Journal of Nursing Management, 2016, 24, E95–E100
Transforming the nursing profession in Saudi Arabia MOHAMMED G. ALGHAMDI
RN, MsN
1
and LINDA D. URDEN
DNSc, RN, CNS, NE-BC, FAAN
2
1
PhD Student and 2Professor of Nursing, Director of Master’s and International Nursing Programs, Hahn School of Nursing and Health Science, University of San Diego, CA, USA
Correspondence Mohammed G. Alghamdi University of San Diego Hahn School of Nursing and Health Science 5998 Alcala Park San Diego, CA 92110 E-mail: [email protected]
ALGHAMDI M.G. & URDEN L.D.
(2016) Journal of Nursing Management 24, E95–E100 Transforming the nursing profession in Saudi Arabia Aim To discuss the impact of health-care policies and regulations on hospitals’ journey towards the Magnet designation in Saudi Arabia. Background Saudi Arabia, like many other countries, faces several challenges in achieving ‘the Gold Standard’ in nursing practice. Centralised management, the absence of a regulatory professional body, lack of a national benchmarking database and a nursing shortage are all major challenges in advancing nursing practice. Key issue The presence of two Magnet-designated hospitals in Saudi Arabia (not affiliated with the Ministry of Health) is an opportunity to explore how this has been achieved within the organisational and professional context. The nursing leaders in the Ministry of Health could be accountable to address the barriers in advancing nursing practice and to raise nursing awareness regarding the adoption of a new culture of excellence. Implications for Nursing Management Nursing managers in the Ministry of Health hospitals are encouraged to assess the hospitals’ readiness to apply for Magnet status. Their readiness must include having a high level of nursing satisfaction and low turnover rate, which goes along with assessing cultural and organisational climates to understand the gaps in work environment and driving evidence of readiness toward achieving Magnet status. Conclusion Health-care policies and regulations, both nationally and globally, can result in several challenges to achieving ‘the Gold Standard’ in nursing practice. These challenges may not be possible to resolve within an organisational level. Collaborative effort and transformational changes are needed to drive the nursing profession toward the best outcomes for our patients and nurses. Keywords: health policy, magnet recognition programme, nursing leadership, Saudi
Arabia Accepted for publication: 1 March 2015
Introduction Registered nurses are the first line of health-care providers; they spend more time and effort on patients than other health-care professionals. The factors that might enhance their satisfaction are essential as their satisfaction will be noted in terms of increasing DOI: 10.1111/jonm.12301 ª 2015 John Wiley & Sons Ltd
patient satisfaction, quality of care, nursing productivity, efficiency and retention (Lu et al. 2005, Mrayyan 2006, Abualrub & Alghamdi 2012). Given the current worldwide nursing shortage which has been a continuing crisis in many different countries for the past decade (International Council of Nursing 2006, World Health Organisation 2006), there is great E95
M. G. Alghamdi and L. D. Urden
interest in nurse retention. Therefore, nurse managers should examine the factors that satisfy and retain nurses. Many other changes have taken place in healthcare settings that must be considered by decision-makers in the health-care system. These changes include patients’ reduced length of stay, uncertainty, unpredictability and emphasis on cost effectiveness, all of which can affect both nurse and patient satisfaction (Curtin 2000, Mrayyan 2006, Al-Hussami 2008). The American Nurses Credentialing Centre (ANCC) established the Magnet Recognition Programme in 1994. The programme recognises health-care organisations for quality patient care, nursing excellence and innovations in nursing practice. There are 14 ‘Forces of Magnetism’ that must be present in the organisation in addition to metrics in the areas of nurse-sensitive outcomes, patient satisfaction and organisational supports. In 2007, a new vision was introduced along with a new Magnet Model, consisting of five components. The 14 Forces of Magnetism remain as the framework and fit into the five components of the new Magnet model (see Table 1). The Magnet Recognition Programme has been described, for example, on the American Nurses Credentialing Centre’s website (American Nurses Association Credentialing Center 2014). These components have been shown to improve nurse, patient and organisational outcomes, and they constitute one solution to the shortage of hospital nurses (Jurkovich et al. 2010). While ANCC introduced their new Magnet model in 2007, there was only one Magnet-designated hospital in the Middle East and only five international Table 1 Magnet model Model components Transformational leadership Structural empowerment
Exemplary professional practice
New knowledge, innovations and improvements Empirical outcomes
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Forces of magnetism Quality of Nursing Leadership (Force no. 1) Management Style (Force no. 3) Organisational Structure (Force no. 2) Personnel Policies and Programs (Force no. 4) Community and the Health-care Organisation (Force no. 10) Image of Nursing (Force no. 12) Professional Development (Force no. 14) Professional Models of Care (Force no. 5) Quality of Care: Ethics, Patient Safety & Quality Infrastructure (Force no. 6) Consultation and Resources (Force no. 8) Autonomy (Force no. 9) Nurses as Teachers (Force no. 11) Interdisciplinary Relationships (Force no. 13) Quality of Care: Research and Evidence-Based Practice (Force no. 6) Quality Improvement (Force no. 7) Quality of Care (Force no. 6)
Magnet facilities from three countries outside the USA (Australia, Singapore and Lebanon) (Walker & Aguilera 2013). Recently, two hospitals from Saudi Arabia (King Faisal Specialist Hospital in Jeddah and Riyadh) took part in the journey toward nursing excellence and achieved Magnet designation (Lovering 2013). Saudi Arabia faces several challenges in achieving ‘the Gold Standard’ in nursing practice. The challenges include, but are not limited to, health-care policies and regulations, educational challenges, sociocultural challenges, staffing shortage and lack of national or international benchmark databases.
