there are no easy remedies for the current nursing shortage. Foreign-trained nurses represent the solution to the global nursing shortage for Saudi Arabia. This workforce is the solution only if FTNs decide to stay and work in Saudi Arabia. Saudi Arabia presents a unique personal and professional challenge for FTNs. This study involved examining those challenges by asking the FTNs their opinions about living and working in the country. The study used grand tour questions to encourage discussion and interaction among participants. A grand tour question in qualitative research is defined as “a broad question asked in an unstructured interview to gain a general overview of a phenomenon, on the basis of which more focused questions are subsequently asked” (Polit & Beck, 2004, p. 719). The first questions generated commonalities between the groups. The questions were nonthreatening and meant to gain insight into the worldview of each FTN. The sessions were a venue for the FTNs to share information. The facilitators felt the groups needed to talk to someone who could pass on the message.
168 The following paragraphs present the exploration, description, and analysis of the focus group data collected during the study. Specific areas addressed were participant demographic information and questions that describe participants’ pull factors to Saudi Arabia (Question 1), issues FTNs face living and working in Saudi Arabia (Question 2), and hygiene-motivator factors contributing to job satisfaction or lack thereof (Questions 3 and 4). The discussions generated several hygiene and motivator factors in one participant conversation. The analysis extracts the significant factors for analysis but leaves the conversation as a whole to allow the reader to gain insight into the participants’ issues and concerns. Demographic Information To create a relaxed atmosphere, participants volunteered personal information. Participants stated their names, nationality, the hospital where they worked and their location, the number of years they had been in the Kingdom and whether they were consecutive or nonconsecutive years, the hospital unit or area of employment, and whether they had future plans to migrate to another country for employment (see Appendix BB for demographic characteristics). The participant demographics of gender, nationality, hospital type, and years in the Kingdom represented a cross-section of FTNs living and working in Jeddah and Makkah, Saudi Arabia. Questions 1 and 2 were grand tour questions to open the discussion and encourage dialogue among the participants. Questions 3 and 4 explored Herzberg’s theoretical framework for job satisfaction and job dissatisfaction. The reported percentages for Questions 1 and 2 revealed the number of participants who spoke to the issue, while the
169 reported percentages for Questions 3 and 4 revealed the frequency of participant stories and not the significance of the stories. Question 1: What Attracted You to Work in Saudi Arabia? Salary Salary was the overwhelming pull factor for 80% of the participants working in Saudi Arabia and this pull factor was representative of participants from the Middle East and Southeast Asia (see Appendix CC for the summary of participant stories and nationalities for Questions 1 and 2). Participants stated that salaries are lowest in the Far East and Middle East. Lack of jobs in the FTNs’ home country related directly to providing an income for their families. Participant 14 explained her situation: In this way [work in Saudi Arabia], I want to stay better. Same like my colleagues [family in Pakistan], very difficult education and food. I want my children to eat nicely, wear nicely, go nicely school. I have to suffer. Salary different, I cannot make that much in Pakistan. The contract and benefit incentives offered by the hospitals in Saudi Arabia were strong pull factors for FTNs. Personal debt or school loans factored into the decisions of 12% of the participants who now work in Saudi Arabia. Participant 3 explained, I had a lot of personal debt, so it took me 6 months to get rid of that, and just as I came to SA [Saudi Arabia], my mother and I bought a house together, a really old house that is falling apart so we have to renovate that. Salary was also a hygiene factor absent for FTNs. Herzberg maintained that salary must be present to maintain a “certain level of employee motivation” (Usugami & Park, 2005, p. 281). When FTNs are unsatisfied with their salaries, they will look elsewhere
170 such as another hospital in the Kingdom or an opportunity in another country. The Arab News (2008, ¶ 1-8) reported the MOH would increase salaries for health-care workers in the private sector to be competitive with the military and specialist hospitals. The MOH hospitals would receive an adjustment in salaries as well. The Arab News report stated a study by the MOH concluded the move to raise salaries would attract more local and foreign workers. There was no official news on the salary increases on the MOH Web site. The participants stated they heard the news through the hospital but the hospitals had not yet delivered the increase. The failure to follow through on salary increases created dissention and distrust among 20% of the FTN participants. For some, salary had been a driving force in consideration of other employment opportunities. As an example, Participant 24’s husband moved to Qatar where salaries are high and she is considering the move to Qatar. Participants stated the cost of living is rising in Saudi Arabia and they do not see the benefit of the salaries. Participant 18 stated her hospital has not given her an evaluation or increment in salary for 10 years. She stays in Saudi Arabia because the work environment is good at her hospital and she receives overtime pay. The work environment is difficult and 36% of the participants stated they are not receiving monetary compensation for the extra workload. Thirty-two percent of the FTNs admitted they make more money in Saudi Arabia than in their own country. It is not an easy decision for FTNs to leave Saudi Arabia. When an FTN finishes a contract, a letter called a no objection certificate (NOC) from the employer means the hospital does not have any objection to the FTN coming back to the Kingdom and working in another hospital. If an FTN does not receive the NOC, he or she must stay out of the Kingdom for 2 years. Policies and practice differ between hospital sectors. It is not the policy of the
171 government hospitals to give out NOCs at the end of contracts for FTNs (A. Harun, personal communication, July 17, 2008; S. Myers, personal communication, July 18, 2008; R. Anderson, personal communication, July 18, 2008). Private hospitals do not award NOCs at end of contract (G. Gaber, personal communication, July 17, 2008). One hospital (not in the study) awards NOC after 3 years of service (I. Rondeau, personal communication, July 18, 2008). Not having the NOC restricts the FTN from employment in Saudi Arabia for 2 years. Religion The second pull factor for 40% of the participants in coming to work in Saudi Arabia was religion, a hygiene factor. Participants stated Saudi Arabia is the home of Islam, and as Muslims, the opportunity to work in Saudi Arabia allowed them to earn money for family and live in an environment that shares their religious values and beliefs. Participants stated it is difficult to travel to Saudi Arabia to perform Hajj and Omrah when living overseas. The cost of attending the religious ceremonies is exorbitant for some families. Stationed in Jeddah or Makkah, FTNs have the opportunity to practice their religion and obtain visas for their families to visit to perform the religious ceremonies. Participant 9 chose Saudi Arabia because it is home of the two Holy cities. Participant 16 stated her primary reason for coming to Saudi Arabia was to earn money and the second reason was she wanted to visit the Holy Mosque. Participant 20 worked in Saudi Arabia prior to this contract and converted to Islam. Participant 20 stated she is a better nurse now after converting and feels that the patients and her colleagues would agree. Participant 20 stated, “Even the bad days I forget because at the end of the day there are more rewarding things and good things.”
172 Experience, Knowledge, and Personal Growth The third pull factor to work in Saudi Arabia initially for 36% of the participants was to gain experience, to increase knowledge, and for personal growth (a motivation factor). Participant 6 stated, “I went abroad to find myself, to have that independence, to start on my own.” Participant 5 stated, “To get more knowledge, this would improve ourself.” Participant 11 stated, “My experience all polyclinic; this is my first time for me in Jeddah in a hospital.” For some, experience is not enough to keep FTNs working in Saudi Arabia. Participant 20 stated, “For career advancement in my country, you think that going abroad to Saudi Arabia for advanced technology. I went to a hospital that had all the old equipment.” Participant 5 stated there is no difference now in work experience between her country and Saudi Arabia. Participant 8 stated that his move from a surgical ward to an outpatient department has caused him to lose his nursing skills Participant 8 is going back to his country because he is losing clinical skills and he lacks a challenge in the job. In summary, salary, religion, and experience and personal growth were strong pull factors for participants to work and live in Saudi Arabia. Remuneration was the strongest pull factor for most participants (80%), with religion being the second pull factor for Muslim participants (40%), and gaining experience, knowledge, and personal growth was the pull factor for 36% of the participants. What pulls participants to work in Saudi Arabia can also push them away. The push factors identified by the participants were that they work in Saudi Arabia for a specified contract time. The workload is often heavier than for noncontract workers with no added compensation. The cost of living is increasing in Saudi Arabia without a requisite increase in salary. Other opportunities
173 allow participants to make a better life for themselves and their families (see Appendix DD for the participants’ full discussion of Question 1). Question 2: What Are the Issues That You Deal With Working in Saudi Arabia? Participants identified many issues related to working in Saudi Arabia. Participants consistently addressed six issues they viewed as relevant: work conditions, personal life, recruitment practices, salary, company policy and administration, and registration and licensure (see Appendix EE for the participants’ full discussion of Question 2). Work Conditions The hygiene factor, work conditions and multiple thought units (or subthemes) were clear issues for 60% of participants. The thought units described under work conditions included staffing (24%), organizational culture (20%), Saudization (16%), standards of nursing care (16%), subcultures (12%), experience and personal growth (12%), communication and language barrier (8%), recognition (from patients; 4%), job satisfaction (4%), professionalism (4%), and lack of appreciation (for commitment to the job; 4%). For brevity, the following paragraphs explore the thought units of staffing, organizational culture, Saudization, standards of nursing care, and subcultures. The thought unit staffing was a major concern for 24% of the participants. The staffing issues experienced by the participants, although prominent at varying levels, were significant and outlined several patient safety issues. Some of these levels included increased physical workload due to high nurse attrition and lower nurse recruitment rates, nonnursing personnel functioning as nurses, scheduling practices for religious holidays, and lack of experience among new FTNs. For example, Participant 23 noted the
174 occurrence of a registered nurse shortage due to high attrition rates in her hospital, while nurse aides are functioning as registered nurses in Participant 1’s hospital. Two participants agreed their workloads were heavier and their work breaks shorter because of limited support staff availability on the units and the necessity of performing nonnursing activities. Holidays and vacations were especially difficult for Participant 2 as there were often an insufficient number of nurses available to cover units. Several participants shared that their workloads are so heavy that one shift will often leave work for the next shift to complete. Participant 3 stated, “You cannot provide holistic care for patients [because of staffing].” Organizational culture as a thought unit has a connection to the work conditions factor facing 20% of the participants. As an overriding definition, organizational culture is the “set of values, customs, and beliefs people have in common with other members of a social unit (e.g. a nation)” (Greenberg & Baron, 2000, p. 17). Hospitals in Saudi Arabia combine collectivist cultures, individualist cultures, and multicultural societies (see Cultural Diversity section in chapter 2). Such diversity in the hospital setting makes organizational cultures unique in every organization. The employees working within the organization best described organizational culture. One participant explained, I found it very, very different this hospital. This is the harshest nursing environment I’ve ever been in. I find it very Draconian. Speaking for my own hospital, systems are bureaucratic, it is a culture of blame, everybody is blaming, they don’t look at what part of the systems enabled that person to make a mistake.
175 Participant 19 was a nurse supervisor in her country of origin and worked as a staff nurse for 10 years at a government hospital in Saudi Arabia. She explained that her current private hospital did not recognize her prior knowledge and expertise: “[Private hospitals] are patronizing. If you are a newcomer, you are down, you are a neophyte. I will be humiliated and feel my self-esteem low.” One participant explained the nursing administrators are from two main nationalities in her hospital and work “is like being in a forest with lots of snakes.” The participant believes there is no one to trust, there is no organization to the department, and the administrators make the work more difficult. Two participants in private hospitals lamented that the organizational culture in their work environment assumed the patient was always right. That is, administrators regularly sided with the patients and their families in disputes between them and the FTNs. In an example of an extreme organizational culture behavior, Participant 18 noted the new medical director in her hospital “calls some nurses rubbish, or are you mentally retarded, or stupid?” The challenges of Saudization in the workplace affected the work of 16% of the participants. The participants noted nursing departments face the challenge of training Saudi nursing students from diverse backgrounds in an effort to combat the current nursing shortage. The FTNs assume additional responsibility by supervising nursing students who have different levels of knowledge and practical experience from various degree-conferring programs. For example, one participant shared her anger and sorrow when she mentored a third-year nursing student who refused to touch a patient despite the participant’s encouragement. The student, though slated to graduate as a nurse in 3 years, had never bathed a patient during her program of study and seemed, according to the
176 participant, to be disinterested in ever doing so. The participant described her experiences with Saudi nurses: I have met a couple of Saudi nurses that I have a lot of respect for. They take a lot of pride [in their work and patients]. But when you look at them [older nurses] and the new ones [students], they are completely different. Participant 5 concurred with this assessment, stating the Saudi nursing students are unqualified in both practical (nursing skills) and communication (English language) competencies. Participant 1 noted, It is better for Saudi nurses to be promoted to higher positions so the workload would be less for the FTN. The Saudization program for nursing needs to be evaluated at the unit level: the language difficulties, the work habits, the training, the work ethics, and more. Standards of nursing care were the fourth thought unit affecting work conditions according to 16% of the participants. The issues surrounding standards of care included a nurse aide performing dialysis access (Participant 1). The current practice of hiring new graduate FTNs for government and private hospitals places additional challenges on the hospitals. The new FTN graduates work as assistant nurses on the units. They train for 2 years and then write the Saudi Council nursing exam to qualify as a registered nurse. With MRQP standards and accreditation, the paperwork and documentation increased significantly for the nurses. Documentation takes 90% of Participant 24’s time at work, while the other 10% is for patient care. One focus group introduced and discussed at length subculture as a thought unit (subtheme to work conditions), which affected 12% of the participants. Subcultures are
177 “smaller cultural groups within larger, primary cultural groups, each of which may have its own well-defined culture” (Greenberg & Baron, 2000, p. 17). Two specific topics emerged from subcultures: crab mentality and the mafia. The crab mentality appears to be typical in the Filipino FTN community. One Filipino participant noted, The shameful part of us Filipinos is the crab mentality and we cannot remove this one from our culture. If you enter a place or join a job and your supervisor will feel that you know something or can do something better than her, she will not accept that fact. She will do everything to put you down. They are afraid. Participant 23 explained the crab mentality as follows: You know the crab when it is put in a pail and one of them wants to crawl up, the other crabs will push it back down. You have heard of the crab bite. They will pull each other down; nobody will get up. The mafia organizes itself from different cultural groups within the organization. One participant resigned from her previous position at a government hospital, as she was afraid of her group on the unit. The participant reflected and explained her experience: They [the mafia] are coercing day-to-day. Like when you lose your job, they are going to get some money from the management. The mafia behaves in such a way that they run you out the door as if they have been promised some percentage of your salary if you should be fired. They work on you so you will leave. You can actually feel that. When you are on duty with the mafia, my God, it is so draining. Personal Life The second issue identified by 56% of the participants was Herzberg’s personal life hygiene factor. Foreign-trained nurses experience culture shock as newcomers to
178 Saudi Arabia. Culture shock is “the tendency for people to become confused and disoriented when adjusting to a new culture” (Greenberg & Baron, 2000, p. 17). The first phase of culture shock lasts a few months and includes optimism and excitement about the new culture. After several months, individuals enter a second phase of culture shock where they experience frustration and confusion while attempting to learn about and adjust to their new cultural surroundings. This is the low point in the process that should dissipate after 6 months. A sense of acceptance and satisfaction occurs then for the individuals who acclimatize to the new environment (Greenberg & Baron, p. 17). Foreign workers in Saudi Arabia quickly realize that to some extent the country restrictions control their freedom, regardless of gender. Although men move around more freely in the country, rules and regulations apply to both genders of foreign workers equally. Unless FTNs live in the community with family, they live in hospital compounds where rules and regulations vary from strict to more lenient. The rules vary among hospital sectors. Buses transport FTNs to work and for shopping. Some hospitals have social clubs that allow FTNs a diversion from the compound setting. Over time, FTNs adjust to the lifestyle, culture, and norms of the country. The salary provides the means to support a family at home and the benefits for some (for example, accommodation) allow the FTN to live in some comfort. Married FTNs can work on married or single contracts, which offer different options and opportunities. Participants stated that having family and friends (thought unit) in the Kingdom was the most important issue for their personal life (hygiene factor). Participant 2 brought her family to Saudi Arabia for a better life and paid for her husband’s visa so they would be together. Her husband has not found employment but they are happy being together as
179 a family. Participant 4 and her husband are both nurses who elected to come on a single contract as the benefits allow more frequent trips home. Participants have returned to work in Saudi Arabia after going home to attend to family issues. One participant is in Saudi Arabia for the second time. She applied to a particular hospital because the director of nursing is from her country and she knows people working there. Participant 9’s family visited twice on a hospital-provided family visa. Recruitment Practices The third factor that 48% of the participants identified as an issue in Saudi Arabia was unscrupulous and onerous recruitment practices and processes. Extracted as a hygiene factor, recruitment practices involve the customer service practices of hospital administrations and recruitment agencies. Participants shared their experiences about recruitment practices from their country. Recruiting practices vary from hospital to hospital in Saudi Arabia and from agency to agency. A contract signed in the country of origin is not always the same contract when the FTN arrives to work in Saudi Arabia. Participants stated the agency misled them in contract issues that included salaries, airfare tickets, differences between single and married contracts (in terms of benefits), costs of a work visa, costs of Iqama, and recruitment placement fees. Iqama is the Arabic word for stay or residence. Expatriates receive an Iqama that identifies a foreign worker who can legally stay to work for an extended period. There is another Iqama for expatriates who are on a short work stay visa. In general, there are two types of Iqama: worker or dependent. The employer is the sponsor for a worker Iqama. The employee can only work for the sponsor. Expatriates
180 with valid Iqamas can sponsor their dependents to live with them but the dependents cannot work legally (K. Hijjazi, personal communication, April 16, 2008). Participants faced reality on arrival in Saudi Arabia when their human resource department distributed a new contract in Arabic outlining benefits and responsibilities. When Participant 6 questioned the process of signing a document she could not read, the human resource personnel told her that if she did not sign, the hospital would hold her salary. Contracts vary from hospital to hospital and sector to sector. Some private hospitals require a 5-year contract, while others offer 2-year contracts. Some government hospitals pay the full cost of the Iqama depending on the point of hire. Some hospitals offer some nationalities yearly tickets home. Saudi Arabia is the country of choice in terms of expeditious employment, especially if you are Filipino and Muslim. Saudi Arabia also has more hospitals than other Arab countries such as United Arab Emirates and Bahrain that makes the process of employment easier. Salary Thirty-two percent of the participants admitted they would move to a new hospital, new country, or even return home altogether if the salary and benefits were better than those provided in their current positions. As reported earlier, Participant 24 was thinking of joining her husband in Qatar after the purported 10% salary increase did not come to fruition. For the government FTNs, there was no official notice of the salary increase, only information spread by word of mouth from other colleagues. Participants were angry when they heard that not everyone would receive the raise. The fact that specific nurse categories received the increase in pay caused dissention and distrust with hospital management. Participants also feel they are working to their maximum ability
181 without compensation for the extra effort. Participant 18 has a friend that wanted to go home at the end of her contract and hospital administrators negotiated a new contract with her to encourage her to stay. The hospital administrators offered her friend more salary and she decided to stay. The negotiation factor is salary and benefits. Company Policy and Administration Continuing education and training was a concern for 24% of the FTNs. Hospitals in Saudi Arabia have varying levels of nursing education departments. In a small private hospital, a nursing supervisor may also function as the nurse educator whereas in larger organizations, the nursing education department has qualified nurse clinicians and educators. The orientation program is evidence of the quality of nursing education and how well new FTNs assimilate to their work area. Nursing education is responsible for assessing nurse competencies prior to hands-on care. When nursing departments do not invest in the orientation program and competency assessment and training, FTNs are vulnerable to errors and occurrences. Two participants happily stated they are able to attend in-hospital education offerings and monthly symposiums presented through the Jeddah Nurses Executive Forum. One participant stated she must obtain permission from the nursing education department to attend any outside symposiums or lectures. Two government sector participants added there are no nursing programs for mentoring or training new hires to the hospital. The participants acknowledged, “You train yourself.” There are challenges to continuing education through nursing degrees in Saudi Arabia. Non-Saudis cannot attend Saudi universities, Saudi private universities are expensive, there is no reimbursement from the employer, and hospitals do not always provide Internet services for FTNs to participate in long-distance or online nursing
182 programs. Participant 13 commented on continuing her education where a master’s degree in nursing would provide more money and opportunities, but she lacks the time to continue her education when working 12-hour shifts sometimes 6 days a week to compensate for the ongoing shortage of nurses in her hospital. Registration and Licensure Saudi registration and licensure is mandatory for FTNs working in Saudi Arabia. Twenty percent of the participants reported being frustrated with the application process to obtain a license, the time it takes to get the license from the Saudi Nursing Council, the nursing title, the number of continuing education units, and the cost. The title on the Saudi license reflects the Saudi Nursing Council’s assessment of the nursing education program in the FTN’s country of origin. For example, all colleges in the Philippines offer baccalaureate programs. Despite the baccalaureate degree being the degree for entry to practice in many Western countries, the Saudi license labels Filipino nurses as technical nurses, the lowest level in the hierarchy of nursing positions. Although Filipino nurses have higher than average professional degrees, the country’s grade-school system terminates at Grade 10 rather than at Grade 12 (S. Abu Zinadh, personal communication, May 16, 2007). Thus, the Saudi Nursing Council considers the first 2 years of a university program in the Philippines as the last 2 years of high school in other countries and essentially penalizes nurses for 2 years of education. Another discrepancy for FTNs was the 60 continuing medical education units required for a Saudi nurse license renewal every 3 years. One participant raised concern about how she would be able to acquire the necessary continuing medical education units when she could not attend symposiums in the community or go to hospital in-services.
183 Participant 1 noted, “We are deprived of education,” despite the costs associated with license acquisition and renewal. Participant 18 stated her hospital deducted money one month from everyone’s paycheck without an explanation. When the FTNs asked why, the finance department explained it was for the Saudi license. The FTNs were upset that the hospital did not tell them in advance. The recruitment process is the first step on the journey to Saudi Arabia for all FTNs. The experience of the recruitment process for 48% of the participants either enhanced their stay or placed added stress on other issues to follow, such as salary and benefits (for 32% of participants). Expectations of life and work in Saudi Arabia change after the honeymoon phase of culture shock. Reality settles in with the uniqueness of working in Saudi Arabia with participants reporting 124% frequency of work conditions stories and 64% frequency of personal life stories. The added pressures of registration and examinations (20% of participants) without continuing education and training in the hospital (24% of participants) are added stressors when trying to settle into a new culture without support systems. Questions 3: Describe to Me a Time When You Felt Exceptionally Happy at Work Questions 3 and 4 are at the heart of Herzberg’s motivation to work theory (motivation-hygiene theory). A semistructured interview format enabled the participants to express and discuss issues relevant to their experiences in Saudi Arabia in fuller detail. Participants recalled many stories that reflected both positive and negative experiences at work. Herzberg allowed each participant the “fair freedom to select the kinds of events he wanted to report to us” (Herzberg, Mausner, & Snyderman, 2007, p. 16). Participants recalled several stories within a hygiene or motivator factor (for example, recognition
184 from patients and supervisors). Some participants expressed two factors within one story (for example, relationship with supervisor and security). The number of participant stories made up the frequency and percentage scores (see Appendix FF for the summary of the participant stories and nationalities for Questions 3 and 4). Recognition Fourteen participants reflected on 18 stories (72%) that illustrated recognition (motivator factor) from supervisors, patients, and physicians as the time when they felt exceptionally happy at work. Recognition from supervisors was most significant for 32% of the participants’ stories. Participant 5 stated his nursing director is a strong and loving person who treats him well when he is “good” (that is, he follows the policies, procedures, rules, and regulations of the Kingdom). Participant 2 has a passion for teaching and she appreciated her nursing director allowing her the opportunity to give a lecture to her colleagues. When she left the hospital, the nursing director held a farewell party for her and made her feel recognized. Participants 24 and 25 described events that recognized them as the best infection control nurse and best nurse of the month, respectively. Participant 24 was surprised for the recognition but was happy to stand in front of her peers and supervisors in the auditorium during the hospital’s infection control week. The recognition was a surprise to Participant 25 so soon after her employment. As a recent nurse graduate, Participant 1 shared a happy story about her placement in the dialysis unit because of her work evaluations and examinations after 6 months working on the medical surgical wards. Participant 9 stated his nursing director supported, encouraged, and motivated the staff through the MRQP process. At the end, the nursing director recognized all the nurses with a certificate and celebration party.
185 Recognition from patients was equally as important in 32% of the participants’ stories. Participant 15 stated that working in the emergency room provided limited contact with patients because they generally came for acute episodic treatment and left immediately thereafter. Thus, her recollection that five patients over a 4-month period thanked her for her care was significant. Participant 16 recalled an incident when one of her sicker patients, a little boy, was feeling better one day and ran up to hug and kiss her. The child’s mother also thanked her. Participant 1 stated there is a particular patient who always asks for her when he comes in for dialysis. Participant 21 stated, “That is rewarding when a patient recognizes your work. Because the work of nurses I think is very hard.” Participant 23 stated a hug or piece of chocolate from her patients were rewards for her work. Eight percent of the participants’ stories mentioned physicians recognizing the participants’ work. Participant 22 stated a new consultant wrote a letter to the nurses and the chair of the department thanking the nurses for their hard work for a particularly difficult patient. The ill child was in the care of the hospital for a long time but the outcome was successful. Participant 18 remembered a significant event when she saved the life of a baby. Resuscitation was unsuccessful and the doctor pronounced the baby dead. Participant 18, certified in the Neonatal Resuscitation Program, inserted an endotracheal tube and resuscitated the baby. The baby continued to do well in the hospital and went home in good condition. Participant 18 stated everyone was happy for her effort, including the physician and her peers.
186 Salary The second most frequent story that reflected a positive experience was salary (hygiene and motivator factor; 16% of stories). Salary is a confidential matter in Saudi Arabia and largely determined by the nurses’ country of origin or passport, experience, and education. Even though salaries and benefits were areas of concern for Southeast Asian participants due to rising costs of living, participants admitted they still made more money in Saudi Arabia than in their own countries. Participant 11 stated her hospital compensates for overtime, up to 40 hours, and that additional hours go toward her vacation hours. One participant received her overtime pay as time back on the vacation hours, even though she would rather have the money. The participant stated that at least the hospital is improving the salary by recognizing the overtime required by the nursing staff. Participant 21 stated frankly, “We are just here because we are earning. We do not care what is bad or good. At the end of the day, we finished the work, we did our best, we didn’t commit mistake, we are happy already.” Salary was determined to be a motivator to work based on the strength of the stories from participants. Work Itself The discussion of work itself (motivator factor) under a time when participants felt exceptionally happy at work was evident for 16% of the participant’s stories. The participants described gaining experience and knowledge as motivators to work. One participant stated she has gained nursing experience in her workplace, gained experience as a nurse in a foreign country, and gained experience from working with a multicultural nursing department. Participant 1 stated she is happy with the patient assignment in dialysis because the nurses on the wards tell her the workload is difficult.
187 Work Conditions Two participants stated the environment in the unit and hospital (work conditions) were motivators for work. Participant 23 stated she found the day shift stressful with the pressures from nursing administration, the physicians, and the added workload of nonnursing duties. She was happy when her supervisor let her work permanent night shift. Participant 1 is conscious of infection control issues in her unit and is happy that supplies are abundant for the patients. Achievement Twelve percent of the participants’ stories included achievement (motivator factor) stories that made them happy at work. Participant 18’s story about resuscitating the baby reflected recognition and personal achievement (thought unit) as a motivator to work. Participants 10 and 12 (8%) stated teamwork (thought unit), working hard, and being involved in the MRQP accreditation process motivated them at work. Relationship With Peers Support from peers was an important hygiene factor for 8% of the stories told by participants. Participant 8 was able to cope with the stress of his work knowing his colleagues felt the same way he did about the work environment in his hospital. One participant told a story that combined a positive experience with a negative experience. As a new employee and newcomer to Saudi Arabia, she has learned about her hospital’s “final file note.” This looming file note caused distress to the participant as she shared her thoughts. The positive experience is that the participant’s peers are willing to help her face or solve any problems she might encounter.
188 Relationship With Supervisors Eight percent of the stories from the private sector participants reflected support from supervisors (hygiene factor) as a positive experience at work. Two participants identified a supervisor and a nursing director as reaching out a hand to help to support the nurses and to help relieve the stress. One participant hired locally at a private hospital explained her supervisor offered her money and a place to stay when she arrived without an Iqama. The other participant stated that teamwork in the nursing department improved the relationships with supervisors. Company Policy and Administration Support through company policies and administration (hygiene factor) was important in 8% of the stories told by government-sector participants. Participant 3 stated that because of MRQP accreditation, the hospital now has policies and procedures that minimize the threat of doing something wrong. Participant 22 stated policies and procedures provide structure to her work when family disputes take over the care of her patients. Responsibility One participant (4%) reflected on responsibility (motivator factor) that made her happy at work. She enjoys the challenge of her work in a critical care area and she has the added responsibility of looking after the dialysis machines due to the nursing and support staff shortage. Participants described several stories of situations that made them exceptionally happy at work. The data summary outlines the overall frequency percentage for the number of stories told for a hygiene or motivator factor. The hospital sector data outline
189 the percentage of participants from the government versus the private sector. The motivator factors that made the participants exceptionally happy at work included recognition (72% frequency; government sector 482%; private sector 20%); salary (16% frequency; private sector 16%), work itself (16% frequency; government sector 12%; private sector 4%), achievement (12% frequency; government sector 4%; private sector 8%), and responsibility (4% frequency; government sector 4%). The stories about work conditions (16% frequency; government sector 4%; private sector 12%), relationship with peers (8% frequency; government sector 8%), relationship with supervisors (8% frequency; private sector 8%), and company policy and administration (8% frequency; government sector 8%) were the hygiene factors that made participants exceptionally happy at work. Salary (hygiene factor) was an important issue for the private sector participants compared to the government participants who did not identify salary as a factor that made them exceptionally happy at work (see Appendix GG). Question 4: Describe to Me a Time When You Felt Exceptionally Bad at Work Company Policy and Administration Appendix HH illustrates the participant’s discussion for Question 4. Ninety-two percent of the stories from participants were about company policy and administration (hygiene factor) that made them feel exceptionally bad at work. Three thought units (subthemes) emerged from company policy and administration: hospital policies and procedures and organizational culture. Participants disclosed 60% of the stories around the thought unit of hospital policies and procedures. Three participants viewed hospital policies and procedures as not implemented by the nursing office and certain staffs using policies and procedures to
190 suit situations and themselves. One participant who was new to the Kingdom and to the hospital recalled an incident that occurred on her shift. There was no orientation to her hospital or her unit and so she followed the actions of the senior staff. Several issues factored into this incident, including medication administered by the wrong route, the charting of patient care and medication administration carried out by another nurse, the staffing schedule did not meet the needs of the patients, and a lack of support from nursing administration. The incident cost one nurse his job and another nurse received a salary cut. Thirty-six percent of the participant stories concerned salary or benefits that originated from hospital policies. The overtime pay policy varies from hospital to hospital. One participant stated it is not the hospital policy to pay nurses overtime for staying late on a regular shift. Most participants’ hospitals have a policy that confirms overtime pay for nurses who work on a Friday (which is the weekend), because they are second on call for the weekend. Participant 14 reported ill to the emergency room at her hospital after Hajj and the physician gave her sick leave. The hospital rescinded the sick leave because they said she did not follow the sick leave policy. Participant 14 stated she did not have an orientation and did not know the sick policy. Participant 7 remembered a time when another health-care contract company absorbed her position. She was required to pay a certain amount of money for this transaction or expect termination. The participant expected reimbursement of the money, but did not receive any reimbursement. Participant 14 stated her hospital required a 2-month notice for vacation leave to prepare all the paperwork, but the hospital is always late paying vacation money. One participant wanted to purchase gifts for her family and 4 hours prior to departure, a
191 disappointed participant still did not have her vacation pay. The participant stated, “When we [all staff] go [to the finance department], we have to cry, then they give.” Participant 11 stated it is common to argue over hospital policies with other departments in the hospital. Human resources informed her that she would pay for her Iqama. The hospital contract stated in English that the hospital is responsible for the cost of the Iqama for the FTNs. Only after arguing the point and showing the contract did Participant 11 get her Iqama. Participant 10 remembered that 10 years ago the hospital was late in issuing her passport for her vacation. She said, “When you are new to the country, you do not know how to get around the barriers.” Organizational culture was the second most frequent thought unit identified by participants (32% of the stories) connected to company policy and administration. Organizational culture related to administrators listening to the patient instead of finding out the root cause of disputes between staff and patient. Participant 22 described a nurse manager who received administration promotions due to her tenure. Participant 22 stated when her manager hired new staff, she hired according to what she wanted and not what the hospital needed. Another issue with nursing management for one participant was “staffing is not based on the acuity of the patient.” The participant angrily stated senior managers are saving money by using a ratio system that does not account for acuity. Participant 7 did not recall a story of a happy day at work because she is resentful that administration clouds her work in the hospital. She wanted to move to Riyadh but her husband would not let her leave. One participant explained hospital administrators did not want to listen to FTNs’ opinions about how to improve the workplace. The organizational culture she noted is that leadership treats comments negatively and against
192 the person trying to improve a situation. The participants explained that the easiest solution for many nurses is to finish the contract and leave the hospital. Organizational change in upper management meant a step back for hospital standards according to one participant. She stated the hospital would not be ready for a CBAHI survey and might not pass. Participant 24 stated her private hospital does not support the nursing profession. As charge nurse, she conducted patient rounds with the physicians in the morning. The first question the physician asked was, “How are the nurses? Are they okay? No problems?” Participant 24 stated the questions provoked the patients to complain. Work Conditions Work conditions were the second most frequent hygiene factor described by participants. Seventy-six percent of the stories told by participants included the thought units (subthemes) of the customs, religion, norms, and culture of the country; lack of staff; communication; fairness; infection risks; and perception of care. Sixteen percent of the stories told by participants involved the customs, religion, norms, and culture of the country. One participant faced particular issues involving the ethical differences in cultures when faced with the patient, family, and medical personnel. The participant felt the patient does not come first in the Saudi culture. Family and medical personnel do not involve the patient in the care plan. One patient she remembered waited until the family and physicians had left the room, and he asked the participant to stop the treatment. The participant stated the different value systems sometimes clash and the family always achieves what it wants. Participant 15 remembered a son of a patient who went to the emergency room physician and told him, “You will not be here if our government would not pay you. You are here to work for us.” A private hospital participant works overtime
193 shifts in the hospital owner’s home taking care of ill family members. She described feeling like a “housemaid” because she is always on call for the family. It is difficult to refuse the assignment because it is the owner of the hospital. Comments regarding lack of staff (thought unit) were significant for 16% of stories disclosed by participants. Participant 22 stated, “Most mistakes are because we are running and shortage [short staffed].” An unacceptable staff schedule in the emergency room contributed to an incident that affected two FTNs. In Saudi Arabia, the government and private hospitals do not assign male nurses to female patients, regardless of age. There was a policy in the hospital regarding staff assignments. The resolution to the staffing issue in the emergency room was to ensure full implementation of the policy. With the nursing shortage, the scheduling of staff may become more problematic. Participant 1 stated that nursing management does not see the heavy workload in her critical care area because the nurses are handling both nursing duties and nonnursing duties. She explained, “They [management] are not following the ideal. For them one nurse for three patients is not understaffed. Aside from the patients, you are doing other duties. No nursing aides, everything you are doing.” Another participant who works in critical care corroborated the workload issue by explaining that the nurses in her unit care for two ventilated patients during the shift and deal with other issues such as relatives and physicians. Sixteen percent of the stories from participants identified communication as an issue. Communication included interdepartmental communication, language barriers, and cultural habits that impede effective communication. Participant 3 described an incident when an inpatient arrived in the outpatient department for a procedure. When taking the
194 patient back to his room, she discovered an isolation sign on his door, which was information not provided prior to the visit to outpatient department. One participant explained that using translators to gain information from a patient does not provide good care. She wanted to be able to hear the information herself because she is not sure what the translator has said and if she is getting the correct information. Participant 3 stated her hospital has a policy that the speaking languages are Arabic and English. When Participant 3 is in charge of her unit, she hears the nurses speaking to each other in their own language. She stated this is not a problem if the conversation is personal. When it comes to patient care, the policy is to speak English or Arabic only. Participant 6 feels if all people, including patients, were educated, “They would understand us.” Fairness was a thought unit expressed in 12% of the stories told by participants. Participants expressed fairness in terms of equality (equal opportunity) and equity (justness). Participant 1 stated the method of calling staff into work is not fair. Nurses on the compound are the first staff called in for extra work, whereas the nurses who live in the community are the last staff notified. Participant 1 felt that her head nurse had power over the nurses who live in the compound. One participant described the treatment of Saudi nurses and FTNs. When Saudi nurses are late to work, management does not comment. Head nurses will question and counsel the FTNs regarding their reason for being late. Participant 8 discussed the documentation required at his JCI-accredited hospital that impaired patient care. He noted he enjoyed spending time with the patients and families, and felt pressure from the clinical nurse to document (in the medical record) all the time. Participant 8 stated other nurses on his unit were not providing good care because they were always documenting.
