Current Challenges Facing Nursing Education in Saudi Arabia

Adel Harb R N PhD^1,2*

¹ Visiting Professor Assistant at King Saud Bin Abdulaziz University for Health Science (KSAU-HS)- Riyadh- KSA
² Nursing Education Department at King Fahad Specialist Hospital- Dammam- KSA

*Corresponding Author: Adel Harb, Visiting Professor Assistant at King Saud Bin Abdulaziz University for Health Science (KSAU-HS)- Riyadh- KSA and Nursing Education Department at King Fahad Specialist Hospital- Dammam- KSA

Received: March 07, 2019; Published: March 25, 2019

Citation: Adel Harb R N. “Current Challenges Facing Nursing Education in Saudi Arabia”. Acta Scientific Paediatrics 2.4 (2019):45-50.

Abstract

Introduction: Kingdom of Saudi Arabia is facing many health related challenges. It was on 1954 when Ministry of Health (MOH) has established Nursing as a profession. Since the last 64 years, nursing has faced many obstacles, difficulties and challenges and there was a direct impact on the growth and development in Nursing Education. Unfortunately, these challenges facing Nursing Education in Saudi Arabia are increasingly complex and dynamic.

Aim: The main purpose of this paper is to highlight and discuss those challenges through Structure – Process- Outcome model.

Methodology: Systematic review of the literature published between 1988 till 2018 were reviewed using different electronic database such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), Pro Quest Central, Expanded Academic ASAP, Wiley Interscience (Wiley), MEDLINE (OVID), and SAGE. Databases were accessed using key words: Saudi Arabia, Nursing, Nursing Education, and Challenges.

Results: There were 36 studies accessed and discussed these challenges but only 30 studies had studied the direct impact on clinical training and staff education. Challenges facing Nursing Educations in KSA were categorized on Structure- Process- Outcome Model. Structural Challenges included shortage of staff and scope of nursing practice, process challenges included role of the Clinical Teachers, educational and teaching methods, specialized certification and communication while the outcome challenges included the assessment of staff competencies.

Recommendations and Implications on Nursing Practice: Based on these challenges facing Nursing Education at clinical setting, the author had a list of recommendations to Nursing Leadership and Educators to overcome and manage these challenges with some strategies to reflect on the present and plan strategically for the future

Conclusion: Many challenges and gaps were cited in the literature that will provide ample opportunity for further studies and researches. As healthcare is one of the main focus areas of the ambitious Saudi Vision 2030 and due to the fact that Ministry of Health in Saudi Arabia has a plan for privatization and formulating Health Clusters, Nursing Leaders in Nursing Administration and Educators must overcome all these challenges facing Nursing Education in the hospital setting.

Keywords: Challenges; Nursing Education; Saudi Arabia

Introduction

Nursing in Kingdom of Saudi Arabia (KSA) has commenced as a nursing profession on 1954 under the direct administration and supervision of Ministry of Health (MOH) [1]. There was a collaboration made on 1958 between MOH and World Health Organization (WHO) to open the 1^st Nursing Diploma Program [2]. Nursing since that time till now had progressed and developed academically and clinically. There are many universities around KSA teach Nursing Curriculum at Bachelor Level and Master Level in different specialties.

Like many other areas in the world, Nursing in KSA had faced many challenges thus the main aim of this study is to address and highlight these challenges from Structure- Process and Outcome Perspectives and then consider some recommendations and strategies to reflect on the present and plan strategically for the future.

Methodology

In order to a get clear picture on the current challenges facing Clinical Nursing Education, Systematic review of the literature published between 1988 till 2018 were reviewed using different electronic database such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), Pro Quest Central, Expanded Academic ASAP, Wiley Interscience (Wiley), MEDLINE (OVID), and SAGE. Databases were accessed using key words: Saudi Arabia, Nursing, Nursing Education, and Challenges. In addition to the literature review, the author 25- years’ experience in nursing (academically and clinically) was considered.