Health-care in Saudi Arabia The healthcare system in Saudi Arabia is categorised as a national system, which provides health services through governmental sectors and agencies for a total population of 28.29 million (UNICEF 2014). The Ministry of Health (MOH) is considered the major government agency committed to providing curative, preventive and rehabilitative health-care services for the Saudi population (around 20.65 million) (Central Department of Statistics and Information 2013). Other governmental agencies that deliver primary, secondary and tertiary care target a specific population who are enrolled in security or the armed forces: the Ministry of National Guard, the Ministry of Defence and Aviation, and the Ministry of Interior. In addition, the government provides care by financing major specialised national tertiary hospitals: King Faisal Specialist Hospital (KFSH) and King Khalid Eye Specialist Hospital (KKESH). The KFSH provides health care on a referral basis using highly advanced technologies for treating complex cases that require advanced and specialised medical care (Almalki et al. 2011).
Centralised management The MOH is the lead government agency responsible for regulating, planning, managing and financing the health-care sector through the Council of Health Services. The Council of Health Services, established by a Royal Decree in 2002 and headed by the Minster of Health, includes representatives from other government and private health sectors. Thus, the MOH is considered a National Health Service (NHS) for the entire population (Almalki et al. 2011). The aim of the council was to create an integrated strategy through constructive cooperation and effective coordination among health parties in Saudi ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E95–E100
Transforming nursing in Saudi Arabia
Arabia to promote health services and eliminate duplication (Council of Health Services 2013). No significant progress has been made on these grounds (Alasmari 2013). Furthermore, such a centralised system, where most of the major decision-making takes place in a small circle of leaders, can lead to significant delays in decisions, resistance to change and less innovative ideas from the front-line level (Ekvall 1996). This inhibits new ideas and approaches to improve the provision of health care in MOH hospitals. In 2009, a new regulation system was issued by the Royal Decree (no. M/30) on approving the unification of the pay scale for all the national health practitioners in governmental health-care agencies. This decision might limit the competition between the governmental hospitals in attracting qualified and competent registered national nurses, or even new nursing students. At the same time, the ANCC Magnet Recognition Programme endeavours to attract and retain nurses by creating competitive salaries and career benefits. During the last decade, the MOH has become less centralised in managing health-care services by adopting an increasing number of self-operated hospitals with independent budgets. Nevertheless, there are still many decisions such as legislating, regulating, planning, budgeting and financing that are controlled by the top-level management of the MOH, while the regional directors of health services and hospital managers are left with little authority but greater responsibility and supervisory roles. Also noteworthy, is that only two Saudi hospitals designated as Magnet institutions (King Faisal Specialist Hospital in Riyadh and Jeddah) are not affiliated with MOH and have a decentralised, independent general organisation. The nursing professional identified shared governance as a key indicator of excellence in nursing practice and thus, traditional centralised management does not work in attracting and retaining strategies (Force 2004, Barden et al. 2011). Hierarchical decisionmaking structures for command and control form barriers to worker autonomy and empowerment, impairing quality of care and creating distrust between managers and workers (Institute of Medicine 2011).
Professional body In Saudi Arabia, there is no professional body or nursing council at the national level with defined accountabilities and responsibilities, such as a nurse practice ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E95–E100
act or nursing code of ethics, to govern nursing practice and provide professional autonomy (Lovering 2013). The Scientific Nursing Board (SNB) was formed in 2002 and is working under the authority of the Saudi Commission for Healthcare Specialties (SCFHS), which might limit its role and influence. The goals set by the SNB included the establishment of accountability systems and credentialing processes, the formulation of criteria for professional practice, the development of educational, ethical, and practical competency standards, and the evaluation of hospitals and health centres for the purpose of education (Abu-Zinadah 2006). The SNB plays a major role in evaluating and equalising the professional certificates as a registration authority or a licencing board. At this time, the nursing profession in Saudi Arabia needs a national regulatory body to develop policies and enforce the laws and rules of nursing practices. However, the foundation of the nursing body is not yet established in the country to rule and regulate the discipline of nursing. In the absence of a regulatory framework, it is essential for nursing leaders in the MOH and in other health-care agencies to articulate the context of nursing care by establishing a professional body to support the discipline and nursing practice.