195 Infection risk was a thought unit expressed by a government participant. Participant 1 in a previous discussion identified the availability of supplies for patients to minimize the risk of infection. She described other issues in the unit that are possible risk factors for patients and staff. Her unit exchanges the isolation machines for infectious diseases because of a lack of equipment for the number of patients. The exchange compromises patient care with the possibility of infection. For staff protection, the participant lamented staff could not use gloves or goggles for patient care. Status Forty-four percent of the experiences described by participants reflected their status in Saudi Arabia and their feelings of discrimination. The participants felt discrimination in several ways, including salary and benefits compared to other nationalities, being looked upon as servants and treated that way, and different levels of respect between cultures from patients and family. One Western participant who worked in a government hospital admitted that nurses he worked with earn half his salary, yet they are doing the same job with the same level of education. He felt the salary and benefit scale created problems in the workplace because a coworker would say to him, “You are making more money than me, you do it.” The participant witnessed patients, families, and physicians treating some nurses like servants. Another Western participant who worked in a government hospital stated she feels disrespect from some Saudi patients and family because she is a female, non-Muslim, and non-Saudi. She has also witnessed different levels of respect from patients and families toward different nationalities in the hospital. For example, families speak down to Indian nurses but do not speak down to Filipino nurses. One participant stated, “Already twice salary increase I
196 never received. Foreign nurses here don’t have the rights, even though you are on the right side.” Relationship With Supervisor Forty-four percent of the stories by participants reflected their relationship with supervisors. The stories revealed that a lack of support from the supervisor was the common thought unit. A participant who worked in a government hospital described an emergency electrical power shutdown incident in the hospital where the nurses attended the emergency without the support of their area supervisor. She explained, “Supervisors look for mistakes from the staff rather than recognize the good things that are accomplished.” Participant 2 wanted to be an educator in her hospital and had the experience for the job, but she did not have the support of the nursing director. One participant who works in a JCI government hospital stated that nursing management does not support quality of patient care. Staff scheduling in the nursing department was according to the number of patients rather than the acuity of the patients. The participant declared that nursing management does not support professional development. She also remembered the lessons learned in her country from incident reporting, a system to identify quality improvement measures that caused the incident rather than laying blame on an individual. The participant explained the communication system of incident reporting in her current hospital, noting, “But when they [supervisors] talk, they leave you lingering; tomorrow you do not know if you are going to have a job.” Security Verbal and physical abuse from patients and families in the hospital accounted for 20% of the stories from both the government and the private sector participants. Two
197 participants recalled abusive situations where higher administration demonstrated a lack of support for FTNs. Participant 16 recalled an incident when a patient sitter hit her on the arm. The nursing supervisor did not report the incident to higher administration. Participant 25 told a story about a difficult long-term patient who was always throwing things at the nurses and other staff. Management did not support the nurses even as repeated incident reports went to nursing and administration over the course of 2 years. One day, the patient threw water at a Saudi social worker and the next day the administration discharged the patient from the hospital. Participant 23 described a patient’s relative pushing her. She called the supervisor to report the incident and the relative told the supervisor that the nurse pushed her. Participant 23 rationalized that the incident occurred because of a lack of staff in her private hospital and the expectations from patients and families for customer service. She explained, “There are not enough nurses to meet the needs of the patient.” One participant in a government hospital remembered that a patient kicked her after she had finished a dressing change on a wound. One participant from the private sector angrily recalled patients who say bad Arabic words to the FTNs, not even knowing if the nurse speaks Arabic or understands the words (words such as dog or donkey in English). Personal Life The last 12% of the stories revealed by participants confirming an exceptionally bad day at work was the hygiene factor personal life. The government participants described their accommodation as affecting their day. Accommodation issues included lack of water for washing clothes or taking baths, too many nurses in one apartment, and no food. With limited outside activities for the participants in the government sector and
198 working full-time and overtime, having respectable accommodations is an important part of the participant’s life. The MOH recognized that the accommodations for health-care workers require improvement and a plan is in place to accomplish this goal (M. Al Osaimi, personal communication, January 9, 2007). The participants’ stories reflected a lack of hygiene factors to stimulate job satisfaction and motivation. The hygiene factors included company policy and administration (92% frequency; government sector 40%; private sector 20%); work conditions (76% frequency; government sector 36%; private sector 12%), status (44% frequency; government sector 16%; private sector 20%), relationship with supervisor (44% frequency; government sector 16%; private sector 8%), security (20% frequency; government sector 8%; private sector 12%), and personal life (12% frequency; government sector 12%). Appendix II illustrates job satisfiers and job dissatisfiers for government and private hospitals, as well as an overview of all the qualitative findings for Questions 3 and 4). Summary The central qualitative question in the study was as follows: How do demographic and work environment factors influence job satisfaction and burnout among FTNs who live and work in Saudi Arabia? Overall, participants indicated job satisfaction through recognition, work itself, salary, work conditions, achievement, company policy and administration, relationship with supervisor, and relationship with peers. The job dissatisfiers included company policy and administration, work conditions, status, relationship with supervisor, security, and personal life. The top two job satisfiers for participants in the government sector were recognition and work itself, while the top two
199 satisfiers for participants in the private sector were recognition and salary. The top two job dissatisfiers for the participants in the government sector were company policy and administration and work conditions, while the top two job dissatisfiers for participants in the private sector were company policy and administration and status. Chapter 5 provides the results of the triangulation design of qualitative and quantitative data to present a worldview of FTNs living and working in Saudi Arabia.
200 CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS Saudi Arabia depends on FTNs to provide health-care services to its population. With the continued shortage of nurses and a worldwide competition for nursing services, Saudi Arabia’s health-care infrastructure is at risk. The purpose of the study was to examine the relationships between demographic factors and work environment factors on hospital characteristics (as dimensions of job satisfaction) and burnout for FTNs working and living in Saudi Arabia. Job satisfaction and burnout are important indicators for recruitment and retention, a current focus of nursing health-care leaders in Saudi Arabia. The literature review in chapter 2 presented the push-pull factors for immigrating nurses, the global challenge of the nursing shortage, the work environment factors that contribute to job satisfaction and burnout, and the factors that make Saudi Arabia a unique destination for FTNs. The mixed-method study used two instruments for hospital characteristics (job satisfaction; NWI-R and PES-NWI), one instrument for burnout (MBI), one demographic questionnaire, and four focus group sessions. The quantitative data identified descriptive statistics from the sample of participants, bivariate statistics to explore the relationships between the dependent and the independent variables, and multiple regression statistics that explored the importance of the independent variables on the dependent variables. The four focus group sessions provided a venue to collect the qualitative data from 25 FTNs. The last phase of the data analysis was to use a triangulation design to present a worldview picture of FTNs who live and work in Saudi Arabia. The findings from chapter 4 demonstrated several demographic factors (i.e., education level and year registered) and work environment factors (i.e., ownership and
201 the number of nurses per 100 beds) that participants perceived as indicators of job satisfaction and burnout. To validate the quantitative results, chapter 5 includes an exploration into the worldview of participants by using the triangulation design for the quantitative and qualitative data. Chapter 5 presents (a) the conclusions of the study, (b) implications for nursing leaders in Saudi Arabia, and (c) recommendations and suggestions for future research. Findings The focus of the study was associations between selected demographic variables and work environment variables and hospital characteristic scores (linked to job satisfaction) and burnout among FTNs working in Saudi Arabia. The current study is the first to include an examination into the relationships of job satisfaction, burnout, and the work environment factors for FTNs in Saudi Arabia. The significance of the current study is that it provided reliable and validated data from which to strategically plan changes within the study nursing departments. The study provided a basis from which nursing departments can improve to recruit and retain FTNs during a nursing shortage. Hospital characteristic (job satisfaction) scores included the subscales from the NWI-R and PESNWI survey instruments. The research on the NWI-R and PES-NWI subscales reflected the results of countless Magnet hospital research studies on hospital characteristics that promote job satisfaction and retention. The research on MBI subscales provided burnout results for nurses in poor work environments that are reflected in the qualitative data of the study. Saudi Arabia has only just started working toward quality improvement by developing its own hospital accreditation standards and survey process (CBAHI). Hospital accreditation standards provide the baseline for an autonomous nursing
202 department within the organization. As Magnet status recognition is some years away for many hospitals in Saudi Arabia, the first step is to implement and maintain the CBAHI standards. The following paragraphs present the analysis of FTN nurse ratings and Research Hypotheses 1-4. Lake (2002, p. 179) used 2.5 as the neutral midpoint on the 4-point response. For the purposes of evaluating the responses from quantitative and qualitative data, 2.5 was the neutral point in the current study. The mean subscale scores for the NWI-R ranged from 2.77 to 2.90, while the mean subscale scores for the PEW-NWI ranged from 2.45 to 2.91. The conclusions pair NWI-R and PES-NWI subscales together, as similarities exist between the two instruments. Not one subscale is over M = 3.0, which reflects room for improvement in the nursing departments in the study. Table 4 provides an outline of the pairing and the mean of the subscales. Organizational Support and Staffing and Resource Adequacy The scores from organizational support (NWI-R) and staffing resource adequacy (PES-NWI) indicate neutral support for the subscales (M = 2.77 and M = 2.45, respectively). In Upenieks’ (2002, p. 568) study, a non-Magnet hospital organizational structure was M = 2.40 and a Magnet hospital organizational structure was M = 2.93. Staffing and resource adequacy on nononcology nurses was M = 2.35 and M = 2.77 in non-Magnet and Magnet hospitals, respectively (Friese, 2005, p. 768). Staffing resource adequacy is the lowest score of all five PES-NWI subscales and organizational support is the second lowest score of the four NWI-R subscales. The organizational support and staffing and resource adequacy items reflect the organizations’ support of nursing in
203 terms of adequate staffing levels, resources for patient care, opportunities for advancement, and support for continuing education. Table 4 NWI-R and PES-NWI Pairing and Means NWI-R Subscale
PES-NWI Mean
Subscale
Mean
Organizational support
2.77
Staffing and resource adequacy
2.45
Control over practice setting
2.60
Nurse participation in hospital affairs
2.55
Nurse physician relationship
2.90
Nursing foundations for quality of care
2.91
Autonomy in practice
2.79
Collegial nurse physician relationship
2.87
Manager ability, leadership, and support
2.70
Staffing The qualitative data corroborated the quantitative findings of organizational support and staffing and resource adequacy. In Question 2 (see Appendix EE), participants identified staffing (thought unit) under work conditions (hygiene factor) as the most frequent issue they deal with while working in Saudi Arabia. Participants noted the patient workload is increasing, nurses cannot provide holistic care to patients, nonlicensed nurses are functioning as registered nurses, the turnover of staff is high, nurses perform nonnursing duties, and there is inadequate coverage during holiday and vacation time. The MBI subscale results corroborated this finding as participants scored high levels of emotional exhaustion and depersonalization. In Question 3 (see Appendix GG) participants identified staffing as the second most frequent issue when they felt exceptionally bad at work. Participant 1 described her
204 return to work after delivering her baby. She had a workload that prohibited her from practicing ideal nursing care. The unit is understaffed, which results in overtime duty with maybe 1 day off each week. Participant 13 described the workload in the intensive care unit where a nurse assignment is two ventilated patients and the nurse assumes responsibility for being available for physicians and relatives. Participant 23 stated that in the private hospital where she worked, lack of staff compromises the patients’ expectations of care. She cited an incident when a relative used the call bell to call her. When she could not answer, the relative called the hospital supervisor. Participant 1 stated administration takes nurses making suggestions for improvement negatively. The comments on staffing suggested that providing high-quality care was challenging. Support for Nursing Participants 13 and 14 shared stories about their supportive supervisors in the private sector. A head nurse assisted Participant 14, who arrived in the hospital as a local hire and without an Iqama. The head nurse offered her money and a place to stay until the hospital resolved the situation. Participant 13 stated that the nursing director and supervisors are working with the nursing staff as a team, supporting them, reaching out to the staff, and trying to relieve their stress. Participants felt exceptionally bad at work when the organization did not support them. The MBI supported the lack of organizational support with the findings of high levels of emotional exhaustion and depersonalization among participants. Lack of staff and overwork contributed to burnout. Organizational culture (thought unit) under work conditions (hygiene factor) was the second most frequent issue identified by participants as issues they face while working in Saudi Arabia. Organizational culture did not support
205 participants when incidents occur between the nurse and patient, when nurses are not recognized for previous qualifications and education (in terms of advancement), and when nurses are physically and verbally abused by patients and families. Participants from the private sector indicated that hospital management listens to the patient and family when there is a complaint against nursing. The nurses receive the blame without an investigation into the incident. One participant stated, “They [management] will never listen to the nurses.” The results are lost jobs or deductions in salary. Physical and verbal abuses (thought units) were status (hygiene factor) issues identified by participants. The culture of the country regards nursing as a low-end career without dignity and respect. Appendix HH outlines several stories of physical and verbal abuse by patients, families, and sitters, as well as administrative staff in the hospital. Participant 23 described an incident with her nursing director who made her feel bad. The nursing director called her to the office and Participant 23 stated, “You cannot imagine how she talks to you. She is the one who gave you all the food you are eating. It is like she bought your life.” Participant 18 disclosed a story of the hospital medical director calling nurses “rubbish, mentally retarded, and stupid.” Participant 22 described a nurse manager who advanced her career from staff nursing and does not necessarily have the skills to be a leader. The participant stated the nurse manager is saving money by not hiring the right skill-mix of staff. For example, a hospital can hire 6 Filipino nurses to one Western nurse (in terms of salary and benefits). The hospital does not have a patient acuity system, so for Participant 22 the workload is heavier because of the skill-mix on the unit. Another participant described the nursing
206 managers in her hospital as advancing in their careers because of their length of tenure and “stepping on the nurses to earn these positions.” Adequate Resources for Staff The government-sector participants identified accommodation as an issue that made them feel exceptionally bad at work. In the study, accommodation (thought unit) is included in adequate resources as it is a condition of the FTNs’ contract. Hospitals provide free accommodation to FTNs hired internationally. The hospital is responsible for their safety and well-being. The accommodation and the FTNs personal life in that accommodation influence their ability to be satisfied at work. Participants described overcrowding in the apartments, lack of privacy, limited water supply, lack of food, and restrictions regarding going off the compound for shopping. The MOH identified accommodation as a priority and they are working to resolve the issues (M. Al Osaimi, personal communication, January 9, 2008). Leaders in the private sector are listening to the nurses and changes are occurring regarding shopping times and improving the compound living situations. Adequate Resources for Patients One government participant identified an infection control issue that related to adequate resources for patients. The participant discussed the risk of acquiring diseases from dialysis machines because the engineers are not following policies regarding infection control. Another participant stated supplies are adequate for patients but staffs do not have goggles and gloves when there is an emergency.
207 Continuing Education In Question 2, participants identified continuing education (thought unit) as a company policy and administration (hygiene factor) issue they face at work. Some government and private-sector participants stated they are attending symposiums and continuing education programs outside and within the hospital. Other participants stated they receive little continuing education. Continuing education is an important issue in the study, as Saudi registration, licensure, and hospital contract renewal is dependent on continuing education units. When the education department in a hospital applies for continuing education units from Saudi Council, the requirements are clear. A continuing education program receives credits based on the content of the lecture and the presenter’s qualifications and experience. The presenter’s qualifications and experience include baccalaureate or higher nurse, experience, and education in the field of program. Chapter 2 presented the Saudi Council’s view on baccalaureate nurses from the Philippines. The Saudi Council recognizes the baccalaureate degree from the Philippines as a technical title and does not provide continuing education units to a speaker with this title. From the study, 59.6% of the participants were Filipino and 65.8% of the participants held a baccalaureate degree or higher. Opportunities for Advancement In Question 3, 4 participants described gaining experience (thought unit) on the job (work itself as a hygiene factor) as an exceptionally happy day at work. Gaining experience on the job provides an opportunity for advancement. The lack of organizational support for continuing education for nurses is a critical issue. A nursing director voiced her frustration when the hospital provides continuing education and
208 experience for FTNs and then they leave to go to another country for work (A. Dababneh, personal communication, April 3, 2008). The fact that nursing directors and participants in the study voiced this anecdotal information is significant as a push factor for FTNs to look for other career opportunities. Control Over the Practice Setting, Nurse Participation in Hospital Affairs, and Nursing Foundations for Quality of Care The scores from control over the practice setting (NWI-R) and nurse participation in hospital affairs (PES-NWI) indicate neutral support for the subscales (M = 2.60 and M = 2.55, respectively). In Upenieks’ (2002, p. 568) study, control over the practice setting was M = 2.34 in non-Magnet hospitals and M = 2.79 in Magnet hospitals. Nurse participation in hospital affairs for nononcology nurses was M = 2.72 and M = 2.98 for non-Magnet and Magnet hospitals, respectively (Friese, 2005, p. 768). Nursing foundations for quality of care for nononcology nurses was M = 3.09 and M = 3.35 for non-Magnet and Magnet hospitals, respectively (Friese, p. 768). Control over the practice setting is the lowest of the NWI-R subscales, while nurse participation in hospital affairs is the second lowest score of the PES-NWI subscales. Nursing foundations for quality of care scored the highest of all subscales (NWI-R and PES-NWI) with M = 2.91. The control over the practice setting, nurse participation in hospital affairs, and nursing foundations for quality of care subscales reflect the influence of the nursing department in exerting influence over others while promoting quality care. Several activities assist nurses in influencing others in promoting quality care that include nurse participation on hospital and nursing committees, interdisciplinary policies and procedures that reflect
209 nursing input, nurse participation on quality improvement projects, and an active inservice and continuing education program for nurses. Policies and Procedures The qualitative data supported the quantitative findings for control over the practice setting, nurse participation in hospital affairs, and nursing foundations for quality of care (see Appendix GG, Question 3). Participants agreed that MRQP accreditation helped promote the nursing presence in the hospital. The hospital Participant 10 worked in achieved MRQP accreditation (achievement, a motivator factor). Participant 10 stated that nurses “got to prepare policies and procedures and people worked very hard at that time (teamwork, a thought unit). Participant 12 stated the nurses in the nursing department were very proud to achieve the first accreditation with MRQP. Preparing for MRQP accreditation motivated hospital administration to involve the nursing departments in policy development for the first time. Nursing developed its own policies regarding practice and education. Hospital committees included nursing representation to comply with MRQP standards. With representation at committee level, nursing had a more powerful voice to improve quality of patient care and assist in hospital-wide policies and procedures. Examples of multidisciplinary policies under the MRQP standards included conscious sedation policy, pain management policy, restraint policy, and patient and family education. Many participants did not see that nursing had control over the practice setting or that nursing participated in hospital affairs. Participant 22 stated that the hospital has good policies but nursing management does not implement them (see Appendix HH, Question 4). Participants 6 and 14 stated that policies and procedures are in place, but no
210 monitoring is in place to ensure compliance of the policies. Participant 8 stated that managers and staffs manipulate policies and procedures in his hospital to suit situations. The comments indicate that nursing managers may be involved in the writing of policies but are not implementing and evaluating them. Nine participants disclosed stories of hospital policies (thought unit) that related to company policy and administration (hygiene factor). The hospital policies related to staffing issues that human resource departments are responsible in developing and implementing. Participants discussed issues such as a salary deduction for their Iqama, a salary increase that not all nurses received, a late passport and salary prior to the nurses’ vacation, payment for transferring to another company to work, sick time, and the overtime policies. The discussion of human resource issues started with recruitment practices, from the recruiter at country of origin to the hospital recruiter, that were common issues participants experienced when working in Saudi Arabia (see Appendix EE, Question 2). Participant 12 stated, “In my [private] hospital the staff can complain as newly hired back to the agency in the Philippines for deductions they did not know about. The agency will respond to the hospital.” Other participants stated that FTNs could complain to their own embassy and the Saudi embassy. Recruitment Practices Administrative policies under the nursing chapter in MRQP standards included a nurse recruiting process that individual nursing directors were not involved in developing and implementing. Recruitment practices from the recruiter and hospital were common issues that participants experienced when working in Saudi Arabia (see Appendix EE, Question 2). In the private sector, a representative from the hospital would go on
211 recruitment trips to India, the Philippines, and other countries. For the MOH, a group of representatives from the main office would go on recruitment trips. The representatives would assess, interview, and test the applicants and offer contracts to the FTNs for employment in Saudi Arabia. Participants stated it is common practice that they are told one thing in their country but receive a different contract when they arrive to work in Saudi Arabia. The process of how FTNs were hired became the responsibility of the hospital nursing director in accordance with the MRQP and CBAHI standards. Full implementation of this standard is not yet Kingdom-wide. Nursing seems not to have any influence over the larger issue of recruitment practice. Orientation and Competency Assessment Orientation programs, competency testing, and skills assessment were refined to reflect the standards of MRQP. Other participants stated they did not receive an orientation to the hospital or to the unit. Participants 16 and 17 are government employees and they stated not all hospitals have orientation programs or competency testing. Participant 15 acknowledged, “There is orientation but new a nurse orients herself. You do all the errands so you orient yourself.” The problem lies in the recruitment process. The MOH assigns the FTNs to the hospitals, sometimes to areas where the FTNs have experience and other times to areas where they do not have experience. Mentoring and training programs are not in place to assist the new FTN in the new specialty area. Participant 15 stated, “There is instruction from MOH that if you do not know what you are doing, don’t try to do it for your own sake. Try to ask first your senior nurse.” One participant stated the MRQP standards for documentation deprive her of adequate time with patients: “Ninety percent writing time, 10% nursing care.” Given
212 the evidence that many nursing directors do not have a free hand in recruiting nursing staff, the challenge for providing quality patient care is in the domain of the nursing education programs. Quality Improvement Participants stated there is still a blame culture in organizations, despite the advancement of quality improvement programs in the hospitals. Participant 17 disclosed the staff nurses received a punishment for the incident in the pediatric emergency room (see Appendix HH) despite the fact that two FTNs were probationary employees and the charge nurse or head nurse of the unit predetermines the staffing schedule. The participant stated that incident reporting is not an opportunity for improvement but an opportunity to find fault in an individual. Nurse–Physician Relationships and Collegial Nurse–Physician Relationships The scores from nurse-physician relationships (NWI-R) and collegial nursephysician relationships (PES-NWI) indicate more positive support for the subscales (M = 2.90 and M = 2.87, respectively). Aiken, Clarke, Sloane, Sochalski, et al. (2001, p. 47) reported similar findings for nurse–physician relationships (80-86%). For the fivecountry study, nurses indicated a higher perception of physicians providing quality care (69-81%) and a higher perception of working with nurses who were competent (85-95%). Nurse–physician relationships were M = 2.78 and M = 3.13 in non-Magnet hospitals and in Magnet hospitals, respectively, in Upenieks’ (2002, p. 568) study. Friese (2005, p. 768) found for nononcology nurses, collegial nurse–physician relationships were M = 2.90 and M = 2.99 in non-Magnet and Magnet hospitals, respectively. Nurse–physician relationships were two of the highest scores of the NWI-R and PES-NWI subscales. A
213 collegial relationship describes a mutually respectful working relationship among colleagues (nursing and medical staff) where each discipline is equally qualified to provide and promote quality patient care. Recognition and Support Two participants identified stories that described recognition from physicians for performing well. One source of recognition was a thank you letter written by the consultant to all the nurses on the unit for their hard work in caring for a particularly ill child whose outcome was positive. The consultant forwarded the letter to the chair of the department, which was another source of recognition. One participant described a physician thanking her for saving a baby’s life. Although the physician pronounced the baby dead after resuscitation measures were futile, the participant continued to resuscitate and the baby started to breathe on its own. “The doctor said I did a good job because the baby is alive,” the participant stated. Cultural and Value Differences The qualitative stories accounted for recognition and support but did not yield any positive stories regarding nurse–physician working relationships. The MBI supported this finding by demonstrating participants had a higher perception of burnout for emotional exhaustion and depersonalization and an average perception of personal accomplishment. Participant 3 described the working relationships in her hospital as difficult and challenging due to cultural norms, religion, values, and customs of the country. She stated the patient does not come first in the plan of care. Physicians in her hospital yield to the family wishes. If the family does not want the patient to know the diagnosis, the physicians does not tell the patient. If the family does not want an antibiotic given every
214 6 hours, “that is how they manage patients,” Participant 3 stated. Participant 3 told a story about a patient she nursed who understood what was going on with his medical care. When the physicians and family left the room, he told the nurse, “Stop it,” meaning stop the treatment and let him die. Participant 3 said, “He is telling me, not the doctors, not telling his family. I couldn’t handle it. It freaked me out, I couldn’t believe it. I will never forget that.” Autonomy Over Practice and Nurse Manager Ability, Leadership, and Support of Nurses The scores from autonomy over practice (NWI-R) and nurse manager ability, leadership, and support of nurses (PES-NWI) indicate neutral support for the subscales (M = 2.79 and M = 2.70, respectively). Autonomy over practice in non-Magnet and Magnet hospitals was M = 2.64 and M = 3.10, respectively, in Upenieks’ (2002, p. 568) study. Nurse manager ability, leadership, and support of nurses for nononcology nurses in non-Magnet and Magnet hospitals was M = 2.74 and M = 2.93, respectively. Autonomy over practice scored the third highest out of four subscales while nurse manager ability, leadership, and support of nurses scored third out of five subscales. Autonomy over practice indicates nursing independence within the discipline with the support of the nurse manager through his or her leadership and skill. To have autonomy in nursing practice, it takes the strength, will, qualifications, leadership skill, and style of the nursing director. In a culture of bureaucratic and physician-driven management, the nursing director’s role cannot be underestimated. Support of Nurses in Practice Participant 2 had the opportunity to demonstrate her knowledge and skill in conducting an education lecture for the nurses. The nursing director supported her in this
215 task even though Participant 2 was not an educator but an operating room staff nurse. Participants 24 and 25 received certificates and recognition from the nursing director, supervisors, and peers for their work as infection control nurses for the unit and the best nurse of the month. Nursing directors supported and encouraged their nurses to meet the challenges of implementing MRQP standards. Makkah Region Quality Program preparation for nursing departments in the Western region was the beginning of an identity for nursing. The standards helped establish nursing departments as an independent discipline that functioned in collaboration with other departments in the hospital. There was an excitement when hospitals achieved accreditation and most hospital directors and owners recognized the nurses as the impetus. Participant 9 stated, “When we passed MRQP, after that we have very nice time in the hospital.” The director of nursing prepared a party for the staff and certificates of recognition. Not all the stories were successful in the long term. Participant 17 stated, “They change the administration now, so again CBAHI will come and maybe we will not pass. The medical director wants to cover the nursing department [so the nursing director reports to the medical director instead of the owner or chief executive of the hospital]. I do not like that.” Participant 22 noted nurse administrators do not have the skills to be effective leaders and stated. The difference between a manager and a leader is a manager will always do the right things. She follows the policies, she doesn’t care if this policy is wrong, she does not question. A leader will do things right. She will say no, find out. Participants 3 and 4 agreed with this philosophy of leadership when describing the file note in their hospital. The participants stated a file note documents evidence of
216 wrongdoing on the part of the staff nurse. Participant 3 stated the file note is in the form of a threat but staff does not take it seriously. Participant 3 stated, “Some people are more interested in threatening others than actually education and making them a real part of the team.” Supervisors did not support the participant in the pediatric emergency room incident (see Appendix HH, Question 4) previously described where both new nurses received punishment for the errors. Participant 17 discussed the issues of the case. First, the scheduling did not cover the unit according to the rule of male nurses caring for female patients (one female nurse and two male nurses on duty). Next, errors occurred in medication administration and documentation regardless of policies and procedures in place and the two new nurses were still on probation without a mentor. Another area of concern was the lack of security and crowd control for an emergency room that was busy with many patients. Most important, no proper investigation of the incident (root-cause analysis) occurred to identify the issues, improve practice, and provide quality care for patients. Participant 17 stated the unit supervisor tried to support her, “but higher administration went on the side of the patient.” Even within the ranks of nursing, support is difficult to maintain. Participant 24 described a day when she was charge nurse and a relative complained about the patient’s Indian nurse. The relative wanted a Filipino nurse only. Administration replaced the FTN for the patient. This type of incident also occurred in Participant 22’s hospital and Participant 22 stated it is “because of the culture here,” where there are different levels of ethnic respect. The subcultures of the crab mentality and mafia identified in the qualitative analysis indicate that nurse managers have little or no control over these phenomena. The Filipino culture is deeply rooted in the crab mentality, which involves pulling those staff
217 members down who are striving to be better. The mafia is a secret society that also targets nursing staff members to fail and can work its way into other disciplines to manipulate situations or people. The subcultures undermine the ability of the nurse manager to create a nursing work environment that promotes diversity and collegial relationships. A former Western nurse manager working in Saudi Arabia stated, If that hospital is staffed primarily by Filipinos then yes, the crab mentality could undermine the nurse manager. But then, it is dependent on the nurse manager and his/her country of origin and their management style. When the nursing staff is spending more time on deciding whom to bring down staff wise, instead of working on better staffing plans or better patient care, then yes, patient outcomes could be affected. The nurse manager needs to be fair and as transparent as possible. (I. Rondeau, personal communication, May 11, 2008) For the focus group participants to acknowledge and discuss that the subcultures exist, indicates that some FTNs lack trust and commitment to the organization. Foreign-trained nurses who engage in the activities of the subcultures destabilize the nursing profession that could potentially affect staff outcomes and patient outcomes. The qualitative finding is consistent with the MBI score of an average perception of personal accomplishment. Language Barriers It is difficult to have autonomy over practice where the majority of FTNs do not speak Arabic as a first language. Many FTNs learn the language while they work in the Kingdom. Participant 4 disclosed her feelings about the language problem and her work, stating, “I want to learn the language, but I can’t. We have staff that translate but you want to do it by yourself. You don’t know if they lost something to the patient, missed
218 something.” Hospitals provide rudimentary Arabic instruction for a short program during orientation. Expanding an Arabic language program, especially for new FTNs, would greatly improve their confidence, communication ability, and status to the patients. Status of Nurses Nurses’ status reflects how autonomous nurses will be over their practice. Recognition of a nurse’s status is from his/her education, experience, competency on the job, performance evaluations, work habits, relationships with coworkers, and relationships with patients and families. One participant stated she had only 6 months of experience in her country before coming to Saudi Arabia, but she did so well on her evaluations and exams that her supervisor placed her in a critical care area to work. Eight participants identified recognition from patients as memorable days at work. One participant described nurses’ work: I counted it, there are 5 patients in 4 months that said thank you. It’s a good thing that what you did something good thing, and in return they appreciate what you did. Being appreciated as a nurse is a good thing. Another participant remembered walking down the hall and someone shouting to her, “That’s my nurse. That’s my nurse.” She stated, “You cannot remember what you did but it was some kind of impact that affected the person’s life.” A physician recognized the hard work of nurses in caring for a critically ill child in Participant 22’s unit and wrote a letter of thanks. The quantitative data indicated that FTNs somewhat agree that nursing has autonomy over practice, yet 7 participants stated that being treated as a housemaid by administration and patients is not uncommon. The literature review in chapter 2 identified
219 the challenges surrounding the nursing profession in Saudi Arabia. Participant 22 stated, “You are non-Saudi, you are non-Muslim, you are a woman, so you become nothing to some of them.” The quantitative data from the FTNs’ subscale ratings and triangulated with the qualitative data presented a worldview of the nursing practice environment for FTNs in Saudi Arabia. The FTNs scored the NWI-R and PES-NWI subscales less than M = 3.0, which indicated that the dependent variables (linked to job satisfaction) are not present in the workplace or the FTNs do not have a clear idea of what constitutes a positive nursing practice environment. The neutral scores on the subscales reflect an assumption that hospital leadership must create the environment for nursing progress and staff nurses must be part of that development. The members of the Jeddah Nurses Executive Forum voted to host a training program on leadership skills and practice and quality improvement training for nursing directors in the region. The nursing directors identified their shortcomings as nursing directors and in meeting the challenges of a changing health-care system. Research Hypotheses 1 and 2 The quantitative data supported Research Hypotheses 1 and 2. An association existed between selected demographic variables and work environment variables and hospital characteristic scores (linked to job satisfaction) among FTNs living in Saudi Arabia. In the bivariate analysis, the first demographic variable, FTNs with diploma or associate degree, reported a higher perception of job satisfaction for the subscales control over the practice setting, nursing foundations for quality of care, nurse–physician relationships, collegial nurse–physician relationships, organizational support, and nurse
220 manager ability, leadership, and support of nurses. The result is important because 65.8% of the participants with a baccalaureate degree or higher, with 59.6% of the participants originating from the Philippines (where nursing entry to practice is baccalaureate degree), reported lower scores in job satisfaction with the hospital characteristics identified above. The multiple regression analysis supported the data with a negative relationship between FTNs with a baccalaureate degree or higher and control over the practice setting, nursing foundations for quality of care, nurse–physician relationships, collegial nurse–physician relationships, organizational support, and nurse manager ability, leaderships, and support of nurses. Baumann and Chung (1999, ¶ 1) reported a correlation exists between education and the complexity of nursing practice. Baccalaureate programs prepare nurses to be independent in nursing practice. Baccalaureate programs emphasize nursing theory, critical thinking and problem solving, nursing process, communication skills, management skills, and continuum of care for the changing global demographics. A baccalaureate degree represents an entry to practice comparable to other disciplines such as pharmacists, social workers, physiotherapists, and respiratory therapists. The baccalaureate level of entry establishes the nursing profession in terms of the expectations of other health-care professionals, including physicians. Filipino FTNs make up the majority of staff nurses in the hospital settings qualified at the baccalaureate level of nursing. Foreign-trained nurses with a baccalaureate degree or higher feel they are not using their knowledge from their education and training in the Saudi work environment. The finding is not surprising as the multiple regression analysis indicated baccalaureate
221 FTNs need support from their nurse managers to utilize their education, training, and skills. The findings indicated that FTNs with a diploma or associate degree assimilated into the hospital organizational culture better than FTNs with a baccalaureate degree or higher. Perhaps the FTNs with a baccalaureate degree or higher experienced the work environment attributes in their home country and expected to work in a similar work environment in Saudi Arabia. Foreign-trained nurses with a diploma or associate degree trained and worked in environments that supported, guided, and supervised them. In Saudi Arabia, FTNs with a diploma or associate degree work as an equal to the FTNs with a baccalaureate degree or higher in terms of nursing responsibilities and accountability. The FTNs with a diploma or associate degree may have viewed the work environment in Saudi Arabia as an opportunity to learn and advance in their career. AboZnadh (1999, p. 88) found that nurses with a baccalaureate degree had more job satisfaction than nurses with lower level degrees. The finding in the current study may indicate the work environment in Saudi Arabia has changed since the Abo-Znadh study. Upenieks (2002, p. 568) found 47% of nurse respondents at non-Magnet hospitals had an associate degree and 31% of nurse respondents had a baccalaureate degree. Job satisfaction increased substantially when there were more baccalaureate nurses in Canadian hospitals (McCutcheon et al., 2005, p. 6). Similarities occurred with the second demographic variable, newly registered FTNs, when there were higher satisfaction scores with control over the practice setting, organizational support, and nurse manager ability, leadership, and support of nurses. The result was significant, as 26% of the sample were newly registered FTNs after 2001,
222 whereas almost 74% of the sample FTNs graduated prior to 2001. The multiple regression analysis supported the bivariate analysis with a positive relationship between being a newly registered nurse after 2001 and control over the practice setting, nursephysician relationships, organizational support, and staffing and resource adequacy. Newly registered nurses are young to the profession, lack experience from their home country, and expect a Western-style health-care system in Saudi Arabia. Many participants in the focus group sessions stated they came to work in Saudi Arabia due to a lack of jobs in their home country. Participants also stated that in their home country, one nurse might be assigned 10 or more patients in a shift. The limited experience of the newly registered FTNs may explain the perception of more control over the practice setting and organizational support, especially if they worked in hospitals with limited staff and resources in their country. The behavior of newly registered nurses might demonstrate willingness to learn, wanting to advance in their career, and enthusiasm for nursing compared to nurses that graduated prior to 2001 who are older, have experience in the profession, and have settled into their career. The newly registered FTNs felt there was adequate staffing and opportunities for advancement and were grateful to the nurse manager for the opportunity to work in Saudi Arabia. Sixty-one percent of the participants were less than 35 years of age. The average age of an American nurse is the mid-40s (Aiken, 2006, p. 8). Aiken, Clarke, Sloane, Sochalski, et al. (2001, p. 46) found England, Scotland, and Germany had higher percentages of nurses under the age of 30 (40.6, 31.9, and 33.6%, respectively) compared to the United States and Canada (19.0 and 10.3%, respectively). Aiken, Clarke, Sloane, Sochalski, et al. concluded nurses in the age group less than 30 years of age were
223 dissatisfied in their jobs and intended to leave the job within a year. Other studies did not support the finding of job satisfaction for newly registered nurses. Previous research indicated the highest percentage of survey participants had more than 10 years experience (Abo-Znadh, 1999, p. 85; Flynn et al., 2005, p. 69; Friese, 2005, p. 768; Manojlovich, 2005, p. 370; Staten et al., 2003, p. 205; Upenieks, 2002, p. 567; Vahey et al., 2004, p. 11-61). The work environment variable married contract FTNs reported higher scores for control over the practice setting, organizational support, and staffing and resource adequacy. The result is significant as 32% of the respondents were on a married contract while almost 68% of the respondents were on a single contract. Sixty-six percent of FTNs were married, while 34% of the respondents reported being single. The multiple regression analysis identified a positive relationship between FTNs on a married contract and control over the practice setting and staffing and resource adequacy. Foreign-trained nurses on a married contract may live on the hospital compound, but more often live in the community, which allows the FTNs a certain amount of freedom and support from having family with them. Family provides social support for FTNs who work in challenging situations. Foreign-trained nurses on a married contract may be older, be more mature, have family support, have worked in Saudi Arabia for many years, and be settled into the lifestyle and work. Foreign-trained nurses on a married contract provide for their family in Saudi Arabia and family in their country of origin. During the focus group sessions, married participants discussed the hospital benefits of living in the community. Despite the lack of some benefits that FTNs on a single contract receive, the salary and benefits are still better in Saudi Arabia than in their
224 own country. There is a sense that FTNs have control over the practice setting and that the hospital is providing adequate resources for patients and enough staff for patient care. This result indicated that staffing levels are adequate for more mature FTNs who have a sense of the larger issues of the nursing shortage. A shortage of staff means more overtime for FTNs who are supporting family. Abo-Znadh (1999, p. 72) discovered nationality, availability of a family member (living with a nurse in Saudi Arabia), and total years of Saudi Arabian experience were predictor variables for job satisfaction. The mix of respondents included Filipino, North American, European, and Saudi. The descriptive statistics indicated 31% of the respondents had family living with them. Although Abo-Znadh’s study is almost 10 years older than the current study, having family in Saudi Arabia promoted job satisfaction among FTNs in both studies. Previous job satisfaction research does not support the current study’s findings, as contract status is particular to Saudi Arabia employment. The demographic variable FTNs’ length of work at current hospital up to 3 years had a negative impact on nurse–physician relationships. This result may be the culture shock effect that FTNs experience when working and living in a new environment. Physicians take on different roles and responsibilities in different settings. The findings indicate that FTNs new to the organization predicted the absence of an effective nurse– physician relationship. The work environment variable government FTNs reported higher satisfaction with nurse manager ability, leadership, and support of nurses. This result is significant, as 43% of the respondents were from the government sector while almost 57% of the respondents were from the private sector. The multiple regression analysis identified a
