The Nursing Workforce in Saudi Arabia Challenges and Opportunities

2019 DISCUSSION PAPER

General Directorate for National Health Economics and Policy Saudi Health Council, Kingdom of Saudi Arabia

2019 DISCUSSION PAPER

The Nursing Workforce in Saudi Arabia Challenges and Opportunities

General Directorate for National Health Economics and Policy Saudi Health Council, Kingdom of Saudi Arabia © 2019 The Saudi Health Council 6293 Olya Road Riyadh 3161-13315 Kingdom of Saudi Arabia Internet: www.shc.gov.sa

This work is a product of the staff of The Saudi Health Council with external contributions. The findings, interpre- tations, and conclusions expressed in this work do not necessarily reflect the views of The Saudi Health Council, its Board of Executive Directors, or the government agencies they represent.

The Saudi Health Council does not guarantee the accuracy of the data included in this work. The boundaries, col- ors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The Saudi Health Council concerning the legal status of any territory or the endorsement or acceptance of such boundaries.

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The material in this work is subject to copyright. Because The Saudi Health Council encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attri- bution to this work is given. Table of Contents

Acknowledgments...... v

1. BACKGROUND...... 1

2. AVAILABILITY OF NURSES...... 3 Opportunities to Improve Inflow...... 4 Opportunities to Reduce Outflow...... 10

3. SKILL MIX OF NURSES...... 15 Opportunities to Optimize Skill Mix...... 17

4. DISTRIBUTION OF NURSES...... 21 Opportunities to Improve Sectoral Distribution...... 23 Opportunities to Improve Geographical Distribution...... 24 Opportunities to Improve Service Level Distribution...... 25

5. PERFORMANCE OF NURSES...... 27 Opportunities to Address Education Constraints...... 28 Opportunities to Address Workplace Constraints...... 29 Opportunities to Optimize Licensure...... 30

6. MAXIMIZING CURRENT NURSING INITIATIVES...... 31

7. GOVERNING THE MARKET FOR NURSES...... 35 Opportunities to Optimize Governance...... 35

8. CONCLUSION...... 39

References...... 41

Appendixes 1–3: Relevant Organizations, Nursing Schools, and Advisory Group Members...... 47 Appendix 1: Table of Organizations Relevant to Saudi Nursing and their Roles...... 47 Appendix 2: Number of Public and Private Nursing Schools, by Geographical Area...... 48 Appendix 3: Advisory Group Members...... 49

iii

Acknowledgments

This report was produced by the General Adwa Alamri, Khalid Al-Moteiry, and Quds Directorate for National Health Economics and Alsafffer. Contributors from the WB included: Kate Policy of the Saudi Health Council (SHC) with Tulenko, Christopher H. Herbst, and Mariam M. technical support from the World Bank (WB). It Hamza. His Excellency Nahar Alazemi, Secretary is an output of the 2019 Reimbursable Advisory General of the Saudi Health Council, and Rekha Services program (RAS) between the World Menon, Practice Manager at the World Bank, pro- Bank and the Kingdom of Saudi Arabia (KSA). vided input and support throughout. Taghred Alghaith (SHC) and Christopher H. Herbst (WB) task led the production of the docu- The aim of this discussion paper is to provide ment. The technical leads of the document were preliminary and unpolished results to encourage Mohammed AlLuhidan (SHC), Kate Tulenko discussion and debate. The findings, interpreta- (WB), and Christopher H. Herbst (WB). tions, and conclusions expressed in this work are those of the authors, and do not necessar- The sections of the report were written jointly ily reflect the views of the Saudi Health Council by a team from the SHC and the WB, under the or the World Bank, their Boards of Directors, umbrella of an advisory group of key nursing or the governments they represent. The World stakeholders from KSA. Contributors from the Bank and the Saudi Health Council do not guar- stakeholder advisory group included: Nabiha antee the accuracy of the data included in this Tashkandi, Mohammed Alghamdi, Fahd Albalawi, work. Citation and the use of material presented and Taqwa Omar. Contributors from the SHC in this report should take into account this pro- included: Mohammed Alluhidan, Ayman Hodhaini, visional character.