National nursing database The national databases assist nursing administrators in knowing where they stand in comparison with other health institutions, nationally and internationally, and supports their decisions to prioritise quality improvement needs (Thompson et al. 2004). In addition, national databases measure attributes of the nursing professionals that are related to the quality of patient care, such as turnover, staffing ratios and nursing education and certification (Montalvo 2007). The data create reports that help to improve quality plans and prevent adverse events. Unfortunately, the lack of a national benchmarking database for nursing quality indicators in Saudi Arabia has forced the nursing administrators in KFSH-Jeddah to submit nurse-sensitive data to the National Database for Nursing Quality Indicators (NDNQI), which was limited to US hospitals in 2005. Thus, in 2007, KFSH-Jeddah became the first hospital outside the USA to join the NDNQI database (Lovering 2013). However, it does not obscure the fact that a lack of national measures and data sources is a major challenge to assessing the delivery of care. E97
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ond highest ratio of nurses after Qatar (74/10 000); other countries in the region, such as Bahrain (36/ 10 000), UAE (41/10 000), and Jordan (40/10 000), have lower rates. These ratios are still lower than other developed countries, such as USA (98/10 000), Canada (105/10 000), United Kingdom (95/10 000), and France (93/10 000) (World Health Organisation 2013). The current nursing shortage, in particular among national nurses, is related to several factors, including an annual population growth rate that has increased by 2.5% each year from 1990 to 2012, and is leading to a greater demand for health care (UNICEF 2014). In addition, there has been an increase in life expectancy from age 69 years in 1990 to age 76 years in 2012 among the Saudi population (World Health Organisation 2013). Such growth among the elderly population affects health-care demands.
Therefore, nursing practice standards are defined by each health-care agency in Saudi Arabia. The nursing leaders in MOH, as the major government agency, could be accountable and responsible for moving toward the development of a National Nursing Database to benchmark our nursing practices with other health-care institutions nationally and globally.
Nursing shortage The insufficient number of Saudi nurses available to meet the health-care needs of the country has led to a reliance on expatriates. Therefore, the MOH and other health-care agencies need to recruit more national nurses and retain current expatriates to minimise the effect of the nursing shortage. The overall number of registered nurses working in Saudi Arabia, including other governmental agencies and the private sector, is 140 389. The number of Saudi registered nurses is 51 350, which represents 36.6% of the total number of nurses working in Saudi Arabia (MOH 2012). Whereas 45 875 (89.3% of all the Saudi registered nurses) are working under the affiliation of the Ministry of Health (Table 2). The MOH’s recent statistics report (2012) shows that the total number of nurses in Saudi Arabia reflects a ratio of 48 nurses per 10 000 people in the population, with an increase of 35% between the years of 2006 and 2012. When compared with other countries in the Middle East, Saudi Arabia has the sec-
Discussion and implications for nursing management Previously, we discussed the major challenges that face the nursing profession in Saudi Arabia. Centralised management, the absence of a regulatory professional body, the lack of a national nursing database, and a nursing shortage are all major challenges in advancing nursing practice and creating excellence in patient care. Therefore, collaborative and collective action is needed to address these barriers and to raise nursing
Table 2 Total registered nurses in Saudi Arabia by health sector, gender, and nationality Saudi registered nurses n Ministry of Health Female 26 466 Male 19 409 Total 45 875 Other governmental agencies* Female 2607 Male 2009 Total 4616 Private sector Female 398 Male 461 Total 859 All health sectors Female 29 471 Male 21 879 Total 51 350
Non-Saudi registered nurses
Total by health sector
%
n
%
n
%
31.9 23.4 55.3
35 650 1423 37 073
43.0 1.7 44.7
62 116 20 832 82 948
74.9 25.1 100.0
9.0 6.9 15.9
21 970 2 482 24 452
75.6 8.5 84.1
24 577 4491 29 068
84.6 15.4 100.0
1.4 1.6 3.0
24 901 2613 27 514
87.8 9.2 97.0
25 299 3074 28 373
89.2 10.8 100.0
21.0 15.6 36.6
82 521 6518 89 039
58.8 4.6 63.4
111 992 28 397 140 389
79.8 20.2 100.0
*Other governmental agencies includes but is not limited to: King Faisal Specialist Hospital in Riyadh and Jeddah, National Guards Medical Services, Ministry of Higher Education Hospitals, Armed Forces Hospitals, Ministry of Interior Medical Services, ARAMCO and Royal Commission Hospitals. Source. The Annual Statistics Book (2012) From the Saudi Ministry of Health.
