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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 75-84

Exploring acute care workplace experiences of Saudi female nurses: Creating career identity


1 Department of Medical-Surgical Nursing, College of Nursing, King Abdulaziz Medical City, National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
2 School of Nursing-Sydney, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia

Date of Submission02-Apr-2019
Date of Decision11-Jun-2019
Date of Acceptance12-Jun-2019
Date of Web Publication23-Sep-2019

Correspondence Address:
Sandra West
Associate professor, School of Nursing-Sydney, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_11_19

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  Abstract 


Background: Saudi registered nurses (RNs) currently comprise 30% of Saudi Arabia's nursing workforce, and turnover/attrition rates remain problematic. No studies exploring Saudi RNs' experiences of acute care work and/or the factors that influence their decision to continue working were located. Purpose: To construct an insightful understanding of the acute care workplace experiences of female Saudi RNs and factors affecting retention. Methods: Snowball sampling was used to recruit 26 female acute care Saudi RNs who were interviewed about their workplace experiences. A constructivist grounded theory approach was used to code and categorize data to construct a shared understanding reflective of the experiences of participants and the researcher as both constructing the meanings given. Results: Shared understandings of patients' culture, religion, and language were assisting Saudi RNs to feel competent in making a unique contribution to patient care. Although participants reported negative impacts from some workplace policies, they were able to create their own identity and to find their own place by creating a career identity as Saudi-Muslim nurses. Successfully creating this unique nursing identity enhanced their motivation, work commitment, and competence; however, difficulties were encountered in accommodating work conditions and working as a minority group within a workplace largely staffed by foreign nurses. Conclusion: Saudi nurses' acute care workplace experiences were found to be complex and challenging and significantly affected by the lack of supportive policies designed to help them to keep working clinically. Implications for Nursing Policy: Workplace retention of Saudi RNs is an organizational issue that needs wide discussion to enable continuing clinical work of Saudi female nurses.

Keywords: Acute care workplace, qualitative study, retention, Saudi female nurses


How to cite this article:
Alsayed S, West S. Exploring acute care workplace experiences of Saudi female nurses: Creating career identity. Saudi Crit Care J 2019;3:75-84

How to cite this URL:
Alsayed S, West S. Exploring acute care workplace experiences of Saudi female nurses: Creating career identity. Saudi Crit Care J [serial online] 2019 [cited 2019 Oct 21];3:75-84. Available from: http://www.sccj-sa.org/text.asp?2019/3/2/75/267613




  Introduction Top


The current Saudi registered nurses (RNs) workforce is 60% female, and this group's high turnover rate compared to male nurses which is understood to be significantly contributing to the shortage of local nurses (Abu-Zinadah 2010), with married female RNs who have/are having children while working 12-h shifts the most likely to leave clinical positions. To date, studies exploring Saudi RNs' turnover have focused on determining cost and other health care organizational consequences, whereas studies exploring the workplace experiences of female Saudi RNs and the likely impact these have on their intentions to remain working clinically have not been located. Addressing retention issues from the perspective of the Saudi RNs will assist development of a deeper understanding of RN's turnover.

The Saudi Arabian government currently relies on expatriates from over 40 countries to provide 80% of the nursing workforce needed for its rapidly growing population (Alhusni et al., 2017).[1] The high turnover rate of expatriate staff does however create instability within the nursing workforce (Health, 2007a), and the Saudi health care system is facing significant challenges in attempting to address the shortage of local nurses. Consequently, the nursing sector has significantly engaged in “Saudization,” a government-driven process designed to replace the expatriate workforce with a Saudi national workforce. Saudization nursing training programs have been established to address the shortage of local nurses and to encourage replacement of expatriate RNs with qualified local RNs (WHO, 2006a). Increasing the number of Saudi RNs will increase Saudi employment (Maben, Al-Thowini et al., 2010) and provide opportunities for experienced Saudi RNs to occupy the senior clinical positions that are mostly occupied by expatriates. Currently, Western RNs remain the preferred recruits in many hospitals; however, the number of expatriates from Philippines is increasing,[2] creating a multicultural workplace where English is the only common language. English is, however, not the first language of Saudi patients and its use for communication between nurses and with patients causes communication problems.