225 negative relationship between the private sector FTNs and nursing foundations for quality of care; nurse manager ability, leadership, and support; and staffing and resource adequacy. Six government participants in the qualitative data described stories of recognition from supervisors. The supportive stories involved successful accreditation with MRQP, staff recognition for infection control nurse and best nurse of the month, and opportunities to work in specialized areas. Abo-Znadh (1999, p. 97) studied two government hospitals in Riyadh and found staff job satisfaction correlated to nationality, total years of Saudi Arabia experience, growth need, and critical psychological states. Working in a government hospital might have contributed to Abo-Znadh’s results. Ten government participants described stories regarding a lack of support from their supervisors. The stories involved lack of staffing, fairness in calling FTNs to work on their day off, discrimination issues, physical and verbal abuse from patients and families, lack of continuing education, and more. The quantitative data might reflect response bias, where participants did not see the nurse manager as responsible for staffing issues, salary and benefit issues, discrimination issues, and more, whereas the qualitative data reflected participants’ open accounts regarding the leadership ability and responsibility of nurse managers to support nursing. The explanation of response bias may explain and support the findings, even though the bivariate analysis failed to support the qualitative data. The private-sector focus group participants described their hospitals as short staffed with a lack of mechanisms to identify problems and improve quality of care, nonsupport of nurses, discrimination issues, physical and verbal abuse issues, and
226 salary and benefit concerns. The qualitative data supported the multiple regression analysis. The demographic variable FTNs pursuing a degree reported higher satisfaction with nurse participation in hospital affairs and nurse manager ability, leadership, and support of nurses. Almost 17% of the FTNs reported they were pursuing a degree, while an overwhelming 83% of the FTNs reported they were not pursuing a degree. Foreigntrained nurses pursuing a degree had a positive correlation to control over the practice setting, nurse participation in hospital affairs, and nurse manager ability, leadership, and support of nurses in the multiple regression analysis. Pursuing higher education and working in Saudi Arabia lends firsthand experience to FTNs regarding the difficulties and challenges a nurse manager faces while working in Saudi Arabia and a greater appreciation of the staffing issues and the ability of the nurse manager to lead and support the nurses. Foreign-trained nurses pursuing a degree may hold higher positions in the hospital and be involved with committee work or quality improvement teams, which provides a management perspective on the work environment. The work environment variable title was significant on the multiple regression analysis. There was a negative correlation between title and nurse manager ability, leadership, and support of nurses and staffing and resource adequacy. Foreign-trained staff nurses made up 75.7% of the participants on the surveys, while other FTNs (charge nurses, supervisors) were 24.3% on the surveys. The result indicates that staff FTNs are not satisfied with the nurse leader’s ability to lead and support them in staffing issues and to provide quality patient care. Friese (2005, p. 769) found that oncology and nononcology staff nurses reported higher job dissatisfaction with nurse manager ability,
227 leadership, and support of nurses in non-Magnet hospitals (M = 2.63 and M = 2.74, respectively). The last work environment variable, number of nurses per 100 beds, was significant on the multiple regression analysis. Participants identified a negative relationship between the number of nurses per 100 beds and autonomy over practice, control over the practice setting, organizational support, nurse participation in hospital affairs, and nurse manager ability, leadership, and support of nurses. The finding indicates the number of nurses per 100 beds predicted the absence of autonomy over practice, control over the practice setting, organizational support, nurse participation in hospital affairs, and nurse manager ability, leadership, and support of nurses. At the time of the survey, 24 nursing directors stated that the staffing ratios ranged from one nurse to between three and seven patients. One hospital nursing director implemented team nursing due to the lack of staff in her hospital. The lack of staff identified by participants in the focus group sessions clearly emphasized the effects of the nursing shortage. Staffing is not the only predictor to the absence of the subscales in the nursing practice environment, but also the nature of the work that nurses perform (nursing and nonnursing duties). In the international study of five countries, Aiken, Clarke, Sloane, Sochalski et al. (2001, p. 49) identified additional duties from respondents that contributed to job dissatisfaction. The additional duties included delivering and retrieving food trays, transporting patients to procedures, housekeeping duties, ordering, and performing and coordinating ancillary services (social worker, dietitian). Although not identified as an issue by participants in the focus group sessions, one participant complained about the amount of time she spent on
228 documentation compared to the time spent on patient care. Nurses in Saudi hospitals share a similar work environment to the environments identified in the United States, Canada, and Germany. A landmark study found that increasing the nurse to patient ratio by one patient per nurse increased job dissatisfaction by 15% and burnout by 23% (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002, p. 1990). Additional studies supported the finding that an increased patient to nurse ratio correlated to job dissatisfaction and increased morbidity and mortality (Lynn & Redman, 2006, p. 688; McCutcheon et al., 2005, p. 4). The findings from the current study indicated that FTNs with a diploma or associate degree, newly registered after 2001, on a married contract, length of work in current hospital up to 3 years, who are government employees, or who are pursuing a degree and staffing levels predicted higher perceptions of job satisfaction for 8 out of the 9 subscales. The NWI-R and PES-NWI subscales represent hospital characteristics that determine retention in certain Magnet hospitals. The current study included the use of the subscales as a baseline to non-Magnet hospitals to determine job satisfaction for demographic and work characteristic variables. The data provide an opportunity for organizations to assess the work environment within the nursing department. Research Hypothesis 3 The quantitative data supported an association between selected demographic variables and work environment variables and burnout among FTNs working in Saudi Arabia. Emotional exhaustion, depersonalization, and personal accomplishment are the subscales for burnout. Emotional exhaustion is a feeling of exhaustion from work itself. Depersonalization is a feeling of distance and uncaring for the patients. Personal
229 accomplishment is a feeling of capability and attainment when working with people. According to Maslach et al. (1996, p. 5), high scores for emotional exhaustion and depersonalization and low scores on personal accomplishment signify a high degree of burnout. Low scores on emotional exhaustion and depersonalization with high scores on personal accomplishment signify a low degree of burnout. Average scores on the three subscales signify an average degree of burnout. The overall survey scores for emotional exhaustion, depersonalization, and personal accomplishment were M = 26.82, M = 11.39, and M = 33.81, respectively. The scores reflect a high degree of burnout for emotional exhaustion, a high degree of burnout for depersonalization, and an average degree of burnout for personal accomplishment. The bivariate and multiple regression analyses identify a relationship between FTNs’ education, title, ownership, and currently pursuing a degree and burnout. Foreigntrained nurses with baccalaureate degree or higher, who were female, and who had a consecutive stay in Saudi Arabia reported higher levels of emotional exhaustion. The demographic factors and work environment factors accounted for 75% of the variance. Foreign-trained nurses with a baccalaureate degree or higher may have more responsibility, are working longer hours, and are assuming an increased workload, which lead to burnout. There was a negative relationship between FTNs on a married contract and emotional exhaustion. An important factor for job satisfaction and lower burnout is for FTNs to have family living with them in Saudi Arabia. The length of time a FTN was in the hospital working (up to 3 years) also suggested a lower perception of emotional exhaustion. Culture shock occurs in the internal and external environment of Saudi Arabia. Working in a new hospital represents transitional periods comparable to culture
230 shock, with new people to meet, a new unit to work on, different patients, and new policies and procedures. Work is exciting and challenging for a few years, thus lower levels of burnout occur. Foreign-trained nurses up to 35 years of age and working in private hospitals reported higher levels of depersonalization or 22% variance. The qualitative data support the finding of depersonalization for FTNs in the private sector where status and security accounted for 20% and 12%, respectively, of the stories told by participants. Status referred to discrimination in salary and benefits; housemaid mentality from hospital administration, patients, families, and physicians; and ethnic discrimination. Security referred to the physical and verbal abuse by hospital administration, patients, families, and physicians. Private sector FTNs expressed a higher level of burnout for depersonalization because of the physical and verbal abuse by patients and families and the lack of organizational support for the issue. The qualitative data corroborated the MBI results. The crab mentality and mafia are security risks for FTNs trying to advance in their career. In the bivariate and multiple regression data, FTNs of other religions, FTNs with a baccalaureate degree or higher, other FTNs (not staff), and FTNs not pursuing a degree reported higher scores for personal accomplishment. Maslach et al. (1996) recommended reporting “personal accomplishment as direct computations of item scores rather than as diminished personal accomplishment based on reversed items” (p. 5). Religion (Islam) was the second pull factor for nurses to work in Saudi Arabia, yet FTNs of other religions reported personal accomplishments in working in Saudi Arabia. The qualitative data confirmed the finding, with Participant 19 stating her work is rewarding and she is
231 gaining knowledge and learning to handle different nationalities and cultures. Foreigntrained nurses with a baccalaureate degree or higher scored a high degree of emotional exhaustion but an average degree of burnout for personal accomplishment. Foreigntrained nurses with a baccalaureate degree or higher have feelings of competence and achievement in their work and a low degree of burnout. The FTNs with a baccalaureate degree or higher may feel personal accomplishment because they are gaining experience and they feel competent and successful in what they are learning from other nurses in the organization. The finding indicated professional nurses get the work done and find ways to feel they have accomplished something worthwhile. Foreign-trained nurses pursuing a degree indicated lower feelings of competence, a lack of achievement and success in their work, and a high degree of burnout. Foreign-trained nurses pursing a degree may be too overwhelmed with the workload, the extra duties, and the lack of nursing staff to feel any successful achievement in their work with people. Staff nurses and FTNs pursuing a degree scored an average degree of burnout for personal accomplishment and had a perception of no personal accomplishment. Burnout has a 25-year history of research. Maslach and Jackson (1984) stated, “Clearly, burnout has its roots in people-oriented, helping professions” (p. 139). The nature of nurses’ work places an inherent stress on nurses. For FTNs working and living in Saudi Arabia, additional stressors in the environment place additional stress on the individual. Flynn and Aiken (2002, p. 71) explored the value of a professional work environment and burnout between international and U.S.-born nurses. Flynn and Aiken (p. 71) concluded a professional nursing practice environment is highly valued by international and U.S. nurses and that an absence of a professional nursing practice
232 environment was a prediction of emotional exhaustion for international (B = -.278, p = .000) and U.S. nurses (B = -.273, p = .000). In terms of the nursing shortage and nurse-topatient ratio, adding one patient to a nurse’s workload increased burnout by 23% in the study by Aiken, Clarke, Sloane, Sochalski, and Silber (2002, p. 1999). In the study by Aiken, Clarke, Sloane, Sochalski, et al. (2001, p. 46), 29-43% of the nurses surveyed in four countries reported a high degree of burnout. German nurses scored the lowest at 15%. Research Hypothesis 4 The analysis identified a positive relationship between gender, education, and nurse participation in hospital affairs and emotional exhaustion. Foreign-trained female nurses with a baccalaureate degree or higher who participate in hospital affairs expressed a feeling of emotional exhaustion in their work. Negative relationships were ownership, length of work at current hospital, worked in Saudi Arabia prior to current contract, autonomy over practice, and staffing and resource adequacy and emotional exhaustion. The finding indicated that emotional exhaustion was present when there was an absence of autonomy over practice and staffing and resource adequacy. The finding of emotional exhaustion and staffing and resource adequacy illustrated the FTNs’ perception of the nursing shortage and a lack of resources due to monetary difficulties in the hospital setting. The absence of autonomy and emotional exhaustion validated the feeling that FTNs who had more responsibility, a heavier workload, and longer working hours experienced burnout. There was a positive relationship between nurse participation in hospital affairs and emotional exhaustion. Foreign-trained nurses who attend committee meetings tend to be the nurse managers, supervisors, or charge nurses. They may be
233 emotionally exhausted due to increased responsibilities with patient care as well as the added responsibilities of attending and participating in committee affairs. Private-sector FTNs, FTNs working in current hospital less than 3 years, and FTNs who worked in Saudi Arabia prior to their current contract did not express a feeling of emotional exhaustion. There was a positive relationship between nurse participation in hospital affairs and emotional exhaustion. This result may indicate that with hospital preparation for accrediting bodies such as JCI and CBAHI, FTNs who assumed patient care were also required to assist the nursing department in preparation of the standards for survey. This is extra work for FTNs who have to take patient assignments due to the nursing shortage and still maintain their administrative duties. A positive relationship existed between ownership and depersonalization, which is the same finding as in Hypotheses 1 and 2. A negative relationship existed between worked in Saudi Arabia prior to current contract and organizational support and depersonalization. An absence of organization support contributed to a feeling of depersonalization as expressed by the focus group participants when telling stories of their status and the discrimination they feel in Saudi Arabia. Foreign-trained nurses who worked in Saudi Arabia prior to their current contract are better prepared to the work and life environment. The data supported this finding. A positive relationship existed between education and personal accomplishment, also identified in Hypotheses 1 and 2. A negative relationship existed between staff FTNs and FTNs currently pursuing a degree and personal accomplishment, also identified in Hypotheses 1 and 2. The current study discovered the absence of autonomy over practice, nursing foundations for quality of care, staffing and resource adequacy, and organizational
234 support lead FTNs to a feeling of emotional exhaustion and depersonalization. Literature supports the findings from the current study. Flynn and Aiken (2002, p. 72) connected the NWI-R subscales to burnout among international and U.S.-born nurses. Friese (2005, p. 770) predicted emotional exhaustion in the absence of staffing and resource adequacy for oncology nurses working in Magnet hospitals. The following paragraphs provide a review of the assumptions, limitations, and delimitations of the current study. Assumptions Foreign-trained nurses in Saudi Arabia will find the results of the current study similar to other studies of job satisfaction and burnout conducted internationally. Organizational leaders will find the results similar to and unique from other studies conducted internationally. There may be some denial regarding the root cause of job dissatisfaction and burnout. Moving forward and building a nursing infrastructure that meets the needs of staff, patients, and families is important during the nursing shortage and for the future health of the nursing profession in Saudi Arabia. The FTNs, although categorized as staff or other, assumed bedside nursing activities in their daily work. The FTNs classified as other had a higher perception of personal accomplishment. The FTNs classified as other are in charge positions and demonstrate more success when working with people. Bedside nurses rarely have an opportunity to be part of interdisciplinary teams and have language barriers with patients and families, and expressed an absence of personal accomplishment. One hospital in Saudi Arabia is on the journey to earning Magnet status and was not in the current study. The MRQP standards stimulated the nursing directors to develop an autonomous work environment containing some of the elements of the subscales.
235 Progress regressed for those hospitals accredited through MRQP according to some participants in the focus group sessions. Limitations The study involved several limitations. The magnitude of the study was a challenge for one person to conduct. The challenges lay in the FTN sample size (almost 6,500 FTNs), the distances between hospitals (within Jeddah and to Makkah), the frequency of visits required to encourage support and commitment to the study, and the cost of the study. The study parameters specified that participants receive the letter of introduction and informed consent prior to the distribution of the surveys. The process of waiting for signed consents resulted in time lost and participants lost. The traveling time was a major factor in the collection and distribution of informed consents and surveys. For example, from the time of distribution of informed consents to the distribution of surveys, FTNs were on vacation or had ended their contracts and left the Kingdom. It was difficult to encourage FTNs to participate for several reasons. Nursing directors stated FTNs were afraid of repercussions despite assurances that the hospital supported the study. At the time of the study, there was a continuous movement of FTNs entering and leaving the Kingdom. Many FTNs were too busy to fill out the surveys because they were ending their contract or moving to another hospital. Foreign-trained nurses were skeptical that the results would move their administration to act on retention issues. Using one hospital characteristic survey (the NWI-R or the PES-NWI) might have improved the response rate on the instruments to minimize the missing data. Although it was impossible to eliminate response bias, monitoring by wave analysis tracked any bias. It was evident from the responses that some FTNs responded favorably and unfavorably
236 regardless of the content, yet the overall aggregated data demonstrated a representative picture of hospital characteristics in Saudi Arabia. Delimitations Only FTNs participated in the study. Administrative staff members participated in the study if they stated they had patient assignments due to the shortage of nurses in their hospitals. All the hospitals in the study were MRQP or JCI accredited. Foreign-trained nurses decided how they wanted to receive the surveys. The methods included postal service, e-mail, or on-site from the nursing office. There were problems with FTNs not receiving the surveys through the postal service or e-mail methods. The situation required delivery of extra survey packets to the nursing office for redistribution. Participants had difficulty with the meaning of some of the language in the MBI survey (for example, callous, the end of my rope). Participants may have had survey fatigue that resulted in missing data. The missing data did not influence the results of the surveys. Although some participants were overly negative, overly positive, or neutral on the surveys, the responses did not influence the overall worldview of the hospital work environment. The next section involves exploring the implications and significance of the findings for the current study. Implications The nursing shortage is not going away. Many countries are rallying to increase the number of students enrolling in nursing programs, to increase the number of faculty, to encourage retirees to come back to work, and to implement retention plans. Many FTNs from Saudi Arabia have started the process of immigrating to countries such as Canada, the United States, and Australia. Although the fallout of the global recession is
237 looming, history can provide nursing leaders in Saudi Arabia with little hope of securing more FTNs. Buerhaus (1994, p. 50) noted the 1990s recession in the United States eased a nursing shortage that had persisted since the mid-1980s. In an economic slow-down, retired nurses typically go back to work because of spousal lay-offs and an increase in nurses’ real wages, which is “the net change in wages after accounting for inflation” (Buerhaus, p. 50). That was the nursing shortage experience from 1994. As noted in chapter 1, the current nursing shortage is different and there remains a need for foreign nurses in countries such as the United States and Australia. A current practice in Florida in the Unites States, called a go-home policy, helps protect nurses’ jobs. To avoid layoffs, the hospitals send nurses home when the unit is not busy. The staff members are not paid or the pay comes from their vacation time. An example is when patients cancel elective surgeries because they cannot afford to pay the cost. If patients are not scheduled for surgery, the unit manager must tell the nurses to go home (I. Rondeau, personal communication, November 8, 2008). For the nursing leaders in Saudi Arabia, the global recession does not negate the fact that there are serious issues in the health-care sector. Job satisfaction, lowering burnout, and retention must still be priorities for nursing and organizational leaders. The next sections include discussions on the significance of the study and the study’s significance to leadership. Significance of the Study The focus of the current study is unique to FTNs’ job satisfaction and burnout while working and living in Saudi Arabia during a nursing shortage. Existing local literature in Saudi Arabia addresses quality of work life with job satisfaction for all
238 nursing staff (Abo-Znadh, 1999). Existing literature addresses job satisfaction and burnout for FTNs in other countries, but the countries do not share the uniqueness of Saudi Arabia. Because of the findings from the current study, the results add a new perspective to job satisfaction, burnout, and the nursing shortage for FTNs living and working in Saudi Arabia. The study results provide evidence that job satisfaction and burnout described in chapter 2 are similar for FTNs in Saudi Arabia and elsewhere in the world. The research findings identified the pull factors for FTNs to work in Saudi Arabia. The research findings confirmed that certain demographic and work environment variables correlate to hospital characteristics (job satisfaction) and burnout. The research findings provide a baseline for Magnet-status research in Saudi Arabia. The correlation of hospital characteristics (NWI-R and PES-NWI subscales) to burnout identifies the importance of a professional nursing practice environment for FTNs. The identification of specific factors that may predict job satisfaction and burnout is significant for retention strategies. The qualitative data, or participants’ own words, add strength to the research findings. The qualitative data complemented the quantitative data and presented a picture of what life and work are like for FTNs in Saudi Arabia. The participants in the focus group sessions added their insights into key issues that will help organizations retain staff. The current study should be a stimulus for further research in the region. Significance to Leadership As a worldview, pragmatism is “typically associated with mixed methods research” (Creswell & Clark, 2007, p. 23). The characteristics of pragmatism include a focus on the consequences of the research, the importance of the question rather than the method, multiple data collection methods that tell the story of the problem, are pluralistic,
239 and are real-world practice oriented (Creswell & Clark, p. 23). Pragmatism is the philosophical foundation of the worldview presented in the current study. The purpose of the study was to explore the relationship between demographic and work environment factors and job satisfaction and burnout for FTNs living and working in Saudi Arabia using mixed-method research. Four hundred and fifty-three FTNs participated in the surveys and 25 FTNs participated in the focus group session from 25 hospitals between Jeddah and Makkah. A professional nursing work environment fosters job satisfaction. Job dissatisfaction and burnout are predictors that an organization lacks a professional nursing work environment (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002, p. 1990; Flynn & Aiken, 2002, p. 71; Friese, 2005, p. 769; Upenieks, 2002, p. 568; and Vahey et al., 2004, p. 11-59). It is time that Saudi Arabia embraces a culture of a national nursing workforce. Categories of Saudi and non-Saudi nurses create barriers and often promote discrimination. The nursing shortage should bring the country leaders (government and private) together to collaborate on the issues and strategically plan a course of action to improve the professional nursing environment. Salary and benefits are a contentious issue. Perhaps a new paradigm can identify a fair and equitable distribution of salary instead of the current paradigm of country of origin. The characteristics of a professional nursing practice environment are autonomy and control over nursing practice, collegial relationships between nurses and physicians, organizational support for staffing, continuing education, quality care, and a nurse manager that is a leader and supports nursing. In order for a professional practice environment to succeed in Saudi Arabia, the nursing profession needs the commitment of
240 hospital leaders, nursing directors, and education directors. Leadership influences the culture of the organization. The findings from the current study include the challenges to transforming the nursing practice in Saudi Arabia. Transformational leaders are necessary to effect change. Tichy and Devanna (as cited in Bass, 1990) defined transformational leadership as a behavior process capable of being learned and managed. It’s a leadership process that is systematic, consisting of purposeful and organized search for changes, systematic analysis, and the capacity to move resources from areas of lesser to greater productivity . . . [to bring about] a strategic transformation. (p. 53) Improving the nursing work environment presents an opportunity for leaders in Saudi Arabia to inspire the nursing workforce and promote job satisfaction and tenure. The current study will be of significance to leaders that develop health-care policy. Nurses inherently want a practice environment that is conducive to learning, professional growth, respect, and dignity. Salary and benefits are important factors for all nurses working in Saudi Arabia. Salary is not the force that drives intrinsic motivation. The current study identified the factors that motivate the FTNs. The factors included support from organizational leaders for staffing and ongoing education, qualified nurse managers who are able to lead and who support nurses, an environment where quality is fundamental in the nursing role, policies and procedures that are implemented and evaluated, and an environment that is safe and supports the profession of nursing. For Saudi Arabia, the research is significant as the first study to look at the practice environment for FTNs who are the backbone of the health-care system. Aiken,
241 Clarke, Sloane, Sochalski, and Silber’s (2002, pp. 1990-1991) study in the United States discovered a 7% increase in patient mortality within 30 days of admission and a 7% increase in failure-to-rescue by adding one patient to a nurse’s workload. Associated with the mortality and failure-to-rescue statistics, job dissatisfaction and burnout were 15 and 23%, respectively. Foreign-trained nurses in Saudi Arabia do not work to their full potential. The frustration is palpable with the quantitative and qualitative data. The global recession may indicate that FTNs will continue to travel to Saudi Arabia for work. The global nursing shortage still threatens the health-care infrastructure of Saudi Arabia. For global leadership studying the nursing shortage and migration of nurses, the current study opens a window into a life and work environment in Saudi Arabia not seen by the outside world. The study provided themes centered on the lived experience of FTNs in a unique setting. Participants identified the push factors for leaving their home countries, the issues that only international recruits’ experience, and the experiences that make them happy in their work and sad in their work. The work provides an income for not only the FTN but also his or her family in the home country. The life and work provides the means for some FTNs to be closer to religious roots. The work provides FTNs with an opportunity to gain experience and move forward in a nursing career. The experiences of FTNs in Saudi Arabia identified in the current study are not unlike the experiences described in other research. Nurses globally experience increased work pressures due to an increased acuity of an aging population, patients with complicated disease and infectious processes, lack of qualified staff to provide quality and safe patient care, a job description that goes beyond the responsibility of professional nurses, and administrators and patients who abuse nurses both physically and verbally. The added
242 pressures for FTNs in Saudi Arabia are not being able to live with family members, the restrictions of the country that create security risks for single FTNs, the diversity of the workplace and inadequate enculturation, and the language barrier that inhibits FTNs’ ability to provide total patient care. The next section identifies recommendations for local, national, and global leaders based on the findings of the current study. Recommendations for Nursing Leaders and Hospital Leaders The current study identified demographic and work environment factors that contributed to job satisfaction and burnout for FTNs living and working in Saudi Arabia. The data do not provide causal relationships between demographic and work environment factors on job satisfaction and burnout, but rather infer a relationship between independent and dependent variables. Based on the worldview presented in the findings, this section discusses recommendations for enhancing the nursing practice environment using Herzberg’s hygiene-motivator theory. Hygiene Factors Salary and benefits. To recruit and retain FTNs to work in Saudi Arabia, healthcare organizations must invest in their personnel and the environment in which they work. Salary was both a satisfier and a dissatisfier for participants. While some feel discrimination exists in the way salary scales are calculated, others feel they are able to provide for their families at home. Salary is not the intrinsic motivator to performing one’s job. The allocation of increases must be fair and handled in an open and honest way. Although participants in general expressed dissatisfaction regarding their salary due to increased demands on them (workload and extra duty), the root of the problem is in the policy implementation of salary and benefits. The problem is Saudi Arabia has no
243 uniform policies to guide salary and benefits. Some hospitals pay for the Iqama, whereas others do not. Some hospitals pay a portion of the Saudi Council license whereas others do not. Some hospitals pay for a yearly ticket home for some nationalities, whereas others do not. Being open and honest will be difficult for some organizations, but this style of leadership fosters credibility and gives the FTNs a sense of inclusion with the organization. Some Saudis and expatriates view life and work in Saudi Arabia as temporary, with the life and work of an FTN tied to a contract. Leaders must strive for some sense of permanency if retention is important to them. In terms of the benefits associated with salary, all FTNs deserve adequate accommodation and an opportunity to live as normal a life as possible in a country with gender restrictions. Participants discussed the benefit of opening up the restrictions by offering extended hours to shop off the compound. Participants discussed the benefit of offering recreational and other activities to enhance the living conditions. Hospitals see the benefit of allowing family members to live with FTN staff. Foreign-trained nurses on a married contract had a higher perception of job satisfaction and lower burnout on certain hospital characteristics. According to the participants in the focus group session, FTNs on a married contract live in the community with their husband. The ability to live with a husband or family members is conducive to a positive worldview, but having to live in crowded conditions is not conducive to even the single nurses from collectivist societies. “If nurses had the opportunity to live on their own, they would” (H. Mabuhay, personal communication, September 23, 2008). The cost of health care in Saudi Arabia is escalating and additional monies for FTNs may not be a priority. A combination of a fair salary and other measures may improve tenure for FTNs.
244 Recruitment. Recruitment can be a positive experience to welcome FTNs to Saudi Arabia. Recruitment agencies are in the business of placing nurses in other countries and should be humanistic in their recruitment activities. The practice of recruiting includes the recruitment teams from hospitals in Saudi Arabia that travel to other countries vying for nursing staff. Recruiting nurses should not be an auction but rather an assessment of the nurses best qualified to practice in Saudi Arabia. If recruiters are offering a certain benefit package, that package should be the same one from the point of hire to the finish point. The problem for many nurses is their inability to stand up to some injustices perpetrated against them. Requiring an FTN to sign an Arabic contract or lose his or her salary is unfair and threatening. The MOH should take the lead on ensuring recruitment agencies are legitimate businesses, and FTNs must have a contact person (not an embassy) to lodge complaints with, investigate complaints against an agency, and ensure contracts are binding from the beginning to the end of the recruitment process. Without a vested interest in the recruitment process, the sentiment of hospital leadership and its environment will forever be one of mistrust. Work conditions. The literature is rich with the challenges facing organizations due to lack of staff. The ideal nursing department is an all-registered nursing staff to improve patient safety and provide quality of care. Foreign-trained nurses identified additional nonnursing activities that take them away from patient care, including documentation requirements. In the current climate of the nursing shortage, nonlicensed nursing personnel could help ease the workload of FTNs in Saudi Arabia by performing the activities that support patient care.
245 Status (Respect and dignity). Nurses are the frontline of the health-care system, and physical or verbal abuse by hospital administration (including physicians), patients, and families is intolerable. Patients, families, and administrators often undervalue the professional image of nursing and the nurse’s role in the health-care system. Zerotolerance policies and procedures protect FTNs from physical and verbal abuse by coworkers, patients, and families. The American Society of Registered Nurses (2008, ¶ 1) found that 56% of nurses surveyed in April 2008 reported being physically and verbally abused by patients. “But there is an underlying truth many have just accepted as being part of the job” (American Society of Registered Nurses, ¶ 3). Leaders must empower FTNs to report any physical or verbal abuse. Leaders must support FTNs by investigating the incident and instituting measures to decrease the risk of reoccurrence. The new culture of professional practice leads to the second solution to the issue of respect and dignity: Saudi licensure. The Saudi Council designates a Filipino nurse as a technical nurse because of the Council’s assessment of the education system in the Philippines. The number of nurses with baccalaureate degree in Saudi Arabia outnumbers those reported in the literature. For many overseas organizations, this is enviable. Filipino nurses work in the United States and Canada on the same license and salary scale as baccalaureate, associate, or diploma nurses. It is time to reassess the designation for Filipinos as the largest group of FTNs working in Saudi Arabia. A revised designation also creates the opportunity for hospitals to receive continuing education units for staff. Diploma and Filipino nurses with baccalaureate degrees do not receive continuing education units for conducting lectures or symposiums, which results in FTNs who are unable to secure the required units to renew their Saudi license.
246 Lastly, it is time for FTNs to occupy a place next to physicians as equal partners in promoting quality and safe care for patients. The first solution to the issue of respect and dignity is to create a culture of partnership. Leadership needs to create a professional work environment where FTNs work as professionals within their scope of practice. Relationships with supervisors and peers. There are challenges to working in a diverse culture. It is leadership’s responsibility to create a high-level performing organization by creating harmony in the workplace. Participants in the focus group sessions shared their inner thoughts. The personal and work lives of an FTN working in Saudi Arabia are inherently connected. Staff members live on the same compound, they may even live in the same apartment, and they work together, which results in very close relationships with all levels of the nursing staff whether the FTN wants it or not. Participants want and need support from supervisors. Supervisors must be qualified in their job or they need training in management and leadership skills. Supervisors have a difficult role within the hospital. They are responsible for the nursing staffs, for the safe care of patients, and to mediate disputes between nursing and other personnel. A manager earns respect from his or her followers, and earning respect is not a given. Participants discussed their experiences of a lack of support from the supervisors in the scheduling and medication error incident, in the emergency electrical outage, in reporting physical or verbal abuse, in the lack of fairness when dealing with staff, and in not replacing staff who call in sick. Participants want support from peers. One focus group participant, new to Saudi Arabia, discussed her relationships with her peers on the unit. She expected nurses from her country to support her. The participant felt the lack of support from peers was due to
247 the pressures from supervisors and management on blaming staff for any reported incident. The nursing staff members work to either cover up occurrences or remain distant from coworkers to avoid becoming involved. The participant stated, “With this culture, nurses are not performing well. The nurse is not doing the right thing anymore. The nurse is tense and stressed. We are just foreigners, here to do a job.” The culture of self-protection was evident in the discussion of the crab mentality and mafia. The subculture groups threaten the staffs on the unit and create a barrier to better teamwork. A cultural diversity program would help to create effective and efficient working relationships among all levels of staff. Topics should include race/ethnicity, nationality, religion, values, ethics, communication (including languages), cross-cultural (mis)perceptions, negating stereotypes, building interpersonal relationships, and conflict prevention and resolution. Motivators Recognition. Participants from both the government (48%) and the private (20%) sectors identified recognition as the number one gesture that made them happy at work. The most frequent story told by participants was when supervisors recognized their accomplishments. Stories reflected recognition for participants’ hard work during MRQP accreditation, the best infection control nurse, the best nurse of the month, recognizing an FTN’s ability to present a lecture to staffs, among others. It is not difficult or costly to build a recognition program into the daily work of staff. The following are some suggestions for the nursing leaders. First, the nursing director should be visible to staff. He or she should make rounds to the units once a week and talk to staff to find out how their work is going, to determine the difficulties staff members face, and to thank them
248 for being there and providing safe and quality care to the patients. Second, the nursing director should have an open door policy. Let the staff know the nursing director is always available for them to support them and to hear their concerns. Third, develop a recognition program such as the infection control nurse and best nurse of the month. Start by recognizing teams such as quality improvement teams that are working on projects. Develop criteria and a team to vote for the best team or best quality improvement project. The process will eliminate bias when voting. Fourth, delegate appropriate staff members to participate on nursing and hospital committees or teams. Include staff in hospital affairs and decision making. The committee time must be part of the workday schedule. Participation in committees should not be on the FTNs’ own time. Fifth, allow educational time for all staff, including supervisors. This requirement is challenging during the nursing shortage, but direct every effort to this goal. To retain staff members, recognizing their work and achievements is part of the solution. Achievement. A pull factor for many FTNs was to gain experience and knowledge in Saudi Arabia. Nursing directors from Jeddah Nurses Executive Forum noted the education and advancement provided to FTNs furthers their career and chances to migrate to other countries. This is an unpleasant fact in any organization. The issues in Saudi Arabia include the cost of recruiting FTNs, salary and benefits, educating the FTNs, the restrictions of the country, and then the FTNs leaving at the end of the contract. Careful selection of qualified and willing FTNs is the first step. Full disclosure of the restrictions in Saudi Arabia, binding contracts between recruitment and hospitals, and a humanistic approach to recruitment and unit placement will help nursing leaders select staffs members who might have tenure in Saudi Arabia. The second step is to build
249 a clinical ladder program. Clinical ladders promote career paths for nurses and a professional nursing work environment. A clinical ladder creates professional development through continuing education. “Progression up the clinical ladder structure is dependent upon the individual nurse meeting defined clinical excellence, skills and competency, professional expertise, and education attainment” (Commonwealth Health Corporation, n.d., p. 2). To support the clinical ladder program, the nursing leader must develop nursing councils. The teams monitor and improve the nursing clinical environment through professional development (education and Saudization), leadership (administrative and fiscal), quality improvement (monitoring indicators), and evidencebased practice (research and practice). Work itself (Professional nursing environment). The nursing environment must move toward Magnet qualities. The quantitative data demonstrated key relationships between demographic variables and work environment variables and job satisfaction and burnout variables. A cohesive workforce will help develop the subscale qualities. For example, FTNs with a diploma or associate degree demonstrated higher satisfaction scores on control over the practice setting, nurse–physician relationships, and organizational support compared to FTNs with a baccalaureate degree or higher. The aim of the research was not to place FTNs in categories but to identify areas of improvement in the work environment. Nursing leadership can work to construct a cohesive nursing department by implementing programs identified under intrinsic motivators, including clinical ladders, clinical practice teams, leadership training, practice councils, cultural diversity training. Nursing leaders must ensure professionalism on all units by assessing the FTNs’
250 educational qualifications, competencies, and experience for providing clinical care. Adequate staffing levels are the major issues facing nursing directors in Saudi Arabia. “Increased nurse staffing in hospitals is associated with better care outcomes, but this association is not necessarily causal” (Kane et al., 1997, p. 5). Nursing directors need a strategic plan on staffing and support services for the nurses. If possible, other staff under the supervision of a professional nurse should handle nonnursing duties. Magnet-status hospitals have self-governing nursing departments. Selfgovernance is a complicated concept but the paradigm includes governance (autonomy and control) as the structure, shared decision making as the process, and shared leadership as the outcome. Porter-O’Grady (2005) noted, “Shared governance is a vehicle for change, growth, and empowerment for the profession and the professional; it is not an end in itself” (p. ix). Self-governance requires qualified and competent nursing leadership (a transformational leader), qualified and competent nursing managers, and overall support from hospital administration in both resources and capital. The findings in the current study do not indicate all hospitals should undergo Magnet accreditation. The Magnet program is a guide to improve the health of nursing departments in Saudi Arabia. Nursing directors can achieve these qualities by embracing and embedding the CBAHI standards as the foundation to the further growth and development of a professional nursing work environment. The study moderators minimized bias and assumptions by working together on data entry and interpretation of findings. Objective findings resulted from the triangulation design of validating the quantitative data with the qualitative data. Interesting data emerged that recommended recruitment be added as a hygiene factor to
251 the theoretical framework. Recruitment was an issue for many focus group participants, who each had his or her own story to tell. Recruitment might be a factor worth investigating for FTNs working in similar situations. The inside stories of crab mentality and mafia provided valuable information on the subcultures that may be currently undermining nursing directors and nursing departments. There was an overwhelming sense that policies and procedures for human resources are not universal. That is, according to the focus group participants, each hospital had its own policy for human resource issues (such as Iqama payment, overtime, and license payment). Similar issues bind the government and private hospitals. The work is not about salary alone, but includes working conditions, nursing director support, personal life, and more. There is an enhanced and appreciative recognition that the nursing profession globally is experiencing difficulty. Nursing leaders and researchers must continue to work toward building a new future for nurses worldwide. Recommendations for Future Research Since the proposal of the current study, no additional research has been forthcoming from Saudi Arabia, although a plethora of current research from the United States, Australia, United Kingdom, Canada, New Zealand, and China provide insight into nursing organizations’ strategies to abate the nursing shortage. The current study was specific in exploring demographic and work environment factors that contribute to job satisfaction and burnout. This section includes a discussion on recommendation for future research. Replicating the current study can enable the comparison of results to the baseline data presented. Further research of the current study following the same methodology and
252 data analysis plan can compare the progress of the nursing departments in terms of nursing practice environment and the implementation of CBAHI standards. Replication of the current study will compare the results of the demographic and work environment factors that constituted the foundation of the current study. Recruitment practices for Saudi Arabia are expanding to countries such as China. The changing cultural environment for nurses plays a role in job satisfaction and burnout, as observed in the data in chapter 4. Expanding the study to include all FTNs in the Kingdom and all hospitals in the Kingdom is a grandiose project that is possible with the assistance of the MOH and the Saudi Council. A study to assess job satisfaction and burnout for Saudi Arabia’s nursing leaders is another recommended area for further research. The results might provide an indication of the challenges of being a nursing leader. Omer (2005, p. 1) explored the leadership styles of unit nurse managers at the National Guard hospitals. An expansion of leadership styles research to the nursing directors of MOH and the private sector might provide a correlation to job satisfaction and burnout. Al-zayyer (2003) studied the nursing shortage, barriers to recruitment and retention, and relationships between the barriers and strategies of recruitment and retention. Recruitment and retention will remain Saudi Arabia’s priority over the long term. To improve the health-care services in the Kingdom, the government and private sector need research to make significant changes. Research is the mechanism for change in Saudi Arabia. It is clear from the data analysis in chapter 4 that all is not well in the hospitals in Saudi Arabia. There is an organizational culture to change, behaviors to modify, and attitudes to improve. The most efficacious way to reach nursing and hospital leaders is through research.