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ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E95–E100
Transforming nursing in Saudi Arabia
awareness regarding the adoption of a new culture of excellence. However, establishment of a national benchmarking database for nursing quality indicators is needed to compare nursing, clinical and organisational outcomes in current Magnet hospitals with our nursing practice. It seems timely for nursing management to assess the Magnet effect on the designated hospitals and to determine if it could help alleviate the professional challenges related to the nursing shortage, autonomy and retention. The Magnet Recognition Programme has been explored in relation to improving workplace environments, shortage and nurse satisfaction; ultimately, patient care quality and safety are embedded within the five Magnet components (Armstrong & Laschinger 2006, Rondeau & Wagar 2006, Stimpfel et al. 2014). Other studies demonstrate that Magnet hospitals could improve the nursing shortage, provide opportunities to influence the workplace and improve professional relationships (Coile 2001, Hess et al. 2011). The Magnet programme continues to have a positive impact on nurses’ decision-making abilities and their professional relationships. In a comparison study between Magnet and non-Magnet facilities, nurses in Magnet hospitals rated relationships with advanced practice nurses, opportunities to influence decisionmaking in the workplace organisation and participation in shared governance higher than did non-Magnet nurses (Hess et al. 2011). The Magnet Recognition Programme was used in different hospitals within multiple clinical settings and different cultural, economic and political contexts (Walker & Aguilera 2013). Therefore, the presence of two Magnet hospitals in Saudi Arabia is an opportunity for nursing managers to explore the impact of Magnet designation on nursing practice and patient outcomes. Furthermore, measuring differences in retaining nurses, enhancing professional practice and improving the workplace environment between Magnet and non-Magnet hospitals would open new perspectives and enhance understanding of nursing care. It is important that nursing management encourages nursing researchers to assess MOH hospitals’ readiness to apply for Magnet status. Their readiness must include having excellent nursing care, a high level of satisfaction and low turnover rate retention, as well as assessing cultural and organisational climates to understand the gaps in work environment and driving evidence of readiness toward achieving Magnet status and excellence in patient care. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E95–E100
Conclusions Health-care policies and regulations can create challenges for an international facility applying for ‘the Gold Standard’ in nursing practice. These challenges may not be possible to resolve within an organisational level. However, readiness for improvement and changes are needed on a national level.
Acknowledgements The authors thank the Saudi Ministry of Health for the sponsorship. The authors also thank the constant encouragement and motivation received from Hahn School of Nursing and Health Science, University of San Diego and extend their sincere gratitude to Dr Mary-Rose Mueller, former Professor, Hahn School of Nursing and Health Science, University of San Diego, for her valuable suggestions and insights.
Source of funding None.
Ethical approval Ethical approval was not required for this paper.
References Abualrub R. & Alghamdi M. (2012) The impact of leadership styles on nurses’ satisfaction and intention to stay among Saudi nurses. Journal of Nursing Management 20 (5), 668– 678. Abu-Zinadah S. (2006) Nursing situation in Saudi Arabia. Available at: http://www.nurse.scfhs.org, accessed 19 March 2007. Alasmari M.N. (2013, Feb 4) The Council of Health Services, How does this flounder! Alwakad E-Newspaper [in Arabic]. Available at: http://alwakad.net/dimofinf/articles.php?action=show&id=7960, accessed 20 April 2014. Al-Hussami M. (2008) Study of nurses’ job satisfaction: the relationship to organizational commitment, perceived organizational support, transactional leadership, transformational leadership, and level of education. European Journal of Scientific Research 22 (2), 286–295. Almalki M., Fitzgerald G. & Clark M. (2011) Health care system in Saudi Arabia: an overview. Eastern Mediterranean Health Journal 17, 784–793. American Nurses Association Credentialing Center (2014) Magnet Recognition Program Model – Overview. Available at: http://www.nursecredentialing.org/Magnet/ProgramOverview/ New-Magnet-Model, accessed 13 March 2014. Armstrong K.J. & Laschinger H. (2006) Structural empowerment, magnet hospital characteristics, and patient safety culture. Journal of Nursing Care Quality 21 (2), 124–132.
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Barden A., Griffin M., Donahue M. & Fitzpatrick J. (2011) Shared governance and empowerment in registered nurses working in a hospital setting. Nursing Administration Quarterly 35 (3), 212–218. Central Department of Statistics and Information (CDSI) (2013) Key Indicators: Saudi Arabia Population. Available at: http://www.unicef.org/infobycountry/saudiarabia_statistics>, accessed 21 April 2014. Coile R.C. (2001) Magnet hospitals use culture, not wages, to solve nursing shortage. Journal of Healthcare Management 46 (4), 224–227. Council of Health Services (2013) Vision and Mission. Available at: http://www.chs.gov.sa/En/Council/Pages/VisionAndMission. aspx, accessed 19 April 2014. Curtin L. (2000) Hot issues in healthcare: safety, quality, and professional discipline. Seminars for Nurse Managers 8 (4), 239–242. Ekvall G. (1996) Organizational climate for creativity and innovation. European Journal of Work and Organizational Psychology 5 (1), 105–123. Force M. (2004) Creating a culture of service excellence: empowering nurses within the shared governance councillor model. The Health Care Manager 23 (3), 262–266. Hess R., Desroches C., Donelan K., Norman L. & Buerhaus P.I. (2011) Perceptions of nurses in Magnet A hospitals, nonMagnet hospitals, and hospitals pursuing Magnet status. Journal of Nursing Administration 41 (7–8), 315–323. Institute of Medicine (2011) The Future of Nursing: Leading Change, Advancing Health. National Academies Press, Washington, DC. International Council of Nursing (2006) The Global Shortage of Registered Nurses: An Overview of Issues and Actions. Available at: http://www.icn.ch/images/stories/documents/publications/GNRI/The_Global_Nursing_Shortage-Priority_Areas_ for_Intervention.pdf, accessed 13 September 2014. Jurkovich P., Karpiuk K. & King C. (2010) Magnet recognition: examples of perioperative excellence. AORN Journal 91 (2), 292–299.