Results

There were 36 studies accessed and discussed these challenges but only 30 studies had studied the direct impact on clinical training and staff education. Challenges facing Nursing Educations in KSA were categorized on Structure- Process- Outcome Model. Structural Challenges included shortage of staff and scope of nursing practice; process challenges included role of the Clinical Teachers, educational and teaching methods, specialized certification and communication while the outcome challenges included the assessment of staff competencies

Structural challenges

• Shortage of staff: The old and present challenge is the shortage of nursing staff at all levels (front line staff, educators…etc). During 1960- 2000, most of the nursing workforce in Saudi Healthcare organizations were expatriates and most of the hospitals in all sectors during this period had challenges related to managing staff shortage. During last two decades, the government in Saudi Arabia decreed that all sectors of the workforce including health sector would be subject to “Saudization” to reduce the reliance on the expatriate workers and to reduce the unemployment rate of Saudi Nationals [3], accordingly, many of the expatiate nurses were replaced by Saudi nationals but they were inadequate to cover the needs of all hospitals thus the nursing shortage remain a challenge. Shortage of staff is always a challenge to nursing educators and clinical teachers as the staff won’t be able to be released to attend any educational professional development activity that will affect his/her quality of nursing care. There should be leadership strategies to overcome staff shortages including nursing educators who teach and train staff nurses to improve patient outcomes [4].
• Scope of Nursing Practice: A study was conducted by Phillips (1988) aimed to analyze the nursing practice in KSA found that the major structural challenge at that time was due to the fact that the Saudi Arabian Nurses Association was in the formation stage and there should

be a collaboration between the universities and other Healthcare Sectors to establish this association. Currently, Nursing Board in the Saudi Commission for Health Specialties has been engaged in standardizing Nursing Practice but “it has not yet formalized a scope of Nursing Practice” [5]. It is recommended to removing of Standard of Practice barriers to enable nurses development and provide a safe- high quality and effective nursing care [6]. Without a clear standard scope of Nursing Practice, Nurse Educators will face many concerns in the clinical practice and there will be barriers in developing staff educational plans.

Process challenges

• Role of the Clinical Teachers: There are many titles cited in the literature for those nurses who are assigned in delivering clinical teaching at beside such as clinical instructors, clinical resource nurses, clinical nurse specialist or nurse educators. However, it was evident that the qualities clinical teachers could be one of the challenges facing Nursing Education. In USA, clinical teaching lacks effectiveness which indicates a need for more active clinical setting that will motivate nurses [7]. Similarly, Saudi nursing clinical teachers had a challenge that impact their ability to be effective in their teaching process and according to Aldawsari., et al. [8] this involves the “pressure from society to pursue more prestigious positions, lack of experience, and lack of support within the organization”.
• Furthermore, the main obstacle here is the quality of the Clinical teachers and preceptors who sometimes lack the competence to employee effective and efficient teaching methods and apply some motivational strategies to assess staff competencies that could leave a negative impact on the quality of teaching process [7]. Clinical teachers must be competent and expert in knowing what adult learners need in order to keep them motivated. Clinical teachers also need to motivate front line nurses “through active participation throughout their teaching practice” [7].
• It is known that clinical teachers at the besides play major roles in delivering knowledge and demonstrating/assessing clinical skills, they are also charged with reinforcing these skills. There role must enhance nurses’ skills and build their self confidence through positive interpersonal communication [9] therefore they should act as role models for nurses because teaching is “dependant not only on the type of clinical experience but also on the character and the skills of the clinical teachers” [7]. In KSA, there is a significant shortage of clinical teachers who are expert in their field. Lack of competent qualified and expert clinical teachers is a major challenge in most of the Educational settings in the hospitals [8] as this will compromise the quality and quantity of the clinical nursing education delivered to the staff.
• Educational and Teaching methods: Education and educational methods will continue to advance as new technologies discovered and advanced [10]. Unfortunately, current nursing education in most of the hospitals in KSA is still following traditional educational methods such as class room teaching.

There is urgent need for a paradigm shift in the process of delivering education and training to the frontline staff. We need to move from informative learning to transformative learning [11] – as shown in Figure 1- and adopt several teaching methods such as role play, group discussion, simulation. The main barriers for this shift will be space availability, resources and financial support.

Nursing Education must move forward from the traditional classroom based to more advanced and modern web based program [10]. Currently, online education is becoming an integral part of formal nursing education [12]. However, nursing educators and clinical teachers need to “inspire their charges while challenging them to deliver competent culturally aware, and evidence – based care [10]. Furthermore, Gazzar [13] found that most nurses cited the in-services and bedside training regardless of the methodology are factors influencing their decision to stay or leave the hospital. This strongly requires nurse educators and clinical teachers to pay attention to the process of delivering their services for staff professional development [14].

Nursing Educators must identify the teaching method and engage the staff in deciding what methods suit their needs and their interest by conducting continuous Learning Need Assessment (LNA). LNA is a modern tool in adult learning for engaging the frontline staff in the educational process and ensure that the professional development plans are more effective and more efficient.