253 The hygiene factor personal life takes on new meaning when applied to FTNs who live and work in Saudi Arabia. The quality of life for FTNs who live on compounds with fellow workers is an important area of research. Personal life and work life are inseparable. Further research into the quality of life for FTNs might provide reasons for job dissatisfaction, lack of tenure, burnout, quality of patient care, and more. Contracted FTNs in the government and private sector have no choice over the benefits (accommodation, family with nurse, recreational activities, shopping times, etc.) of the job as these are constrained by the economic resources of the employer. The FTNs’ personal life directly affects job satisfaction and burnout. It is important to continue research in this area to be competitive to other countries. A study of the perceptions of Saudi nurses on job satisfaction and burnout may provide additional information specific to their work and personal life. Saudization of the nursing profession will continue to play a major role for the nursing directorate of the MOH. As more nurses who are Saudi enter the workplace, their perspectives on the work environment will be crucial. The Magnet status qualities represent original research into the nursing work environments that retained staffs. One hospital in Saudi Arabia is preparing for the Magnet accreditation. The qualities of a Magnet hospital are the subscales used in the current study. A local hospital that achieves Magnet status may have valuable insight into the unique characteristics of the Saudi health-care system that will assist other nursing leaders. Summary and Conclusion The quantitative findings confirmed an association between demographic and work environment factors and hospitals characteristics (job satisfaction). The
254 demographic variables included religion, education level, year registered, length of work at current hospital, worked in Saudi Arabia prior to current contract, consecutive versus nonconsecutive stay in Saudi Arabia, and FTNs pursuing a degree. The work environment factors included title, ownership, contract type, and number of nurses per 100 beds. The demographic factors that indicated a relationship to burnout included gender, age, religion, length of work at current hospital, worked in Saudi Arabia prior to current contract, consecutive versus nonconsecutive stay in Saudi Arabia, and FTNs pursuing a degree. The work environment factors included title, ownership, and contract type. The absence of autonomy over practice, nurse participation in hospital affairs, nursing foundations for quality of care, and staffing and resource adequacy were associated with emotional exhaustion while the absence of organizational support was associated with depersonalization. The qualitative data identified motivator stories related to recognition, work itself, and achievement as an exceptionally good day at work. Hygiene stories that related to exceptionally happy days at work included company policy and administration, work conditions, relationship with supervisor, salary, and relationship with peers. Stories that related to exceptionally bad days at work included the hygiene factors of company policy and administration, work conditions, status, relationship with supervisors, security, and personal life. Triangulating the qualitative and quantitative data resulted in identifying themes related to hospital characteristics (job satisfaction). The following points summarize the triangulation findings:
255 1. Organizational support and staffing and resource adequacy: The lack of staff is clearly an issue supported in the data. Organizations are not supporting FTNs with the activities that they assume (nonnursing activities, hospital committee members) and are not supporting the nursing profession by providing continuing education and opportunities for advancement. Organizational leaders are not implementing and maintaining policies and procedures that support the FTNs. Organizational support must ensure a personal life for FTNs that promotes job satisfaction and lessens burnout, but does not go against the religious and cultural aspects of the country. 2. Control over the practice setting, nurse participation in hospital affairs, and nursing foundations for quality of care: Through the implementation of MRQP standards, FTNs viewed some control over the practice setting. Foreign-trained nurses are involved with hospital committees that provided a gateway for organizational participation and monitoring the nursing quality program. Foreign-trained nurses see little control over the recruitment issues that needs organizational and leadership support. Policies and procedures, orientation, and competency training exist through the MRQP and CBAHI standards. Organizational leaders must ensure the implementation of these standards to provide job satisfaction. 3. Nurse–physician relationships and collegial nurse–physician relationships: Foreign-trained nurses supported the working relationship with physicians. Physicians demonstrated recognition and support for the nursing staff. Conflicts developed when cultural and value differences arose when physicians and the organization did not support and promote patient-centered care.
256 4. Autonomy over practice and nurse manager ability, leadership, and support of nurses: Foreign-trained nurses viewed little autonomy over practice by the lack of the nurse manager ability, leadership, and support of nurses. To have an autonomous nursing environment where nurses have control over their practice, requires the skills and leadership of an effective nurse manager. Subcultures within the nursing department continue to undermine the nursing profession and are problematic for nursing managers. Communication and language barriers prohibit nursing autonomy for nurse managers and staffs. The hierarchy of the hospitals in the current study illustrated the significance of having Arabic as a second language. Foreign-trained nurses are in a vulnerable position when they must use an interpreter to assess a patient and plan care. The nursing profession in Saudi Arabia lags behind the recognition of the profession in other countries. Being treated as a housemaid was not the expectation of FTNs coming to work in Saudi Arabia. Nursing managers seem to have little control over this issue due to the lack or absence of autonomy over practice. Saudi Arabia’s organizational and nursing leaders face many challenges in promoting job satisfaction, decreasing burnout, and improving tenure for FTNs. The worldview of the FTNs living and working in Saudi Arabia presented similar issues to previous research but identified unique issues specific to Saudi Arabia. The current study indicated job satisfaction and burnout positively correlated to certain demographic and work environment factors. Leaders should not view demographic and work environment factors in one context. Rather, leaders must view the findings from the current study in the full context of the quantitative and qualitative results. Transformational leadership and support from health-care leaders in Saudi Arabia can effect needed changes in the
257 professional nursing work environment. Nurses in the Kingdom must work collaboratively and cooperatively to implement a nursing environment that will result in job satisfaction, decreased burnout, and tenure for FTNs.
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274 Nehring, V. (2003). A snapshot of nursing in Qatar. Nursing Education Perspectives, 24(5), 226-229. Retrieved April 19, 2005, from ProQuest Database. Neuman, W. L. (2003). Social research methods: Qualitative and quantitative approaches (5th ed.). Boston: Allyn & Bacon. Omer, T. Y. (2005). Leadership style of nurse managers at the Saudi National Guard Hospitals. Dissertation Abstracts International, 66 (03), 1399B. (UMI No. 3167542) Oulton, J. A. (2006). The global nursing shortage: An overview of issues and actions. Policy, Politics, & Nursing Practice, 7(3), 34S-39S. Retrieved November 10, 2006, from Sage Full-Text Collections. Overland, M. A. (2005, January 7). A nursing crisis in the Philippines. The Chronicle of Higher Education, 51(18). Retrieved April 29, 2005, from ProQuest Database. Pakkiasamy, D. (2004). Saudi Arabia’s plan for changing its workforce. Retrieved March 31, 2005, from http://www.Saudi-US-Relations.org Pearson Virtual University Enterprises. (2007, February 20). NCLEX licensure testing: The NCLEX® examination. Retrieved March 9, 2007, from http://www.vue.com/ nclex/ Philippine Overseas Employment Administration. (2004, July). Things you should know about working in Saudi Arabia: Working in the Kingdom of Saudi Arabia. Retrieved April 17, 2005, from http://www.poea.gov.ph/Country/ksa.htm Philips, B. (1998). The true religion of God (3rd ed.). Riyadh, Saudi Arabia: AlHomaidhi Press. Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods (7th ed.).
275 Philadelphia: Lippincott Williams & Wilkins. Polt, C. A. (2004, March/April). Working abroad as a nurse: A great demand for nurses worldwide. Transitions Abroad Magazine. Retrieved April 17, 2005, from http://www.transitionsabroad.com/publications/magazine/0403/ working_abroad_as_a_nurse.shtml Pond, B., & McPake, B. (2006). The health migration crisis: The role of four organisations for economic cooperation and development countries. The Lancet, 367(9520), 1448-1455. Retrieved September 7, 2006, from http://www.thelancet.com/journals/lancet/article/PIIS0140673606683463/fulltext Porter-O’Grady, T. (2005). Implementing shared governance: Creating a professional organization. Retrieved April 10, 2008, from http://www.tpogassociates.com/SharedGovernance/htm Priestley, L. (2000). Nursing in a foreign country. Australian Nursing Journal, 7(11), 1819. Retrieved April 22, 2005, from ProQuest Database. Rasooldeen, M. (2008, June 4). Health coverage for 4 million domestic helpers. Arab News. Retrieved September 28, 2008, from http://www.arabnews.com/?page=18section=0&article=110565&4=4&m=6&y=2 008 Rasooldeen, M. (2008, February 18). Ministry to review health workers salaries. Arab News. Retrieved October 5, 2008, from http://www.arabnews.com/ ?page=18section=0&article=106905&d=18&m=2&y=2008 Reinardy, S. (2007). Satisfaction vs. sacrifice: Sports editors assess the influences of life issues on job satisfaction. Journalism & Mass Communication Quarterly, 84,
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281 APPENDIX A: PERMISSION LETTER FROM HEALTH RESOURCES AND SERVICES ADMINISTRATION Recently you requested personal assistance from our on-line support center. Below is a summary of your request and our response. We will assume your issue has been resolved if we do not hear from you within 48 hours. Thank you for allowing us to be of service to you. To update your question from our support site, click the following link or paste it into your web browser. http://answers.hrsa.gov/cgibin/hrsa.cfg/php/enduser/
[email protected]&p_next_p age=myq_upd.php&p_iid=17141&p_created=1174734163 Subject --------------------------------------------------------------permission to use information from copyright publications Discussion Thread --------------------------------------------------------------Response (Inga Franklin) - 03/26/2007 01:51 PM It's okay if you use this information. Please make sure you reference it. Customer (Joan Mitchell) - 03/24/2007 07:02 AM Good afternoon, I am a doctoral student living and working in Saudi Arabia. I would like to use some diagrams in my proposal that I found in your documents. The diagrams include: 1. Chart 1, page 3 in Projected supply, demand, and shortages of registered nurses: 20002020 (July 2002). 2. Exhibit 4, page 4 in What is behind HRSA's projected supply, demand, and shortage of registered nurses. 3. Exhibit 11, page 10 in What is behind HRSA's projected supply, demand, and shortage of registered nurses. Thank you for your assistance. Regards, Joan Mitchell RN Auto-Response - 03/24/2007 07:02 AM Question Reference #070324-000015 ---------------------------------------------------------------
282 Category Level 1: Health Professions Category Level 2: General Date Created: 03/24/2007 07:02 AM Last Updated: 03/26/2007 01:51 PM Status: Waiting Alternate Email: [---001:001557:10665---] Inga Franklin National Center for Health Workforce Analysis Health Resources and Services Administration
283 APPENDIX B: HERZBERG’S MOTIVATION–HYGIENE THEORY
284 APPENDIX C: MINISTRY OF HEALTH LETTER OF SUPPORT
285 APPENDIX D: TRANSLATED MINISTRY OF HEALTH LETTER OF SUPPORT
286 APPENDIX E: STUDY PROTOCOL Foreign-Trained Nurses in Saudi Arabia: The Challenges of Recruiting and Retaining Staff Nurses A phase 1, mixed method research, multi-center study of the variables that contribute to job satisfaction and burnout of foreign-trained nurses in Saudi Arabia. Regulatory Sponsor:
Joan Mitchell
Funding Sponsor:
Self funded
Study Product:
N/A
Protocol Number:
N/A
IND Number:
N/A
Study Summary
Short Title
Foreign-Trained Nurses in Saudi Arabia: The Challenges of Recruiting and Retaining Staff Nurses N/A
Protocol Number
N/A
Phase
Phase 1
Methodology
Mixed method research (survey tools and focus group sessions)
Study Duration
Three months at time of implementing survey distribution. Twenty-eight hospitals meet the criteria to participate in this study in Jeddah and Makkah The purpose of this study will be to examine the relationship between demographic and work environment factors on job satisfaction and burnout among foreign-trained nurses working in Saudi Arabia. Previous studies have focused on the significance of nurses’ job satisfaction and burnout within the context of the nursing shortage. Sample size at this time is estimated to be 1000 foreign-trained nurses (SNs, charge nurses, head nurses) The methodology: descriptive statistics, bivariate using correlation procedures, multiple regression, and triangulation.
Title
Study Center(s)
Objectives
Number of Subjects Statistical Methodology
287 Introduction This document is a protocol for a human research study. This study must meet the U.S. and international standards of Good Clinical Practice (FDA Title 21 part 312 and International Conference on Harmonization guidelines), applicable government regulations and institutional research policies and procedures. Background The nursing shortage challenges policy makers in developed and developing nations. According to Pond and McPake (2006, p. 1448), analysts posit the recent rise in immigration of nurses and physicians from low and middle income countries to high income countries will continue to play a major role in the global health care shortage for decades. As a recipient nation for health care professionals, Saudi Arabia has been dependent on foreign-trained nurses since the 1950s (Tumulty, 2001, p. 285). Despite its financial stability, Saudi Arabia is a developing nation. It remains dependent on foreigntrained nurses as it continues to develop its health care infrastructure for a society of 27 million people (World Facts, 2004-2006). According to the Ministry of Health (1425 H., 2004 G), 76% of working nurses are non-Saudis in all sectors of the health care arena (this includes Ministry of Health [MOH}, private, and military). Dependence on foreigntrained nurses in Saudi Arabia poses a threat to the health care infrastructure of the country (Tumulty, 2001, p. 286). Health care policy in all sectors must reflect priority measures to retain and recruit foreign-trained nurses. Risk/Benefits There are no risks for the organizations participating in this study. Hospitals and subjects are anonymous and all information collected is confidential to the researcher, statistician, and university mentor. The benefits include sharing of the research study with participating organizations that are facing the challenges of recruiting and retaining foreign-trained nurses. Study Objectives The primary objective for this study is to identify what variables influence job satisfaction and burnout for foreign-trained nurses who live and work in Saudi Arabia. The secondary objective is to correlate variables to the study’s theoretical model – Herzberg’s Two – Factor theory of motivation and hygiene (Herzberg, 1974). Study Design General Design • Mixed method study with analysis in an explanatory correlation design • Foreign-trained nurses will volunteer to participate in the study. All foreigntrained nurses will receive a description of the research and a consent form. Survey distribution will occur in the hospitals by the researcher. Foreign-trained nurses will participate in focus group discussions after the completion of the surveys. This method of distribution ensures random sampling with no bias.
288 Primary Study Endpoints The primary endpoint will be the sample size requirement Subject Selection and Withdrawal Inclusion Criteria • Hospitals with accreditation in Makkah Region Quality Program (MRQP) Accreditation or Joint Commission International (JCI) Accreditation • Foreign-trained or expatriate registered nurses • Staff nurses, charge nurses, or other nurses that perform beside care • Voluntary participation by subject • Verbal and written understanding of English Exclusion Criteria • Those hospitals not accredited • Saudi registered nurses • Administrative nurses that are at an organizational level above charge nurse • Staff nurses III, nurse aide, midwife without registration Subject Recruitment and Screening The researcher will distribute a cover letter and consent form describing the research and requesting participation in the study. When the researcher receives the consent form, the nurse will receive the surveys. The researcher will elicit participants for the focus group sessions while distributing the surveys. The participant will schedule a suitable session depending on work schedule. Early Withdrawal of Subjects Withdrawal of Subjects The participants (including subjects and hospitals) can withdraw from the study by notifying the researcher. Data Collection and Follow-up for Withdrawn Subjects Participants must complete three survey tools and a demographic survey to be included in the study. Not all participants will attend the focus group sessions, but there will be a representative sample.
289 Study Procedures Visit 1 – Coordinate distribution of cover letters and consent forms to all foreigntrained nurses meeting the criteria in all hospitals. Visit 2 – Pick up consent forms from secured locked box in the hospital. Distribute surveys to foreign-trained nurses who signed consent form. Visit 3 – Collect surveys from secured locked box in the hospital. Statistical Plan Sample Size Determination Twenty-five hospitals agreed to participate out of 28. Based on documentation from the nursing directors, an estimate of the number of foreign-trained nurses employed in the 25 hospitals is 4,531 (excluding 10% for administrative staff). Using the sample error formula (Creswell, 2002, p. 634), the sample size for the quantitative data will be 356 (with confidence level at 95% and the confidence interval at 4%). Additional participants will add validity to the study. The researcher will be prepared to accept 1000 surveys and 2 additional focus group sessions. Statistical Methods The surveys will provide data for quantitative methodology and focus group sessions will provide data for qualitative methodology. The methodology includes four steps. The first step will be the identification of dependent variables and independent variables. The dependent variables include job satisfaction and burnout. Independent variables include a subset of demographic and work environment variables. The second step will be descriptive statistics that explains the participants and hospitals. The third step will be bivariate descriptive statistics. This procedure will explain the relationship between two variables. For example, job satisfaction correlated with age, marital status, and education. The fourth step will be multiple regression statistics. This procedure will explain multiple relationships between the dependent variables and independent variables. Focus group sessions using Herzberg’s theoretical framework will provide the qualitative data. Triangulation of the quantitative and qualitative data may assist in understanding the personal and professional issues of foreign-trained nurses in Saudi Arabia. Subject Population(s) for Analysis • All-randomized population: meeting the criteria of staff nurse I, staff nurse II, and charge nurse
290 Data Handling and Record Keeping Confidentiality Information about study subjects and hospitals will be confidential and managed according to the requirements of the Institutional Review Board (IRB) of the University of Phoenix, Phoenix, United States of America. Only the researcher, researcher’s mentor, and statistician will know the data collected. The regulations require a signed subject authorization informing the subject of the following: • • • • • • •
Comprehensive explanation of the research Expected duration of the participation by the subject Description of the risks Description of the benefits Statement of confidentiality Contact information for questions The participation is strictly voluntary, that by completing the informed consent the participant agrees to participate in the study, including surveys and focus group sessions. There is no penalty for withdrawing
Source Documents Source data includes three surveys (Nursing Work Index – Revised, the Practice Environment Scale of the Nursing Work Index, and the Maslach Burnout Inventory), a demographic survey, and focus group discussions. Records Retention The researcher will retain the records for three years after approval of the research from University of Phoenix, and until the research is published in a peer-reviewed journal. Ethical Considerations This study will meet the professional standards of conduct as outlined by the University of Phoenix. These standards include practice of research, professional issues, and treatment of research participants. Participating hospitals signed an informed consent to use the premises and subjects. Participants will receive an introduction letter to the study that provides information for them to make a decision to participate. A signed consent form is required for participation in the study. Study Finances Funding Source The researcher is responsible for funding this project.
291 Conflict of Interest There is no conflict of interest. Publication Plan The University facilitates the archiving and publication (optional) of the research. References This is the bibliography section for any information cited in the protocol. Creswell, J. W. (2002). Educational research: Planning, conducting, and evaluating quantitative and qualitative research. Upper Saddle River, NJ: Pearson Education. Herzberg, F. (1974). Motivation-hygiene profiles: Pinpointing what ails the organization. Organizational Dynamics 3(2), 18. Retrieved on December 3, 2006, from EBSCOhost Database. Ministry of Health (1425 H., 2004 G.). Health statistical year book. The Kingdom of Saudi Arabia Ministry of Health: Author. Pond, B., & McPake, B. (2006). The health migration crisis: The role of four organizations for economic cooperation and development countries. The Lancet, 367(9520), 1448. Retrieved on September 7, 2006, from http://www.thelancet.com/journals/lancet/article/PIIS0140673606683463/fulltext Tumulty, G. (2001). Professional development of nursing in Saudi Arabia. Journal of Nursing Scholarship, 33(3), 285. University of Phoenix (2003). Doctor of education in educational leadership, Research handbook. University of Phoenix: Author. World Facts (2004-2006). Facts about Saudi Arabia: Geography of Saudi Arabia. Retrieved on September 8, 2006, from http://worldfacts.us/Saudi-Arabia.htm Attachments This section should contain all pertinent documents for the study. The following list examples of potential attachments: • • • • • •
Informed Consent: Permission to Use Premises, Name, and/or Subjects Letter of Collaboration Nursing Work Index - Revised Practice Environment Scale of the Nursing Work Index Maslach Burnout Inventory Demographic Survey
292 APPENDIX F: INTRODUCTION LETTER TO STUDY Name of Hospital: __________________ Date: ___________________ Hospital Representative: ___________________
I am a student at the University of Phoenix working on a Doctorate in Educational Leadership (Ed.D.). I am conducting a research study entitled Foreign-Trained Nurses in Saudi Arabia: The Challenges of Recruiting and Retaining Staff Nurses. The purpose of the research study is to explore the association between the foreign-trained nurses’ motivation for working in hospitals in Saudi Arabia, values related to job satisfaction, nurse burnout, and factors related to nurse retention or tenure. The study will also identify organizational attributes that characterize professional nursing practice environments that contribute to job satisfaction and tenure. Your participation will involve your consent to allow me to enter the hospital premises to distribute questionnaires, collect questionnaires, invite foreign-trained nurses to participate in focus group sessions, and to be available to the foreign-trained nurses if they have any questions. I anticipate the distribution and collection of questionnaires will require two weeks. The focus group session will be two hours, conducted on the foreigntrained nurse’s off-duty time, and away from the hospital premises. Your participation in this study is voluntary. If you choose not to participate or to withdraw from the study, you can do so without penalty or loss of benefit to you. The results of the research study may be published but your name will not appear and your results will remain confidential. In this research, there are no foreseeable risks to you except “none”. Although there may be no direct benefit to you, the possible benefit of your participation is the data gathered in this study may provide health care leaders with information on the factors contributing to job satisfaction, those variables that contribute to tenure, and the nurses’ desire to work in Saudi Arabia. Given the worsening global nursing shortage, this information will assist in building recruitment and retention strategies for your organization. If you have any questions concerning the research study, please call me. The return of questionnaires to this researcher and participation in the focus group session indicates the subject’s consent to participate. Sincerely, Joan Mitchell
293 APPENDIX G: LETTER OF COLLABORATION AMONG INSTITUTIONS UNIVERSITY OF PHOENIX Date: ___/___/___ To: University of the Provost/Institutional Review Board University of Phoenix This letter acknowledges that ____________________ is collaborating with (Name of the agency) Ms/Mr ________________ (Name of the student) enrolled in the ______________ program at the University of Phoenix in conducting the proposed research. We understand the purpose of this research is _________________________ and will be conducted under the supervision of Dr. _______________________. (Faculty name) This project will be an integral part of our institution/agency and will be conducted as a collaborative effort and will be part of our curriculum/research/data/service delivery model. Sincerely, _______________________________ Representative, Collaborating Institution/Agency
294 APPENDIX H: INFORMED CONSENT: PERMISSION TO USE PREMISES, NAME, AND/OR SUBJECTS UNIVERSITY OF PHOENIX INFORMED CONSENT: PERMISSION TO USE PREMISES, NAME, AND/OR SUBJECTS (Facility/Organization/University/Institution, or Association) ____________________________________________________________ Name of the Facility/Organization/University/Institution, or Association I hereby authorize ___________________, student of University of Phoenix, to use the premises, names, and/or subjects requested to conduct a study entitled (insert title of research study or a brief description of research study).
__________________________________ Signature ____________________________ Title ___________________________ Name of Facility
___/___/___ Date
295 APPENDIX I: INTRODUCTION LETTER TO PARTICIPANTS Date: Dear Participant, I am a registered nurse and student in the Doctor of Educational Leadership (Ed.D.) program with the University of Phoenix, Phoenix, Arizona, United States of America (U. S. A.). For my doctoral dissertation, I am conducting a study titled Foreign-Trained Nurses in Saudi Arabia: The Challenges of Recruiting and Retaining Staff Nurses. I have lived and worked as a nurse in Saudi Arabia for eleven years where I have witnessed the evolving nursing practice and the changes in labor force. Today, job satisfaction and staff burnout are turning into critical policy issues in countries around the world. The rise in global demand for nurses worldwide has forced health care providers to focus on nursing staff retention and has led to significant improvements in the nursing work environment. Saudi Arabia, like other gulf states, relies mainly on foreign-trained nurses from over fifty countries. The proposed study will help in shedding some light on the nurses’ experience in Saudi Arabia and will assist health care leaders in identifying factors that may assist them in better retaining foreign-trained nurses. Findings from the study can be benchmarked against findings from other countries. I invite the following participants in this study: foreign-trained nurse, staff nurse I, staff nurse II, charge nurse, voluntary participation, ability to read and write English, and are 18 years old and older. I have obtained permission from your hospital administration to use the hospital premises to conduct the study. The hospital leadership is interested in the results of the data that will be collected. Your participation in the study, as well as your responses to the survey, will remain confidential and anonymous. Findings from the study will be reported in aggregate formats and individual responses will not be identified in any way. To fulfill the privacy requirements mandated by the University of Phoenix and your hospitals, the respondent’s consent is required. To participate in the surveys and focus groups, I need a signed informed consent from participants. Please complete the enclosed consent form and information on how you would like the survey distributed to you. For participating in the focus group session, I need your phone number to contact you so we can schedule a date and time that is convenient with your working schedule. Put the informed consent form in the plain envelope and seal. Take the envelope to the hospital mailroom and drop in the locked box. This is to ensure confidentiality and anonymity. Please have the consent forms in the mailbox by date. Maintaining confidentiality and anonymity is the researcher’s priority. Only the researcher will see the informed consent forms. There are no identifying names or numbers on the envelopes or surveys. The informed consent form allows you to choose how you want to receive the surveys: interoffice mail, hand delivered by researcher, or email. This is an attempt to allay any fears about participation, confidentiality, and anonymity. The focus group sessions will be conducted in the researcher’s home, away from hospital grounds. I do need your phone number so I can call you to schedule a time that is convenient with your schedule.
296 Participants may feel there is a risk that management will know about your participation in the study and possible repercussions from participation. The hospital leadership has signed a consent form for me to conduct the research in the hospital with foreign-trained nurses and supports the study. The hospital is preparing for the Central Board Accreditation of Healthcare Institutions (CBAHI). One of the standards requires the nursing department to develop a strategic plan for retention of nurses. The findings from this study will benefit hospital leadership, the nursing department, and nurses. The surveys are standardized assessment tools with 110 questions. There is also a demographic questionnaire with 20 data elements. It will take you approximately 15 minutes to complete the surveys. You will not be asked to provide any identifiable personal information. If you have any questions about the questionnaire or surveys, please contact me. In completing the survey, there is no right or wrong answer, only your true feelings about job satisfaction and burnout. To enhance the utility of your responses, please ensure that you answer all the questions on the survey. I will conduct taped focus group sessions that will assist me in examining the issues surrounding job satisfaction and staff burnout from a different angle. This is an opportunity to discuss your working and living experiences in Saudi Arabia, in an informal setting with nurses from other facilities. Data collected in the focus group session will also be confidential and anonymous. In closing, I value your support in completing the surveys and participating in the focus group session. It is only through your voice the health care leadership will hear about those factors that will contribute to retaining foreign-trained nurses in Saudi Arabia. You may not see the benefits of your comments this year, but you will assist in shaping the future of nursing practice for the years ahead. Thank you for your time and contribution. If you have any questions, please contact my mentor or me.
297 APPENDIX J: INFORMED CONSENT FOR PARTICIPANTS 18 YEARS OF AGE AND OLDER Dear foreign-trained nurse, I am a student at the University of Phoenix working on a Doctorate in Educational Leadership (Ed.D.). I am conducting a research study entitled Foreign-Trained Nurses in Saudi Arabia: The Challenges of Recruiting and Retaining Staff Nurses. The purpose of the research study is to explore the association between the foreign-trained nurses’ motivation for working in hospitals in Saudi Arabia, values related to job satisfaction, nurse burnout, and factors related to nurse retention or tenure. The study will also identify organizational attributes that characterize professional nursing practice environments that contribute to job satisfaction and tenure. This research study is twofold, consisting of surveys and focus group sessions. Signing this consent form is for survey participation only, focus group participation only, or survey and focus group participation. Your participation will involve completing three surveys and a demographic questionnaire that will take approximately 15 minutes to complete. The surveys are valid and reliable instruments used in the health care field. The surveys explore the work environment, job satisfaction, and burnout. Focus group sessions will involve a 1- to 2-hour taped group interview with your colleagues to discuss your working and living experiences in Saudi Arabia as a foreigntrained nurse. The discussion will focus on what attracted you to come to Saudi Arabia for work and how long you plan to stay. The discussion will address what you like and do not like about your work and Saudi Arabia. The group will share when they felt good and bad at work. The discussion will ask for suggestions on how leaders can retain foreigntrained nurses in Saudi Arabia. The data from the surveys will be analyzed through a series of steps; descriptive statistics, and bivariate statistics and through multiple regression. The data from the recorded interviews as expressed by the groups will be analyzed and categorized into themes. These themes will be correlated with the survey data in a statistical calculation called triangulation. Triangulation converge the data to demonstrate an accurate representation of reality. According to University of Phoenix regulations, the data (including the tapes) must be retained for 3 years. The consent forms will be stored in a locked cupboard in the researcher’s home. The electronic data will be stored in the researcher’s computer in a separate electronic file with password protection. A backup of the electronic data will be stored on a flash drive and kept in the locked cupboard in the researcher’s home. The focus group tapes will also be secured in a locked cupboard in the researcher’s home. The locked cupboard will be accessible to only the researcher. The home is a secure single dwelling for the researcher and her husband. No one will have access to this information. At the end of the 3 years, all data will be destroyed.
298 Your participation in this study is voluntary. If you choose not to participate or to withdraw from the study, you can do so without penalty or loss of benefit to you. The results of the research study may be published but your name will not be used and your individual and hospital information will be maintained in confidence. In this research, there are no foreseeable risks to you except disclosing sensitive information to me during the survey and focus group process. Although there may be no direct benefit to you, the possible benefit of your participation is the experiential information you will share with other study participants. This information may provide insight into the challenges of recruiting and retaining foreigntrained nurses in Saudi Arabia and assist hospital leadership with developing, implementing, and managing an effective recruitment and retention strategy program. Please read the following statement and sign your name and date where indicated. By signing this form I acknowledge that I understand the nature of the study, the potential risks and benefits to me as a participant, and the means by which my identity and information will be collected, stored, destroyed, and kept confidential. I understand that I may choose to withdraw my participation in the study without penalty. My signature on this form also indicates that I am not a member of any protected category of participants (minor, pregnant woman when considered part of a designated research group of women, prisoner, or cognitively impaired), that I am 18 years old or older, and that I give my permission to voluntarily serve as a participant in the study described. ___________________________ Student Researcher Name (Print)
__________________________________ Student Researcher Signature & Date
___________________________ Participant Name (Print)
__________________________________ Participant Signature & Date
_________________________________________ Participant Phone Number (for focus group session) How would you like to receive the surveys? Please check one box and add additional information. interoffice mail:
Unit/Ward/mailbox # ______________
email:
email address: __________________
1. hand delivered by researcher:
Unit/Ward: ________________
299 If you have any questions concerning the research study, you can reach me at the following numbers and email or my mentor. Sincerely, Joan E. Mitchell
300 APPENDIX K: THANK YOU LETTER TO MINISTRY OF HEALTH
Tuesday, January 30, 2007 To Mrs Muneera Al Osaimi General Directorate of Nursing Ministry of Health I would like to express my appreciation for your assistance in the completion of my Doctor in Educational Leadership program with the University of Phoenix, Phoenix, Arizona, U.S.A. I will be sharing with you the full report of my findings upon completion of the study. The respondents and facilities will be kept in the strictest confidence and privacy. Only my mentor, my statistician, and I will have this knowledge. The data will be reported in aggregate format and the results will be reported in a way that will not allow reverse identification of facilities. The data collected will be for the requirements of completing my degree. I am enclosing with this letter the study protocol and the surveys that will be used. Thank you for your support as I move forward on this project. Please feel free to contact me at any time if you have any questions or concerns. I will keep in touch with your office. Yours sincerely, Joan Mitchell
301 APPENDIX L: CONFIDENTIALITY STATEMENTS
302
303
304 APPENDIX M: DEMOGRAPHIC SURVEY Revised: August 2007 1.
What is your gender? (please √ one) Male
2.
Female
What is your age? (please √ one) ≤ 25 26-35 36-45 46-55 ≥ 56
3.
What is your nationality? ______________________________
4.
What is your religion? (please √ one) Muslim Other
5.
What is your highest nursing education? (please √ one) Associate Degree Diploma Bachelors Post Graduate Certificate Masters (Post Graduate) Doctorate
6.
When did you qualify as a registered nurse? Year ________________
305 7.
What is your current position? (if you are a charge nurse < than 75% of your time, choose staff nurse I or II) (please √ one) Staff nurse I Staff nurse II Charge Nurse
8.
What hospital do you work in now? (name of the hospital please) _______________________________________________
9.
How long have you worked in this hospital? (please √ one) < than one year 1 – 3 years 3 – 5 years 5 – 10 years > 10 years. Please specify the number of years _______________
10.
What is your salary range per month? (please √ one) SR ≤ 1,500 SR 1,501 – 5,000 SR 5,001 – 10,000 SR 10,001 – 15,000 SR ≥ 15001
11. Have you worked in the Kingdom before? (please √ one) Yes
No
306 12. How long have you been living in the Kingdom of Saudi Arabia? (please √ one) < than one year 1 – 3 years 3 – 5 years 5 – 10 years > 10 years. Please specify the number of years _______________ 13.
The total time that you have been in Saudi Arabia is: (please √ one) Consecutive Non-consecutive
14.
Where was your point of hire for your current job? (please √ one) North America (Canada, United States) Europe (such as, European Union, including United Kingdom, Ireland) Far East (such as, Malaysia, Singapore, Philippines, China, Pakistan) Middle East (such as, Lebanon, Jordan, Egypt) Africa (including northern African countries, South Africa) Other (please specify the country of origin) _________________________
15. Are you married? (please √ one) Yes 16.
No
If you answered yes to question # 15, is your family here with you (husband, children)? (please √ one) Yes
No
17. What contract are you on? (please √ one) Single Married
307 18. How long is your contract? (please √ one) Locum 1 year 2 years 3 years Other. Specify ______________ 19. Is your contract renewable? (please √ one) Yes No 20.
Are you currently pursuing a degree? (please √ one) Yes
No
Please feel free to add any additional comments about your working and living experience in Saudi Arabia: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Return to (name) ____________________________ by (date/time) ________________ at (place) ________________________
Thank you for your participation in this research project.
308 APPENDIX N: NURSING WORK INDEX – REVISED For each item in this section, please indicate the extent to which you agree that the following items ARE PRESENT IN YOUR CURRENT JOB. Indicate your degree of agreement by circling the appropriate number. # PRESENT IN STRONGLY SOMEWHAT SOMEWHAT STRONGLY CURRENT JOB AGREE AGREE DISAGREE DISAGREE 1. Adequate support services allow me to spend time with my patients.
1
2
3
4
2. Physicians and nurses have good working relationships.
1
2
3
4
3. A good orientation program for newly employed nurses.
1
2
3
4
4. A supervisory staff that is supportive of nurses.
1
2
3
4
5. A satisfactory salary.
1
2
3
4
6. Nursing controls its own practice.
1
2
3
4
7. Active inservice/continuing education programs for nurses.
1
2
3
4
8. Career development/clinical ladder opportunity.
1
2
3
4
9. Opportunity for staff nurses to participate in policy decisions.
1
2
3
4
10. Support for new and innovative ideas about patient care.
1
2
3
4
11. Enough time and opportunity to discuss patient care problems with other nurses.
1
2
3
4
12. Enough registered nurses on staff to
1
2
3
4
309 #
PRESENT IN CURRENT JOB
STRONGLY SOMEWHAT SOMEWHAT STRONGLY AGREE AGREE DISAGREE DISAGREE
provide quality patient care. 13. A nurse manager who is a good manager and leader.