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Lovering S. (2013) Magnet designation in Saudi Arabia. Journal of Nursing Administration 43 (12), 619–620. Lu H., While A. & Barriball K. (2005) Job satisfaction among nurses: a literature review. International Journal of Nursing Studies 42 (2), 211–227. Ministry of Health (2012) Annual Statistics Book. Available at: http://www.moh.gov.sa/en/Pages/Default.aspx, accessed 23 April 2014. Montalvo I. (2007) The national database of nursing quality indicators (NDNQI). OJIN: The Online Journal of Issues in Nursing 12 (3), Manuscript 2. Mrayyan M.T. (2006) Jordanian nurses’ job satisfaction, patients’ satisfaction and quality of nursing care. International Nursing Review 53, 224–230. Rondeau K.V. & Wagar T.H. (2006) Nurse and resident satisfaction in magnet long-term care organizations: do high involvement approaches matter? Journal of Nursing Management 14, 244–250. Stimpfel A.W., Rosen J.E. & McHugh M.D. (2014) Understanding the role of the professional practice environment on quality of care in Magnet and non-Magnet hospitals. Journal of Nursing Administration 14 (1), 244–250. Thompson C., Cullum N., McCaughan D., Sheldon T. & Raynor P. (2004) Nurses, information use, and clinical decision making-the real world potential for evidence-based decisions in nursing. Evidence Based Nursing 7 (3), 68–72. UNICEF (2014) Saudi Arabia — statistics. The United Nations Children’s Emergency Fund. Available at: http://www.unicef.org/infobycountry/saudiarabia_statistics, accessed 21 April 2014. Walker K. & Aguilera J. (2013) The international Magnet journey. Nursing Management 44 (10), 50–52. World Health Organisation (2006) The World Health Report 2006 – Working Together for Health. Available at: http:// www.who.int/whr/2006/en/, accessed 13 September 2014. World Health Organisation (2013) Aggregated Data: Density per 1000 Data by Country. Available at: http://apps.who.int/ gho/data/node.main.A1444, accessed 22 April 2014.
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E95–E100
Transforming the nursing profession in Saudi Arabia MOHAMMED G. ALGHAMDI
RN, MsN
1
and LINDA D. URDEN
DNSc, RN, CNS, NE-BC, FAAN
2
1
PhD Student and 2Professor of Nursing, Director of Master’s and International Nursing Programs, Hahn School of Nursing and Health Science, University of San Diego, CA, USA
Correspondence Mohammed G. Alghamdi University of San Diego Hahn School of Nursing and Health Science 5998 Alcala Park San Diego, CA 92110 E-mail: [email protected]
ALGHAMDI M.G. & URDEN L.D.
(2016) Journal of Nursing Management 24, E95–E100 Transforming the nursing profession in Saudi Arabia Aim To discuss the impact of health-care policies and regulations on hospitals’ journey towards the Magnet designation in Saudi Arabia. Background Saudi Arabia, like many other countries, faces several challenges in achieving ‘the Gold Standard’ in nursing practice. Centralised management, the absence of a regulatory professional body, lack of a national benchmarking database and a nursing shortage are all major challenges in advancing nursing practice. Key issue The presence of two Magnet-designated hospitals in Saudi Arabia (not affiliated with the Ministry of Health) is an opportunity to explore how this has been achieved within the organisational and professional context. The nursing leaders in the Ministry of Health could be accountable to address the barriers in advancing nursing practice and to raise nursing awareness regarding the adoption of a new culture of excellence. Implications for Nursing Management Nursing managers in the Ministry of Health hospitals are encouraged to assess the hospitals’ readiness to apply for Magnet status. Their readiness must include having a high level of nursing satisfaction and low turnover rate, which goes along with assessing cultural and organisational climates to understand the gaps in work environment and driving evidence of readiness toward achieving Magnet status. Conclusion Health-care policies and regulations, both nationally and globally, can result in several challenges to achieving ‘the Gold Standard’ in nursing practice. These challenges may not be possible to resolve within an organisational level. Collaborative effort and transformational changes are needed to drive the nursing profession toward the best outcomes for our patients and nurses. Keywords: health policy, magnet recognition programme, nursing leadership, Saudi
Arabia Accepted for publication: 1 March 2015
Introduction Registered nurses are the first line of health-care providers; they spend more time and effort on patients than other health-care professionals. The factors that might enhance their satisfaction are essential as their satisfaction will be noted in terms of increasing DOI: 10.1111/jonm.12301 ª 2015 John Wiley & Sons Ltd