Specialized certification

Although bachelor’s degree is the minimum entry into practice around the world, it is required that nursing has professional specialized certification to proof that nurses are “engaged in lifeline learning” [15]. Therefore, and according to Institute of Medicine (IOM), nursing education must advance in order to have more prepared nurses for the future and to provide efficient, effective and collaborative healthcare [10].

This is a challenge for Nursing Administration and Nursing Educators in the practice setting. There are many Saudi Nurses are hired with Diploma degree and many others providing nursing care in specialized areas without professional development programs to certify them.

Nurses after graduation must be equipped with adequate knowledge and skills but armed with the ability to learn new relevant knowledge to critical care or other specialized area [16]. These specialized courses will enhance the nursing confidence and increase their ability to provide high quality care [17].

The main challenge in this aspect is the lack of Nurse Practitioner as advanced nursing role. The International Council of Nurses (ICN) defines Advanced Practice Nursing thus: “A Nurse Practitioner/Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/ he is credentialed to practice. A master’s degree is recommended for entry level” [18].

Advanced Nursing Role is underutilized [19]. Although there are Master Nursing Programs in Saudi Universities and many Post Graduate Diploma Programs conducted through the Saudi Commission for Health Specialties but still many Saudi nurses are not yet credentialed in these courses to enable them practice their specialized role. Furthermore, Despite anecdotal information that some Saudi nurses have studied APN at international universities, there is little data available on their career progression once they back to KSA [20].

Joint Commission International (JCI) as international standards and also National Standards are mandating nurses to be qualified and credentialed prior to commence their specialized role. There are many factors and barriers for achieving staff credentialing that could include but not limited to shortage of staff, financial constraints, lack of leadership support, lack of staff compliance.

Role of nurses therefore must be expanded to include all clinical specializations such as management, education, practice, research and other fields thus Saudi Nurses knowledge and skills should be increased [21].

KSA government has a mechanism to include all diplomas for bridging programs and those nurses with Bachelor Degree will undergo post graduate diploma and Master Studies and or PhD to enable them enhancing their specialized practice or support them to work at the academic level in the universities. In each hospital in KSA there is a project for Career Development Plan for Saudization and succession plan that aims at reducing the reliance on the expatriate workforce and reduce the Saudi nurses who are not recruited [3].

The questions raised when seeking advanced nursing role in KSA will be: are we ready to have this paradigm shift and create a nurse practitioner as advanced nursing role?. We need to consider that some healthcare providers and physicians may resist this role. On the other hand, there are no legislations and regulations to protect the nurse practitioner role [22]. Saudi Arabia has yet to clarify and define and then legislate this role by building a model based on Saudi Healthcare Culture and patient population needs [20]. Finally, this title needs infrastructural reforms in order to establish it and prepare nurses for this transition.

Communication

Nursing Education is facing another global challenge in multidisciplinary professional communication that should be addressed by nursing leadership. Joint Commission International (JCI) maintains that poor communication is a major challenge among all hospital (Joint Commission 2014). Nurses at all levels must enhance their communication skills and Nurse Educators must play a major role in improving cross professional communication [10].

Kuo and Kao [23] found that clinical teachers must make teaching process more effective by “harmonious interpersonal relationship” Furthermore, Nurse Educator must act as a role example as (S)he is with the front line staff for teaching, training and developing their learning plan [8].

Outcome Challenges

Staff competency assessment

The main outcome challenge facing nursing educators is the staff competency assessment. Despite the fact that the national and international accreditation agencies are mandating healthcare providers to keep their credentials and competencies updated but still remain a serios issue. A competent health workforce is essential to achieving universal health workers who are equipped with knowledge, skills, and attitude [24].

There should be a competency assessment program in each hospital for all nurses at different levels that include front line staff nurses through generic and unit specific competencies, front line leaders (Charge Nurses and Coordinators), Middle Line leaders (Nurse Managers, Head Nurses and Supervisors), senior or executive leaders through the American Organization for Nurse Executive (AONE) competencies. The AONE competencies detail the knowledge, skills and attitude that guide the practice of nurse leaders in executive level/practice regardless of their educational background, title or setting [25].