Background

The Saudi health care system faces significant challenges in addressing the shortage of local, nurses. The majority of nurses in Saudi health organizations are expatriates with a high turnover rate (Abu-Zinadah, 2012). As a result, the Saudi health care system is facing considerable workforce instability. According to a Ministry of Health (MOH) 2009 report, the total health workforce in Saudi Arabia, including all sectors, is about two-hundred thousand (210, 062), of which more than half (105, 512) work in the MOH (Health, 2009).[3] According to this report, local nurses rate is only 44.5%.

Given the health workforce shortages described above, the Saudi government has taken significant measures to teach and train Saudis at all levels of healthcare services. For example, since 1958, a number of medical, nursing, and health schools have been opened by the government to achieve this goal.[4] The total number of governmental medical schools has reached 62 colleges for medicine as well as nursing around the Saudi Kingdom(Health, 2007a). Efforts with establishing Saudization training programs, aimed at substituting the large number of expatriate professionals with qualified Saudis in all sectors, including health (Tumulty, 2001; WHO, 2006a). The budget allocation for training and scholarships has increased significantly, and many of the MOH employees are offered a chance to pursue their studies abroad, to improve their skills and quality of care.[3]

This strategy may decrease the rate of turnover among health care professionals as it gives the opportunity firstly for employment as well as the administrative positions (Rambur et al., 2003). Nevertheless, the government need to adopt other strategies to overcome the continuing challenge of turnover among health professionals, particularly nurses.

Long-term, sustainable strategies developed by the MOH in cooperation with other governmental sectors and the private sector are needed to address this issue. A good example of such cooperation is the King Abdullah International Scholarship Programme that was established by the Ministry of Higher Education in 2005. Stage 4 of this program gave the opportunity for individuals to pursue higher education overseas, in areas facing substantial workforce shortages such as health specialties including medicine, nursing, pharmacy, and health sciences like radiology and physical therapy.[3] However, more colleges, schools, and programs need to be established around the Saudi Kingdom.

Female nurses represent a significant segment of Saudi women who work in nontraditional areas, the experience of those nurses will inform an understanding of the work/life interaction process within Saudi context and how work/life interaction might affect the intention to stay in the clinical field. Researchwise, recent studies investigating the importance of the work/life balance and its impacts on work satisfaction and turnover behavior among health care professionals (See, for example, Brooks and Anderson, 2004, 2005; Hsu and Kernohan, 2006).[5] These studies argue that the concept of work/life integration is one that strongly influences workers' productivity and commitment to their work and acknowledges that nursing is highly demanding work involving long hours and managing heavy workloads, which may affect workers' well-being. There is a growing body of work exploring work/life integration among nurses; however, the majority of these are reporting hospital-based research in western countries (Lingard et al., 2007; Kaiser, 2011; Skinner et al., 2011).[5]

The situation of female Saudi nurses is difficult because the working hours are very long compared to other more traditionally accepted jobs for Saudi women (working hours for teachers do not exceed 6 h a day), and furthermore, shift and night work are required which is another issue facing them. These reasons make nursing as profession not yet fully accepted within some areas of Saudi society, especially that the majority of Saudi nurses are young mothers and have home and children responsibilities. These issues point to some possible reasons for the female nurse turnover rate being higher than that of male nurses (Abu-Zinadah, 2010),[4] the details of their experiences need to be considered when attempting to think about the methods that can be used to assist Saudi female nurses to stay working in the clinical field.

There is a significant need to conduct further studies of work/life integration in different health settings – such as Saudi Arabia – which is experiencing similar chronic shortages of local health care professionals, although these shortages are occurring in very different cultural and social circumstances. To date, while some studies are documenting the attrition/retention rates within the Saudi nursing workforce,[4] there are no Saudi studies specifically exploring the clinically working Saudi RNs' intentions to remain or leave the workforce. Therefore, the reasons for the increasing turnover behavior of Saudi female Arabian nurses remain largely unknown.

Considering this context, a major research study was designed to explore the experiences of how Saudi nurses maintain their clinical nursing roles along with their other social roles, and how this affects their decision to continue working. Saudi RNs were found to be interacting daily within three social contexts: workplace, home, and society. This paper reports only the analysis of workplace-related data.