1
2
3
4
14. A chief nursing officer is highly visible and accessible to staff.
1
2
3
4
15. Flexible or modified work schedules are available.
1
2
3
4
16. Enough staff to get the work done.
1
2
3
4
17. Freedom to make important patient care and work decisions.
1
2
3
4
18. Praise and recognition for a job well done.
1
2
3
4
19. Clinical nurse specialists who provide patient care consultation.
1
2
3
4
20. Team nursing as the nursing delivery system.
1
2
3
4
21. Total patient care as the nursing delivery system.
1
2
3
4
22. Primary nursing as the nursing delivery system.
1
2
3
4
23. Good relationships with other departments such as housekeeping and dietary.
1
2
3
4
24. Not being placed in a position of having to do things that are against my nursing judgment.
1
2
3
4
310 #
PRESENT IN CURRENT JOB
STRONGLY SOMEWHAT SOMEWHAT STRONGLY AGREE AGREE DISAGREE DISAGREE
25. High standards of nursing care are expected by the administration.
1
2
3
4
26. A chief nursing executive is equal in power and authority to other top-level executives.
1
2
3
4
27. Much teamwork between nurses and doctors.
1
2
3
4
28. Physicians give high quality medical care.
1
2
3
4
29. Opportunities for advancement.
1
2
3
4
30. Nursing staff is supported in pursuing degrees in nursing.
1
2
3
4
31. A clear philosophy of nursing pervades the patient care environment.
1
2
3
4
32. Nurses actively participate in efforts to control cost.
1
2
3
4
33. Working with nurses who are clinically competent.
1
2
3
4
34. The nursing staff participate in selecting new equipment.
1
2
3
4
35. A nurse manager backs up the nursing staff in decision making, even if the conflict is with a physician.
1
2
3
4
36. An administration that listens and responds to employee concerns.
1
2
3
4
311 #
PRESENT IN CURRENT JOB
STRONGLY SOMEWHAT SOMEWHAT STRONGLY AGREE AGREE DISAGREE DISAGREE
37. An active quality assurance program.
1
2
3
4
38. Staff nurses are involved in the internal governance of the hospital (eg., practice and policy committees).
1
2
3
4
39. Collaboration (joint practice) between nurses and physicians.
1
2
3
4
40. A preceptor program for newly hired registered nurses.
1
2
3
4
41. Nursing care is based on a nursing rather than medical model.
1
2
3
4
42. Staff nurses have the opportunity to serve on hospital and nursing committees.
1
2
3
4
43. The contributions that nurses make to patient care are publicly acknowledged.
1
2
3
4
44. Nurse managers consult with staff on daily problems and procedures.
1
2
3
4
45. The work environment is pleasant, attractive, and comfortable.
1
2
3
4
46. Opportunity to work on a highly specialized unit.
1
2
3
4
47. Written, up-to-date nursing care plans for all patients.
1
2
3
4
312 #
PRESENT IN CURRENT JOB
STRONGLY SOMEWHAT SOMEWHAT STRONGLY AGREE AGREE DISAGREE DISAGREE
48. Patient assignments foster continuity of care (i.e., the same nurse cares for the patient from one day to the next).
1
2
3
4
49. Regular, permanently assigned staff nurses never have to float to another unit.
1
2
3
4
50. Staff nurses actively participate in developing their work schedules (i.e., what days they work; days off; etc.).
1
2
3
4
51. Standardized policies, procedures, and ways of doing things.
1
2
3
4
52. Use of nursing diagnoses.
1
2
3
4
53. Floating, so that staffing is equalized among units.
1
2
3
4
54. Each nursing unit determines its own policies and procedures.
1
2
3
4
55. Use of a problemoriented medical record.
1
2
3
4
56. Working with experienced nurses who “know” the hospital.
1
2
3
4
57. Nursing care plans are verbally transmitted from nurse to nurse.
1
2
3
4
313
Thank you for taking the time to finish this survey. Source: Aiken, L. H., & Patrician, P. A. (2000). Measuring organizational traits of hospitals: The revised nursing work index. Nursing Research, 49(3), 146-153.
314 APPENDIX O: PERMISSION LETTER FROM DR AIKEN
315 APPENDIX P: THE PRACTICE ENVIRONMENT SCALE OF THE NURSING WORK INDEX For each item, please indicate the extent to which you agree that the item is PRESENT IN YOUR CURRENT JOB. Indicate your degree of agreement by circling the appropriate number. Strongly Strongly Agree Agree Disagree Disagree 1 Adequate support services allow me to spend time with my patients.
1
2
3
4
2 Physicians and nurses have good working relationships
1
2
3
4
3 A supervisory staff that is supportive of the nurses.
1
2
3
4
4 Active staff development or continuing education programs for nurses.
1
2
3
4
5 Career development/clinical ladder opportunity.
1
2
3
4
6 Opportunity for staff nurses to participate in policy decisions.
1
2
3
4
7 Supervisors use mistakes as learning opportunities, not criticism.
1
2
3
4
8 Enough time and opportunity to discuss patient care problems with other nurses
1
2
3
4
9 Enough registered nurses to provide quality patient care.
1
2
3
4
10 A nurse manager who is a good manager and leader.
1
2
3
4
11 A chief nursing officer who is highly visible and accessible to staff
1
2
3
4
12 Enough staff to get the work done
1
2
3
4
13 Praise and recognition for a job well done.
1
2
3
4
14 High standards of nursing care are expected by the administration
1
2
3
4
15 A chief nursing officer equal in power and authority to other top-level hospital executives
1
2
3
4
16 A lot of team work between nurses and physicians.
1
2
3
4
316 Strongly Strongly Agree Agree Disagree Disagree 17 Opportunities for advancement.
1
2
3
4
18 A clear philosophy of nursing that pervades the patient care environment.
1
2
3
4
19 Working with nurses who are clinically competent.
1
2
3
4
20 A nurse manager who backs up the nursing staff in decision making, even if the conflict is with a physician.
1
2
3
4
21 Administration that listens and responds to employee concerns.
1
2
3
4
22 An active quality assurance program.
1
2
3
4
23 Staff nurses are involved in the internal governance of the hospital (e.g., practice and policy committees).
1
2
3
4
24 Collaboration (joint practice) between nurses and physicians.
1
2
3
4
25 A preceptor program for newly hired RNs
1
2
3
4
26 Nursing care is based on a nursing, rather than a medical, model.
1
2
3
4
27 Staff nurses have the opportunity to serve on hospital and nursing committees.
1
2
3
4
28 Nursing administrators consult with staff on daily problems and procedures
1
2
3
4
29 Written, up-to-date nursing care plans for all patients.
1
2
3
4
30 Patient care assignments that foster continuity of care, i.e., the same nurse cares for the patient from one day to the next.
1
2
3
4
31 Use of nursing diagnoses.
1
2
3
4
Thank you for taking the time to finish this survey. Source: Lake, E. T. (2002). Development of the practice environment scale of the nursing work index. Research in Nursing & Health, 25(3): 176-188.
317 APPENDIX Q: PERMISSION LETTER FROM DR. LAKE
318 APPENDIX R: PERMISSION LETTER FROM CPP, INC
319 APPENDIX S: FOCUS GROUP SESSIONS DEMOGRAPHICS OF PARTICIPANTS: Sample size – eight participants (total 32 participants) Time – for one to two hours Setting – participants from different types of hospitals (MOH, private, and military) Characteristics – all foreign registered nurses, charge nurse, head nurse all foreign nationalities Number of focus groups – four Setting of focus group – neutral area (researcher’s home). Transportation and food provided. Identification of Participants – card at their place in the room – a number and the number of years working in the Kingdom (example # 1 20 years) QUESTIONS: 1. What attracted you to work in Saudi Arabia? 2. How long did you plan on working in Saudi Arabia? 3. How long do you plan to work in Saudi Arabia? 4. What factors keep you here? 5. What would cause you to leave? 6. What are your plans for the future? 7. When did you feel exceptionally good at work? 8. When did you feel exceptionally bad at work? 9. What suggestions do you have to retain nurses in Saudi Arabia? HOUSEKEEPING ISSUES: 1. Welcome to participants. 2. Tape recorder will collect comments. Names and hospitals are confidential. 3. Introduce moderators. Confidentiality is guaranteed by the moderators 4. You are free to leave the discussion at any time if you wish not to participate. 5. The purpose of this discussion is to discuss your experiences as a foreign-trained nurse living and working in Saudi Arabia. What brought you here, what keeps you here, how long you plan to stay, and what retention strategies could the hospitals implement to keep you in the hospital. 6. The moderator will clarify comments but will not be part of the discussion. The moderator will encourage participants to share stories about their work and life in Saudi Arabia. 7. The moderator hopes the participants will be open and honest during the discussion. There are no repercussions to participating in this research. 8. We will start the session by going around the room to each participant and then move to a more relaxed question – answer discussion. 9. One person speaking at a time, the moderator wants to ensure participation from everyone. 10. We treat each other with respect and dignity and everyone’s opinion is valid. 11. You are free to leave the discussion to go to the washroom. We will have a break
320 mid-way through the session. 12. Are there any questions before we start? References Herzberg, F. (1966). Work and the nature of man. New York, N.Y.: The World Publishing Company. McLafferty, I. (2004). Methodological issues in nursing research: Focus group interviews as a data collection strategy. Journal of Advanced Nursing, 48(2), 187. Retrieved on March 15, 2007, from EBSCOhost Database.
321 APPENDIX T: HOSPITAL VISITS IN MARCH AND APRIL 2008 Date
Hospital
Time
Hospital
Time
Hospital
Wed, Mar 19
Private
9–11 am
Private
11:30 am–1:30 Private
Time 2–4pm
pm Sat, Mar 22
Private
2–4 pm
Private
6–8 pm
Sun, Mar 23
Private
2–4 pm
Mon, Mar 24
Private
12 pm
Private
6–8 pm
Tues, Mar 25 Government 9 am–12
Government 1–4 pm
Private
5–7 pm
pm Wed, Mar 26
Private
9–11 am
Private
12–2 pm
Private
3–5 pm
Sun, Mar 30
Government 10 am–1
Private
2–4 pm
Private
6–8 pm
Wed, Apr 2
Private
2–4 pm
Thurs, Apr 3
Private
1:30–3:30 pm
Sat, Apr 5
Private
2–5 pm
Private
6–8 pm
Government 1–4 pm
Private
6–8 pm
pm
Sun, Apr 6
Private
11 am–12 pm
Sun, Apr 13
Government 4:15– 5:15 pm
Grey Hospitals – hospitals not visited due to medical director refused visit to hospital to talk to nurses or director of nursing unavailable (scheduled a meeting in place of my visit)
322 APPENDIX U: CONSENT AND SURVEY DISTRIBUTION AND COLLECTION DATA G = government P = Private Total nursing staff
Participants Total
Actual
Consents
Hospital Type Beds (Dec 2007) distribution distribution received
Surveys % received %
A
G
440
530
430
430
54
8.0
49
11.4
B
G
850
850
650
444
186
41.9
83
18.7
C
G
286
386
320
320
60
18.8
21
6.6
D
G
500
850
635
635
72
11.3
19
3.0
E
P
25
60
54
54
17
31.5
11
20.4
F
P
80
69
60
60
13
21.7
13
21.7
G
P
86
132
100
80
9
11.3
3
3.8
H
P
559
420
300
300
1
.3
1
.3
I
P
197
272
170
170
22
12.9
19
11.2
J
P
103
115
87
87
44
50.6
25
28.7
K
P
152
391
300
264
40
15.1
5
1.9
L
P
240
461
350
350
57
16.3
16
4.6
M
P
100
65
50
40
27
67.5
13
32.5
N
P
130
211
115
96
42
43.8
9
21.4
O
P
100
40
30
30
23
76.7
17
56.7
P
P
35
82
70
66
40
60.6
24
36.4
323 Total nursing staff
Participants Total
Actual
Consents
Hospital Type Beds (Dec 2007) distribution distribution received
Surveys % received %
Q
P
75
182
65
65
35
53.8
19
29.2
R
P
65
94
50
50
9
18.0
2
4.0
S
P
95
119
85
85
29
34.1
4
4.7
T
P
63
108
65
58
22
38.0
16
27.6
U
P
100
79
60
54
14
26.0
13
24.0
V
P
28
36
33
33
18
54.5
12
36.4
W
P
30
85
55
55
25
45.5
12
21.8
X
P
45
35
27
27
26
96.3
21
77.8
Y
G
340
802
570
570
59
10.4
26
4.6
Total
25
6474
4731
4423
944
21.3
453
48.0
324 APPENDIX V: VARIABLE DESCRIPTION AND CODING AND HOSPITAL INFORMATION Variable Description and Codes Variable Gender
Description Respondent’s Gender
Age
Respondent’s Age in Years
Nationality
Respondent’s Country of Birth
Religion
Respondent’s Religion
Educational Level
Respondent’s Highest Level of Education
Year Registered
Respondent’s Year of Registration
Title
Respondent’s Title
Ownership
Respondent’s Hospital
Length of Work at Current Hospital
Respondent’s Length of Work at Current Hospital in Years
First Contract in Respondent’s First Contract in Saudi Saudi Arabia Arabia Length of Time in Saudi Arabia
Coding 0 = Male 1 = Female 0 = > 35 Years 1 = Up to 35 Years 0 = Others 1 = SE Asian 0 = Other 1 = Muslim O = Diploma or Associate Degree 1 = Bachelor Degree or Higher 0 = Prior to 2001 1 = 2001 and After 0 = Other 1 = Staff Nurse 0 = Government 1 = Private 0 = > than 3 years 1 = Up to 3 years 0 = No 1 = Yes
Respondent’s Length of Time in Saudi Arabia in Years 0 = > than 3 Years 1 = Up to 3 Years
Worked in Kingdom Prior to Current Contract
Respondent’s Work History in the Kingdom Prior to this Contract
Stay in Saudi Arabia
Respondent’s Nonconsecutive or Consecutive Stay in Saudi Arabia
Married
Is Respondent Married
Contract Type
Respondent’s Contract Type
0 = No 1 = Yes 0 = Nonconsecutive 1 = Consecutive 0 = No 1 = Yes 0 = Single
325 Variable
Description
Family with Nurse in Kingdom
Respondent’s Family with Nurse in Kingdom
Pursuing a Degree
Respondent’s Continuing Education Status
Coding 1 = Married 0 = No 1 = Yes 0 = No 1 = Yes
Hospital Information Hospital A B C D E F G H I J K L M N O P Q R S T U V W X Y T = 25
Beds 440 850 286 500 25 80 86 559 197 103 152 240 100 130 100 35 75 65 95 63 100 28 30 45 340
Total Nursing Staff (Dec 2007) 530 850 386 850 60 69 132 420 272 115 391 461 65 211 40 82 182 94 119 108 79 36 85 35 802 T = 6474
Staffing Ratio Nurse: Patient 1:6 1:5 1:5 1:6 1:5 1:5 1:5 1:5 1:6 1:4 1:3 1:6 1:5 1:5 1:5 1:3 1:5 1:6 1:6 1:5 Team Nursing 1:7 1:4 1:5 1:6
326 Nursing Work Index – Revised: Data Coding
Subscale Autonomy over Practice
Question # 4 6 17 24
35
Control over Practice Setting
1
11
12 13 16 46 48
Nurse – physician
2
Statement A supervisory staff that is supportive of nurses. Nursing controls its own practice. Freedom to make important patient care and work decisions. Not being placed in a position of having to do things that are against my nursing judgment. A nurse manager backs up the nursing staff in decision making, even if the conflict is with a physician. Adequate support services allow me to spend time with my patients. Enough time and opportunity to discuss patient care problems with other nurses. Enough registered nurses on staff to provide quality patient care. A nurse manager who is a good manager and leader. Enough staff to get the work done. Opportunity to work on a highly specialized unit. Patient assignments foster continuity of care (i.e., the same nurse cares for the patient from one day to the next). Physicians and nurses have good working
Score 1-4
Minimum to maximum score
1-4 1-4 1-4
1-4
5-20
1-4
1-4
1-4 1-4 1-4 1-4 1-4
1-4
7-28
327
Subscale relationships
Question # 27 39
Organizational support
1
2 6 11
12 13 17 24
27 48
Statement relationships. Much teamwork between nurses and doctors. Collaboration (joint practice) between nurses and physicians. Adequate support services allow me to spend time with my patients. Physicians and nurses have good working relationships. Nursing controls its own practice. Enough time and opportunity to discuss patient care problems with other nurses. Enough registered nurses on staff to provide quality patient care. A nurse manager who is a good manager and leader. Freedom to make important patient care and work decisions. Not being placed in a position of having to do things that are against my nursing judgment. Much teamwork between nurses and doctors. Patient assignments foster continuity of care (i.e., the same nurse cares for the patient from one day to the next).
Total Questions = 25 Questions Used = 15 Repeats include: 1, 2, 6, 11, 12, 13, 17, 24, 27, 48
Score
Minimum to maximum score
1-4 1-4
3-12
1-4
1-4 1-4 1-4
1-4 1-4 1-4 1-4
1-4 1-4
10-40
328 Autonomy score range 5-20 Control over Practice Setting score range 7-28 Nurse-Physician Relationships score range 3-12 Organizational Support score range 10-40
1=strongly agree 2 = somewhat agree 3 = somewhat disagree 4=strongly disagree
Total score range 25-100 Practice Environment Scale – Nursing Work Index – Revised: Data Coding Subscale Nurse participation in hospital affairs
Nursing foundations for quality of care
Question # Statement 5 Career development/clinical ladder opportunity. 6 Opportunity for staff nurses to participate in policy decisions. 11 A chief nursing officer who is highly visible and accessible to staff 15 A chief nursing officer equal in power and authority to other toplevel hospital executives 17 Opportunities for advancement. 21 Administration that listens and responds to employee concerns. 23 Staff nurses are involved in the internal governance of the hospital (e.g., practice and policy committees). 27 Staff nurses have the opportunity to serve on hospital and nursing committees. 28 Nursing administrators consult with staff on daily problems and procedures 4 Active staff development or continuing education programs for nurses.
Score 1-4
Minimum to maximum score
1-4 1-4 1-4
1-4 1-4 1-4
1-4
1-4
1-4
9-36
329
Subscale
Nurse manager ability, leadership and support of nurses
Question # Statement 14 High standards of nursing care are expected by the administration 18 A clear philosophy of nursing that pervades the patient care environment. 19 Working with nurses who are clinically competent. 22 An active quality assurance program. 25 A preceptor program for newly hired RNs 26 Nursing care is based on a nursing, rather than a medical model 29 Written, up-to-date nursing care plans for all patients. 30 Patient care assignments that foster continuity of care, i.e., the same nurse cares for the patient from one day to the next. 31 Use of nursing diagnoses. 3 A supervisory staff that is supportive of the nurses. 7 10 13 20
Staffing and resource adequacy
1
Supervisors use mistakes as learning opportunities, not criticism. A nurse manager who is a good manager and leader. Praise and recognition for a job well done. A nurse manager who backs up the nursing staff in decision making, even if the conflict is with a physician. Adequate support services allow me to spend time with my
Score 1-4
Minimum to maximum score
1-4 1-4 1-4 1-4 1-4 1-4 1-4
1-4 1-4
10-40
1-4 1-4 1-4 1-4
1-4
5-20
330
Subscale
Question # 8
9 12 Collegial nurse – physician relationships
2 16 24
Statement patients. Enough time and opportunity to discuss patient care problems with other nurses Enough registered nurses to provide quality patient care. Enough staff to get the work done Physicians and nurses have good working relationships A lot of team work between nurses and physicians. Collaboration (joint practice) between nurses and physicians.
Score
Minimum to maximum score
1-4
1-4 1-4
4-16
1-4 1-4 1-4
3-12
Total Questions = 25 Questions Used = 15 Repeats include: 1, 2, 6, 11, 12, 13, 17, 24, 27, 48 Nurse Participation in Hospital Affairs score range 9-36 Nursing Foundations for Quality of Care score range 10-40 Nurse Manager Ability, Leadership and Support of Nurses score range 5-20 Staffing and Resource Adequacy score range 4-16 Collegial Nurse – Physician Relationships score range 3-12
1=strongly agree 2 = agree 3 = disagree 4=strongly disagree
Total score range 31-124 SCORING DIRECTIONS Score each item so that higher numbers indicate greater agreement. Thus, if Astrongly agree@ was coded 1, and Astrongly disagree@ was coded 4, you must first reverse code (by subtracting each answer from 5) before calculating subscale scores. Once the coding is in the right direction, calculate nurse-specific subscale scores as the mean of the items in the subscale. The mean permits easy comparison across subscales. For hospital-level scores, calculate the item-level means at the hospital level. Then proceed with the standard computation for subscale scores. This approach permits all nurse responses, including responses of nurses who did not answer all items, to be included in the hospital score.
331 Calculate an overall PES-NWI “composite” score as the mean of the five subscale scores. This approach gives equal weight to the subscales, rather than to the items. Maslach Burnout Index: Data Coding Subscale
Question #
Emotional 1, 2, 3, 6, 8, 13, 14, 16, 20 Exhaustion Depersonalization 5, 10, 11, 15, 22 Personal 4, 7, 9, 12, 17, 18, 19, 21 Accomplishments Total Questions = 22 Emotional Exhaustion score range 0-54 Depersonalization score range 0-30 Personal Accomplishments score range 0-48 Total score range 0-132
Score 0-6
Minimum to maximum score 0-54
0-6 0-6
0-30 0-48
0= never 1 = a few times a year or less 2 = once a month or less 3 = a few times a month 4 = once a week 5 = a few times a week 6 = every day
332 APPENDIX W: ORIGINAL FORMAT AND RECODED FORMAT OF STUDY VARIABLES (DESCRIPTIVE STATISTICS) Original format Variable
Recoded format Value
Variable and coding
Gender Male Female
%
n
Respondent’s gender 23
0 = Male
428
23
5.1
428
94.9
0 = > 35 years
175
39.1
1 = Up to 35 years
273
60.9
36
8.0
415
92.0
1 = Female
Age
Respondent’s age in years Up to 25 years
65
26-35 years
208
36-45 years
111
46-55 years
56
56 years and over
8
Nationality SE Asian ME
Respondent’s country of birth 415 27
Western
6
Other
3
Religion
0 = Others 1 = SE Asian
Respondent’s religion
Other
302
0 = Other
302
67.3
Muslim
147
1 = Muslim
147
32.7
Educational level Diploma or associate
Respondent’s highest level of education 154
0 = Diploma or associate
154
34.2
333 Original format Variable
Recoded format Value
Variable and coding
degree Bachelor degree and
n
%
degree 296
higher
1 = Bachelor degree and
296
65.8
higher
Year qualified as RN
Respondent’s year of registration
Until 1990
103
0 = Prior to 2001
305
73.8
1991-2000
202
1 = 2001 and after
108
26.2
2001 +
108
Title
Respondent’s title
Other
106
0 = Other
106
24.3
Staff Nurse
330
1 = Staff Nurse
330
75.7
Ownership
Respondent’s hospital
Government
197
0 = Government
197
43.5
Private
256
1 = Private
256
56.5
Nurse patient ratio
Number of nurses per 100 beds
1:3
29
1:4
37
1:5
231
1:6
130
1:7
12
Team NSG
14
Length of work at current hospital
Respondent’s length of work at current hospital
334 Original format Variable New up to 3 years 3-5 Years 5 Years Plus
Recoded format Value
Variable and coding
n
%
243
0 = > than 3 years
197
44.8
70
1 = Up to 3 years
243
55.2
127
Salary Up to 1,500
50
1,501-5,000
374
> 5,000
16
Worked in Kingdom
Respondent’s work history in Kingdom prior to
prior to current contract
this contract
No
285
0 = No
285
64.2
Yes
159
1 = Yes
159
35.8
First contract in SA
Respondent’s first contract in Saudi Arabia
No
159
0 = No
159
35.8
Yes
285
1 = Yes
285
64.2
Years in Kingdom
Respondent’s length of time in Saudi Arabia in years
New up to 3 years 3-5 years 5 years plus Stay in SA
195
0 = > than 3 years
245
55.7
67
1 = Up to 3 years
195
44.3
178 Respondent’s nonconsecutive or consecutive stay in Saudi Arabia
335 Original format Variable
Recoded format Value
Variable and coding
n
%
Consecutive
304 0 = Nonconsecutive
142
31.8
Nonconsecutive
142 1 = Consecutive
304
68.2
Point of hire Africa
2
Australia
2
Europe
1
Far East
385
Middle East
57
New Zealand
1
Other
1
Married
Is respondent married?
No
150
0 = No
150
34.0
Yes
291
1 = Yes
291
66.0
Family with RN in SA
Respondent’s family with nurse in Saudi Arabia
No
160
0 = No
160
53.5
Yes
139
1 = Yes
139
46.5
Contract type
Respondent’s contract type
Single
295
0 = Single
295
67.8
Married
140
1 = Married
140
32.2
Length of contract 1 year
132
336 Original format Variable 2 years
Recoded format Value
Variable and coding
%
n
254
3 years plus
39
Other
20
Is contract renewable No
35
Yes
405
Currently pursuing a degree
Respondent’s continuing education status
No
349
0 = No
349
83.3
Yes
70
1 = Yes
70
16.7
337 APPENDIX X: DETAILED DESCRIPTIVE STATISTICS Detailed Descriptive Statistics for Age, Year Qualified, and Nationality Variable and description
n
%
Up to 25 years
69
14.9
26-35 years
214
46.2
36-45 years
111
24.0
46-55 years
56
12.1
56 years and over
8
1.7
1990 or before
103
22.7
1991-2000
202
44.6
2001 +
108
23.8
Australian
2
.4
Bangladesh
1
.2
British
1
.2
Canadian
1
.2
Chinese
7
1.5
Egypt
23
5.0
Indian
112
24.2
Indonesian
7
1.5
Jordan
4
.9
Age
Year qualified as an RN
Nationality
338 Variable and description
n
%
Malaysian
7
1.5
New Zealand
1
.2
Pakistan
13
2.8
Philippines
276
59.6
South Africa
1
.2
Sri Lanka
1
.2
Tunisia
1
.2
339 APPENDIX Y: BIVARIATE STATISTICS (T TEST)
Nurse Working Index - Revised Variable Gender Male Female Age ≥ 36 years Up to 35 years Nationality Others SE Asian Religion Other Muslim Educational level Diploma or associate degree Bachelor degree or higher Year registered Prior to 2001 2001 and after Title Other Staff nurse Ownership Government Private Length of work at current hospital > 3 years Up to 3 years First contract in SA No Yes
Autonomy in practice n M SD t
Control over practice setting Nurse–physician relationships Organizational support n M SD t n M SD t n M SD t
23 13.35 3.084 421 13.96 3.292
23 .930 422
17.26 4.721 18.20 4.686
173 13.79 3.321 268 14.03 3.268
173 .728 269
36 13.64 3.449 408 13.96 3.269 298 13.92 3.375 144 13.97 3.109
23 .931 422
1.820 2.223
23 -.021 421
26.74 5.979 27.68 5.936
.738
17.80 4.553 173 18.35 4.761 1.229 269
8.70 2.032 8.68 2.318
173 -.072 268
27.30 5.847 27.84 5.997
.942
36 .535 409
18.19 4.810 18.15 4.682
36 -.054 409
9.03 8.66
2.299 2.194
36 -.929 408
27.78 5.836 27.62 5.951 -.153
298 .152 145
17.99 4.789 298 18.51 4.491 1.112 145
8.64 8.81
2.151 2.289
298 .715 144
27.45 6.095 28.08 5.607 1.070
154 14.33 3.290 154 289 13.73 3.267 -1.846 290
18.89* 4.953 154 17.77 4.508 -2.416 290
9.03* 8.50
2.294 2.138
154 28.77** 5.921 -2.368 289 27.04 5.873 -2.952
302 301 13.67 3.205 301 17.67 4.579 107 14.45* 3.470 2.030 107 19.15** 4.881 2.728 107
8.53 8.93
2.179 2.344
301 27.07 5.701 1.576 107 28.74* 6.452 2.371
106 14.10 3.301 106 324 13.86 3.246 -1.077 325
17.82 4.645 18.25 4.702
8.63 2.197 8.70 2.207
195 14.18 3.197 195 251 13.76 3.344 -1.331 252
18.51 4.761 195 17.90 4.638 -1.363 252
8.85 8.57
2.235 2.170
195 -1.330 251
28.09 5.916 27.32 5.959 -1.358
194 14.04 3.307 194 239 13.85 3.216 -.578 240
17.98 4.665 18.33 4.694
194 .772 240
8.83 2.171 8.59 2.205
194 -1.148 239
27.74 5.893 27.61 5.938 -.221
156 13.58 3.199 156 281 14.17 3.272 1.835 282
18.01 4.547 18.27 4.755
157 .564 281
8.45 2.123 8.84 2.227
156 1.847 281
27.29 5.780 27.92 5.976 1.084
106 .822 325
8.70 8.69
106 .257 324
27.41 5.945 27.71 5.906
.458
340 Nurse Working Index - Revised Variable Length of time in SA > 3 years Up to 3 years Worked in SA prior to current contract No Yes Stay in SA Nonconsecutive Consecutive Married No Yes Contract type Single Married Family with nurse in SA No Yes Pursuing a degree No Yes * p < .05. ** p 36 years 170 22.55 5.904 Up to 35 years 264 23.22 6.248 1.122 Nationality Others 35 22.46 5.431 SE Asian 402 23.03 6.164 .589 Religion Other 294 22.79 6.104 Muslim 141 23.35 6.147 .900 Educational level Diploma or associate 151 23.35 6.040 degree Bachelor degree or higher 285 22.78 6.148 -.941 Year registered Prior to 2001 298 22.60 6.206 2001 and after 103 23.35 5.916 1.089 Title Other 103 22.65 6.529 Staff nurse 321 23.03 5.992 .521 Ownership Government 189 23.61 6.219 Private 249 22.52 5.976 -1.848 Length of work at current hospital > 3 years 193 22.66 6.182 Up to 3 years 235 23.20 6.049 .911 First contract in SA No 156 22.87 5.916 Yes 276 23.07 6.221 .331 Length of time in SA > 3 years 240 22.90 6.203 Up to 3 years 187 23.11 5.971 .342 Worked in SA prior to current contract No 276 23.07 6.221 Yes 156 22.87 5.916 -.331
Nursing foundations for quality of care n M SD t
Nurse manager ability, leadership, and support of nurses n M SD t
Staffing and resource adequacy n M SD t
Collegial nurse physician relationship n M SD t
23 402
28.74 29.07
6.002 5.312
.256
22 416
12.73 13.51
3.355 3.261
22 1.074 417
9.50 3.335 9.81 2.864
.422
23 416
8.17 8.63
1.922 1.998
1.116
165 257
28.64 29.30
5.366 5.325
1.231
170 265
13.26 13.59
3.322 3.239
170 1.014 266
9.66 2.853 9.86 2.902
.696
170 266
8.62 8.60
1.955 2.032
-.083
34 391
28.97 29.06
5.797 5.312
.083
35 403
13.77 13.45
2.777 3.307
35 -.648 404
9.86 2.942 9.78 2.884
-.140
35 404
8.94 8.58
1.765 2.013
-1.148
283 140
29.30 28.54
5.042 5.929
-1.376
294 142
13.29 13.83
3.361 3.060
295 1.667 142
9.66 2.849 10.11 2.939 1.531
294 143
8.58 8.69
1.923 2.141
.491
147
29.75*
5.193
150
14.04**
2.996
151
9.98 2.888
150
8.88*
2.006
277
28.68
5.405
-1.990
287
13.17
3.370
-2.647 287
9.70 2.885
-.964
288
8.47
1.980
-2.045
288 101
28.83 29.31
5.501 5.270
.768
298 103
13.21 13.97*
3.281 3.303
299 2.024 103
9.56 2.807 10.17 2.941 1.816
298 104
8.52 8.60
2.020 1.973
.336
96 317
28.79 29.08
6.026 5.151
.418
103 322
13.88 13.30
3.288 3.276
103 -1.574 323
-.765
103 323
8.66 8.57
2.145 1.966
-.380
185 241
29.56 28.66
5.385 5.281
-1.726
190 249
13.88* 13.17
3.354 3.165
190 -2.240 250
10.03 2.959 9.60 2.820 -1.528
190 250
8.72 8.53
2.050 1.947
-1.000
185 231
28.81 29.17
5.296 5.388
.688
194 235
13.41 13.51
3.400 3.170
194 .294 236
9.71 2.852 9.84 2.906
.458
194 236
8.71 8.50
2.054 1.958
-1.058
150 270
28.89 29.17
5.336 5.374
.514
155 278
13.29 13.59
3.373 3.214
155 .890 279
9.67 2.813 9.87 2.921
.688
156 278
8.48 8.68
1.929 2.044
.991
230 186
28.99 29.19
5.467 5.211
.393
241 187
13.37 13.64
3.430 3.063
241 .862 188
9.77 2.872 9.81 2.911
.164
241 188
8.66 8.58
1.990 2.010
-.411
270 150
29.17 28.89
5.374 5.336
-.514
278 155
13.59 13.29
3.214 3.373
279 -.890 155
9.87 2.921 9.67 2.813
-.688
278 156
8.68 8.48
2.044 1.929
-.991
9.95 3.024 9.69 2.832
342 Practice Environment Scale of Nursing Work Index Variable Nurse participation in hospital affairs n M SD t Stay in SA Nonconsecutive 138 22.91 6.102 Consecutive 295 23.03 6.135 .186 Married No 143 23.42 6.018 Yes 285 22.78 6.162 -1.025 Contract type Single 286 22.99 5.946 Married 137 23.13 6.482 .222 Family with nurse in SA No 155 22.64 6.299 Yes 138 23.08 6.091 .609 Pursuing a degree No 338 22.67 6.030 Yes 67 24.64* 6.237 2.371 * p 36 years Up to 35 years Nationality Others SE Asian Religion Other Muslim Educational level Diploma or associate degree Bachelor degree or higher Year registered Prior to 2001 2001 and After Title Other Staff Nurse Ownership Government Private Length of work at current hospital > 3 years Up to 3 years First contract in SA No
n
Emotional exhaustion M SD t
n
Depersonalization M SD t
n
Personal accomplishments M SD t
20 363
22.45 10.976 27.00 10.775
16 1.808 288
9.50 4.885 11.50 5.077
22 1.593 394
32.45 33.86
8.819 8.817
146 234
27.02 11.049 26.49 10.660
106 -.460 195
10.83 5.082 11.65 5.037
160 1.331 253
34.61 33.17
8.661 8.875 -1.629
29 354
25.28 9.494 26.89 10.923
30 .868 274
11.90 4.894 11.34 5.104
35 -.589 381
31.20 34.03
9.225 8.748
252 129
27.07 10.773 26.05 10.847
196 -.865 106
11.54 5.459 11.18 4.344
277 -.588 137
34.41* 32.43
8.299 9.684 -2.156
120 24.71 9.793 262 27.63* 11.104
101 2.474 202
11.60 5.091 11.30 5.094
136 -.475 279
32.24 34.51*
9.602 8.320
191 82
11.24 4.983 12.17 5.018
279 1.414 101
34.32 33.23
8.610 8.769 -1.077
72 -.598 224
8.196 8.933 -2.218
.729
1.742
2.478
258 91
26.55 11.017 26.81 9.973
96 275
27.39 10.370 26.64 10.944
11.25 4.735 11.51 5.251
100 .393 304
35.43* 33.29
167 217
27.78 10.918 138 10.76 4.836 26.07 10.761 -1.536 167 11.91* 5.220
179 1.994 238
34.15 33.55
8.749 8.863
171 203
27.22 11.366 26.25 10.265
131 -.862 166
11.24 5.355 11.50 4.916
182 .425 225
34.49 33.28
8.553 8.910 -1.403
133
25.97 11.023
97
10.86 4.603
146
34.16
8.677
.207
-.683
344 Maslach Burnout Inventory Variable Yes Length of time in SA > 3 years Up to 3 years Worked in SA prior to current contract No Yes Stay in SA Nonconsecutive Consecutive Married No Yes Contract type Single Married Family with nurse in SA No Yes Pursuing a degree No Yes * p < .05 ** p < .01
Emotional exhaustion Depersonalization Personal accomplishments n M SD t n M SD t n M SD t 245 27.06 10.652 .930 202 11.67 5.334 1.283 265 33.49 8.937 -.745 208 166
26.72 11.394 26.70 9.973
155 -.016 142
245 133
27.06 10.652 25.97 11.023
-.930
224 .516 183
34.01 33.24
8.766 8.948
-.875
11.67 5.334 265 10.86 4.603 -1.283 146
33.49 34.16
8.937 8.677
.745
120 259
26.07 11.101 27.01 10.651
11.15 4.590 11.54 5.298
129 .643 283
34.43 33.47
8.753 8.881 -1.036
131 243
27.86 11.018 113 26.03 10.592 -1.553 184
11.98 5.555 141 10.96 4.732 -1.633 266
33.52 33.80
8.459 9.064
.317
258 110
27.22 11.329 200 25.16 9.111 -1.683 92
11.47 5.180 10.92 4.809
278 -.884 123
33.80 33.51
8.746 9.231
-.295
124 127
26.72 11.449 25.70 10.165
-.744
96 95
11.41 5.381 141 10.68 4.400 -1.015 133
33.87 33.65
9.293 9.029
-.191
301 58
26.82 10.530 25.81 11.916
-.604
232 50
202 97
86 .781 214
11.25 5.300 11.55 4.865
11.47 5.280 11.44 4.102
-.038
326 34.70** 8.344 60 30.40 10.393 -3.522
345 APPENDIX Z: CORRELATION MATRIX 1 1. Autonomy over Practice
2
3
4
5
6
7
8
9
10
11
12
1
2. Control over Practice Setting
.697**
1
3. Nurse-Physician Relationships
.610** .624**
4. Organizational Support
.867** .898** .764**
5. Nurse Participation in Hospital Affairs
.634** .639** .492** .648**
6. Nursing Foundations for Quality of Care
.608** .614** .484** .635** .760**
1 1 1 1
7. Nurse Manager Ability, Leadership, and Support .685** .682** .506** .686** .754** .661**
1
of Nurses 8. Staffing and Resource Adequacy
.566** .768** .458** .695** .618** .606** .683**
9. Collegial Nurse-Physician Relationships
.521** .490** .717** .611** .567** .559** .593** .511**
10. Emotional Exhaustion
-.256** -.294** -.182** -.293** -.119* -.227** -.222** -.300** -.134**
11. Depersonalization
-.189** -.157** -.164** -.204** -.111 -.191** -.159** -.168**
12. Personal Accomplishments
.044
-.029
-.017
-.011
-.013
.009
* Correlation is significant at the .05 level (2-tailed). ** Correlation is significant at the .01 level (2-tailed).