BACKGROUND 1

Saudi Arabia is undergoing a significant health system transformation that includes privati- zation, expansion of care, and focus on value for money. Since nurses represent the highest number of health professionals in the health system and are essential to all aspects of care, the reform of Saudi nursing will be critical to the success of the Saudi health system. The Saudi nursing model has the opportunity to be transformed into a global model for a satisfying career path that can also provide efficient, high-quality health care to every Saudi citizen. This presents a unique opportunity to find creative solutions to health system challenges, to focus on nursing solutions, and for KSA to become a leader in nursing in the region and globally.

Drawing on information and data available in were found and reviewed, and the most relevant 2019, this paper summarizes the status of the articles are included in the reference list (see nursing profession in Saudi Arabia, highlight- Box 1). Moreover, the paper was informed by ing some of its key challenges and opportuni- the unique insider knowledge of a small advisory ties. The paper identifies and presents various group of representative stakeholders on nursing options for nursing interventions and policies from across the sectors in KSA. This included the and is intended to be used as a resource for dis- President of the National Nursing Association, cussion and ideas on nursing reform. The paper the Head of the Scientific Council of Nurses, and was not designed to be a rigorous analysis of the the Head of the Professional Council of Nurses nursing labor market in Saudi Arabia. Instead, it (see Appendix 3 for the full list). The paper was was designed to elicit discussion and to serve as developed jointly under the auspices of this advi- a background document for rigorous analytical sory group, which was invaluable in terms of work, and planning efforts, including the devel- input, feedback, and revision. opment of health workforce policies and strategies for Saudi Arabia. The remainder of the paper is organized as follows, highlighting the key challenges and oppor- In order to develop a reference set for this paper, tunities in each section: Section 2 discusses the articles, presentations, and documents were gath- availability of nurses in KSA. Section 3 discusses ered from the SHC, the Ministry of Health (MOH), the skill mix of nurses. Section 4 discusses the dis- and the Saudi Commission for Health Specialties tribution of nurses, and Section 5 discusses the (SCFHS). In addition, a literature search was con- performance of nurses (focusing on skills, compe- ducted for articles and books on Saudi nursing tencies, and motivation). Section 6 briefly discusses in PubMed and WorldCat. Over 100 references how to strengthen the ongoing interventions

1 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

proposed for nursing, and Section 7 summa- BOX 1: LITERATURE REVIEW METHODOLOGY rizes key aspects related to governance and management. Section 8 provides a short conclusion. A search was performed on PubMed for English articles with the keywords “nurses” and “Saudi Arabia” in the Title/Abstract. This Throughout this paper, Saudi national nurses yielded 347 articles. On imposing an additional criterion of arti- (Saudi citizens) are referred to as “Saudi nurses” cles published within the last 5 years (2014 onwards), 186 arti- and nurses of non-Saudi citizenship are referred cles were found. This formed the basic search criteria. to as “foreign nurses.” The status of the Saudi For references in this study, the base search was modified nursing model was analyzed through the lens to include specific keywords in the Title/Abstract area—quality of both the Saudi health system and trends in of care (7), performance (9), motivation (4), job satisfaction (11), health systems around the world. Current and retention (8), recruitment (4), burnout (1), and leadership (15). future challenges were identified and opportu- The total number of articles found (59) were listed. This list nities for ways forward were generated. While was then reviewed for duplicates and a list of 39 articles was challenges are indicated, data limitations pre- obtained. vented an in-depth assessment. Instead, the paper pays particular attention to the different interventions that could be considered to improve the availability, distribution, and performance of national nurses in KSA.