Aim of study

To construct an insightful understanding of the acute care workplace experiences of female Saudi RN's and factors affecting retention.


  Methods Top


Design

A qualitative approach allowed exploration of the meanings that female Saudi RNs attach to their experiences of fitting into this workplace. Constructive grounded theory was used to generate a shared understanding between individual accounts and personal views to provide complex textual descriptions of how individuals experience the research issue.

Setting and sample

Twenty-six female Saudi RNs who worked a 12-h shift system in acute care areas of a major Government Hospital in Saudi Arabia were interviewed. Participants were required to be Saudi female nurses who hold a Bachelor of Nursing degree and have two or more years of nursing experience in acute care. Potential participants were contacted by mail, and a snowballing process was later used to assist recruitment.

Data collection

Participant characteristics sheet was distributed prior each interview to determine the demographic characteristics of each, participant. See [Table 1]. The semi-structured interview questions initially focused on factors the researchers perceived as potentially influencing participants' decisions to remain employed as clinical nurses. These were reviewed and adapted to reflect emerging data following each round of interviews. Each interview was conducted face-to-face in Arabic to ensure participants could talk fluently about their lives. Data were initially transcribed in Arabic then cross-checked for transcription accuracy by an Arabic-speaking colleague. Thereafter, transcripts were translated into English and a percentage of the two versions cross-checked by another bilingual translator to establish the fidelity of the translation process.
Table 1: Participant characteristics

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Ethical considerations

Ethics approval was provided by the data collection site in Saudi Arabia and a university human ethics committee [Ref No.: MF/KFG]. Before each interview, informed written consent was obtained. Each interview was deidentified, and all comments and responses were anonymized during initial transcription.

Data analysis

Data were examined and initially coded using a line-by-line approach and a written description for each code developed. Substantive codes were then created. The constant comparative method was used to compare the elements presented in one data source with that from another. Subcategories were then created, and focused coding subsequently led to the development of major categories that linked the previously generated subcategories.

Rigor/trustworthiness

To ensure rigor, this study was designed to demonstrate transparency. Its reporting includes extensive data tables to clearly document the coding and categorizing process. The English and Arabic versions of transcribed data and cross-checked translations are available. Trustworthiness was established by the involvement of all authors in every aspect of the data analysis process.


  Results Top


The three categories that have emerged from this analysis will now be explored.

Accommodating conditions of work

This category addresses several key areas where the workplace directly impacted participants' lives. Examples of data underpinning the subcategories are provided in [Table 2].
Table 2: Category data extract: Accommodating conditions of work

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Organization of shifts

Inflexible working arrangements were a major concern. Many participants were dissatisfied with nurse administrators' organization of shift schedules. As there was no opportunity to request preferred shifts, many complained of the stress caused by their attempts to meet work requirements while dealing with family-related or emergency issues. Participants with complex family situations or chronic conditions also experienced difficulties in organizing shift schedules to accommodate their specific circumstances. While shift scheduling is not the focus of this study, there is an extensive literature discussing the consequences of inflexible work scheduling and its effect on the satisfaction and productivity levels of nurses that emphasizes the advantages of flexible shift schedules for nurse retention.

Salary and allowances

Most participants viewed salaries and other financial benefits as important determinants of the perceived social and professional status of nurses and as strong motivators for clinical nurses to continue working. However, participants reported considerable dissatisfaction with their salaries and other financial allowances, as it was felt that these were not meeting their material needs (this reflects participants' dissatisfaction with a decrease in RNs' basic monthly salary announced by the MOH at this time).

Many participants believed that they should be paid financial bonuses for working night and weekend shifts as incentives for nurses to work these less favorable shifts. Similarly, some participants suggested that nurses working closely with infectious and other patient groups where there is significant risk of personal illness or injury to staff should receive a monthly hazard-recognition allowance.

Leave/recognition of religious holidays

In Saudi Arabia, religious occasions are very special times for all Saudi families, and every family member is expected to attend. Participants described both their anger and disappointment at what they perceived as the neglect of their need for religious leave to observe these occasions. This situation was further exacerbated by participants' awareness of the strong administrative support given to foreign nurses requesting Christmas vacations and the consequent requirements for Saudi nurses to work during this period, without reciprocation for significant Muslim holidays.