.003
1
-.037
1 1
-.113
.494**
1
.034
.178** .163** 1
346 APPENDIX AA: MULTIPLE REGRESSION STATISTICS Nursing Work Index – Revised Demographic Variables Gender: Female Age: Up to 35 Years Nationality: SE Asian Religion: Muslim Degree: BS or higher Year Registered: 2001 + Title: Staff Nurse Ownership: Private Length of Work at Current Hospital: Up to 3 Years First Contract in SA: Yes Length of Time in SA: Up to 3 Years Worked in SA Prior to Current Contract: Yes Stay in Saudi Arabia: Consecutive Married: Yes Contract Type: Married Family in SA: Yes Currently pursuing degree: Yes Number of nurses per 100 beds Constant F Value N Adjusted R²
Autonomy over Practice p b
Control over Practice Setting p b
-1.191 2.027
.024 .001
Nurse-Physician Relationships p b
-.648 .680
-.513
-.663
-.011 15.742 10.210 357 .049
.009 .023
Organizational Support p b
-1.821 1.552
.006 .031
-.014 30.296 8.040 357 .056
.006 .000
.050
.062
.000 .000
-1.056
.059
1.044
.059
1.100 -.011 19.946 5.687 357 .073
.099 .010 .000
9.174 4.310 358 .027
.000
347 Practice Environment Scale – NWI-R Demographic Variables
Nurse Participation in Hospital Affairs b
Gender: Female Age: Up to 35 Years Nationality: SE Asian Religion: Muslim Degree: BS or higher Year Registered: 2001 + Title: Staff Nurse Ownership: Private Length of Work at Current Hospital: Up to 3 Years First Contract in SA: Yes Length of Time in SA: Up to 3 Years Worked in SA Prior to Current Contract: Yes Stay in Saudi Arabia: Consecutive Married: Yes Contract Type: Married Family in SA: Yes Currently pursuing degree: Yes Number of nurses per 100 beds Constant F Value N Adjusted R²
p
Nursing Foundations for Quality of Care b
-1.119 -1.033 -1.286
p
.091 .094 .033
Nurse Manager Ability, Leadership, and Support of Nurses p b
-.909 -1.178 -.903
Staffing and Resource Adequacy b
.016 .004 .013
.032 .042 .000
30.624 3.240 344 .019
.820 -.006 .000 16.009 5.085 351 .055
.083 .047 .000
b
p
-.433
.060
8.844 3.574 352 .007
.000
.916 .012 -.620 .078 -.735 .019
.917 1.919 -.011 23.926 4.254 351 .018
p
Collegial NursePhysician Relationships
10.016 4.343 352 .037
.006
.000
348
Maslach Burnout Inventory Demographic Variables Gender: Female Age: Up to 35 Years Nationality: SE Asian Religion: Muslim Degree: BS or higher Year Registered: 2001 + Title: Staff Nurse Ownership: Private Length of Work at Current Hospital: Up to 3 Years First Contract in SA: Yes Length of Time in SA: Up to 3 Years Worked in SA Prior to Current Contract: Yes Stay in Saudi Arabia: Consecutive Married: Yes Contract Type: Married Family in SA: Yes Currently pursuing degree: Yes Number of nurses per 100 beds Constant F Value N Adjusted R²
Emotional Exhaustion p b 5.990 .017
Depersonalization p b 1.206
5.023
2.759
.006
-1.861
.077
-4.449
.001
34.369
.000
.042
.062
2.402
.070
-2.425
.065
17.798 5.931 306 .075
.073
.000 1.326
-2.254
Personal Accomplishments p b
.000
9.935 3.695 237 .022
.000 7.750 331 .058
349 Maslach Burnout Inventory Emotional Exhaustion
Depersonalization
Demographic Variables and NWI-R and PES-NWI Subscales Gender: Female Age: Up to 35 Years Nationality: SE Asian Religion: Muslim Degree: BS or higher Year Registered: 2001 + Title: Staff Nurse Ownership: Private Length of Work at Current Hospital: Up to 3 Years First Contract in SA: Yes Length of Time in SA: Up to 3 Years Worked in SA Prior to Current Contract: Yes Stay in Saudi Arabia: Consecutive Married: Yes Contract Type: Married Family in SA: Yes Currently pursuing degree: Yes Number of nurses per 100 beds Autonomy over Practice Control over Practice Setting Nurse-Physician Relationships Organizational Support Nurse Participation in Hospital Affairs Nursing Foundations for Quality of Care Nurse Manager Ability, Leadership, and Support of Nurses Staffing and Resource Adequacy Collegial Nurse-Physician Relationships Constant F Value N
b 4.691
p
b
p
.052
4.397
.000
-2.274 -2.257
.056 .056
1.322
.043
-3.618
.004
-1.266
.068
-.867
Personal Accomplishments p b
2.744
.006
-2.183
.041
-4.157
.002
34.610 7.560 314
.000
.001
.426 -.296
.021 .092
-.773
.008
41.201 8.025 287
.000
-.219
.000
17.171 7.915 222
.000
350 Maslach Burnout Inventory Emotional Exhaustion
Depersonalization
Demographic Variables and NWI-R and PES-NWI Subscales b Adjusted R²
.181
p
b .085
p
Personal Accomplishments p b .059
351 APPENDIX BB: FOCUS GROUP CHARACTERISTICS
Variable
N
%
Male
3
12.0
Female
22
88.0
Philippines
17
68.0
India
2
8.0
South Africa
2
8.0
New Zealand
1
4.0
Pakistan
2
8.0
Egypt
1
4.0
Government
14
56.0
Private
11
44.0
Jeddah
20
80%
Makkah
5
20%
< 1 year
3
12.0
1-3 years
7
28.0
4-5 years
2
8.0
Gender
Nationality
Hospital type
City of employment
Years in Kingdom of Saudi Arabia
352
Variable
N
%
6-10 years
8
32.0
> 11 years
5
20.0
Consecutive
15
60.0
Nonconsecutive
10
40.0
Yes
13
52.0
No
2
8.0
Maybe
3
12.0
No answer
7
28.0
Time in Kingdom of Saudi Arabia: Consecutive or nonconsecutive
Do you plan to work in another country?
353 APPENDIX CC: SUMMARY OF PARTICIPANT STORIES AND NATIONALITIES (QUESTIONS 1 AND 2)
Question 1: What attracted you to work in Saudi Arabia? Themes Salary
Personal life
Thought Unit
Contract and benefits Lack of jobs Personal debt Religion
Work conditions Experience, knowledge, Personal growth
Number of Participants 1, 2, 3, 4, 6, 7, 9, 10, 12, 13, 14, 15, 16, 17, 17, 20, 22, 23, 24, 25 1, 2, 4, 6, 7, 9, 12, 13, 14, 16, 17, 20, 22, 23, 24 15, 17, 25 3 2, 6, 9, 11, 13, 14, 16, 18, 20, 21 1, 2, 5, 6, 8, 11, 17, 18, 19 1, 2, 5, 11, 17, 18, 19 6, 8
Nationalities Philippines, Egypt, South Africa, Pakistan, India Philippines, Egypt, Pakistan, South Africa Philippines South Africa Egypt, Philippines, Pakistan Philippines, Egypt, India, New Zealand Philippines, Egypt, India Philippines, New Zealand
354 Question 2: What are the issues that you deal with working in Saudi Arabia? Themes
Thought Unit
Work conditions
Staffing Organizational culture Saudization Standards of nursing care Subcultures Personal life Family and friends Lifestyle Accommodation, food benefit Restrictions of country Recruitment practices Salary
Company policy and administration Registration and licensure
Tax Free Salary, Housing, Health Care, Ticket, Yearly Service Award (from Government) Continuing Education & Training Link to education, training, & professionalism
Number of Participants 1, 2, 3, 5, 8, 11, 15, 16, 18, 19, 20, 22, 23, 24, 25
Nationalities
9 1, 3, 5, 6, 7, 8, 12, 13, 14, 15, 19, 20 1, 3, 6, 7, 13, 18, 19, 24
Pakistan Philippines, South Africa, India, New Zealand, Pakistan Philippines, South Africa
Philippines, Egypt, South Africa, India, New Zealand 1, 2, 3, 22, 23, 25 Philippines, Egypt, South Africa, 8, 16, 18, 19, 23 New Zealand, Philippines 1, 2, 3, 5 Philippines, Egypt, South Africa, India 1, 18, 19, 24 Philippines 22, 23, 24 South Africa, Philippines 2, 4, 5, 6, 7, 9, Egypt, Philippines, 12, 14, 16, 17, India, Pakistan, 18, 21, 22, 23 South Africa 2, 4, 5, 6, 7, 9, Egypt, Philippines, India, Pakistan 12, 14, 16, 17, 21, 23 18, 22 Philippines, South Africa 18 Philippines
2, 3, 5, 13, 15, 17 Egypt, South Africa, India, Philippines 1, 2, 18, 19, 21 Philippines, Egypt
355 APPENDIX DD: PULL / PUSH FACTORS Question 1: What attracted you to work in Saudi Arabia? Factor
Thought Unit
Gov’t (G) or Private (P)
P#
Salary
G
P1
G
P2
G
P4
Quotes and Comments
Salary is both a hygiene and motivator factor in Herzberg’s theory. Salary and other benefits in SA are pull factors for FTNs. The salary and benefits keep FTNs in SA. Higher wages, providing for family (housing, food, and education), lack of jobs, buying a house, paying off debts are other factors that push nurses to look for employment outside their country. SA is a country of choice or a strong pull factor for nurses to work abroad with free housing, free health care, and tax-free salary in SA. P1 stated: she came to SA to “earn money for foreign licensure exam and also to pay my agency for school. Instead of paying for foreign licensure exam, I had to prioritize my accountability to my country. My other agency sponsored my 3rd and 4th year college tuition fees. They were supposed to be in charge for my examination and other policies for going to the U.S. Unfortunately, I had to withdraw because my area right now is not included in their job hiring. Employers are looking for ICU, OR, ER, medical/surgical. I am in the hemodialysis so I cannot. They are going to categorize me, I will be in the lower rank because of my experience, I have not been exposed to too much equipment. For me I can earn better here than in my own country. But the money is still not that good. The peso now is going up.” P2 stated: “I came for money. Now in Egypt very bad situation, all the people suffering from all the things are high, cannot live, and our salary there is very low. My salary here is okay.” In Egypt P2 would make SR 300/month as supervisor. She trained in the best hospital with good education but still made very low salary. P4 stated: “We came for better pay of course because in Philippines I could say we have good hospitals just like here but you are not satisfied with your salary. You can provide for your own In SA), I have my own family now but I have one brother and one sister who are
356 Factor
Salary
Thought Unit
Gov’t (G) or Private (P)
P#
G
P6
G
P7
G G
P9 P10
P
P12
P
P13
P
P14
G G
P16 P17
Quotes and Comments
still studying and I want to help them.” P6 stated: “Helping my family because I am the eldest and I want to help them (family) financially” P6 stated: “Then the problem is we don’t have that money to support us again (if they move to another country or hospital in SA)” P7 stated: “Financially because abroad they give us high salary, in Philippines we cannot apply there easily.” P9 stated: “and as a male, I want to support my family also (still in his country).” P10 stated: “We think other countries will be better than our country; the salaries are poor (in India), I have to support my family, I have a son” Husband is in SA now, son is now married and has family of his own. P12 stated: “For financial reasons we (P12 and friends) came back, did not go to London, or somewhere. All of my friends came back here in Jeddah and we start again for a new life. So maybe now we try to exit again and find a new life, for increment, for financial reasons.” P13 stated: “I think it’s almost all the reasons was mentioned, maybe for us Filipinos through the active recruit, it is financial, really. Especially if you have family in the Philippines. Like for me when I came here, it was not planned. I have already a daughter at that time. My husband was not working so and I am the one to finish school only. I have to find better living for my daughter. Until now, I am still here because of the same reason because my daughter is in high school and needs more.” P14 stated: “In this way, I want to stay better. Same like my colleagues (family in Pakistan), very difficult education and food, I want my children to eat nicely, wear nicely, go nicely school, I have to suffer. Salary different, I cannot make that much in Pakistan.” Salaries in Pakistan are not going up as in other countries. P16 stated: “Providing money for my mother.” P17 stated: “In the Philippines I worked there after graduating from the school in 2005. I worked in the university for free. I was a scholar there and I have to pay back something for letting me study without payment. The moment I knew that I passed the exams in the
357 Factor
Salary
Thought Unit
Gov’t (G) or Private (P)
P#
P
P24
P G
P20 P22
P
P23
G
P15
Quotes and Comments
Philippines, I immediately applied in POEA (recruiter). What came into my mind, I have to go to SA to work, earn experience, at the same time earn money for myself and for my family. I aim in gong to the USA, specifically New York or anywhere in the USA where I can earn more money since most of the sponsors there also came from my province in the Philippines Many of the Filipinos formed a group and supported some of the Filipinos who are less fortunate, to go to school. In return I would like to serve the other Filipinos, so just for experience and money, to serve myself and my family.” P24 stated: When P24 came to SA many years ago she thought she would do her contract and go home. P24 was working in the government hospital in her country and her salary was low. The family was having financial difficulties so P24 came to SA. She came to earn money. Family ended up coming to SA which keeps her here. P20 stated: “For all of us, financial.” She helps to support her family at home. P22 came originally in 1998 for 3 years to pay for child’s education and to buy a house. “During that year I was barely managing to hold everything together. At that time, South Africa had just been introduced to SA because the first nurses came only in 1995.” P22 took a specialized pediatric course and was hired for SA. “What keeps me here is the tax at home. Salaries are somewhat better but they are not keeping up with the inflation rate. Private sector is better paying than government.” The tax-free salary keeps P22 here. South Africa felt the nursing shortage a year ago, also for physicians. “A lot of nurses here in SA. When you go to the hospitals (in South Africa) you can see the shortage of nurses and doctors.” South Africa is trying to get nurses back home by increasing salaries. P23 stated she spent money in the Philippines applying to the U.S. for work. P23 is married and left two children in the Philippines to work and earn money in Saudi Arabia. P15 stated: “Cannot have good work in Philippines because I am newly graduated. I am from (province) so no good work in hospital. I worked one year and tried to apply in UAE but luckily I was hired here. Worked in private hospital so was paid. Low salary (in Philippines) compared to salary here. Yes, I support family, I am the only one working
358 Factor
Thought Unit
Gov’t (G) or Private (P)
P#
G
P17
G
P25
G
P3
G
P2
G G
P9 P6
P
P11
P
P14
Religion
Religion
Quotes and Comments
overseas.” P17 stated: “I had no money (because of school), I had no finances for myself, and I had to work for my family.” Also a lack of jobs in Philippines. P25 stated she graduated in 1994 and it was difficult to find work in the Philippines. “I feel easier coming to SA because requirements are less, not like the USA where they ask for examinations. For SA we can just present our documents that we are graduates of nursing so we can come here.” P25 came leaving a two and one- year old behind even though she knew SA was not free like her country. She had to find a job for her family. P25 went home and thought she would go to another country. She lost money being at home and applied back for work in SA. P25 stays in SA because now her children need money for school. The money and her family being here keeps P25 working in SA. P3 stated: “I had a lot of personal debt, so it took me 6 months to get rid of that, and just as I came to SA, my mother and I bought a house together, a really old house that is falling apart so we have to renovate that.” Makkah is a pull factor for Muslim participants. P2 stated: “And we are going to love SA because we are Muslim; I came here also to make Omrah and Hajj. Very easy for me. But if I live in Egypt, how much money will I spend (to come for Omrah and Hajj)? Everything for the money, for my nursing, I can do something, I can learn more, and also for my Holy, I can go to Makkah to make Omrah, very easy for me.” P9 stated: “Choose SA because two Holy Cities here.” P6 stated: “But still I am happy and lucky to have there because the Kabah (Holy place) is there. Of course I was in Makkah, Holy City that is a big thing, happy for me.” P6 did not know she would be assigned to a hospital in Makkah. P11 stated: “For me, why I am here in Jeddah, because of religion.” P11 has been to SA on and off since 1996. P14 stated: “At that time, my reason (to come to SA) was to perform Omrah and Hajj.”
359 Factor
Thought Unit
Gov’t (G) or Private (P) P
G P P
P
P
P#
Quotes and Comments
P13 P13 stated: “Two years to go and I will also be finished my contract. Until now, I still don’t know if whether I will still come back here, yes there the religion is here. For me, frankly, in the … I am not that much religious. I am not even wearing tarah there. Here we are really covered.” P16 P16 stated: “I came here besides the money, because I want to visit the Holy Mosque.” P18 P18 stated: “I am Muslim and I want to visit Holy Land. To go to Omrah and Hajj is very expensive, to stay here is very easy.” P20 P20 stated: “When I came here (back to SA) in 2004 I converted into Islam. When I was at the old hospital, all the doctors were telling me all of this. I bought the Koran and some books so when I was home, I was able to read all of this. And then when I came back here I converted (ilhumdilala), almost 4 years. And I see the difference, really.” P20 P20 stated: “I can see the difference, and I can feel the difference. They (other Muslims) can see it also, the way this Islam made a difference to my life. I am giving my best in taking care of my patients. I work in ICU and all the doctors, even my fellow nurses, you can ask, and all the patients. All this thank you, this make me worthy. Even sometimes, I can’t remember the bad days, you can’t deny that it (bad days) comes. But after the end of the day you have to think there are more rewarding things and good things.” Facilitator question: “When you look at yourself from before you converted until now that you have converted and how you practiced your nursing, do you think you are a better nurse after you converted?” P20 stated: “Yes. Facilitator question: “So do you think the reason for the doctors treating you has to do with you converted or because of the way you are practicing nursing?” P20 stated: “The way that I practice nursing, I think it counts when I became a Muslim. But I think it is more of the work.” P21 P21 stated: “The patients, the treatment of doctors and nurses for the religion. Because she
360 Factor
Experience and knowledge
Thought Unit
Gov’t (G) or Private (P)
P#
G
P1
G
P2
P P
P5 P11
G P P
P17 P18 P19
G
P6
Quotes and Comments
is a Muslim, they treat her well” P1 stated: “My second objective is for experience and learning.” P2 stated: “Need to know something, need to make something for my life. When I came here, I thank God. The work is okay, I can take information, I can go to lectures, I can learn more, I can read also, always I am reading. I need to know everything in my job. I like my job.” P5 stated: “To get more knowledge, this would improve ourself.” P11 stated: “My experience all polyclinic, this is my first time for me in Jeddah in a hospital.” P17 stated: “What came into my mind, I have to go to SA to work, earn experience.” P18 stated: “To gain experience and serve another people, I am happy.” P19 stated: Finds X ward boring as she was not trained as X ward nurse. During Ramadan and other times, the OPD nurses relieve on the ward. “This is the time I feel I am really a nurse. Now in an area in OPD that is more interesting as there are more procedures.” P6 stated: “I went abroad to find myself, to have that independence to start on my own. If I was staying in the Philippines, not enough to support my family, here I can live on my own and provide for my family, to improve myself.”
361 APPENDIX EE: DAILY ISSUES Question 2: What are the issues that you deal with working in Saudi Arabia? Factor
Work Condition
Thought unit
Staffing
Gov’t (G) or Private (P) G
P#
P3
G
P2
G
P1
G
P22
Quotes and Comments
P3 stated: “Cannot provide holistic care for patients (because of staffing).” P2 stated: “At Eid holiday received days off for all Saudi nurses, only foreign nurses on shift. Four nurses for all ICU, 1 nurse handling 3 patients with intubation. My friend she cannot do anything for her patients. One patient died, she had 3 patients. How is she going to handle everything? One patient for CT scan, one patient died, and one patient for blood work, all at the same time. What will she do, she is crying inside. She is asking the doctor what will she do first, you tell me. Se is feeling very bad. This patient dies without anything, without CPR, for what, just keep quiet, because no staff for doing anything, all staff on holiday.” P1 stated: “In our hospital some nurse aides acting like nurses. You cannot train, because, he is Arabic but not Saudi. He is doing dialysis, he is pricking the fistula, but he is not a nurse. Everyone knows, even our supervisor.” P22 stated: “You have to be strong to make it here, because of the culture, of the attitudes of the other people, and the workload is overwhelming. The workload is less in my country.” P22 described the shift in her country in the government schedule. “Everyone gets a break, you have some social contact, and you come back to work refreshed. Three nights is much heavier than
362 Factor
Work Condition
Thought unit
Gov’t (G) or Private (P)
P#
G
P22
P
P23
Staffing
G
P25
Organizational Culture
G
P8
Quotes and Comments
the 7 nights I used to do (in South Africa). You can ask any nurse that is coming from South Africa. In SA you can come in at 7 pm and don’t stop until tomorrow morning when you hand over. The breaks make a difference.” P22 stated: “The turnover is very high. The ward depends on the senior staff. New people have to ask and they do not know the policies.” This makes a heavier workload. P23 stated: “Several senior people are leaving the hospital. A charge nurse that has been there 12 years, another nurse manager that has been there for 20 years. There are no plans to groom someone into the positions when they leave. No one wants to take the responsibility of the unit. More Indians are coming who are not thorough in their job. They pass the buck, they will endorse the patient without cannula, they will endorse the patient bleeding, they will leave the patient dirty, not clean the patient. Filipinos are better than Indians in terms of caring. We can see from the patient they don’t really like these people. They comment we don’t want Indian because they smell bad.” P25 stated: “The workload is very hard here compared to Philippines. Three nurses for 30 patients and no support because of lack of staff. Nursing care is different here. In the Philippines the relatives assist the nurses in patient care. Here the nurses are expected to do everything. Even the water is sitting there, they look at you and you pour them water.” P8 stated: “I found it very, very different, the hospital. This is the harshest nursing environment I’ve ever been in. I find it very Draconian, speaking for my own hospital, systems very
363 Factor
Thought unit
Gov’t (G) or Private (P)
P#
P
P19
P/P
P18 / P19
Quotes and Comments
bureaucratic, it is a culture of blame, everybody is blaming, they don’t look at what part of the systems enabled that person to make a mistake. People do make mistakes. There is some victimization and harassment going on, quite frankly. Which if it had been in X country, I would have been on the floor with, from a union perspective. There is few people that you can go to. (I) saw some real nasty stuff, and that was vindicated by another person on the X floor, who said can I go and talk to you? It may as well have been me suffering that same seat that he was in because he was saying exactly the same things about exactly the same issues, with regards to some of the same people. Wow, it isn’t me. I was at the point of questioning my career, am I in the right job here? So that’s how difficult it was. D floor is very different.” P19 stated: Nurse worked for MOH for 10 years. “MOH is better. Notice it with the doctors, colleagues, nursing officers (supervisors). In private hospital there is patronizing. If you are a newcomer, you are down, you are the neophyte. I will be humiliated and feel my self-esteem is low. As far as I am concerned, I know how to work since I came from different areas. I worked medical-surgical, I worked in Philippines as supervisor in a 700-bed capacity hospital. In MOH there are no supervisors, they are not hiring supervisors (as foreign-trained), hiring all staff nurses. You have to work as staff nurse. In MOH I worked as charge nurse for 6-7 years.” P19 gained other experience by training and working in dialysis, ICU. P18 and P19: “It is understandable in the private hospital, the patient is always right. They will never listen to the nurses.”
364 Factor
Work Condition
Thought unit
Organizational Culture
Gov’t (G) or Private (P) P
P23
P
P18
P#
Quotes and Comments
P23 stated: “I have experienced bad things with my fellow Filipinos, the treatment is not good. Not to talk about the hospital itself they do not treat their nurses as special people. The Saudis are good but the other blood are not good. I have asked my fellow nurses, before the (hospital) was good; the job was easy, because before it was handled by the British. It is being handled by Filipinos and Egyptians. It is like being in a forest with lots of snakes. That is how hard it is in our work.” P18 stated: Medical director is a Saudi and nursing director reports to him. “He is calling some nurses rubbish or are you mentally retarded, or stupid? But now he is already unfair and not treating equal to the nurses. He is in favor of operating room nurses (MD is a surgeon). And now he wants nursing director will be changed but the owner said no. Communication between the two of them is not good, they let the pharmacist be a mediator between them.” Clarification: Communication is a problem and disagreement with the management affects your perception of a good work environment? P18 stated: “Yes, because before even though we were not receiving a lot salary we are happy because everybody is approachable, you did not hear that you are rubbish, you are stupid, you are … So even though you are receiving money, is only secondary. If you are not treated nicely, and then you are in stress every day, no. It‘s better to receive a low salary and your work environment is good. But to receive a big salary and every now and then you are prone to mistakes and you are always stressed.”
365 Factor
Work Condition
Thought unit
Gov’t (G) or Private (P) G
P16
Saudization
G
P3
Saudization
P
P5
P#
Quotes and Comments
P16 stated: “My colleagues are not approachable.” (in terms of learning new work area) P3 stated: “It is not just that. One thing that made me very angry and sad at the same time, now SA is training their own nurses, so they (staff) wanted to put together a policy of nurses. You would think that we are training their own staff now, this would be a vision. A third year nurse, she won’t touch the patient, she never bathed a human being in her life and she is already in her third year. She can qualify in three years. What are they going to do? A lot of the South Africans are asking a lot of questions. They get very angry, they drum it into them that these are your people, this is your country, you should have a lot more pride and respect. The odd few do roll up their sleeves and try, I do understand the culture, but if you are not going to be bothered then who cares? It is bad, from a South African perspective we come from a nation that we are fighting for our people for a long time. And that national pride story. The military wants to be the best in this and that, so you expect things as generations to be rising up, and from a medical perspective, from a nursing perspective, they are not, they are definitely not. I have met a couple of Saudi nurses that I have a lot of respect for. They take a lot of pride. But when you look at them and the new ones, they are completely different.” P5 stated: “We also sometimes see them working in the OR. Very nice, cooperative, they understand, they are trying to learn more. They are very expert, more expert than some. The problem is the unqualified only. We are trying to teach them to become more good. This is our aim, suppose one is going to misbehave, we will
366 Factor
Thought unit
Gov’t (G) or Private (P)
P#
G
P2
G
P3
G
P1
G
P1
Quotes and Comments
teach them good so they become more good. Actually, some persons they don’t know English, we have to say it to them. But never ever, in 10 years I am here, saw anyone abuse the human beings.” P2 stated: “We have in our hospital nurses excellent, excellent, she knows everything. And she wants to learn more. She wants to do everything. Almost all the nurses coming like that. Maybe she is coming into nurses but not like nurses, maybe for her obligatory. Before maybe one, two nurses, but now hundreds of nurses or two hundred nurses coming.” P3 stated: “We are talking about people who are actually doing the education. This is a general comment from our perspective. I cannot speak about the whole of SA. This is what gives me an impression of what the country is facing and because I have been a student, I enjoyed my training, I loved going to the departments and being challenged, going to theatre (when P3 was training).” P1 stated: “So even if the Saudi just came, he/she will be promoted to a higher position, even if he/she not yet that experienced. It would be better if the Saudi’s become the boss and all the foreigners do the work, because the workload will become lighter. Need MOH to understand the Saudization program, the nurse leaders to understand what is happening at the unit level, the language, the training, the work habits, work ethics.” P1 stated: “In our hospital some nurse aides acting like nurses. You cannot train, because, he is Arabic but not Saudi. He is doing dialysis, he is pricking the fistula, but he is not a nurse. Everyone knows, even our supervisor.”
367 Factor
Work Condition
Thought unit
Saudization
Standards of Nursing Care
Subcultural Differences; Cultures within a Culture
Gov’t (G) or Private (P) P
P24
P
P18
P
P19
P
P24
P
P23
P#
Quotes and Comments
P24 stated: “When you are in a private hospital you are bound by policies and procedure. Too much paperwork, 90% writing and 10% nursing care. I worked in the Philippines before and thanks God all our patients became well, they went home walking, and our kardex is only one page like this (P24 demonstrates by showing a piece of paper, one side). In our hospital we will maybe finish 10 pages of this stupid paper.” P24 stated that everything is documented: if the patient calls the nurse, document. “When the patient complains, administration pampers them.” P18 stated: “MOH is hiring newly graduated nurses without experience but private hospitals cannot do that.” P19 stated: “In our hospital we have newly graduated nurses which they are recruiting from the Philippines, they wear a brown badge – assistant nurses – after two years they are allowed to take the Saudi Council and at this time they are allowed to be called registered nurses. It is a “training period”, to get the visas. Hospital has a continuing education program for the new nurses. The salary is less until they qualify.” P24 stated: “The shameful part of us Filipinos is this crab mentality. We cannot remove this one from our culture. If you enter a place or join a job and your superior will feel that you know something or you can do better than her, she will not accept that fact, she will do everything to put you down. They are afraid.” P23 stated: “P24 is right, they have a crab mentality. That when they saw someone, oh this is a threat to us, they kill her” Facilitator question: “What do you call this?” P23 “Crab mentality. You know the crab, when it is put in a pail,
368 Factor
Work Condition
Thought unit
Subcultures
Gov’t (G) or Private (P)
P#
G
P22
G
P22
Quotes and Comments
and one of them wants to crawl up, they will push it down. You have heard of the crab bite? They will pull each other down, nobody will get up.” Only the Filipinos in the group knew about this saying. Facilitator question: “Do you have the same attitude at home?” P23 “Of course not.” Facilitator question: “It is maybe a survival instinct that come onto people when they live in a place like this?” P23 “Yes, survival of the fittest.” P22 stated: “There is a nurse manager who is doing the same thing. She is not Filipino.” P22 describes the nurse manager as a long-time employee, was a staff nurse. She was promoted because they (the hospital) could not get a nurse manager. She selects a new nurse according to what she wants, not by what the qualifications are. P22 stated: “You take the positive from your colleagues because in the whole ward we do not have the mafia. In X hospital (P22’s previous hospital), what made me leave there because I don’t like job hopping unless there is something really bad other than the money. I left the hospital because there was starting to be a mafia there. You were not sure if you came on duty if you still had a job. There were three groups. I am sorry to say they were Filipinos, they were very bad. Filipino against Filipino, Filipino against other nationalities, they were very bad. I decided to resign. The thing is the support that you get from your colleagues. If you are so busy on the ward and we find we do not get support from superiors.” P22 has a good working group now. “For me it is my
369 Factor
Thought unit
Gov’t (G) or Private (P)
P#
Quotes and Comments
way of coping. I don’t look at it (work) as hard, I know it is hard but I don’t approach it as something that is a problem. I approach it as a challenge, something that I am going to overcome.” Facilitator question: “So is that the same mentality as the crab mentality? The people who are considered the mafia are also like the crabs, they keep everybody within their group” P22 stated: “I think the mafia is even worse. They are coercing day to day. Like when you lose your job they are going to get some money from the management. If you should be fired, the way the mafia acts is like at my old hospital. The mafia behaves in such a way that they run you out the door as if they have been promised some percentage of your salary if you should be fired. They work on you so you will leave. You can actually feel that. When you are on duty with them, with the mafia, my God, it is so draining.” This is the reason why P22 left her previous hospital. Facilitator observation: “The best thing to do as a manager with the mafia on board is to identify who the leader or leaders are. Make sure that you are working together because that way your unit will function. If you are not aware that you have one, you will be worked against” Facilitator described her experience as a staff member on a unit. The mafia was a strong group of Filipinos. She had a good relationship with the group as a staff nurse. When she was promoted to head nurse, she had their blessing from the beginning. Facilitator did not have a problem. But others who had been the head nurse and who did not have that blessing, everything the head nurse said was rejected” Facilitator question: “How do you identify these people?”
370 Factor
Work Condition
Thought unit
Experience / Personal Growth
Gov’t (G) or Private (P)
P#
Quotes and Comments
G
P8
Facilitator observation: “From my point of view, if you come from outside you won’t know and this is very difficult. You can come and say this is the mafia but how do you know if this is true? You cannot tell. Unless you work within an experience what a teamwork is like and that is not something you just get from a couple of shifts. This is a long-term thing” P22 stated: “The leader of the group, you should be wary of people who are … don’t be so gullible like believe everything that the support nurse will tell you. If the same people come to you and tell you stories or complain about someone all the time, it shouldn’t be like this. Managers tend to believe these people. They always want to be on your good side and then they always talk bad about you whether it is true or not about the other people” Facilitator observation: “The people who are involved in this are not bad people” P22 “No they are not bad people.” Facilitator observation: “It is just a survival technique and they honestly I think they are doing it in the best interest of everyone. So it’s not that they are going to work, let me sabotage some teamwork here. I don’t think that is the case. I think they come to work that this is the best way. And it is just a pure survival technique that has developed over time.” P22 “The person who is the victim of that team, you really feel it is very bad. It is something that you really feel scared.” P8 stated: “I have met some beautiful, fabulous people here”
G
P8
P8 stated: “The reason why I am not going to stay another year is
371 Factor
Work Condition
Thought unit
Gov’t (G) or Private (P)
P#
Experience / Personal Growth
P
P20
Communication / Language Barrier Language barrier
P
P19
G
P15
Recognition
G
P25
Job Satisfaction
P
P11
Quotes and Comments
because I am de-skilling. I’m losing my clinical skills. This is the main reason why I am going to exit. There is no challenge, I love a challenge. All we do basically is sticking bits of paper in files and putting them in slots, day after day. I was a team leader for a while and that gave me a nice challenge, I enjoyed doing that. But when the team leader came back, I had to step back. The challenge has now gone.” P20 stated: “For career advancement, in the Philippines you think of going abroad like in SA, for advanced technology. But it’s all the same. I went to a hospital that had all the old equipment.” P19 stated: “It is the most difficult, the language barrier, especially with the patients.” P15 stated: When Filipino nurse requires assistance, she approaches a Filipino nurse. Even though there are Indians, Pakistani, in the department. New Saudi nurse aides are used as interpreter. Doctors interpret. P25 worked in Taif first. “The province is very strict; we can see these attitudes that their mind is very closed. But we can compare in Jeddah that some people here are open-minded. We can see Saudis here are not covering the face, but in Taif all the Saudis are not opening the face. We can also compare the attitude. It was very difficult working there. Now I am in Jeddah, the mind is not too closed but the attitude is the same. They are rude, but not all, not 100% but 30% with a good attitude. They say thank you very much in which you are very, very happy.” P11 stated: “The environment also, if your work environment is good, that is a motivator too.”
372 Factor
Thought unit
Gov’t (G) or Private (P) G
P3
Lack of Appreciation
G
P3
Friends / Family
G
P2
P
P5
G
P4
G/G/P
P6 / P7 / P12
Professionalism
Personal Life
Personal Life
Friends / Family
P#
Quotes and Comments
P3 stated: “There are lots of Filipinos I met that are not interested in that (continuing education), they prefer just functioning, they are not interested in furthering themselves.” P3 stated: “Nurses are committed to their job. There is no appreciation for that (commitment to job). At the end of the day, if you are going to contract someone for a certain amount of time, and you think they work well, I think the managers and the people that run the hospital need to take that into consideration to retain staff.” P2 stated: “I bring my husband through a visa. Not on my visa, I spend SR 7000 to buy free visa, this means he can work. My husband came here but cannot find job. He has been with me now, 2/1/2 years without job. He is looking for job. He is driver for me, he helps with my two daughters to go to school and me to go to work. He helps me in the life here, because you should have one man.” P5 stated: “No wife, no life. The hospital posted the visa for all of them. The wife stays home, not working.” P4 stated: Came with husband who is also a nurse. Wanted single contract for better benefits (husband and wife stay in separate compounds provided by hospital). “We came as an option, we did not want it to be married. We chose the single because we can go home every 6 months to see our baby. If we are married, we can go home annual.” P6, P7, and P12 stated: It is important to have friends or family here.