patient satisfaction, quality of care, nursing productivity, efficiency and retention (Lu et al. 2005, Mrayyan 2006, Abualrub & Alghamdi 2012). Given the current worldwide nursing shortage which has been a continuing crisis in many different countries for the past decade (International Council of Nursing 2006, World Health Organisation 2006), there is great E95
M. G. Alghamdi and L. D. Urden
interest in nurse retention. Therefore, nurse managers should examine the factors that satisfy and retain nurses. Many other changes have taken place in healthcare settings that must be considered by decision-makers in the health-care system. These changes include patients’ reduced length of stay, uncertainty, unpredictability and emphasis on cost effectiveness, all of which can affect both nurse and patient satisfaction (Curtin 2000, Mrayyan 2006, Al-Hussami 2008). The American Nurses Credentialing Centre (ANCC) established the Magnet Recognition Programme in 1994. The programme recognises health-care organisations for quality patient care, nursing excellence and innovations in nursing practice. There are 14 ‘Forces of Magnetism’ that must be present in the organisation in addition to metrics in the areas of nurse-sensitive outcomes, patient satisfaction and organisational supports. In 2007, a new vision was introduced along with a new Magnet Model, consisting of five components. The 14 Forces of Magnetism remain as the framework and fit into the five components of the new Magnet model (see Table 1). The Magnet Recognition Programme has been described, for example, on the American Nurses Credentialing Centre’s website (American Nurses Association Credentialing Center 2014). These components have been shown to improve nurse, patient and organisational outcomes, and they constitute one solution to the shortage of hospital nurses (Jurkovich et al. 2010). While ANCC introduced their new Magnet model in 2007, there was only one Magnet-designated hospital in the Middle East and only five international Table 1 Magnet model Model components Transformational leadership Structural empowerment
Exemplary professional practice
New knowledge, innovations and improvements Empirical outcomes
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Forces of magnetism Quality of Nursing Leadership (Force no. 1) Management Style (Force no. 3) Organisational Structure (Force no. 2) Personnel Policies and Programs (Force no. 4) Community and the Health-care Organisation (Force no. 10) Image of Nursing (Force no. 12) Professional Development (Force no. 14) Professional Models of Care (Force no. 5) Quality of Care: Ethics, Patient Safety & Quality Infrastructure (Force no. 6) Consultation and Resources (Force no. 8) Autonomy (Force no. 9) Nurses as Teachers (Force no. 11) Interdisciplinary Relationships (Force no. 13) Quality of Care: Research and Evidence-Based Practice (Force no. 6) Quality Improvement (Force no. 7) Quality of Care (Force no. 6)
Magnet facilities from three countries outside the USA (Australia, Singapore and Lebanon) (Walker & Aguilera 2013). Recently, two hospitals from Saudi Arabia (King Faisal Specialist Hospital in Jeddah and Riyadh) took part in the journey toward nursing excellence and achieved Magnet designation (Lovering 2013). Saudi Arabia faces several challenges in achieving ‘the Gold Standard’ in nursing practice. The challenges include, but are not limited to, health-care policies and regulations, educational challenges, sociocultural challenges, staffing shortage and lack of national or international benchmark databases.
Health-care in Saudi Arabia The healthcare system in Saudi Arabia is categorised as a national system, which provides health services through governmental sectors and agencies for a total population of 28.29 million (UNICEF 2014). The Ministry of Health (MOH) is considered the major government agency committed to providing curative, preventive and rehabilitative health-care services for the Saudi population (around 20.65 million) (Central Department of Statistics and Information 2013). Other governmental agencies that deliver primary, secondary and tertiary care target a specific population who are enrolled in security or the armed forces: the Ministry of National Guard, the Ministry of Defence and Aviation, and the Ministry of Interior. In addition, the government provides care by financing major specialised national tertiary hospitals: King Faisal Specialist Hospital (KFSH) and King Khalid Eye Specialist Hospital (KKESH). The KFSH provides health care on a referral basis using highly advanced technologies for treating complex cases that require advanced and specialised medical care (Almalki et al. 2011).