Participants described what they identified as an “unfair” vacation policies that differentiated between Saudi and foreign nurses by allowing foreign nurses to schedule their vacations according to personal needs but allocated leave to local nurses. Participants perceived administrative bias in the priority given to applications from foreign nurses, with allocations to Saudi nurses only occurring once the foreign nurses' applications had been determined.

Lack of support for working mothers

Saudi Labor Law states that female employees are entitled to 10 weeks' maternity leave on full salary after 3 years work, or half salary if they have worked <3 years (Gazzaz 2009). They are also entitled to 1 h/day for breastfeeding for 2 years after returning to work (a time-period consistent with Islamic belief about the needs of a child). Participants with children found it difficult to sustain the demands of shift work without adequate postnatal rest, and this relatively short period of maternity leave increased the difficulty of returning shift/clinical work. Other participants perceived that it was the workplace implementation of these national entitlements for maternity leave and breastfeeding time that discouraged many nurses from continuing clinical work. While participants were permitted one breastfeeding hour during their 12-h shift for the first 5 months after maternity leave, the lack of accessible breastfeeding spaces, as well as reliable and affordable childcare in close proximity to their workplaces, meant that for most, it would not be possible to effectively breastfeed within their allocated hour.

Creating a place at work

This category emerged from participants' descriptions of their experience working as Saudi nurses in areas where the majority of nurses were not Saudi nationals, and the long predominance of Western clinical and management cultures had strongly influenced the social and cultural structure of the workplace. Examples of data underpinning this category are provided in [Table 3].
Table 3: Category data extract: Creating a place at work

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Saudi nurses: Working as a minority

As a numerical minority within this workplace, participants described experiencing discrimination, isolation, and neglect by the foreign nurses working there. These experiences were particularly evident when foreign nurses occupied positions of authority and were responsible for participants' performance evaluations, renewal of contracts, and access to opportunities for promotion. While minority groups may sometimes be viewed as different or invisible but equal, participants' accounts indicate that they believed their foreign colleagues perceived Saudi nurses as having low levels of clinical competence and an inability to accept challenges, and a tendency to exhibit high levels of absenteeism and poor punctuality.

Saudi Nurses: Working for foreign nurse administrators

Participants experienced the presence of foreign nurse administrators (the dominant managerial group) as creating a power imbalance within their workplace. Foreign nurse administrators were perceived by participants to be misusing their authority both passively, by failing to support Saudi nurses, and more actively, by directly hindering the promotion and progression of Saudi nurses, both as individuals and as an identifiable group of employees.

Participants' work evaluations were commonly completed by foreign nurses, and in their view, these frequently less-than-positive evaluations were then used by foreign nurse administrators to limit opportunities for Saudi nurses when competing for positions held by or available to foreign nurses. Participants saw this as an example of how nurse administrators actively assisted foreign nurses within the promotional processes, an observation that then directly contributed to the participants' feelings of disempowerment. This power imbalance resulted in participants being fearful of speaking to or raising issues with nurse administrators whom they did not feel would listen fairly – or worse, may use the issue as basis for a poor evaluation. Participants' perception that they were foreigners in their own country was therefore seen as a consequence of the many years of foreign domination in the management.

Saudi nurses are the only group who enter this workplace as new graduates; they have therefore been positioned as a subordinate group and perceived by their administrators as a new inexperienced group with less training and competency. However, despite having gained experience, data indicate that the way nursing administrators manage Saudi nurses continues to exclude them from attaining senior management positions and provide few opportunities for Saudi nurses to demonstrate their competence and leadership skills.

While many participants described feelings of discontent about the discriminative attitudes of individual foreign nurse administrators, others clearly labeled their experiences as evidence of racism within their workplace. Reported incidents included participants being described by nurse administrators as “lowering the quality of nursing,” or nurse administrators deliberately ignoring Saudi nurses while courteously addressing foreign nurses in front of them. Such incidents are understood here as being indicative of a racist workplace that excludes the Saudi nurse, while simultaneously ensuring that she understands herself as subordinate to other dominant non-Saudi nationalities.

