Research - International Journal of Medical Research & Health Sciences ( 2021) Volume 10, Issue 10
The Nursing Image in Saudi Arabia: A Narrative Review on what it was and what is our VisionAnwar Al-Khunizi1*, Areej Al-Otaibi1, Ali Al-Anazi1, Adel S. Bashatah1 and Syed Wajid2
2Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
Anwar Al-Khunizi, Department of Nursing Administration and Education, College of Nursing, King Saud University, Riyadh, Saudi Arabia, Email: email@example.com
Received: 28-Sep-2021 Accepted Date: Oct 22, 2021 ; Published: 29-Oct-2021, DOI: O
Nursing has been in existence since the first human beings and has changed and improved in parallel with globalization. Like all professions, nursing is significantly influenced by the specific society it serves. Even more, the nurse’s public image appears to be negative in countries where strong cultural traditions strongly restrict women’s involvement in occupations outside the home. Although the society looks at nurses with some disrespect so that individuals were afraid of joining nursing even if they like it. The negative image was shaped due to the lack of expansion in nursing education. In the Kingdom of Saudi Arabia, the nursing profession faces significant challenges, including; failure to recruit high academic students into nursing education, poor nursing identity, and lack of awareness about the nursing profession. Furthermore, the nursing profession’s community awareness and public image are critical to recruiting and retaining students into nursing education and improving nurses’ sense of identity.
Nursing image, Challenges, Vision, Saudi Arabia
Nursing has been in existence since the first human beings and has changed and improved in parallel with globalization. Like all professions, nursing is significantly influenced by the specific society it serves [1,2]. According to Cambridge, the image is defined as a picture in your mind or an idea of how someone or something is. In the same way, the nursing image is essential for the nursing profession . It is the way the profession appears to others, including to the general public. The most important is that an image can influence nurses themselves, just like nurses may feel depressed or less effective if others view them negatively . Even more, the image of nursing matters as it influences not just recruitment but the retention, recognition, and value of the profession and ultimately the health and well-being of individuals, families, and communities [5-8]. Besides, since a long time ago, the image of nursing has been shaped by television and movies, which forge gender stereotypes and often portray the nurse as the doctor’s assistant rather than a teammate, or simply as a background character [9-11].
Meanwhile, Stanley examined the portrayal of nurses in feature films since 1900 and found that the earlier films present them as “self-sacrificial” or “sexy.” Still, more recently, they have been shown as “self-confident” professionals . The scant representation of nurses in the media and the ambiguous messages about them could be affecting recruitment [13,14]. The public may not clearly understand the role nurses play due to their media representations . Similarly, several researchers have explored the physician’s image of a nurse, whereas others have assessed patients’ perceptions. Some have explored other healthcare workers’ image of a nurse, a nurse’s public image, and media image. The stereotypical, traditional public and the nurse’s image among nurses themselves have been identified as having a significant relationship with their job satisfaction plans, self-esteem, self-concept, job performance, turnover intentions, and professionalization .
In the Kingdom of Saudi Arabia, the nursing profession faces significant challenges, including; failure to recruit high academic students into nursing education, poor nursing identity, and lack of awareness about the nursing profession. Furthermore, the nursing profession’s community awareness and public image are critical to recruiting and retaining students into nursing education and improving nurses’ sense of identity . Moreover, nursing’s image and value are an international concern in high, low, and middle-income countries [7,11,17]. We urgently need highly prepared leaders to advocate for the nursing profession in research, academic areas, and clinical settings.
Nursing Image in the past in Saudi Arabia
In the eastern region, Rufaida Bin Sa’ad Al-Asalmyia was the first woman to practice nursing. Rufaidah is a noun derived from the verb’ rafada,’ which means providing help and support for others. Rufaidah learned and developed her nursing skills from her father, a well-known healer . Besides serving during wartime, Rufaidah practiced nursing in peacetime by treating sick people, training other nurses, looking after poor people, and solving social issues . However, in the western region, Florence Nightingale is often recognized as the founder of modern nursing; historically, nursing services have evolved through caring for the sick and wounded people .