2 AVAILABILITY OF NURSES 2

The proportion of nurses to the population in KSA is on par with Organisation for Economic Co-operation and Development (OECD) countries when taking into account all nurses; however, it is very low when taking into account only Saudi nurses. Most of the nurses in KSA are foreign nationals. In 2018, KSA had a total of 125, 379 nurses, however only 12,607 (approximately 10 percent) were Saudi (SCFHS 2018). When taking into account population numbers, Saudi Arabia is home to 5.5+ Saudi foreign nurses per 1,000 population. When considering Saudi nurses only, the ratio is 2.1 per 1,000 population (Figure 1). This is far below the OECD average of 8.8 nurses per 1,000 population. The vast majority (around 70 percent) of Saudi nurses are female, while 30 percent are male.

Foreign nurses are comprised of just a few and where there is a higher likelihood of obtain- nationalities (predominantly Indian, Philippine, ing citizenship. and Malaysian). This labor market dependence is risky: a change in political relations with these The number of nurses produced in Saudi Arabia is countries could result in a rapid withdrawal of extremely low when compared to a selected num- large numbers of nurses, leaving the health sec- ber of OECD countries. Saudi Arabia produces tor struggling to provide care. In addition, as around 10.8 nurses per 100,000 population, the economies in these countries strengthen, far below countries such as Germany, Canada nurses will be less willing to work abroad and and the United States (Figure 2). The heavy reli- are likely to demand higher salaries. It is pre- ance upon expatriates for the health workforce dicted that KSA will also need to compete more reflects, in part, the low numbers of nursing stu- for the limited number of foreign nurses. As dents trained at Saudi nursing schools. the shortage in nurses worsens in OECD countries, those countries will hire more foreign Saudi Arabia also has a relatively high rate of nurses. For example, the United Kingdom of nursing turnover—higher than in many other Great Britain and Northern Ireland (UK) has low- countries. In Saudi Arabia, nursing turnover rates ered the English language standards for nursing are estimated to be around 20 percent, twice the licensure and has made the application pro- rate of countries such as the United Kingdom cess easier. Germany has recently introduced (see Figure 3). Turnover reflects the loss of a minimum nursing staffing ratios that will dra- nurse in the labor market but is also a big driver matically increase demand and recruitment of of cost. Turnover cost per nurse ranges from foreign nurses. In general, foreign nurses have US$15,000 in the United Kingdom to US$20– a preference for countries with similar cultures 25,000 in Australia and US$50,000 in the United

3 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

FIGURE 1 NURSES PER 1,000 POPULATION IN THE LABOR MARKET (SAUDI ONLY AND SAUDI + NON-SAUDI)

N N

UK UAE T T O F B S S G D GCC A GCC OECD A OECD N N S S A S S A S

Source: OECD 2017; World Bank 2014; MOH 2016. Notes: OECD data are for 2015 or most recent year; GCC data are for 2015; KSA data are for 2016. OECD Health at a Glance data are used for OECD countries; World Bank Indicators are used for non-OECD countries; MOH data are used for KSA.

States (Duffield et al., 2014). Assuming that cost the opportunities to increase nursing availability in KSA is similar to that in the United Kingdom, by addressing these two main overarching chal- it is estimated that nurse turnover is costing the lenges. KSA health system nearly SAR 2.6 billion annually.

Overall, the shortage of Saudi Nurses is largely a Opportunities to Improve Inflow result first, ofthe low number of nurses flowing into the labor market, shaped by a notion that the nurs- Targeted awareness campaigns and pipeline ing profession is not always considered attractive, programs should be considered to increase pop- that education capacity to produce more nurses is ulation demand to enter the nursing profession. limited, and that labor market absorption of grad- While more recent anecdotal evidence suggests uates is constrained by the sub-par clinical skills that low population demand to become nurses of nursing graduates (particularly from private is no longer a key bottleneck in Saudi Arabia sector schools). And second, it is a result of high (evidenced by the large number of applicants to numbers of nurses flowing out of the labor market, nursing schools), much of the existing literature in large part due to non-family-friendly working suggests nursing does not rank highly among environments and occupational hazards (includ- high school student job choices (Bagadood ing difficult working hours, infection risks, and 2016). Until there is more clarity, efforts should orthopedic injuries including lower back pain). continue to be directed toward improving the The following provides an overview of some of image of nursing.