Foreign nurses: Protecting their jobs

Participants talked of their strained relations with their foreign colleagues, perceiving such tension as the result of the foreign nurses' discomfort with the presence of Saudi nurses within the workplace. Attempts to exclude Saudi nurses from the workplace were described which indicates the existence of silent and hidden workplace conflict that affects the interpersonal relationships of all staff. Participants described how foreign nurses generated persistent personal pressure on Saudi nurses, were very competitive in the workplace and consistently failed to provide reasonable levels of collegial support for new graduate Saudi nurses.

Participants were aware that foreign nurses were fearful that the implementation of Saudization programs would lead to the loss of their employment and some participants attributed their difficult professional relationships with some foreign nurses to such fears. Participants saw considerable workplace conflict as being generated by what they understood as constant competition between Saudi nurses who were intent on developing themselves to achieve senior positions and foreign nurses who did not want to return to their home country and were therefore protecting their current positions from replacement by Saudi nurses. Understandably, then, the conflicting goals of both groups were affecting the professional and collegial relationships.

Patient attitudes/beliefs about Saudi nurses

Although the number of Saudi nurses in this hospital has steadily increased, for many Saudi patients and their families, there is a residual lack of trust in the clinical capability of Saudi nurses and their ability to effectively replace foreign staff. The development of therapeutic relationships between foreign nurses and patients depends on the former's ability to deliver high-quality nursing care in the absence of any direct verbal communication. Patients and their families have however been watching foreign nurses providing care without direct verbal communication for many years and have developed an expectation of a specific approach to nursing based on their trust in foreign nurses.

Therefore, the long-term presence of foreign nurses has shaped patient expectations of care and has normalized their ways of nursing. Hence, some patients and families feel more comfortable with foreign nurses and are therefore reluctant to accept other ways of nursing, including the ability to directly communicate with the nurse. This reliance by some patients on their previous experiences and expectations of foreign nurses also decreases the need for the organization to further involve Saudi nurses in some areas of patient care. Participants were very aware that some patients may lack trust in Saudi nurses and identified this as a significant cause of their difficulty in building professional confidence.

Medical staff attitudes/beliefs about Saudi nurses

Participants described both foreign and Saudi medical staff demonstrating negative attitudes toward Saudi nurses. This was especially evident in the clear mistrust demonstrated by some Saudi physicians and their freely expressed strong preference for working with foreign nurses. The long period of Saudi health care dependence on foreign nurses, as well as the familiarity of many Saudi medical staff with the practices of the country in which they completed their own training, are likely to have contributed to this reliance on foreign nurses.

This situation is further complicated by the presence of new graduate Saudi nurses within the workplace and exacerbated by hospital policies requiring all new graduates nurses, and all newly employed Saudi nurses (regardless of their postgraduation nursing experience) to complete 12 months of supervised practice and competency testing before they are permitted to work independently. Such policies that not only severely impact the professional confidence of Saudi nurses, but also signals a level of organizational distrust that confirms the existing negative attitudes about Saudi nurses. Currently, the foreign nursing workforce is comprised of nurses who have completed several years of clinical experience. Therefore, although foreign nurses come from diverse backgrounds, they enter the Saudi workplace only after undertaking further advanced training and associated competency testing – the verification of which is then not required on arrival in Saudi Arabia. Consequently, other health professionals do not interact with inexperienced foreign nurses. Perhaps not surprisingly then, participants report that both foreign and Saudi medical staff appear to think that all Saudi nurses are new to the profession and need more time to become sufficiently competent to effectively replace the foreign nurses.

Bringing a Saudi nursing identity to the workplace

This category emerged from the analysis of subcategories addressing participants' perceptions of the advantages of working as Saudi RNs within this workplace. Examples of data underpinning the subcategories are provided in [Table 4].
Table 4: Category data extract: Bringing the Saudi nursing identity to workplace

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Contributing to the patient experience

While some patients preferred being nursed by foreign nurses (see previous section), participants described how others appeared more comfortable and confident when nursed by Saudi nurses. Participants perceived these patients and their families as feeling supported and emotionally secure when their Saudi nurse understood and met their needs. Many participants developed strong relationships with patients and their families, with several stating that they felt considerable responsibility for them. Other participants clearly recognized the difficulties patients experienced when being nursed by foreign nurses and were working hard to mitigate these problems to improve patient care and enhance patient–nurse relationships.