The main concerns and challenges that encounter nurse educators in the clinical setting and related to the competency assessment are but not limited to:

• The attitude and perception of the staff toward the competency assessment: staff nurses are scared from the tests and exams, it is the responsibility of the nurse educator or clinical teacher to ensure that staff are motivated to assess their knowledge and they are not threatened if they did not pass it. Clinical teachers must adopt some techniques and methods rather than the traditional supervisory method. They could assess the staff competencies by observational methods, or through online testing, or using the simulation techniques.
• The quantity of the competencies is a big concern: The number of generic and unit specific competencies are so many and the staff has to pass these competencies in order to maintain their job.
• Assessment Methodology or validation tools: there are several validation tools found in the literature but some hospitals are adopting novice to expert model (Benner 1986) and others are adopting Blooms Taxonomy while there are some hospital are using Met/Non Met criteria or other scoring system.
• The validity of the competencies is also a concern. The frequency of competencies to be reassessed varies between one hospital and the others. Competencies are specific skills and behaviors important to the role (McCarthy and Fitzpatric 2009) and these competencies that require skills tend to be decreased thus they should be tested regularly [26-28]. However all hospitals in KSA must be accredited nationally thus the competencies are tested every year that will remain a challenge for nursing educators/clinical teachers as this is time consuming.
• Measuring the efficiency and effectiveness of the competency assessment. Nursing Educators are always busy assess staff competency but they need to ensure that the nurses performance and patient outcome are improved.
• The Knowledge- Skills and Attitude domains to assess staff competency is a serious challenge. Nurse educators must be focus in enhancing staff knowledge and skills

and report the attitude of the staff or behavioral aspects to the nurse managers. Negative attitude such as noncompliance with competency must be addressed. We need to know that noncompliance could be related to:

1. Lack of knowledge/skills
2. Time constraints
3. Work overload/shortage of staff
4. Communication barriers
5. Lack of feedback
6. Lack of standards/policies and guidelines as references
7. Staff feeling of the outcome of the competency assessment (scared)
8. Lack of Nurse Manager support

Nurses must comply with the hospital regulations and national/ international standards and must be accountable for assessing and reassessing their competencies. They should comply with competency standards for the basis of planning relevant and targeted educational programs to enhance nurses professional level [25].

Recommendations and implications for nursing practice

Based on these challenges facing Nursing Education at clinical setting as shown on Figure 2, We need to consider the following recommendations and strategies to reflect on the present and plan strategically for the future:

• Nursing Leadership in KSA has been found to be more effective with transformational approach [4], thus senior nurse leaders must create leadership strategies to facilitate and overcome structural challenges related to nursing workforce and shortage of staff that will improve outcome of nursing practice [1]. Nursing leaders in KSA need to ensure that there are adequate well-trained nurses who will provide a good quality healthcare to the kingdoms growing population [29]. Furthermore, there is a strong need for Saudi Nurses Association that will standardize the scope of Nursing Practice and overcome some challenges that could face nursing educators in the clinical setting.
• There should be serious efforts and more collaboration between universities and healthcare organizations and Saudi Commissioning for Health Specialties in order to create and empower the role of Advanced Nursing Practitioner and other specialized certifications. This will support both Saudi and other expatriate nurses who are prevented from practicing their specialized role that they are entitled to in their country of origin. We need to address this legislation as urgent [20].
• Nursing education leaders must look at the process challenges and continue to be a dynamic field. There should be a significant support to shift from informative learning to transformative learning considering non traditional teaching methods, simulation, bedside teaching. Furthermore, potential challenges related to lack of preparing clinical teachers must be considered by conducting professional development courses and workshops for the clinical teachers and educators. They need to enhance their competencies, teaching skills improve communication and interprofessional communication. This will be a good strategy to enhance a positive learning environment that will have a positive impact on nursing education and patient outcome.
• There should be multidisciplinary efforts to improve and promote a positive staff attitude towards the importance of continuous clinical evidence based education. Frontline nurses must hold the accountability for their competencies and professional portfolio and comply with organizational requirements and standards.

Conclusion

Many challenges and gaps were cited in the literature that will provide ample opportunity for further studies and researches. As healthcare is one of the main focus areas of the ambitious Saudi Vision 2030 and the National Transformation Plan 2020 [30], and due to the fact that Ministry of Health in Saudi Arabia has a plan for privatization and formulating Health Clusters, Nursing Leaders in Nursing Administration and Education must overcome all these challenges facing Nursing Education in the hospital setting.

Conflict of Interest Disclosure

There are no conflicts of interest.

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Copyright: © 2019 Adel Harb R N. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.