Despite the government’s efforts to recruit Saudi nationals, the social stigma attached to the nursing profession remains . The negative image and low status of nursing, inadequate nursing education, as well as traditional and cultural values, have been major factors inhibiting Saudi nationals from entering the nursing profession [22-26]. Therefore, in 1958, the first formal training for nurses was initiated at a Health Institute in Riyadh by the Saudi Arabian Ministry of Health in collaboration with the World Health Organization. Since then, nursing education in Saudi Arabia has gone through many different phases. The first Bachelor of Science in Nursing program was established by the College of Nursing at King Saud University in 1976 .
As early as the 19th century, the issue of the image was the main concern. For example, the deplorable working conditions and the unsanitary clothing of Sairy Gamp and Betsy Prig so keenly described by Charles Dickens in the book Martin Chuzzlewit represents the ‘dark age of nursing’ in England in the middle age to late 1800s [28,29]. However, Sairy Gamp called Sarah Gamp in A Third Look Article . In Britain, data collected by Mori indicate that the public does not recognize the nurse with high social, economic status. In addition, in Canada, the nursing profession has changed dramatically over the last 30 years . However, it is still the image in the media as the “less objective and less skilled than the medical profession . While in Egypt nursing has long been de-valued . Hassan in 1980 reported that it was only by establishing two baccalaureate-nursing programs in 1955 and 1964 that the nursing image improved . Moreover, In Kuwait, Meleis found that most people are resistant to enroll in nursing because of the bad image, long duty hours, and mixing with the opposite sex .
In the Republic of Indonesia, the nursing image is likely seen as assistants to physicians and committed to housekeeping duties, rather than devoted to caring, similar to Shields. Hartati said that nurses are regarded as “doctors” helpers. This image could discourage the young generation from choosing nursing as a career . In Saudi Arabia, like many areas of the world, nursing is a less desirable career choice due to community image, family rejection, cultural and communal values, long working hours, and mixing with members of the opposite gender. The worry of not being “marriageable” and accepted was the main reason why Saudi females didn’t like nursing as a career . Even more, the nurse’s public image appears to be negative in countries where strong cultural traditions strongly restrict women’s involvement in occupations outside the home . Society looks at nurses with some disrespect so that girls are afraid of joining nursing even if they like it. Some girls had to terminate their studies to get married because their husbands and their families do not accept nursing as professional work .
The negative image was shaped due to the lack of expansion in nursing education. As known as nursing school began in 1954, with only a 1-year training program. While the First Bachelor of Science in Nursing (BSN) was established in 1976, it was limited to women only; in 2004, a BSN program for men was established . Recently, new universities in Saudi Arabia have offered BSN courses for both males and females; due to the poor image of nursing practice compared with other health professions, nursing courses in SA tend to have low enrollment levels . In 1990, during the second Gulf War, many expatriate nurses left the country without notice. This resulted in a staffing crisis that made the policy of “Saudization” a priority in the health care setting. The nursing system in Saudi Arabia depends on expatriate nurses, recruited from different countries from different religions, cultures, social values, and languages.
That can create barriers between expatriate nurses and local patients. Typically offered a single contract, most of them cannot exceed one year, and there is no guarantee of renewal .
To sum up, the nursing profession had a good reputation in Islam traditionally; it was mentioned for the first time during the time of Prophet Muhammad (when it served the Muslim armies during periods of war). Although nursing was long existence in Saudi Arabia and Islamic history, nursing is not viewed positively in Saudi culture. There are many government efforts to attract and retain more Saudi nurses in the profession. However, they still encounter obstacles such as working environments, limited options for balancing work and family responsibilities with long duty hours, and the perception of nursing’s role and the poor image attached to it .
The Present Nursing Image in Saudi Arabia
Although the remarkable progress in nursing and professionalism, nursing still suffers from nursing perception and its contribution to the health field and services provided to patients . As some societies in different countries of the world still view nursing as nothing more than workers with white-uniformed, called “Angels of Mercy or White Angels” and their work is limited to carrying out doctors’ orders, giving injections, and measuring vital signs . Besides, these communities and even other health practitioners do not understand nurses’ independent functions . The impact of nurses’ uniform style on a nursing image is controversial and has created debate in the literature . The original reason for designing the uniform was to reflect the image of neatness and cleanliness . The most important conflicting problem with clothing style is the similar uniforms worn by different healthcare professionals and nonprofessionals. In some countries, every worker in the healthcare setting, including professional nurses, dieticians, physical therapists, and even housekeeping staff, wear a similar white-coloured uniform .