Sharing the language of patients

Arabic, the formal language of Saudi Arabia, is a rich language with many regional accents and pronunciations that can complicate understanding. Saudi patients frequently complain of miscommunication with foreign non-Arabic speaking nurses and in an acute care clinical environment; this may affect patients in many and often serious ways. Participants, therefore, frequently acted as the link between the patient and the medical team to convey patients' concerns, feelings, needs, and inquiries. This is extremely valuable work that enhances the therapeutic relationship between the patient and their medical team and is a key element of ensuring patient safety and understanding of medical procedures and treatments. Therefore, it is not surprising that many participants have focused on their familiarity with their patients' language as one of the major contributions made by Saudi nurses. For participants, though, understanding the patients' language involved more than being an effective translator or interpreter: as nurses, the importance lay in the sharing of the language with patients, removing barriers and enhancing communication with patients, which improves the quality of nursing care and the available emotional support. Participants understood that the existence of mutual understanding between nurse and patient was crucial for forming the strong bonds necessary for effective therapeutic relationships.

Sharing cultural and religious understandings

The importance of sharing and understanding patients' cultural values and religious beliefs was frequently emphasized by participants as a major point of distinction for the Saudi nurse. Participants were clear in their view that understanding a patient's culture and religion was an important element in effectively nursing someone, especially in the Saudi Arabian society where most people are influenced by Islamic beliefs and cultural values that extend to influence patients' expectations of health care. Many participants perceived their patients' level of experienced comfort was related to the sense of belonging and the social attachment consequent to their sharing of culture and religion. Participants felt responsible as Saudis to protect and advocate for patient rights in ways that were fully respectful of patients' religious values and demands for personal privacy. Many participants believed that desired quality of patient care could not be achieved unless the nurses' understanding of a patient's needs included these aspects of care. Therefore, participants felt that patients both needed and valued them within this workplace and believed that as Saudi nurses, they were meeting their patients' needs more effectively than their foreign colleagues.

Being the first

Several participants described the challenge of developing their clinical competence and associated professional confidence when working in departments that had not previously employed Saudi nurses. For example, four participants were the first Saudi nurses employed in their respective departments, and they found the constant demands to prove their competence as nurses, including the need to develop professional trust with other health professional colleagues, to be a particularly challenging as in their experience being Saudi nurses within this workplace still often meant they were not trusted as experienced professionals. Participants understood that despite their high level of commitment and good performance at work, gaining trust and developing professional confidence required time and had worked hard to establish their professional skills and knowledge, nevertheless they continued to experience gaining the trust of both patients and physicians as a constant struggle. Some participants, however, were self-empowered and self-motivated by the uniqueness of their experiences and believed that they were developing a new role – that of Saudi nurses within their workplace.


  Discussion Top


The previous absence of Saudi nurses with equivalent experience or seniority in this large government hospital has led to the organization basing its standards of nursing care and ways of practice on those established by Western nurses. However, the hospital's reliance on the expertise of a largely expatriate nursing workforce has also meant that being nursed by a Western/foreign nurse has become the expected experience of many patients. The small number of Saudi nurses and the relatively short time they have been employed in this workplace has meant that foreign nurses continue to dominate senior clinical and administrative positions, which in turn is perceived by participants as a cause of discrimination.

Discrimination against minority groups causes inequities, resulting in constraints in both workplace and the social relations among those groups (Cordon 2006). In addition, workplace discrimination causes unequal access to opportunities, which leads to feelings of abuse and oppression for the minority group (Schiek et al. 2011). Participants frequently described how the organizational preference for foreign staff (imposed by the organizational structure) has empowered foreign nurses. Thus, Saudi nurses were excluded from organizational roles and functions. The apparent workplace preference for foreign nurses, as well as the organizational provision of this group with services and policies that empower them and meet their needs – without the consideration of Saudi nurses' needs – could thus be described as the result of institutional racism within this facility.