Centralised management The MOH is the lead government agency responsible for regulating, planning, managing and financing the health-care sector through the Council of Health Services. The Council of Health Services, established by a Royal Decree in 2002 and headed by the Minster of Health, includes representatives from other government and private health sectors. Thus, the MOH is considered a National Health Service (NHS) for the entire population (Almalki et al. 2011). The aim of the council was to create an integrated strategy through constructive cooperation and effective coordination among health parties in Saudi ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E95–E100
Transforming nursing in Saudi Arabia
Arabia to promote health services and eliminate duplication (Council of Health Services 2013). No significant progress has been made on these grounds (Alasmari 2013). Furthermore, such a centralised system, where most of the major decision-making takes place in a small circle of leaders, can lead to significant delays in decisions, resistance to change and less innovative ideas from the front-line level (Ekvall 1996). This inhibits new ideas and approaches to improve the provision of health care in MOH hospitals. In 2009, a new regulation system was issued by the Royal Decree (no. M/30) on approving the unification of the pay scale for all the national health practitioners in governmental health-care agencies. This decision might limit the competition between the governmental hospitals in attracting qualified and competent registered national nurses, or even new nursing students. At the same time, the ANCC Magnet Recognition Programme endeavours to attract and retain nurses by creating competitive salaries and career benefits. During the last decade, the MOH has become less centralised in managing health-care services by adopting an increasing number of self-operated hospitals with independent budgets. Nevertheless, there are still many decisions such as legislating, regulating, planning, budgeting and financing that are controlled by the top-level management of the MOH, while the regional directors of health services and hospital managers are left with little authority but greater responsibility and supervisory roles. Also noteworthy, is that only two Saudi hospitals designated as Magnet institutions (King Faisal Specialist Hospital in Riyadh and Jeddah) are not affiliated with MOH and have a decentralised, independent general organisation. The nursing professional identified shared governance as a key indicator of excellence in nursing practice and thus, traditional centralised management does not work in attracting and retaining strategies (Force 2004, Barden et al. 2011). Hierarchical decisionmaking structures for command and control form barriers to worker autonomy and empowerment, impairing quality of care and creating distrust between managers and workers (Institute of Medicine 2011).
Professional body In Saudi Arabia, there is no professional body or nursing council at the national level with defined accountabilities and responsibilities, such as a nurse practice ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E95–E100
act or nursing code of ethics, to govern nursing practice and provide professional autonomy (Lovering 2013). The Scientific Nursing Board (SNB) was formed in 2002 and is working under the authority of the Saudi Commission for Healthcare Specialties (SCFHS), which might limit its role and influence. The goals set by the SNB included the establishment of accountability systems and credentialing processes, the formulation of criteria for professional practice, the development of educational, ethical, and practical competency standards, and the evaluation of hospitals and health centres for the purpose of education (Abu-Zinadah 2006). The SNB plays a major role in evaluating and equalising the professional certificates as a registration authority or a licencing board. At this time, the nursing profession in Saudi Arabia needs a national regulatory body to develop policies and enforce the laws and rules of nursing practices. However, the foundation of the nursing body is not yet established in the country to rule and regulate the discipline of nursing. In the absence of a regulatory framework, it is essential for nursing leaders in the MOH and in other health-care agencies to articulate the context of nursing care by establishing a professional body to support the discipline and nursing practice.
National nursing database The national databases assist nursing administrators in knowing where they stand in comparison with other health institutions, nationally and internationally, and supports their decisions to prioritise quality improvement needs (Thompson et al. 2004). In addition, national databases measure attributes of the nursing professionals that are related to the quality of patient care, such as turnover, staffing ratios and nursing education and certification (Montalvo 2007). The data create reports that help to improve quality plans and prevent adverse events. Unfortunately, the lack of a national benchmarking database for nursing quality indicators in Saudi Arabia has forced the nursing administrators in KFSH-Jeddah to submit nurse-sensitive data to the National Database for Nursing Quality Indicators (NDNQI), which was limited to US hospitals in 2005. Thus, in 2007, KFSH-Jeddah became the first hospital outside the USA to join the NDNQI database (Lovering 2013). However, it does not obscure the fact that a lack of national measures and data sources is a major challenge to assessing the delivery of care. E97
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ond highest ratio of nurses after Qatar (74/10 000); other countries in the region, such as Bahrain (36/ 10 000), UAE (41/10 000), and Jordan (40/10 000), have lower rates. These ratios are still lower than other developed countries, such as USA (98/10 000), Canada (105/10 000), United Kingdom (95/10 000), and France (93/10 000) (World Health Organisation 2013). The current nursing shortage, in particular among national nurses, is related to several factors, including an annual population growth rate that has increased by 2.5% each year from 1990 to 2012, and is leading to a greater demand for health care (UNICEF 2014). In addition, there has been an increase in life expectancy from age 69 years in 1990 to age 76 years in 2012 among the Saudi population (World Health Organisation 2013). Such growth among the elderly population affects health-care demands.
Therefore, nursing practice standards are defined by each health-care agency in Saudi Arabia. The nursing leaders in MOH, as the major government agency, could be accountable and responsible for moving toward the development of a National Nursing Database to benchmark our nursing practices with other health-care institutions nationally and globally.