373 Factor
Thought unit
Lifestyle
Gov’t (G) or Private (P) P
P14
G
P17
G
P16
P
P21
G
P9
P
P23
G
P22
P#
Quotes and Comments
P14 stated: “This is better than Pakistan, so I want to stay here. Moving to other countries takes them farther away from family. Also, family can visit here where that may be harder to do in other countries.” P17 stated: “This was the second time I applied (for SA). I already knew some people at (MOH) hospital. DON is Filipino. I knew one person who worked here and they hired me. The first application I had, they called me, but I turned down. I think for me it is better because I knew somebody also working in the hospital.” P16 stated: “My sister is also working in Makkah at MOH hospital.” P21 stated: “Went home to have a child, did not get pregnant. Got bored in the Philippines so went back to same hospital (in SA).” P21 has friends in SA and it fast to adjust to the hospital. Husband is a teacher and is in the Philippines. P9 stated: “They (hospital) provide me with family visa, so two times my family come here for visit.” P23 stated: “That is the hardest part of it, my family is in the Philippines and how can you leave out the one you are feeling, how can you bring it out into the open when another fellow nurse is experiencing what you are experiencing. So I couldn’t jive, you would feel the same way, you would share the same negative thing. The environment is really not good.” P22 stated: “I have been away from home now 10 years, so it is somewhat difficult to say that I know that I will go back home, I might decide to travel somewhere else.” P22 has a best friend that
374 Factor
Personal Life
Thought unit
Lifestyle
Accommodation, Food Benefit
Gov’t (G) or Private (P)
P
P#
P18
Quotes and Comments
went home but came back in six months because it is so expensive. “If you have been out of South Africa it is difficult to stay at home. A lot of nurses went home but came back. What we realize, if you have been here more than 2 years, the South Africans then it means you will not make it back home. The ones who never come back were here are the ones that stayed for one or two years, because they have not gotten used to the salary here. You sort of change your lifestyle here and your family also. Lifestyle changes and it is difficult to go back home.” P18 stated: “To go to Omrah and Haj is very expensive, to stay here is very easy, also no income tax at all (in SA), if you go to Canada or London, there is tax that is very expensive. Half of you salary would go to the government. Now according to our friends, in London, they prioritize the British. They said that they (British) are finishing nursing (school) and must accommodate them. Some nurses are terminated, and then you will go home.” P18 stated that her friend went on working visa, can get resident visa in 4 years. Now the rules have changed to 5 years to wait for resident visa. But they are taking the British nurses first and the rules may change again. The situation is different. Britain has stopped hiring foreign-trained nurses (Filipinos). The USA is still taking foreigntrained nurses but it is a very long process- 5-6 years and very hard process. P18 is here with husband, both working at same hospital. Some nurses pay for electricity, gas, four nurses per bedroom, up to 12 nurses per flat depending on hospital, common area that is for all nurses, 1-2 bathrooms, free food (for non-Western
375 Factor
Thought unit
Gov’t (G) or Private (P)
P#
P
P18
G
P9
G
P6
Restrictions of Country
Personal Life
Recruitment Practices
Restrictions of Country
Quotes and Comments
nationalities), one kitchen for all, sharing with different nationalities and religions. P18 stated: “Before if you stay in accommodation, you are not allowed to go out. On Friday 5 pm to 10:30 pm. On Monday 9:30 pm to 11:30 pm. But now (after passing MRQP) they (nurses) requested to go out; when off duty (the nurses). Off compound times now 8 am until 11:30 pm every day.” The reason for the restrictions is to protect the females in this segregated, Islamic society. There are increased security risks as single females stay out later in the evening. Researcher had to drive to Makkah with driver in order to sign a nurse out from her hospital and sign her back in at the end of the session. The hospital would not allow the Makkah nurse to travel with a driver they did not know and would not release a bus to drive the nurse to the session. P9 stated: When participant arrived 10 years ago, he could not travel alone to Holy City. “As a male I cannot travel also. I had to get permission from Interior Ministry, before 10 years.” “I worked in Qassim (at that time) but now I can travel without that paper, they finished that system.” P6 was hired by HPO (recruitment company within MOH). “Actually, it is very disappointing part on my part, because from Philippines, we have this offer of appointment. Say after 11 months we can go home. Then they will shoulder everything, the fare, the roundtrip. But what happened, when you are at the hospital, they provided us another contract, another contract in Arabic form, and then we say we need English, because we cannot
376 Factor
Thought unit
Gov’t (G) or Private (P)
P#
P
P13
G
P6
P
P12
G
P7
P
P13
Quotes and Comments
understand Arabic. They tell us they will provide after. If we will not sign on that, they will tell us, they will hold our salary. So what can we do? We need to sign that, we need our salary also. But still I am happy and lucky to have there because the Kabah (Holy place) is there.” Recruiter in Philippines assigned P6 to Hospital X in Makkah but did not tell her about the hospital, culture, or social life. P13 stated: “If I am a new staff, I should pay my placement fee, I should pay my visa fee, and I should pay my Iqama fee. It will be deducted every month from your salary once you get here (SA). It was not stated in the contract that we must pay these things, accommodation, there are so many things.” The problem lies in both the recruiting agency and hospital the participants stated. P6 stated: “It is not written, in our hospital, the Egyptian nurse they are not paying for their Iqama, only the Filipino and Pakistani and India.” P12 stated: “In my hospital, the staff can complain as newly hired back to the agency in the Philippines for deductions they did not know about. The agency will respond to the hospital.” P7 stated: Contract misleading for nurses: salary, ticket. P7 was very angry at way she was treated with recruitment and hospital. She is married, met her husband here. She is on single contract but can live outside the compound with her husband and daughter. P13 stated: “I want to comment on the contract and the ticket, because really it is true. The contract we sign in the Philippines, the salary is different than the salary that we will come here. And the airfare ticket, at least for them (pointing to government nurses)
377 Factor
Recruitment Practices
Thought unit
Gov’t (G) or Private (P)
G
P#
P8
Quotes and Comments
I think they are giving half (ticket ½ paid). If you go local (hired as a local hire), for us, no. You will not get that. If you go for local leave (within the Kingdom) and you are entitled for a ticket, they will not give it to you, any percentage. They will not give it to you, only vacation pay. I came here as a staff nurse, it was a 5year contract and then when I renew my contract, it was very hard that I was promoted to charge nurse. They increased my salary by heart and now I am acting head nurse. The problem is now they don’t have system for increasing salary for situation like this. For me, I said no, I will not take the responsibility if you will not increase my salary, although I know the in and out of the area.” Nurses complained to labor (department) in the Philippines. The labor department took some action against the agency and it was blacklisted. “The problem is they changed the name of this agency and I don’t know how they have the permit.” Staff went to embassy in SA to complain about these things. “For us we are paying our Iqama, where in fact I heard they even published in the hospital newspaper that X hospitals should not pay the Iqama. But for us we are paying. They are renewing every year so we are paying SR 850. And this will be deducted from us.” P8 stated: “The recruitment agency that I work with actually allocated me to the Y hospital” P8 had offer of two jobs, one in SA, one in UAE. “The reason why I chose here was simply because it was close to the UK, so I could fulfill some dreams of going to Egypt, the UK, and Ireland. So that was one of the reasons, it was a self-centered reason. The pay was the same even though a more responsible job (in UAE). I knew Dubai was more
378 Factor
Recruitment Practices
Thought unit
Gov’t (G) or Private (P)
P#
G
P8
G
P8
G
P15
G/P/P
P1 / P19 / P20
G/G
P1 /
Quotes and Comments
expensive, so it would cost me more to live there” P8 worked better with the agency that was recruiting for SA rather than the other agency for UAE. P8 described the practice of visitor visa. “This visa brings staff in quickly. The hospital is aware that this happens. This practice affects the nurse: the nurse has to get extensions of the Iqama, bank accounts frozen, cannot go out on vacation because he does not have a re-entry visa. (The hospital) did not tell the nurse this would happen. Hospital wants western staff quickly because of skill mix quotas. Nurse is 6 months into contract, but that contract will be severed, he has to come in on a new contract, which means he will lose the benefits of that contract. The agency got him in quickly with a visitor visa.” P8 stated: “When I got here I found things a little bit different than what I had been told. People have left within a week because they were shown pictures of hospital on the foreshore of the Red Sea, superimposed.” (misrepresentation of hospital setting) P15 stated: “Some problems but I can handle. When we applied with Saudi Recruitment Office (SRO), we were told what hospital we would go to. We did not have to pay placement fees.” No fee with SRO which is MOH. P1, 19, and 20: “I think SA is the fastest, easiest (country) to get to. All the agencies, the fastest, especially for Muslims and nurses from the Philippines. More hospitals in SA than in Qatar or UAE. It takes a long time to apply in other countries and you are spending all your money while you wait for a job.” P1, and P3: “Some of the feedback, they’re telling that, some of
379 Factor
Thought unit
Gov’t (G) or Private (P)
P#
P3
G/G/P
Salary
Salary
Tax Free Salary, Housing, Health Care, Ticket, Yearly Service Award (from Gov’t)
P
P1 / P3 / P5 P14
P
P24
G
P1
G
P3
G
P3
Quotes and Comments
the nurses before, they are suffering a lot because they are stuck in very, very far hospitals, in rural areas. To get the NCLEX exam it takes South Africans two to three years, that’s standard, that’s you straight online going through the U.S., but if you go through some of the agencies, they can prolong it 5-6-7 years and come up with various excuses. So now people are no longer believing that.” P1, P3, and P5: “They are taking too much money (from the nurses), they (the nurses) are suffering also.” P14 stated: “I came with the company as staff nurse. They pay your salary after 3 months, they are not paying.” She wanted to leave the company, they told her she could go, and you have to resign the job. “This time was very hard for me. The private hospital wanted the Iqama. I paid SR 2,500 for Iqama, then I paid also the company, SR 3,500, then I paid the hospital to retain half sponsorship, SR 1,700.” P14 is a local hire. P24 stated: Now P24 is thinking about moving to Qatar where her husband is because the money here is not as good with everything going up. “Since last year our hospital is promising us 10% increase, until now nothing happened.” P1 stated: “for me I can earn better here than in my own country, but the money is still not that good. The peso now is going up” P3 stated: “When I came here the exchange rate was almost double, and it has just gone straight down. Now that I am exiting (going home) it is up again.” P3 stated: “We have to whimper and complain and beg just for a little increase to make our life better.” story about pharmacist who
380 Factor
Thought unit
Gov’t (G) or Private (P)
P#
G/G
P6 / P7
G
P6
P
P13
P
P18
P
P18
Quotes and Comments
asked for a ridiculous salary and bosses are having a meeting about it (they are thinking about the increase). P6 and P7 stated: Hospital sends out Arabic information and nurses must sign. Nurses hear that MOH has increased salaries but not everyone gets an increase. This caused dissention and distrust with hospital management. P6 stated: “The work there is work overload but we are not being compensated for that.” P13 stated: “Like overtime pay. Before it was a very bad system, even in the nursing department. But now as we change the nursing director, we can see improvement. We don’t actually have overtime pay in the hospital. It is only time back. Make overtime, they just give you any time when the unit will not be busy.” P18 stated: “No evaluation and no salary increment for 10 years. Environment is good and we can earn money by doing extra duty, they pay us. When we try to write for increment, the MD says the owner will not give because we have less income (private hospitals make less money because they depend on insurance and private pay – no money from SA government). Leave it or take it. Some nurses pass an exit paper, I want to go on exit, and after that they will increase the salary to keep them. On exit they will get their increase, six months vacation, exit-reentry visa, and we will give you your benefits.” P18 stated: Husband is director of nursing. “When he was offered the job he accepted only with agreement on how he would do his job, it was negotiated. For example, he wanted to be able to hire the nurses. They accepted his terms of employment. During
381 Factor
Company Policy and Administration
Thought unit
Continuing Education & Training
Gov’t (G) or Private (P)
P#
P
P19
G
P3
P
P5
G
P3
G
P2
Quotes and Comments
MRQP, policies and procedures were developed. Difference from pre-MRQP and post-MRQP (good).” P19 stated: “Problem with the salary now (in SA), that is why all the Filipinos are leaving (SA).” P3 stated: “Our hospital is always doing lectures.” P5 stated: “We go to Hospital X for symposiums every month.” JNEF symposiums but no CMEs. P3 stated: “Filipino nurse asked to remove catheter from patient. She tugged at it gently (without taking out water from balloon), thank God, then she cut it and discharged the patient. The patient came in a couple of days later with an infected urethra obviously. She didn’t bother asking, was too proud or too scared, we don’t know. I would rather look like a fool for not knowing, or I can’t remember because I have not done it in a long time, than put a patient in a position of coming back in worse of a problem which we are going to be fixing.” P2 stated: “The education department head, she says if we attend any lecture, even in the night (on the nurses’ own time), even outside the hospital, she will shout at us, and she will make a problem the next day. I went to a lecture from 7-9 pm, outside of my duty, she (nurse educator) saw me there, she knows me. She asked why you are here? You inform your head nurse, nursing department? She told her she could not attend the next day’s lecture. I cry too much. You feel like you are in prison. I pay for the lecture myself. This happens to all people including Saudis.
382 Factor
Registration and licensure
Thought unit
Link to education, training, & professionalism
Gov’t (G) or Private (P)
P#
P
P13
G/G
P15 / P17
G
P2
P/P
P18 / P19
Quotes and Comments
Don’t know why, who will I ask? You cannot go to any lecture without permission from nursing education.” P13 stated: Comment about doing degree while working here. “For me if I have a master’s degree, this is an extra point for me. I can go somewhere else. I have been thinking lately why they are not offering …but of course we cannot do like this, we work 12 hours, where do we get free hours to go for school?” P15 and P17 stated: Some nurses in MOH hospitals assigned to areas where they had experience. Others put in areas that were new with no mentoring or training program provided. “Train yourself. There is orientation but new nurse orients him/herself. You do all the errands so you orient yourself.” The MOH nurses stated before they do something new, they ask the older staff. There is no competency training program. “There is instruction from MOH that if you do not know what you are doing, don’t try to do it for your own sake. Try to ask first your senior nurse.” P2 stated: “I will take for 3 years (SA license), from where I take 60 hours CME? I don’t have CMEs. If you do not renew your Saudi Council, then your contract will finish. Actually the one going for the lecture the same, the head nurse and one nurse friend for her (meaning not all staff have equal opportunity to attend lectures.” P18 and 19 stated: “New requirement now, to pass Saudi exam in Philippines before coming to SA.” The exam is offered in the country before the nurse is hired. MOH not requiring their nurses to get Saudi Council exam. The recruitment of MOH nurses are really hard. You have this written examination and oral
383 Factor
Thought unit
Gov’t (G) or Private (P)
P#
G
P1
G
P1
P
P18
P/P/P P
P18 / P19 / P21 P19
P
P21
G
P1
Quotes and Comments
examination. And they were requiring 3 years experience when I first came here. Now it is 2 years experience.” P1 stated: “Apply as new applicant, not renewal. We work, we are deprived of education.” P1 stated: “It is a requirement in Saudi Council that you must have the certificates from the symposiums, a certain number of hours. But since I arrived here, I never attended a symposium. Lecture in our unit yes but we get one hour. One hour is not enough, sometimes a 30-minute lecture.” P18 stated: In regards to Saudi Council, the hospital cut SR 500 from paycheck but did not tell the nurses why. When they (the nurses) asked, the reply was it was for the MOH for Saudi Council (exam). Why did you not tell us before, explain that, or have a memo that you will take the Saudi Council but you will be the one to pay? They (the nurses) negotiated with the hospital so the hospital paid ½ of the fee (SR 250).” P18, 19, and 21: “Only the private hospitals have to write this exam. The license is SR 1000 and renewal is SR 200. P19 stated: “You have to show the certificate of employment from all hospitals. And they want the originals. This is a reason why so many nurses are going now.” P21 stated: “In my opinion, this is again a reason for the Filipinos for not coming to SA because of the Saudi Council.” P1 stated: “Another one is the Saudi Council. We are telling only one month you will get the card. But now more than 6 months I am always going there to get the card but it still is not available.
384 Factor
Relationship with supervisors
Thought unit
Lack of support
Gov’t (G) or Private (P)
P#
P
P19
G
P8
P
P24
Quotes and Comments
Before they allow you to go on vacation, a renewal contract, you must pay in Riyadh Bank for Saudi Council, even though you will just show the receipt without the card itself. It is already considered as you already complied with the requirements. You just pay even though you did not pass the application in King Abdulaziz University for Saudi Council, you are considered okay. You have to pay for basic life support training. Then you have your vacation.” P19 stated: “Supervisor is of same nationality but gives everyone a hard time.” P19 expects supervisor to be fair. “She should treat staff equally, because as we can see, especially those that are close to her, she favors them. The only problem is our supervisor, really unapproachable, favoring some people, especially those nurses coming from the same place (the same province as the supervisor in the Philippines). They can easily ask for overtime without any hassle, even to get a health form to see a doctor. It is easier for some and she gives some people a hard time.” P8 stated: Was doing teaching with patient. P8 was sitting with patient and family sharing a cup of coffee (cannot refuse a coffee when Saudi offers, considered bad manners) and the clinical nurse said he was too friendly. P24 stated: That she had a complaint from an insurance patient’s family. P24 “At 6 am I checked the blood sugar of my patient. So her BS was only 70, so I have to give some nourishment. I took some juice from her refrigerator and some sandwich. I assisted her to sit up in chair. At the end she told the insurance person who was doing rounds, that I woke the patient up to make him buy
385 Factor
Achievement
Thought unit
Gov’t (G) or Private (P)
P#
Going abroad to work
G
P8
Independence
G
P6
Quotes and Comments
juice from the store. I told the person that I would not do that, I have been here for 7 years. Something the patient tells them they believe. At least they can protect the nurse or whatever, they can explain.” Patient stated a different story from the nurses’ version and administration believed the patient. The supervisor investigated the incident and the following day P24 received a letter that stated she was unprofessional and very rude. P8 stated: “I came here to fulfill a dream, to come to the Middle East. Forty years nursing tomorrow, so I am getting towards the end of things, I’ve got these things I want to do. So I decided to come here.” P6 stated: “I went abroad to find myself, to have that independence to start on my own. If I was staying in the Philippines, not enough to support my family. Here I can live on my own and provide for my family.”
386 APPENDIX FF: SUMMARY OF PARTICIPANT STORIES AND NATIONALITIES (QUESTIONS 3 AND 4)
Questions 3: Describe to Me a Time When You Felt Exceptionally Happy at Work Themes
Thought Unit
Recognition
11, 13, 14, 21 14, 21 11 13 1, 6, 7, 19 6, 7, 19
Philippines Philippines
1 1, 5, 11, 23 5, 11 23 1
Philippines Philippines, India India, Philippines Philippines Philippines
Teamwork Personal Support
10, 12, 18 10, 12 18 4, 8
Support
13, 14
India, Philippines India, Philippines Philippines Philippines, New Zealand Philippines, Pakistan
Support through policies and procedures Challenge in the work
3, 22
South Africa
1
Philippines
Patients Physicians Salary Salary and benefits Overtime pay Time back in lieu of overtime Work itself Experience and knowledge Workload Work conditions Environment Scheduling Infection control issues Achievement
Responsibility
Nationalities Philippines, Egypt, South Africa, India, Pakistan Philippines, Egypt, India, Pakistan Philippines, South Africa, India Philippines, South Africa Philippines, Pakistan Pakistan Philippines Philippines
Supervisors
Relationship with peers Relationship with supervisors Company policy and administration
Number of Participants 1, 1, 2, 2, 2, 3, 5, 5, 9, 15, 16, 17, 18, 21, 22, 23, 24, 25 1, 2, 2, 2, 5, 9, 24, 25 1, 3, 5, 15, 16, 17, 21, 23 18, 22
387 Question 4: Describe to Me a Time When You Felt Exceptionally Bad at Work Themes
Thought Unit
Company policy and administration Policies and procedures
Organizational culture Work conditions Customs, religion, norms, and culture of country Lack of staff
Status
Relationship with supervisor Security Personal life
Number of Participants 1, 1, 1, 2, 2, 3, 4, 6, 7, 7, 8, 10, 11, 12, 14, 14, 14, 17, 17, 22, 22, 23, 24 1, 1, 2, 3, 4, 6, 7, 8, 10, 11, 14, 14, 14, 17, 22 1, 7, 12, 17, 22, 22, 23, 24 1, 1, 1, 1, 1, 3, 3, 3, 3, 4, 6, 6, 8, 13, 14, 15, 17, 22, 23 3, 3, 14, 15 1, 13, 17, 22, 23
Communication barrier
3, 3, 4, 6
Fairness
1, 6, 8
Infection risks Perception of care Discrimination
1, 1 1 2, 6, 8, 8, 13, 14, 18, 20, 22, 23, 23
Lack of support
2, 2, 16, 22, 22, 22, 23, 23, 23, 24, 25 16, 18, 21, 23, 25
Verbal and physical abuse Accommodation
1, 2, 3
Nationalities Philippines, Egypt, South Africa, New Zealand, India, Pakistan Philippines, Egypt, South Africa, New Zealand, India, Pakistan Philippines, South Africa Philippines, South Africa, New Zealand, Pakistan South Africa, Philippines, Pakistan Philippines, South Africa South Africa, Philippines Philippines, New Zealand Philippines Philippines Egypt, Philippines, New Zealand, Pakistan, South Africa Egypt, South Africa, Philippines Philippines Philippines, Egypt, South Africa
388
APPENDIX GG: EXCEPTIONALLY HAPPY STORIES Question 3: Describe to me a time when you felt exceptionally happy at work
Factors
Thought Unit
Recognition
From supervisor
Recognition
From supervisor
Gov’t (G) P # or Private (P) P P5 G
P2
G
P2
P
P24
Comments and Quotes P5 stated: “Strong and loving nursing director. If I am good then they treat me good.” In another hospital in SA, P2 had the opportunity to demonstrate her education and experience. She received recognition for her education and experience and received an appreciation certificate from director of nursing. P2 stated: “Asked my supervisor, director of nursing, if I could do lecture for nurses. I told her I give lecture in Egypt so she said, give me lecture for all the nurses here. Okay, so I can do like this, very easy. I heard it is very difficult to give lecture like that in SA (being a foreigner).” “I make swapping from Dammam to Jeddah and she make very big party for me. I was very happy in that moment. I get the certificate and all the staff appreciate me.” It was like a family in this hospital for P2. P2 stated: “She (DON) is very, very good. She make us like family. She is very excellent. I go home to prepare lecture and I want to make very good lecture. Only one day I make very good lecture and even she and all the administration there; education, infection control, everybody attend my lecture. She was very happy for me. She took me from OR and put me in the education department.” P24 stated: Every year the hospital has an infection control week. “Every year they choose a best infection nurse of the year. Last year I
389
Factors
Recognition
Recognition
Thought Unit
From supervisor
From patients
Gov’t (G) or Private (P)
P#
G
P25
G
P1
G
P2
G
P9
G
P3
Comments and Quotes was not thinking I was the one.” It came as a surprise to P24 that she was named the best infection control nurse for her unit. She received her award in the auditorium in front of her peers and senior nurse managers. “When they announced the person, I was not thinking. Someone told me to go up on stage. For what?” There was financial recognition as well with the prize. “For your hard work, somebody appreciated.” Facilitator question: “Would you have been as happy if there had been no financial acknowledgment?” P24 stated: “Yes of course. Because on that day I received a plaque of appreciation. After five days, I received the money.” P25 stated: “Like P24, last year I received this recognition for best nurse of the month. I was very happy. I did not expect people would recognize me. The head nurses and supervisors selected the best nurse. I was very happy, I was new. They recognized how I am working.” P1 stated: “My experience is in medical/surgical. I only work in the Philippines for 6 months. But here is SA, I was chosen because of the evaluation and exams, they put me in hemodialysis.” P2 stated: “I do not complain about the workload. Actually I am the head nurses’ favorite. Because I am the first choice to be pulled out everywhere.” P9 stated: “When we passed MRQP after that we have very nice time in the hospital.” Staff received a certificate from nursing department. “From the nursing side only, we had party.” Nursing recognized the hard effort. DON was supportive, encouraged, and motivated the staff. P3 stated: “You do not realize how you are impacting people’s lives. You might be minding your own business, walking down the corridor. And you hear someone whose language you do not understand that well anyway, screaming, ‘that’s P3, my nurse, there’s my nurse’. Cannot
390
Factors
Thought Unit
Gov’t (G) or Private (P)
P#
G
P1
Recognition
From patients
P G
P5 P15
Recognition
From patients
G
P16
Comments and Quotes remember what you did but it was some kind of an impact that affected the person’s life. They are glad to see you, they are happy, and you feel good. It’s like you know, whatever you did, their dressing or were kind to them or whatever. And some patients I know will specifically come to the department and they look for you. They know they can get what they need.” P1 stated: “There are some patients who specify for foreign nurse, they do not like Saudi nurses. They see that foreign nurses care for their job. The Saudi nurses start the procedure and then leave the patient to drink tea. During dialysis, you are the one coping with their work because the patient might drop his blood pressure or collapse. You are the one running. You can feel patients appreciate your work.” There is a psychotic patient that asks for P1 each time he comes for treatment. “I feel happy that there are some patients that appreciate me.” P5 stated: “Feel appreciation from patients for service.” P15 stated: “The good thing in nursing is when you hear the patient saying, thank you sister. I care for them for a while in ER, at the end of it, when they will be discharged, they will say, sister thank you. I counted it, there are five patients in 4 months that said thank you. It’s a good thing that you did a good thing and in return they appreciate what you did. Being appreciated as a nurse is a good thing. Almost every day (you) hear sister, yella, sura, sura, sura (in Arabic) (in English, sister come here, hurry, hurry, hurry …), no thank you.” P16 stated: “For me I don’t have a problem with the patients. I find them nice. There was a time when I was handling a difficult patient. He was always irritable, because he does not recognize me. But one day, maybe he is already feeling better,. One day when I came to work, when he saw me, he hugged me and kissed me here (pointing to her cheek) (it was a
391
Factors
Recognition
Thought Unit
From physicians
Gov’t (G) or Private (P)
P#
P
P21
G
P17
P
P23
G
P22
P
P18
Comments and Quotes little boy). And also a time when there was his mother and she saw me and hugged me and kissed me and said, you are very nice.” P16 stated when she worked in Taif, the people were not as nice. In Makkah she sees a difference in the patients and people in general. P21 stated: “When a patient came back and when they told me, sister thank you very much I am okay now. I feel good in that way. That is rewarding when patient recognize your work. Because the work of nurses I think is very hard.” P17 stated: “When a patient comes to you and says thank you, even you will feel better, my patient said thank you to me.” P23 stated: “When you receive a chocolate from the patient or giving you money or giving you thank you it’s a very good recognition. The patients in the hospital, there are lots of those people before. But now you can see how hard life is in SA. They would hug you, give you food in your mouth, and thank you very much.” P22 stated: Late last year we received a letter.” P22 describes a child that they nursed for a long time. It was a sick child. “One of the consultants, Saudi but graduated from the USA, came to the hospital last year new. The consultant wrote a thank you letter to the nurses for their hard work with this child. The letter was also sent to the Pediatric Chairman. “We were so surprised. P18 stated: They had a premature baby that was not doing well and prognosis was poor. One day at work, the baby arrested. “Everything was done, really by the attending. Still the ECG, everything was zero. Then because I already passed the NRP, the doctor said to me, wrap the baby, already pronounced dead. So my thought is, if I was to insert the ET tube, I try myself, make ambu bag, then I connect it to the O2. Then I saw there is breathing, regain the breathing. I called the doctor, doctor
392
Factors
Salary
Thought Unit
Gov’t (G) or Private (P)
P#
Salary / Benefits
P
P21
Overtime pay
P P
P14 P11
Time back in lieu
P
P13
Comments and Quotes the baby is breathing, and he said, how come, I told you to wrap the baby. No I said, I inserted the ET tube and do ambu bag and it alive again. It was the last ET tube inserted in the baby. And then the baby was discharged after 3 months in good condition. That is why I said, that I am very happy that I saw the baby. It is almost dead already and I make it alive.” Nurses with NRP are allowed to intubate babies in NICU. Facilitator question: “When you did that and saved the life of this baby, did you meet any resistance after you did it?” P18 stated: “No, everyone was happy. I just remember my child. If this is my boy and the nurse did not do anything, it feels so bad. I am already allowed to do it, so why not? The doctor said I did a good, good job because the baby is alive. I said to them (nurses), don’t hesitate, don’t be afraid, if you are competent to it, do it, why not? But if you are not sure, it is better to ask to your superior. Don’t be afraid, don’t be ashamed. If they will say you don’t know anything. No, I will not be ashamed because this is life” Salary is a confidential matter in SA. When we discussed money, a general question was asked: Is money a motivator for you to work here? Majority stated yes, even though they have issues with the salary, benefits, they still make more money in SA than in their own country. P21 stated: “We are just here because we are earning. We do not care what is bad or good. At the end of the day, we finished the work, we did our best, we didn’t commit mistake, we are happy already.” P14 stated: “Only salary.” P11 stated: “They are paying us for overtime. They will only pay 40 hours, then the time is added on to vacation.” P13 stated: “Regarding this problem, I think with this crowd (focus
393
Factors
Work Itself
Thought Unit
Experience, knowledge, advancement, achievement
Gov’t (G) or Private (P)
P#
P
P19
G/G
P6 / P7
Work Itself
Workload
G
P1
Work Condition
Environment
P
P11
Comments and Quotes group) we have better because right now we improve. Ok, we don’t have the overtime pay, but they are giving us the time back. The hours are okay, some of the nurses are already satisfied as long as you give these hours, it’s okay.” P19 stated: “One thing I consider good in coming to SA is I learned so many things, so many procedures, new procedures which I think if I stayed in the Philippines I did not learn. Because I was working as public health nurse. So I considered that lucky for me. Learning dialysis, learning techniques in orthopedics, because in my previous hospital, I was assigned in surgical ward. In OB ward I learned so many things there. I was really thankful because it helped me a lot, as a better person. Because here, we are alone. So we have to face these difficulties. If we are going to submit to these difficulties without fighting and standing up against them, then we will go home beaten. It was really rewarding for me, not only in financial matter but also in knowledge. As well as in my profession. I also have come to meet different kinds of people, different nationalities, which is really, at first I was really conscious. I was really curious why they (hospitals) have different cultures. In the long run I have to understand and I have to learn to deal with them. And happily I have adjusted myself well. It is really rewarding.” P6 and P 7 stated: “For me not really that I don’t like (my work). It is just problems with administration. But for the work, no problem. It is a good thing, it’s an experience.” P1 stated: “I am happy also because I am in a special area – dialysis. It is a better area unlike the ward where many are saying work in ward is very difficult compared to my area. They (nurses) have more things to do.” P1 had preceptor for 3 months and is independent now in her work. P11 stated: “The environment also, if your work environment is good,
394
Factors
Achievement
Thought Unit
Gov’t (G) or Private (P)
P#
P
P5
Schedule
P
P23
Infection control
G
P1
Teamwork
P
P12
G
P10
P
P18
Personal achievement
Comments and Quotes that is a motivator too.” P5 stated: “Because I am working in the OR, they (the patient) is coming happy and they leave happy.” P23 stated: P23 requested to work night shift as a straight shift, and the supervisor allowed her to do this. The day shift was too stressful for P23. Too many responsibilities with physicians, family, patients. Night shift is a quieter less stressful time. P1 stated: “I am happy for the Saudi because here we never reuse any dialyzer. If the patient does not like that dialyzer because it is too big for him, we will throw. It is already opened, we cannot give to other patients.” P12 stated: “The good thing happened to us when we passed the MRQP. Proud really because it is our first time to be accredited.” P10 stated: “Very happy when we passed the MRQP. We got to prepare the policies and procedures, people worked very hard at that time.” This incident is also under recognition (motivator factor) from physician (thought unit). P18 stated: They had a premature baby that was not doing well and prognosis was poor. One day at work, the baby arrested. “Everything was done, really by the attending. Still the ECG, everything was zero. Then because I already passed the NRP, the doctor said to me, wrap the baby, already pronounced dead. So my thought is, if I was to insert the ET tube, I try myself, make ambu bag, then I connect it to the O2. Then I saw there is breathing, regain the breathing. I called the doctor, doctor the baby is breathing, and he said, how come, I told you to wrap the baby. No I said, I inserted the ET tube and do ambu bag and it alive again. It was the last ET tube inserted in the baby. And then the baby was discharged after 3 months in good condition. That is why I said, that
395
Factors
Relationship with peers
Relationship with supervisor
Thought Unit
Support
Support
Gov’t (G) or Private (P)
P#
G
P4
G
P8
P
P14
Comments and Quotes I am very happy that I saw the baby. It is almost dead already and I make it alive.” Nurses with NRP are allowed to intubate babies in NICU. Facilitator question: “When you did that and saved the life of this baby, did you meet any resistance after you did it?” P18 stated: “No, everyone was happy. I just remember my child. If this is my boy and the nurse did not do anything, it feels so bad. I am already allowed to do it, so why not? The doctor said I did a good, good job because the baby is alive. I said to them (nurses), don’t hesitate, don’t be afraid, if you are competent to it, do it, why not? But if you are not sure, it is better to ask to your superior. Don’t be afraid, don’t be ashamed. If they will say you don’t know anything. No, I will not be ashamed because this is life” P4 stated: “Your profession is a nurse. Your job is not to do something that you might encounter to be a problem. But it makes you feel good when there are still some people who are willing to help you, to face the problems or solve the problems.” P8 stated: “There is a person that came to see me working on the same unit, who said exactly the same things about the same issues about the same people that I am talking about, that vindicated me a bit. That’s the good thing about it, I felt it wasn’t me. I was questioning my career. I was questioning my competency when I saved directly two people’s lives, who would have probably died. That hasn’t been mentioned.” P14 stated: When PI4 started new job at private hospital, the head nurse of the unit reached out a hand to help her. “Good for me, I told you I came here without Iqama. My head nurse was very kind to me. She helped me a lot in this problem. Very nice lady, she offered me money, she tell me I can go to her house to stay.”
396
Factors
Thought Unit
Gov’t (G) P # or Private (P) P P13
Company policy and administration
Support through policies
G
P22
Company policy and administration Responsibility
Support through policies
G
P3
Challenge in the work
G
P1
Comments and Quotes P13 stated: “The good point there for us now our nursing administration. We really have this teamwork. All supervisors and our nursing director is always supporting us. That is a very good point. The nursing department is trying to reach out to the staff. What can we do to relieve your stress, what do you want, an extra lunch?” P22 stated: “The thing is our sitters have a paper that they sign. That they are going to help the nurses. If I am busy with patient care maybe I have to run. If the call bell goes, I run. If I find that I am called to switch off the TV, she knows the next time no one will switch off the TV for her when she uses the call bell. The sitters are expected to help. P3 stated: “Our manager makes sure that whatever the policy, we have to follow the policy and this is what you are supposed to do. So if you are going to get file noted, you will basically know why.” P1 stated: “I am happy because you are doing everything. There is only 1 technician for 60 machines. So if there are some problems the nurses are already trained to trouble-shoot the machine.”
397
APPENDIX HH: EXCEPTIONALLY BAD STORIES Question 4: Describe to me when you felt exceptionally bad at work
Factors
Company policy and administration
Company policy and administration
Thought Unit
Gov’t P# (G) or Private (P) Hospital policy G / P P6 / P14 G G
P8 P2
G
P22
G
P10
Hospital policy P
P11
Comments and Quotes
P6 and P14 stated: Nurses stated that hospitals have policies and procedures, they are not always followed as written. P8 stated: “People bend the policies to suit the situation and themselves.” P2 stated: “My head nurse does not have contract. I think for 3 years she don’t have contract. There is a problem with our administration, they are lazy. Other hospitals post memo to tell nurses about salary increase. Our hospital never ever posts any memo telling about increase, increments. We will only learn from other sisters in other hospitals the King give this amount of money for the nurses. It is very frustrating.” P22 stated: “My hospital has good policies but nursing management does not implement them. Like the overtime policy and not getting additional help when someone is sick.” P22 stated she transported a patient to a sister hospital and noticed the environment is better there and policies are implemented. P10 stated: She worked for the company ten years ago. Still remembers this time as a bad time because they were late getting the passport to her. “When you are new to the country, you do not know how to get around the barriers.” P11 stated: “They told us they will deduct from our salary for our Iqama, I told HR if you will deduct from our salary for our Iqama, it is better to send us (nurse and friend home). It is written in English that we will not pay for our Iqama. They changed the policy for us.”
398
Factors
Company policy and administration
Thought Unit
Gov’t P# (G) or Private (P) G P1
P
P14
G
P7
Hospital policy G
P1
Comments and Quotes
P1 stated: “Our hospital is basically corrupt. Even the people there for an Iqama, it is only SR 500. But they are asking for more than that. The one in charge for the nurses, he is getting SR 50 extra. So how many nurses are there? When getting the money they are very fast, when giving the money, they are not (fast).” P14 stated: “Not for me but all the staff. When we are going on vacation, two months before we have to give our application for leave. Till the end, we never get our benefits. Supposed to get our money, our passports, like that. Daily we have to go into the office. If 12 o’clock my flight, so 8 o’clock we don’t have even money in our hand. We cannot buy something. So this is very bad. All the time for all (staff). When we go, we have to cry, then they give.” P7 stated: She was a company employee who was absorbed by MOH. “Our hospital director gave us 24 hours to pay the company. Pay SR 2000 they said, the money would be returned after one month. Then we pay. If cannot pay, you are automatically terminated. Then we pay. They say, after you sign the contract, we will return (the money). Then they did not return.” P7 lives in the community with her husband. A local hire contract provides different benefits than the nurses hired internationally. Because the nurse was absorbed by MOH, they were told that every year they would double their salary. They were absorbed in Aug. Nurses were paid very low salaries with the company. They did not receive the salary increase. “In the contract also, there is written that for those people living outside, they are providing the transportation and housing allowance which we did not get until now. They are promising but not giving.” “Regarding the overtime, if it is regular days, even though you extend your work until 12 am, you cannot count that. We do not have overtime. If you are second on call on a Fri, that is the only time you can get overtime, but regular days you cannot. You are supposed to have 2 days off after 13 days of straight
399
Factors
Thought Unit
Gov’t (G) or Private (P)
P#
P
P14
G/G
P3 / P4
Comments and Quotes
duty. But sometimes they tell us they are understaffed. There is mismanagement in the giving of the schedule. They will take one off, you will only have one off-duty, that is the problem. We are the ones doing everything. We mix the bicarbonate, there is no mixer. We clean the machines, everything. Your work is not just a nurse, you are not doing what is your job description.” P14 stated: Was not given orientation on sick leave policy. When she reported ill to ER after Hajj, the doctor gave her 2 days off. Because she did not follow policy, they revoked the 2 days and gave her time off without pay. P3 and P4 stated: “What makes me feel bad is the awful people. Because not everybody in the area is willing to help you, and there are some people that put more pressure on you. Not even thinking it could come under situation, how would you feel that way. My colleagues who are working with me in the X clinic (supporters) and those people higher than me (non-supporters), it’s like they are threatening you with your job. You will receive a final file note. Of course, we are not perfect. Those higher than me must know they still have their responsibilities to support your staff” P4 stated: “A staff I know was given a final file note for not following the policy on sick leave. Policy states the employee must call in to family health 2 hours before shift. They must go to staff health before start of clinic. We cannot go during our clinic. Everyone knows the sick leave policy. She ended up coming into work because she did not get to family health.” P3 stated: “The only thing with the files story is people use it as a threat. I use it for when I am sick and tired of telling you the same thing over and over and you are not listening. That’s the only reason I use it. Some people are more interested in threatening others than actually educating and making them a real part of the team. Manager should review all policies with staff. Staff do not take file notes seriously.”
400
Factors
Company policy and administration
Thought Unit
Gov’t P# (G) or Private (P) Hospital policy G P17 & Organizational culture
Comments and Quotes
P17 stated: “I was working in Pediatric ER during 3-month probation. I was new. I was doing what other nurses were doing. A Tylenol suppository was ordered for a child with a fever. Patients are waiting, it was very busy. The patients do not like to wait and are calling to the nurse to hurry. There were only 3 nurses, one female, two males. A male nurse carried out the giving of the paracetamol suppository. Accordingly it was introduced to the vagina of the child. There was an investigation. It happened that I was the one that documented.” Practice in the ER was for one person to carry out the order and the other nurse to document. “They were hurrying, the doctors were pressuring the nurses, the patients were pressuring the nurses and doctors. The father (a Saudi employee of the hospital) came back with daughter saying, ‘there was a spot of blood at the vagina’. The child was referred to maternity hospital and everything cleared. We are helping each other.” P17 did not see the patient at all. “During that time it was endorsement time (change of shift).” They wanted P17 to name the male nurse that gave the medication. She could not because she did not know which nurse gave the medication. They terminated the male staff who the mother said gave the medication. P17 had salary cut for 10 days. Questions arose regarding male nurses seeing the female child. “Shat happened during that time, I was new, I was really innocent. The male nurse was also new at that time, also Filipino. It was the male nurse that was really sure the suppository went into the anus, but the father insisted it was the vagina. It could have been a scratch. When checked by other hospital, hymen was intact, “investigations were clear.” P17 followed the practice of the other nurses in the area. This is an example of being in a situation as a new nurse, new country, and lack of support from the system. The unit supervisor could relate to the situation, she also was in the same situation. “The unit supervisor tried to support me, but the higher administration went on the side of the patient.”