In Saudi Arabia, nursing programs have had poor enrollment rates due to the bad reputation of the nursing profession across the community. This bad reputation was stimulated by mixed working environments, cultural reasons, family roles, and varied working conditions, including the night shift, especially for female nurses. However, the low enrolment rates have been addressed inequitably by the Ministry of Education by establishing enrolment in nursing programs that are open access for students who were rejected from other health professions due to a low GPA .
Many studies conducted in Saudi Arabia identified many reasons behind female students’ choice of not choosing nursing as a career; reasons include a negative image of a nursing career, family disagreement, long working hours, working with the opposite gender, and the worry of not getting married. However, the nursing workforce is recruited from many different countries; most come from India or the Philippines. Consequently, all of these negatives dramatically and significantly lead to an inability to retain national nurses for a long time, leading to an excessive increase in the recruitment of expatriate nurses . According to Elmorshedy, AlAmrani, Hassan, Fayed, and Albrecht, the majority of awareness about the nursing profession was still poor. Although the night shift is a barrier for not selecting the nursing profession, this may be due to the sociocultural factors in the gulf area and Saudi Arabia, which is not acceptable for women to work at night shift. Moreover, lack of autonomy, powerlessness, and decision-making power is associated with a negative public image .
Moreover, the nursing profession is considered by Saudi society with a poor image as it is considered as a job for those with low standing in society. During the last decade, the MOH has become less centralized to manage healthcare services by opening an independent health care cluster with autonomous budgets. Nonetheless, many decisions, such as regulation, legislation, planning, and investment, are controlled by the top-level management of the MOH . The Ministry of Health allowed Saudi women to study in the nursing program on the condition that they remain covered, provide care to female patients only and not work with male physicians or even work afternoon or night shifts. However, because of socio-cultural norms, Saudi females, and even males who choose nursing as a career face many negative criticisms and difficulties .
Our Future Image
Americans rate the honesty and ethics of nurses at the top of all professional jobs for the 18th year in a row, according to the classification carried out by Gallup in the United States of America . That is a reflection of how American society sees nurses. It is evidence of the possibility of changing the image of nursing in any society. The Saudi government plans to improve the nursing image and reach that level by giving the nurses the proper appreciation of their knowledge, skills, effort, and value of their work. To do that, we need to work on many aspects that might improve our nursing profession’s image and respect.
First, the health system’s significant changes in the Kingdom of Saudi Arabia, which is proceeding with astonishing acceleration, require profound changes in nursing education, both before and after they obtain a license to practice the profession. That includes preparing nurses for a better and more in-depth understanding of care management and the methods used to improve quality and manage change. Moreover, since education is the cornerstone of preparing nurses, it must be permanent and robust, considering the outputs that deserve credit in people’s lives. The quality of patient care depends on the strength and quality of the nursing preparation in universities, and much research is supported by the fact that fewer medication errors and lower mortality rates are related to nursing preparation and their higher and specialized degrees [47,48].
Besides, nurses need to be prepared for patients’ diverse needs and instill leadership values in them. The development must include health policy, leadership, quality improvement, health care financing (as we are currently witnessing the term governance as part of the 2030 vision for the Kingdom of Saudi Arabia), and integrative teamwork in the health system. Therefore, psychological preparation for multiple roles and nursing specialties in the work environment includes primary care, long-term care, and acute care. The development and complexity of work in hospitals requires highly educated and equipped nurses to deal with these complicities. The nursing profession in hospitals requires nurses to take critical and rapid decisions to care for patients. It depends on using sophisticated and complex technology to save their lives with complete knowledge and nursing skills to analyse and operate this technology. Also, to follow up and improve patients’ caring with chronic issues outside hospitals to prevent their deterioration. We need to provide a smooth educational system for the transition to higher education programs while maintaining full mastery of skills and competencies to complete the degree programs and the written council examinations. Future nurses will be equipped with high-standard skills to diagnose, treat, prescribe, and dispense medications by modifying the new nursing school curriculum. That will most definitely have a good impact on the future of nursing in Saudi Arabia.