Managers who actively discriminate against an ethnic minority frequently act based on their subconscious assumptions about the group and their experience that these assumptions are rarely challenged.[6] Consequently, this has a negative impact on the work experience of the ethnic minority employees. Similarly, in this study, the attitudes and beliefs of foreign nurses regarding the limited experience, professionalism, and efficiency of Saudi nurses are perceived to be shared by foreign clinical nurses and nurse administrators and to remain unchallenged by the organization. Therefore, the capabilities of Saudi nurses are constantly questioned, despite their attempt to fit in and advance their careers within this workplace.

Importantly, it was obvious that many workplace structures and policies were perceived by participants to have been designed to fit the needs of the non-Saudi nurse, i.e., the majority. Such an approach makes it difficult for Saudi nurses to accommodate work conditions, as exemplified in such matters as annual leave, recognition of religious holidays, maternity leave, and support for mothers returning to work and sets up opportunities to reinforce existing attitudes toward Saudi nurses. Despite the challenges they face to retain their employment, these currently working Saudi nurses were attempting to accommodate the conditions of work; but, this study has uncovered a significant need for the organization to reformulate policies and regulations to consider their needs to help them continue working.

The minority positioning of these nurses has stimulated a strong need for them to create a career identity as Saudi nurses. These participants have chosen to be distinguishable as Saudi nurses within the workplace, understanding that they belonged to a social category where shared language, religion, and values established the uniqueness of everyone's self-concept (Stets et al. 2000) and brought them closer to patients and their families. In fact, participants had developed career identities that differed in their behavior, role performance, and attitude, allowing them to categorize themselves based on these differences within a larger group of foreign nurses.

The participants have realized the importance of their shared common cultural and religious background in both gaining the trust of patients and delivering high-quality nursing care. Such positioning reflects both nurses and patients' perceptions about the advantages of involving Saudi nurses in patient care and the contribution they make in highlighting the therapeutic value of speaking the language of patients and improving patient comfort through cultural and religious understanding.

A career identity is a structure of meanings within which people link their own motivation, interests, and competencies with acceptable career roles, which then enables them to fit into their assigned role (Blau 2003). Creating a career identity is found to increase an individual's commitment to work. Similarly, participants demonstrated a strong commitment to their nursing identity and confirm this identity through their relationships with others like them within the workplace and with their patients.

This has influenced the way participants developed their career identity and how they used models of nursing preferred within Saudi Arabian society. However, despite the participants' demonstrations of high level of competence and efficiency in their work, they continue to struggle to create a place for themselves within a complex workplace.

Limitations

This study has been conducted in only one of Saudi's several health care systems, and therefore, the findings presented here may not reflect the experiences of all Saudi nurses.


  Conclusion and Policy Implication Top


The workplace experiences of Saudi nurses working in acute care settings have been found to be complex and challenging. The multicultural structure of this hospital and the predominance of Western/foreign nurses in senior positions has not only influenced the workplace in terms of its positioning of Saudi nurses as a minority group but also in its assumption of similar social and cultural circumstances for both Saudi and foreign female nurses. Thus, many participants have described experiences of “everyday racism” and dissatisfaction with their position within the workplace.

Despite the mistrust of Saudi nurses and the challenge of continually needing to establish a place for themselves within the workplace, these nurses found alternative ways to strengthen their Saudi nurse identity and their ability to incorporate their Islamic values and Saudi culture into their care for patients and their families – the social contribution that participants value the most. This approach has therefore allowed them to overcome many challenges while establishing a career identity.

In this workplace, their identity is not only that of “nurse” but that of “Saudi nurse” whenever they are engaging with others. Nurses developed their identity as Saudi nurses despite the difficulties they experience in attempting to develop their clinical confidence when working with more experienced and rarely supportive foreign clinical nurses.

Stakeholders should begin to consider the needs of the Saudi nurse at workplace when they make workplace policies to improve her situation as well as to help her stay longer in clinical filed. Retention of Saudi nurses should not be considered as individual experience but as an organizational issue that should be discussed widely for the problem to be addressed effectively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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