Nursing shortage The insufficient number of Saudi nurses available to meet the health-care needs of the country has led to a reliance on expatriates. Therefore, the MOH and other health-care agencies need to recruit more national nurses and retain current expatriates to minimise the effect of the nursing shortage. The overall number of registered nurses working in Saudi Arabia, including other governmental agencies and the private sector, is 140 389. The number of Saudi registered nurses is 51 350, which represents 36.6% of the total number of nurses working in Saudi Arabia (MOH 2012). Whereas 45 875 (89.3% of all the Saudi registered nurses) are working under the affiliation of the Ministry of Health (Table 2). The MOH’s recent statistics report (2012) shows that the total number of nurses in Saudi Arabia reflects a ratio of 48 nurses per 10 000 people in the population, with an increase of 35% between the years of 2006 and 2012. When compared with other countries in the Middle East, Saudi Arabia has the sec-
Discussion and implications for nursing management Previously, we discussed the major challenges that face the nursing profession in Saudi Arabia. Centralised management, the absence of a regulatory professional body, the lack of a national nursing database, and a nursing shortage are all major challenges in advancing nursing practice and creating excellence in patient care. Therefore, collaborative and collective action is needed to address these barriers and to raise nursing
Table 2 Total registered nurses in Saudi Arabia by health sector, gender, and nationality Saudi registered nurses n Ministry of Health Female 26 466 Male 19 409 Total 45 875 Other governmental agencies* Female 2607 Male 2009 Total 4616 Private sector Female 398 Male 461 Total 859 All health sectors Female 29 471 Male 21 879 Total 51 350
Non-Saudi registered nurses
Total by health sector
%
n
%
n
%
31.9 23.4 55.3
35 650 1423 37 073
43.0 1.7 44.7
62 116 20 832 82 948
74.9 25.1 100.0
9.0 6.9 15.9
21 970 2 482 24 452
75.6 8.5 84.1
24 577 4491 29 068
84.6 15.4 100.0
1.4 1.6 3.0
24 901 2613 27 514
87.8 9.2 97.0
25 299 3074 28 373
89.2 10.8 100.0
21.0 15.6 36.6
82 521 6518 89 039
58.8 4.6 63.4
111 992 28 397 140 389
79.8 20.2 100.0
*Other governmental agencies includes but is not limited to: King Faisal Specialist Hospital in Riyadh and Jeddah, National Guards Medical Services, Ministry of Higher Education Hospitals, Armed Forces Hospitals, Ministry of Interior Medical Services, ARAMCO and Royal Commission Hospitals. Source. The Annual Statistics Book (2012) From the Saudi Ministry of Health.
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Transforming nursing in Saudi Arabia
awareness regarding the adoption of a new culture of excellence. However, establishment of a national benchmarking database for nursing quality indicators is needed to compare nursing, clinical and organisational outcomes in current Magnet hospitals with our nursing practice. It seems timely for nursing management to assess the Magnet effect on the designated hospitals and to determine if it could help alleviate the professional challenges related to the nursing shortage, autonomy and retention. The Magnet Recognition Programme has been explored in relation to improving workplace environments, shortage and nurse satisfaction; ultimately, patient care quality and safety are embedded within the five Magnet components (Armstrong & Laschinger 2006, Rondeau & Wagar 2006, Stimpfel et al. 2014). Other studies demonstrate that Magnet hospitals could improve the nursing shortage, provide opportunities to influence the workplace and improve professional relationships (Coile 2001, Hess et al. 2011). The Magnet programme continues to have a positive impact on nurses’ decision-making abilities and their professional relationships. In a comparison study between Magnet and non-Magnet facilities, nurses in Magnet hospitals rated relationships with advanced practice nurses, opportunities to influence decisionmaking in the workplace organisation and participation in shared governance higher than did non-Magnet nurses (Hess et al. 2011). The Magnet Recognition Programme was used in different hospitals within multiple clinical settings and different cultural, economic and political contexts (Walker & Aguilera 2013). Therefore, the presence of two Magnet hospitals in Saudi Arabia is an opportunity for nursing managers to explore the impact of Magnet designation on nursing practice and patient outcomes. Furthermore, measuring differences in retaining nurses, enhancing professional practice and improving the workplace environment between Magnet and non-Magnet hospitals would open new perspectives and enhance understanding of nursing care. It is important that nursing management encourages nursing researchers to assess MOH hospitals’ readiness to apply for Magnet status. Their readiness must include having excellent nursing care, a high level of satisfaction and low turnover rate retention, as well as assessing cultural and organisational climates to understand the gaps in work environment and driving evidence of readiness toward achieving Magnet status and excellence in patient care. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E95–E100
Conclusions Health-care policies and regulations can create challenges for an international facility applying for ‘the Gold Standard’ in nursing practice. These challenges may not be possible to resolve within an organisational level. However, readiness for improvement and changes are needed on a national level.
Acknowledgements The authors thank the Saudi Ministry of Health for the sponsorship. The authors also thank the constant encouragement and motivation received from Hahn School of Nursing and Health Science, University of San Diego and extend their sincere gratitude to Dr Mary-Rose Mueller, former Professor, Hahn School of Nursing and Health Science, University of San Diego, for her valuable suggestions and insights.
Source of funding None.
Ethical approval Ethical approval was not required for this paper.
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