Second, the Saudi vision 2030 calls for unifying nursing leaders, educators, and practitioners toward nursing transformation. Nursing transformation requires improving the quality of delivered care, a more substantial education foundation, establishing an autonomous regulatory council, formulating a clear scope of nursing practice based on nurses’ knowledge and skills, and reducing professional constraints . The government of Saudi Arabia has laid the cornerstone towards a promising future by identifying needs and then working to achieve them through Saudi vision 2030. This vision resulted from all ministries’ contributions, where they were involved in a joint solidarity action towards the vision. That was with unlimited support from the Kingdom of Saudi Arabia leadership . The best evidence of the trend’s sincerity was the enormous fund associated with this vision, as the total budget support for 2019 on education and health care amounted to SAR 365 billion .
The Saudi vision’s ultimate goal is to improve the social image of the nursing profession and reduce turnover . The nursing profession in the health system constitutes the largest number in the health sector. Therefore, it was necessary for nursing to receive the attention of visionaries. One of the goals of Saudi Arabia’s Vision 2030 is to increase the attractiveness of the nursing profession . Besides, increase applicants from high school graduates to nursing colleges and cover the shortage. After the first wave of the Coronavirus Pandemic 2020, another support from the crown prince to issue a scholarship program for nursing . Eventually, improving nursing education and nursing image in Saudi will be reflected in healthcare quality, which is among the vision pillars. Ministry of Health plans to attract more Saudis to the nursing profession by enhancing and improving the work environment and increasing the numbers of registered Saudi nurses .
However, nursing salaries in the Kingdom of Saudi Arabia might be a challenge toward the professional attraction. It varies significantly according to organization, experience, and nationality. Figure 1 illustrates the salaries of expatriate nurses in more than one health institution. King Faisal Specialist Hospital and Research Center (KSHRC) is the highest paid, at a rate of 84,940 Saudi riyals, followed by military hospitals and medical cities, while the private sector is the lowest compared to the rest . The salaries paid to Saudis nurses also differ from others, as in government facilities represented by the Ministry of Health; there is a unique salary scale for Saudi nursing. Nursing is appointed at the beginning of the ladder and continues to increase as experience increases. This scale’s disadvantage is not considering the differences in work locations, shifts, and official holidays.
For example, there is no difference in salary between workers in hospitals or primary care centres, and there is also no difference in working in intensive care or emergency from one side compared with another nurse working in outpatient clinics. Whereas the significant problem is that salaries do not differ between those who work night shifts, weekends, and annual holidays compared to those who work on a routine morning work while enjoying the weekends and annual holidays. That represents the biggest challenge in creating an attractive nursing environment and improving the nursing image in Saudi. As one of the Nurses’ Bill of Rights created by the American Nurses Association (ANA) to improve their work environment stat that “Nurses have the right to fair compensation for their work, consistent with their knowledge, experience, and professional responsibilities  (Figure 1).
Finally, mass media is needed to correct the public misconceptions about nursing. The first step to improve the current situation and enhance employment is raising the awareness of these issues to the Saudi society about the importance of Saudization in the healthcare sector. That will positively enhance the mutual trust between the Saudi nurse and their patients. Furthermore, the nursing profession leaders have a significant part in highlighting their roles and improving nursing misconception as the leaders have regular attendance at official meetings and conferences, which are accompanied by television or press interviews. Likewise, the nurses themselves must realize that they have the necessary strength and responsibility to start making change. It is advisable to participate in health policy issues to show seriousness and professionalism and to have unique opinions based on nursing knowledge and experiences. It is also possible to show nurses’ roles in hospitals through their platforms or blogs that include permanent supervision and follow-up.
Conflicts of Interest
The authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.
Anwar Al-Khunizi, Areej Al-Otaibi, Ali Al-Anazi1, wrote the original draft; Adel S. Bashatah and Syed Wajid reviewed and edited the manuscript; Adel S. Bashatah performed the supervision; Adel S. Bashatah acquired the fund. All authors have read and agreed to the published version of the manuscript.
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