401
Factors
Company policy and administration
Thought Unit
Organizational culture
Gov’t P# (G) or Private (P) G P22
P
P23
Comments and Quotes
P22 stated: “There is a nurse manager who is doing the same thing. She is not Filipino.” P22 describes the nurse manager as a long-time employee, was a staff nurse. “She was promoted because they could not get a nurse manager. She selects a new nurse according to what she wants. The senior managers are all expats, but they are saving their riyals at the expense of the nurses. This is why they say we can nurse up to 5 patients disregarding the acuity of the patient. They do not care how sick the patients are. The managers never come to assess the patient.” P23 stated: She describes a management style that talks about the problems and finds a solution and then they take it out to the hospital. Not in her current hospital. “The supervisor sees the problem in the person, an incident report is written, given to nursing director. The ND will call you to her office, and talk to you. You cannot imagine how she talks to you. She is the one who gave you all the food you are eating, it’s like she bought your life.” P23 described an incident where practice is not always correct according to policy. People do what they want but it is not the policy. Then once in a while the nurse is caught doing the wrong thing. An order was missed because of this practice (file was in doctor room) and P23 realized that it was her mistake. The resident doctor supported P23. After several days, the supervisor brought a piece of paper for her to sign. The doctor did not tell the nurse and the nurse was in a hurry to care of the patient. “I admitted the mistake, it’s ok, it’s really true, I did not read the file because I was in a hurry to go back and had to show the blood tests. Maybe it is like this because they became supervisors, nursing directors, because they have been in the hospital for so long. And they were appointed this way because of seniority. I have earned my masters from the Philippines. It’s not just because you have experience. You should have the knowledge and skills on how to take care of your people. Your people should be protected
402
Factors
Company policy and administration
Company policy and administration
Thought Unit
Organizational culture
Organizational culture
Gov’t (G) or Private (P)
P#
G
P7
G
P1
P
P12
P
P24
Comments and Quotes
because they are the ones giving you money for the hospital. The nurses should be the gold in the hospital. But they are not. What management is doing is stepping on the nurses to earn these positions. That’s why the turnover of nurses in the hospital, Indians are coming in, Filipinos are going out to Canada. They (management) talk and call you an idiot, are you a real nurse?” P7 stated: Could not think of any exceptional happy day at work. The lies from administration cloud her work in the hospital. She is resentful. Wanted to move to Riyadh but husband would not allow her to go. P1 stated: “If you will suggest, they will not listen. They will take it negatively and against you. So better to keep quiet. The best solution is to finish your contract and go exit, but until now I do not have contract.” P12 stated: “They change the administration now, so again CBAHI will come and maybe we will not pass. After the medical director was changed, other positions changed. Medical director also wants to cover the nursing department. I do not like that (this is going backwards on the standards. Standard states that nursing department report to CEO).” P24 stated: There are grand rounds every day with many disciplines. “I am in charge and so I go on rounds with the doctors. I observed, the first question when they enter the room, ‘how are the nurses, they’re ok, no problem?’ They provoke the patient to complain. Some patients don’t like Indian nurses, because I am a charge nurse. When a complaint come, I am the one attending the complaint first. One Indian nurse told me, ‘go check room …, they are telling me something I cannot understand’. Because this is a new nurse, working only 5 months, she is poor in Arabic, she is poor girl also. So I went in there, the relative is complaining, ‘I don’t want any Indian nurse in this room. I want Filipino nurse only’” Administration will provide the patient with the nurse they want.”
403
Factors
Work conditions
Thought Unit
Gov’t P# (G) or Private (P) G P22
Customs, G religion, norms, culture of country
P3
G
P3
Comments and Quotes
P22 stated: “That’s also one of the things, most nurse managers I know for a fact, were taken from the floor and made nurse manager. I can see her actions, she doesn’t have the leadership skills, she cannot lead her group, she is just managing. The difference between a leader and manager is, a manager will always do the right things. She follows the policies, she doesn’t care if this policy is wrong, she does not question. A leader will do things right. She will say no, find out. Managers never want to find out, because it will come back to them. they never want to find out. Anyway, it is easier to point at the obvious and say this nurse did this, and nobody wants to find out why and get to the cause of the problem.” P3 stated: “What medical staff must do for patients and what family wants causes many, many times a big conflict between nursing staff, patient relations, management, and the family. They think we are not doing our jobs and from my perspective work is very dissatisfying. I just know there is a constant fight between the nurses that run the department, management, and the directors of the hospital, always back and forth about issues like this” P3 stated: “One of the sad situations, I do understand the Saudi culture is very different, to me it is not that different, to me there isn’t… When you are in a medical system, it should be run in such a way where people understand that once you walk into a hospital the patient comes first. And most of the time we have to submit to what the family says. If the doctor says you must give the antibiotic 6 hourly but the family says don’t do it now, you don’t do it now. And that is how they manage patients. It made me so sad. I remember the one patient I nursed, he waited until his family was gone and he asked me to stop it (treatment). He is telling me, not telling the doctors, not telling his family. I couldn’t handle it. It freaked me out. I couldn’t believe it. I will never forget that. He understood what he was going on. What do you do? The hospital is not
404
Factors
Work conditions
Thought Unit
Gov’t (G) or Private (P)
P#
P
P14
Customs, G religion, norms, culture of country
P15
Lack of staff
P1
G
Comments and Quotes
letting what is best for the care of the patient to what the people want.” P14 stated: “But when they need (owner & family in home), we have to go in the home. To give injection, to give insulin, to take the blood sugar. They do not want to bring here (take family to hospital). They pay us salary but still we are feeling like housemaid. Every time on call, so we cannot refuse also because they are our owner. I went there for 8 months. I was going morning, evening, night. Some people do two years there. P14’s daughter wants to do MBA in private school. She lives without husband here and she wants to work overtime. “Now they are having a plan again to send me to family villa, because I need money for overtime. They put me a lot there. So I will not go.” P15 stated: “I was in female screening, all patients waiting outside. One patient came in wheelchair with son. The complaint is abdominal pain. He (son) went to doctor without ER file. Because I have other files before that patient. So he went inside, he shouted at our doctor, I can’t understand anything but all I can say is he is a liar. At the end our doctor did not see the patient. The son went directly to the medical director. The medical director went to the ER screening room. I was there. The son told that the doctor did not see my mother, she is ill, but he (doctor) is here (this is the bad thing) because we are paying them. We are the ones paying them. You will not be here if our government would not pay you. You are here to work for us.” P15 states that after they see a patient complain, the other patients will also complain about the service. Because they see that everything gets done for the patient that was complaining
P1 stated: “I just delivered and I came back in less than a month. I had no exemption during my pregnancy. I am the only one nurse working there and
405
Factors
Thought Unit
Gov’t (G) or Private (P)
P#
Work conditions
Lack of staff
G
P17
Work conditions
Lack of staff
G
P22
P
P23
Comments and Quotes
there are 8 machines functioning. So in your 8 hours you can dialyze 7, 8, 9 patients at the same time. But ideally, in dialysis it must be 1:1 because in the Philippines we were practicing that. There is too much workload, you cannot practice the ideal. You are running. We are handling maximum patients. They are not following the ideal, for them one nurse for three patients, it is not understaffed, for them. Aside from the patients, you are doing other duties. No nursing aides, everything you are doing. You cannot practice the ideal, although you have the equipment, all the supplies are for the patients. Only one nurse has too many patients.” This incident is also under company policy and administration (hygiene factor) and hospital policy / organizational culture (thought unit). P17 stated: “The difficulty of the situation (at work), with only 3 nurses, lots of patients (300), hand-over time, and “this is the way we do it” attitude. The incident occurred during Haj, the hospital was full, there were no extra nurses to help. Having 3 nurses in the ER is enough. They only assign 2 nurses in that area (during normal times). We cater to emergency pediatric cases and children with fever and cough that can be treated at home, what can we do? We can do what we can do. P17 describes “Working like horses. We are not working as nurses. We are working as security guards, just to keep patients calm. There was a solution (to the critical incident), they made all female nurses (in Pediatric ER) because of that mistake. There was pressure from the patients to hurry.” P22 stated: “Most mistakes are because we are running and shortage (that is short of staff).” P23 stated: “As for me, I did not have these worse experiences. I would like to share my work environment with you. We are working 3 bedside nurses. We have 26-bed capacity. We have one charge nurse, one medication nurse. The
406
Factors
Thought Unit
Workload Work conditions
Gov’t (G) or Private (P)
P
P#
P13
Communication G barrier
P3
G
P4
Comments and Quotes
worse thing, this private hospital we don’t handle patients that doesn’t have much money. The hospital accommodates people who have money because money counts in this hospital. So, even if a tissue is thrown from the bed, you will pick it up. It’s like you are a maid in the hospital. When you did not answer the bell, they (an insured patient) will call the supervisors. So, the supervisor will attend. I was pushed by the relative of a patient. I called the supervisor, because I was only 6 months (in the hospital) then. My initial comment was to tell the supervisor that she pushed me. The relative told the supervisor that I pushed her. I was even asked why I did this. This incident happened because of lack of staff that should be there to support all the patient’s needs. The management don’t see it. We have 9 units, not including the DR, ER, ICU, special areas. We only have one supervisor. What if there are 10 code blues happening in one minute, how can she attend to it?” P13 stated: “Work overload, really for us in ICU, we should be 1:1 as much as possible. But my staff is taking 2 ventilated patients and still relatives will come, doctors problem, or these problem. The hospital system problem itself.” P3 stated: “One of the patient’s that was brought to us for consultation. There was no need to sit and wait for the file. We were busy, no indication of a problem. Consultation documented nothing. So, I decided to push the patient to ward. The patient is showing me the door (of his room). A big bold barrier precautions sign on the door. I almost died. Now I have to read the file and phone the ward and tell them that whoever is in that room, kick them out so housekeeping can sterilize the room. And then I have to go to my department and clean everything the patient touched. We do not know what we are transmitting.” P4 stated: “It is hard for me to understand (Arabic language). I want to learn the language but I can’t. We have staff that translate, but you want to do it by
407
Factors
Work conditions
Thought Unit
Fairness
Gov’t (G) or Private (P)
P#
G
P3
G
P6
G
P1
G
P6
G
P8
Comments and Quotes
yourself. You don’t know if they lost something to the patient, missed something.” P3 stated: “The staff are speaking Tagalog or Arabic, not one English speaking person. You are put in a position where you manage the section. You go to the managers and explain why this is working and why this is not working. Half the information is disseminated in Tagalog, or in Arabic. They are telling each other stuff that you as the person do not know. If it is personal, it is none of your business. The policy is the language is English or Arabic only. You feel you are a little bit out of it, as far as communication. They (staff) are not explaining to patient about their OR.” P6 stated: She does not speak Arabic. “Not all people are educated. If they were educated, they would understand us (in English)” P1 stated: “Distribution of workload not fair. Especially us that live in the dorm. For those that live out (the community), she (HN) will not ask them to go on duty because they are difficult. Usually the ones that stay in the dorm, we are the ones suffering. So the distribution of the load is not fair. She (HN) has power over us. She will not call the ones that live out. We become the underdogs of the nationals (Saudis) when we work here.” P6 stated: “I also consider the fairness. We also have Saudi nurses. They come late. The head nurse is very considerate of the Saudi nurse. For us we come late for 15 minutes and they ask what is this?” P6 describes a day when she had 3 patients. The head nurse came to her and asked, “What is this?” pointing to the garbage can. “Head nurse (Saudi) said I will throw you from the Kingdom.” The nurse almost cried because she was looking after the patient as her priority. “Really bad, why is it like this, why is this happening. They are unfair.” P8 stated: He described his probationary period on C floor. Mentor took dislike to him. “I started to be micromanaged; documentation, medication charts. I was
408
Factors
Work conditions
Thought Unit
Infection risk
Perception of Care
Gov’t (G) or Private (P)
P#
G
P1
G
P1
G
P1
Comments and Quotes
assessed every time I was on duty, two times a day.” P8 had regular interviews with unit manager and mentor. Unit manager said very little. “Hard to work” as he was being assessed continuously. They questioned his competencies and documentation. He was getting mixed messages as to policies. P8 set up a meeting and it was more an interrogation rather than meeting. He was threatened with exit. “Met with nursing director. She was very good. Came to do an assessment of me. She was satisfied. It was by mutual agreement that this exiting thing was blocked and that I move out of floor C and move to D. On exit report it actually says something about my memory.” Supervisors thought P8 has problems with memory and advised seeing a doctor. “Two preceptors told me I was doing very well. One thing was that I was not documenting enough, every 2 hours. You have 6 patients, when do you have time to look after the patients? I knew people who were not giving adequate care because of this documentation.” P1 stated: “We notice there is contamination with the machines (dialysis). You can easily get disease, here the local disease is Hepa, Hepa C. There is possibility to acquire it from the machine because our engineers sometimes exchange the machine. So that is a problem.” P1 stated: “If there is an emergency or there is blood leaking in the line, we are not able to wear gloves anymore. So, you are touching the blood with bare hands. No hazard pay, no goggles for protection. There are supplies when it comes to patient yes but not for the nurses.” P1 stated: “When it comes to the medical side, we are training the doctors, because the doctors are also leaving, especially the new ones. They are leaving our hospital maybe because they don’t like the way it is run or the workload, and the salary is not satisfying. Sometimes also mismanagement in the treatment of the patient and you will feel sad. Especially if it is a foreign
409
Factors
Status
Status
Thought Unit
Discrimination
Discrimination
Gov’t (G) or Private (P)
P#
G
P2
G
P8
P
P13
P
P14
Comments and Quotes
patient. They will just die. So that’s why when I was pregnant I never ever wanted to deliver here. I am afraid, in (such and such hospital). They use general anesthesia and sometimes the patient suffers from over dosage. They do not recover any more.” P 2 stated: “Already twice salary increase, I never received. Foreign nurse here don’t have the rights, even though you are on the right side. My salary the same. I go to ministry, he say, next time, next time. Now there is a letter from DON that says no one has authority to go to ministry of health. We get a letter to sign. There are some (nurses) that received already (pay increase), but very few.” P8 stated: He feels discrimination in salary and benefits with other nationalities. Once a foreign-nurse becomes a national of a western country, the nurse will earn that salary scale from that country. The Filipino nurses feel there is stereotyping in terms of seeing them as housemaids rather than nurses because Filipinos are in the homes. This seems to apply to both educated and uneducated Saudis. Doctors treat the nurses like housemaids as well. P13 stated: “Egyptians are not coming for staff nurse, they are made supervisor or nursing director, something like this. But the treatment, it is unfair. They don’t have, maybe 1 out of 10 may be qualified and competent for that position. But the rest …. And they will get more salary than the one qualified, like for us nationality.” P14 stated: “But when they need (owner & family in home), we have to go in the home. To give injection, to give insulin, to take the blood sugar. They do not want to bring here (take family to hospital). They pay us salary but still we are feeling like housemaid. Every time on call, so we cannot refuse also because they are our owner. I went there for 8 months. I was going morning, evening, night. Some people do two years there. P14’s daughter wants to do
410
Factors
Status
Thought Unit
Discrimination
Gov’t (G) or Private (P)
P#
G
P6
P
P23
G
P8
G
P22
Comments and Quotes
MBA in private school. She lives without husband here and she wants to work overtime. “Now they are having a plan again to send me to family villa, because I need money for overtime. They put me a lot there. So I will not go.” P6 stated: “When I first came here, the people itself – Saudi people. In the Philippines, you are really nursing. Here it is like you are a housemaid. Like that (P6 snaps her fingers to demonstrate). “Sura sura, yella yella … like that (hurry hurry, come come). I am saying I am only one, what can I do?” P23 stated: “Management calls us their servants, housemaids. I did not study 4 years in my country to be called a servant.” P8 stated: “Salary is discriminatory. These nurses who work in my department (Filipinos), doing the same job as I am doing, get ½ the salary that I get. The fact that they come from a less affluent society than I do should not dictate that they get less pay. That is what I have been told is the reason. If they are doing exactly the same job I am doing, they should get the same pay. Absolutely, it does provide a problem. I have had it said to me, ‘you are making more money than me, you do it’. I understand that, I can relate to that. Recently we got a 30% increase, only Western people got the raise. The reason because then the wages did not equate to what you could get at home. This appears to be a recruitment and retention strategy to keep Westerners in the hospital.” P22 stated: “It (Saudi preference for Filipino nurses instead of Indian) is also because of the culture here. This place has a tendency to treat people like subhumans. You see it in the way they generally treat people. This is not because they are nurses, but this is the general way of treating Indians in SA. SA is treating Indians as sub-human. When they talk to them, they don’t talk to them, they talk at them you know like, just do this or else. They talk to Filipinos better. You are non-Saudi, you are non-Muslim, you are a woman, so you become nothing to some of them. There are those who are really good people
411
Factors
Thought Unit
Gov’t (G) or Private (P)
P/P P Relationship with Lack of support G supervisor
P#
Comments and Quotes
who know you are a human being like everyone else. The culture also treats you as maids here. The mother will call and you go. They are sitting, she is not a paying patient. She points to the TV expecting the nurse to turn off the TV.” P22 handles these situations by not understanding Arabic; she turns around and leaves the room. The mother is not the patient, the child is the patient. P22 does not argue, just says that she does not understand. P18 / P18 and P20 stated: “They (patients) do not treat us as nurses sometimes. They P20 call us like their shigala (housemaid). They say, give me cup of tea, can you get my slippers.” P 19 stated: “They think the nursing profession is very low.” P23 P23 stated “If the nurse does not do what the patient wants, if we don’t do it, we will be in the nursing office.” P22 P22 stated: “I can assure you it is not about being in a private hospital. I am in X hospital. When you are saying when you are very busy, and you need… (help). I remember this particular day, which I always refer to when I think of lack of assistance from the supervisor. I can’t remember when, maybe three years ago, it was mid afternoon, just after 1 pm, and then the lights went off in the whole ward. The electricity failed and there was no kick-off for the back-up system. And we have in my unit, we have got a separate area for stable patients, and at that time two of them have ventilator. We have chronic patients who are there who are dependent on ventilators. The nurses had to run to ambu bag the patients. The nurse in charge was in the treatment room and just about to start an abdominal paracentesis on the patient. You know the doctor was just with the needle like this (demonstrating), I will never forget. Then I rushed to the phone, the phones were dead. I ran to the nearest exit, then I realized the whole hospital down because I could see the passages were dark.” She was not able to get in touch with the supervisor. “Do you know it was more than two hours, the lights were still were not there. The phones came back in 15 minutes
412
Factors
Thought Unit
Gov’t (G) or Private (P)
Relationship with Lack of support P supervisor
P#
P24
Comments and Quotes
but no body ever called the ward or came to see what was happening on site. Nobody came to see, ‘girls, how are you? How are you managing?’ Nobody came (angry tone, voice raised). It was like a nightmare. I will never forget the way I felt. I felt this place is not safe. Our supervisor came later and went straight to the one ventilated patient and she just played (with the child). (She did not say), people this is what happened in the hospital, so how did you manage? She did not even refer to the situation, nothing. We were not going to ask her anything. We survived without her. One of the many incidents when you find there is no support. As she (another participant) was saying, when something goes wrong, you will find the supervisor coming. When you are busy you will not see her. Once you see her you must know, you ask what happened, why is she here. She is never there to give support. It is just show she is there.” P22 stated that the supervisor came hours after the incident and is angry because it was their supervisor and she did not have the decency to tell the staff what happened. To have them involved, wanting recognition that they managed the crisis. “What kind of management is this? To me it was not professional.” P22 stated the supervisor came to the unit and played with the child as if nothing had happened. There was no nurse manager at that time so it was an even more poignant incident because the supervisor should have been there for support. “Attitude of the people here, you have to be strong. Attitude is people want to have your job, the way they are. It is the way they make you feel. There is never a time when you feel supported.” P22 adjusts her work issues with her social life and her friends. On her off days, she thinks about time off and is very active. P24 stated: “You know if you do 10 good things, nobody (supervisors) will notice it. If you do one small single thing, everybody will get the back of you. Why you do this, why are you not professional, why are you like this?”
413
Factors
Thought Unit
Gov’t P# (G) or Private (P) Relationship with Lack of support G P2 supervisor
P
P23
G
P2
Relationship with Lack of support G supervisor
P16
Comments and Quotes
P2 sated: Was not treated well by nursing director when she first arrived in Jeddah. Was not given the chance to demonstrate her education and experience in lecturing. The nursing director placed the nurse in a vulnerable situations and wrote her up for being insubordinate. She wanted to leave the job and make exit home. P2 stated: “my head nurse, she is also bad” “She is always telling to me, you are foreign nurse, you should do, follow me, and she put me over the Saudi nurses. Until now I don’t have clinic.” No support from nursing management, she wants a challenge in her work, feels discrimination as foreigner P23 stated: “In one shift there is one supervisor for the floor. That supervisor stay doing roaming, roaming around finding what’s wrong and not finding what he can do for the station. If we are busy, you will not find the supervisor there. Where you will find him, I do not know. Only God knows where is your supervisor. When you are relaxed and sitting, ah, you are not doing anything, one staff short in ER, go to help. See what they are doing for the staff.” P2 stated: “I told her my education, and asked to be in education. She talking to me very bad. I feel very bad. She telling me, ‘What you came from Egypt as supervisor. You cannot sit in my position.’ She asked, ‘You came here for what? Your position is good there, why did you come here?’ I said for money, she told me ‘You came for money. Okay. You do whatever I put you to do.’” P2 loves education and wanted to be in education. “She put me on Z floor and this for male with catheter. I told the doctor that I could not be with him, to see the naked man. There were too many male nurses on the floor. The head nurse wrote a letter about her that she refused to do nursing care. She sent me to OPD.” P16 stated: “But in X city I had an experience where I was hit by a murafi (patient sitter) here (she points to right arm). Just because we were not able to
414
Factors
Thought Unit
Gov’t (G) or Private (P)
P#
P
P23
Relationship with Lack of support G supervisor
P25
Comments and Quotes
attend to the needs (of the patient) immediately. Because only 2 nurses per shift. Because the system there is functional (team nursing). One charge nurse and one medication nurse. My arm become red, very red. The nursing supervisor she did not go to the medical director (meaning no support). It is always the patient that is right. The nurses are not protected.” This incident is also under work conditions (hygiene factor) and lack of staff (thought unit). P23 stated: “As for me, I did not have these worse experiences. I would like to share my work environment with you. We are working 3 bedside nurses. We have 26-bed capacity. We have one charge nurse, one medication nurse. The worse thing, this private hospital we don’t handle patients that doesn’t have much money. The hospital accommodates people who have money because money counts in this hospital. So, even if a tissue is thrown from the bed, you will pick it up. It’s like you are a maid in the hospital. When you did not answer the bell, they (an insured patient) will call the supervisors. So, the supervisor will attend. I was pushed by the relative of a patient. I called the supervisor, because I was only 6 months (in the hospital) then. My initial comment was to tell the supervisor that she pushed me. The relative told the supervisor that I pushed her. I was even asked why I did this. This incident happened because of lack of staff that should be there to support all the patient’s needs. The management don’t see it. We have 9 units, not including the DR, ER, ICU, special areas. We only have one supervisor. What if there are 10 code blues happening in one minute, how can she attend to it?” P25 stated: In her previous hospital there was a very demanding patient that had been in the hospital for 4 years. “He hit our Filipino head nurse. One day he wanted water and he threw water at her, very rude patient. The staff wrote incident reports about the many incidents. They had social services intervene.
415
Factors
Thought Unit
Gov’t (G) or Private (P)
Relationship with Lack of support P supervisor
P#
P23
Comments and Quotes
Patient would call administration and they would see the patient. Nothing will happen. They will not investigate what is really happened between the nurses and patient. One day, he called the nurses. He wants something, we could not be there. The social worker came and at that moment he (patient) was very angry. He threw water at the social worker, almost hit his head. The social worker ducked to miss the water. From that moment the patient was discharged. For us, foreign nurses he (the patient) is doing very bad things for how many years? On that one day he throw water to the Saudi. From that very moment, one letter and he was discharged. If we have complaints and if the Saudis have complaints, what is the difference? They will only see the Saudi. But for us we are craving for help. We are craving for support. They did not do anything. Sometimes they are supporting but most time not. Especially when it comes to the patient. They will not listen to the nurses.” This was the first time that the social worker had an altercation with the patient, but the patient was discharged immediately for his actions. Facilitator question: “Your supervisor is a Filipino. Do you have a different expectation to somebody who is from your own culture or do you see a difference when somebody is in charge being from your own country and culture and background? Do you have different expectations to that and do they (supervisors) treat the Filipinos harsher than any other nationality supervisor would have done?” P23 stated: “What I have learned, what I have experienced from this hospital, is Filipinos are the worst people. They are like Egyptians also, because I have experienced Egyptians. They are the worst people around. It is not that I am being biased about my fellow Filipinos. But in our country when you see a nurse from your own province, we share a lot. So the same in here. We are foreigners. Why don’t we just care? Why don’t we just look into the solution
416
Factors
Thought Unit
Gov’t (G) or Private (P)
P#
Relationship with Lack of support G supervisor for quality care
P22
Lack of support G for professional development
P22
Physical abuse
P16
Security
G
Comments and Quotes
and not into the problem? What’s happening in my hospital, they do not look into the problem. They look into the person. It should not be the factor. The factor should be the solution so that it won’t happen again. But it’s not like that.” Nursing director and management are sited by P23 as being the problem in this issue. With this culture, nurses are not performing well. “The nurse is not doing the right thing anymore. The nurse is tense and stressed, not performing well. We are just foreigners. We are here to do the job. Like what the owner says, if you cannot stay, then you can go.” P22 stated: “The senior managers are all expats. But they are saving their riyals at the expense of the nurses. This is why they say we can nurse up to 5 patients, disregarding the acuity of the patient. They do not care how sick the patients are. The managers never come to see and assess the patient.” P22 stated: At home her pediatric hospital was independent from other departments that were also pediatric but there was one nursing director. “If you made a mistake, it is not like someone wants to kill you. We used to write incident reports; we used to go to the matron’s office. We called it the red carpet. Go to the red carpet and answer for whatever you have done. After being scolded (our matrons are like military), they are so militant, so strict. When you go there you are scolded but at the end of the day, they teach you that this is not going to happen again. Because then you know there is a future for me in this place. But when they (current supervisors) talk they leave you lingering, tomorrow you do not know if you are going to have a job. No teaching. They do not make it a teaching session, so that you don’t make the same mistake.” This incident is also under relationship with supervisor (hygiene factor) and lack of support (thought unit). P16 stated: “But in X city I had an experience where I was hit by a murafi
417
Factors
Thought Unit
Gov’t (G) or Private (P)
P#
Security
Physical abuse
P
P23
Security
Physical abuse
P
P21
Comments and Quotes
(patient sitter) here (she points to right arm). Just because we were not able to attend to the needs (of the patient) immediately. Because only 2 nurses per shift. Because the system there is functional (team nursing). One charge nurse and one medication nurse. My arm become red, very red. The nursing supervisor she did not go to the medical director (meaning no support). It is always the patient that is right. The nurses are not protected.” This incident is also under work conditions (hygiene factor) and lack of staff (thought unit) and under relationship with supervisor (hygiene factor) and lack of support (thought unit). P23 stated: “As for me, I did not have these worse experiences. I would like to share my work environment with you. We are working 3 bedside nurses. We have 26-bed capacity. We have one charge nurse, one medication nurse. The worse thing, this private hospital we don’t handle patients that doesn’t have much money. The hospital accommodates people who have money because money counts in this hospital. So, even if a tissue is thrown from the bed, you will pick it up. It’s like you are a maid in the hospital. When you did not answer the bell, they (an insured patient) will call the supervisors. So, the supervisor will attend. I was pushed by the relative of a patient. I called the supervisor, because I was only 6 months (in the hospital) then. My initial comment was to tell the supervisor that she pushed me. The relative told the supervisor that I pushed her. I was even asked why I did this. This incident happened because of lack of staff that should be there to support all the patient’s needs. The management don’t see it. We have 9 units, not including the DR, ER, ICU, special areas. We only have one supervisor. What if there are 10 code blues happening in one minute, how can she attend to it?” P21 stated: “I think I have one bad experience when I was working in OPD, ortho department. One patient came with a post ACL reconstruction. Then we
418
Factors
Security
Thought Unit
Physical abuse
Gov’t (G) or Private (P)
G
P#
P25
Comments and Quotes
did dressing together with my doctor. Then this clinic is very busy every day. We are very fast doing it (dressing change). We are in a hurry to do the procedures every day. When my doctor finished cleaning the wound, he told me okay finish this one and then close it. Send the patient home. My doctor left to see another patient. When I let the patient sit down in wheelchair, he kicked me. Because maybe he feels pain. while I am alone, I am holding the postoperative site. So it was very difficult for me to carry him. His mother doesn’t help carrying her son. Why did you kick me? The patient said, ‘You must carry me because it is very painful.’ What can I do? I shouted at the patient, ‘Why are you doing this to me? I did everything for you, then this in return. I am doing my best, that you cannot feel any pain.’ Then the doctor came. He asked, ‘What happened?’ I told him that the patient is very impolite, he kicked me. ‘He did that to you?’ he (the doctor) said. I said ‘Yes.’ This is very disgusting doctor. Then I told my doctor that I would not do any dressing with this patient anymore. Even in the Philippines the patients do not treat nurses this way.” The patient said sorry to her at a follow-up appointment. This incident is also under relationship with supervisor (hygiene factor) and lack of support (thought unit) P25 stated: In her previous hospital there was a very demanding patient that had been in the hospital for 4 years. “He hit our Filipino head nurse. One day he wanted water and he threw water at her, very rude patient. The staff wrote incident reports about the many incidents. They had social services intervene. Patient would call administration and they would see the patient. Nothing will happen. They will not investigate what is really happened between the nurses and patient. One day, he called the nurses. He wants something, we could not be there. The social worker came and at that moment he (patient) was very angry. He threw water at the social worker, almost hit his head. The social
419
Factors
Thought Unit
Gov’t (G) or Private (P)
P
P#
Security
Verbal abuse
P18
Personal Life
Accommodation G
P1
G
P3
Comments and Quotes
worker ducked to miss the water. From that moment the patient was discharged. For us, foreign nurses he (the patient) is doing very bad things for how many years? On that one day he throw water to the Saudi. From that very moment, one letter and he was discharged. If we have complaints and if the Saudis have complaints, what is the difference? They will only see the Saudi. But for us we are craving for help. We are craving for support. They did not do anything. Sometimes they are supporting but most time not. Especially when it comes to the patient. They will not listen to the nurses.” This was the first time that the social worker had an altercation with the patient, but the patient was discharged immediately for his actions. P18 stated: “When I first came to SA, the language barrier. If you assign to a patient and you don’t know what to say, and she is saying something but you don’t understand. And you just by action you can anticipate what she needs. Because sometimes Yemeni, or Sudanese, or whatsoever the nationality, the Arabic is not the same. And sometimes they are saying bad words. For example, they (the patient) are calling (you did not yet come because you are busy), and then they say yakall (like a dog, donkey, animal). So if we know, we tell them don’t say bad words, because we are not doing bad things to you. Because if we are doing bad things, you would not recover. So you are not the only patient we are attending, we have a lot.” P1 stated: “We do not get good food. For accommodation we are suffering from water shortage. In one flat there are 7-8 nurses, 2 per room. In our contract we were supposed to get 1 room accommodation.” P3 stated: “We have the same problem. A married couple is in one room with child. Wife telling me she is petrified that her daughter will wake up and see them (being intimate). We had someone from Riyadh to do a complete evaluation of the hospital. So the hospital did not take them to the
420
Factors
Personal Life
Thought Unit
Gov’t (G) or Private (P)
Accommodation G
P#
P2
Comments and Quotes
accommodation. But the nursing staff explained to the evaluators the situation. I don’t care about the accommodation. Put me in a dorm situation, I will be fine. They said things were going to change but it will not change overnight. They promised in Riyadh they would do it (changes). Up until now they have not done it (move people over to another compound).” P2 stated: “Only two hours of water in a day. No water in the dorm. In other compounds, they have 24 hours water (depends on nationality). If you know someone, you get favors. Problems with food service in hospital. See staff (kitchen staff) taking food out back door. Give staff (nursing staff) small servings. Do not have good hours to get to cafeteria. Give us the lowest of the food. Apple not good or banana. ”
421
APPENDIX II: QUALITATIVE DATA
Hygiene Factors
Intrinsic Motivators 10 0 90 80
J ob S atisfac tion
% Frequency
70
J ob D is satis fa ction
60 50 40 30 20 10
Figure JJ1. Percentage frequency of FTN job satisfiers and job dissatisfiers.
er s i th
na p
w
so er
hi
P
tio ns R
ea
hi p ns el at io R
Fa ctor s
pe
ll if e
ry al a
ur S
ec
S
i ty
or rv
is
s w
W
or
i th
su pe
ta tu S
k
co
ny pa om C
nd it i on
y po lic
i li ib po ns
R
es
ie ve ch A
ty
t en m
it s k or W
R
ec
og n
i ti
el f
on
0
422
Hygiene Factors
Intrinsic Motivators 60
% Frequency
50
% Government
40
% Private
30 20 10
s w ith
pe er
y
Figure JJ2. Percentage frequency of government and private FTNs exceptionally good day at work.
R ea
w ith sh ip io n
R el at
Factors
tio ns hi p
su p
k W or
Sa la r
er vi so r
n co nd iti o
lic y pa n
y
po
y C om
R es po ns ib il i t
en t Ac hi ev em
its el f k W or
R ec og
ni ti
on
0
423
Hygiene Factors 45
40
% Government % Private
35
% Frequency
30
25
20
15
10
5
0 Company policy
Work condition
Status
Relationship with supervisor
Security
Personal Life
Factors
Figure JJ3. Percentage frequency of government and private FTNs exceptionally bad day at work.
424 APPENDIX JJ: HYPOTHESES 1 AND 2: BIVARIATE RESULTS (T TEST)
Variables Gender Age Nationality Religion Education Year Registered Title Ownership Length of Work at Current Hospital First Contract in SA Length of Time in SA Worked in SA Prior to Current Contract Stay in Saudi Arabia Married Contract Type
Hypothesis 1 Hypothesis 2 NWI PES 1 2 3 4 1 2 3 4 5 AT CT RS OS PT QM NM SR CR
X
X X
X
X X
X
X X
X
X
X
X
X
Family in SA: Yes
Currently pursuing degree X = denotes statistical significance Key: NWI-R AT = autonomy over practice CT = control in the practice RS = nurse-physician relationships OS = organizational support
X
X
PES-NWI PT = nurse participation in hospital affairs QM = nursing foundations for quality of care NM = nurse manager ability, leadership, and support of nurses SR = staffing and resource adequacy CR = collegial nurse-physician relationships
425 APPENDIX KK: HYPOTHESIS 3: BIVARIATE RESULTS (T TEST)
Variables Gender Age Nationality Religion Education Year Registered Title Ownership Length of Work at Current Hospital First Contract in SA Length of Time in SA Worked in SA Prior to Current Contract Stay in Saudi Arabia Married Contract Type Family in SA: Yes Currently pursuing degree
X = denotes statistical significance Key: EE = emotional exhaustion DP = depersonalization PA = personal accomplishment
Hypothesis 3 MBI 1 2 3 EE DP PA
X X
X
X X
X
426 APPENDIX LL: HYPOTHESES 1 AND 2: MULITPLE REGRESSION RESULTS
Variables Gender Age Nationality Religion Education Year Registered Title Ownership Length of Work at Current Hospital First Contract in SA Length of Time in SA Worked in SA Prior to Current Contract Stay in Saudi Arabia Married Contract Type
Hypothesis 1 Hypothesis 2 NWI PES 1 2 3 4 1 2 3 4 5 AT CT RS OS PT QM NM SR CR
X X
X X
X X
X X
X
X
X X
X X X X
X
X X X
X
Family in SA: Yes
Currently pursuing degree X Number of nurses per 100 X X beds X = denotes statistical significance
Key: NWI-R AT = autonomy over practice CT = control in the practice RS = nurse-physician relationships OS = organizational support
X
X X
X X
PES-NWI PT = nurse participation in hospital affairs QM = nursing foundations for quality of care NM = nurse manager ability, leadership, and support of nurses SR = staffing and resource adequacy CR = collegial nurse-physician relationships
427 APPENDIX MM: HYPOTHESIS 3: MULTIPLE REGRESSION RESULTS
Variables Gender Age Nationality Religion Education Year Registered Title Ownership Length of Work at Current Hospital First Contract in SA Length of Time in SA Worked in SA Prior to Current Contract Stay in Saudi Arabia Married Contract Type Family in SA: Yes Currently pursuing degree Number of nurses per 100 beds
X = denotes statistical significance Key: EE = emotional exhaustion DP = depersonalization PA = personal accomplishment
Hypothesis 3 MBI 1 2 3 EE DP PA X X X
X X X
X
X X X
428 APPENDIX NN: HYPOTHESIS 4: MULTIPLE REGRESSION RESULTS
Variables Gender Age Nationality Religion Education Year Registered Title Ownership Length of Work at Current Hospital First Contract in SA Length of Time in SA Worked in SA Prior to Current Contract Stay in Saudi Arabia Married Contract Type Family in SA: Yes Currently pursuing degree Number of nurses per 100 beds Autonomy over Practice Control over Practice Setting Nurse-Physician Relationships Organizational Support Nurse Participation in Hospital Affairs Nursing Foundations for Quality of Care Nurse Manager Ability, Leadership, and Support of Nurses Staffing and Resource Adequacy Collegial Nurse-Physician Relationships
Hypothesis 4 MBI 1 2 3 EE DP PA X
X
X X
X X
X
X
X
X X* X* X* X* X*
X = denotes statistical significance * = significant correlation based on Pearson’s r. All others are based on ANOVA. Key: EE = emotional exhaustion DP = depersonalization PA = personal accomplishment