4 AVAILABILITY OF NURSES

FIGURE 2 THE PROPORTION OF SAUDI NURSES PRODUCED IN KSA IS VERY LOW

N N

I KSA USA C T F P N C P A G N

Source: OCED (2017); SCFHS (2018). Notes: OECD data are for 2015 or most recent year; KSA data are for 2018.

FIGURE 3 NURSING TURNOVER RATES, ACROSS ALL SECTORS

Nursing Turnover Rates

UK US A S A H

Source: Duffield et al. (2014); HR.

5 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

FIGURE 4 MORE MALES COULD BE ENCOURAGED TO ENTER THE NURSING PROFESSION

Number of Nursing School Graduates in 2018, by Gender

Source: SCFHS (2018).

Awareness campaigns for nursing may be espe- exposing them to various career opportunities cially important for sub-populations such as within health care, including meeting represen- males or individuals from rural and conservative tatives from professions as diverse as phlebot- communities, where there may be more stigma omy, hospital engineering, prosthetics, and toward nursing as a career. In Saudi Arabia, the medical physics as well as subspecialists within number of males that graduate relative to their nursing such as nursing informatics, advanced female counterparts is low (see Figure 4). In addi- practice nursing, telenursing, and so on. These tion, awareness campaigns are important given schools integrate health care across the cur- that traditional female careers such as nursing riculum: for example, writing courses include compete with other fields such as business and sections of writing for health care, and math computer science for students. These non-nursing courses include calculating drug doses. Middle careers may be seen as more modern or sci- school, high school, and community college stu- entific, which points to the need to present the dents interested in careers in the allied health nursing profession as science-based and progres- professions can join the Health Occupations sive. This can be done through multiple channels, Students Association, which supports them with including traditional and social media campaigns. education, activities, and networking.

Pipeline programs targeting middle and high Ensuring that all primary and secondary schools school students should also be considered. provide good-quality science education is also These programs can be as simple as having critical. Lack of A-level science classes is cited nurses speak in schools, or pupils visit health as one barrier to students from lower-quality providers to learn about the nursing profession. schools in poor or rural communities (Metcalfe Or it can be as advanced as health science high 2016). Although literacy in Saudi Arabia has schools, similar to those in the United States and grown rapidly from 10 percent in 1960 to 99 per- Germany. Such schools prepare students by cent currently for children of school-leaving age,

6 AVAILABILITY OF NURSES

FIGURE 5 MINIMUM MONTHLY COMPENSATION (MIN AND MAX) OF NURSES BY LEVEL OF EDUCATION (HARMONIZED SALARY SCALE)

Monthly Salary (SARs)

A N R N D N

performance in the standardized global math (see section below on skill mix), make roughly tests, the Trends in International Mathematics half that amount (Figure 5). The harmonized and Science Study (TIMSS), show that science edu- salary scale introduced in 2008 across govern- cation in Saudi Arabia could be improved. In the ment sectors represented a significant increase short run, bridging programs that would enable in salaries for nurses in the MOH sector, but high school graduates to take the necessary sci- many nurses in other sectors saw their sala- ence classes and enter nursing school are needed. ries reduced—see the section on distribution In the long run, this issue can be solved by ensur- across sectors. There is a need to benchmark ing that all schools offer the classes required to the overall compensation package for nurs- enter health care professional programs. ing, comparing the wages of bachelor nurses with the wages of other bachelor-level jobs, The competitiveness of nursing salaries in and, most importantly, strategies to communi- relation to those in other professions and dif- cate such information to prospective as well as ferent specialties should be revisited. The existing nurses. This should be done in addition notion that nursing salaries are too low to be to considering wage premiums for the occupa- attractive to Saudi nationals is frequently con- tional health risks of some nursing specialties, sidered a key deterrent to entering the profes- as well as for night, weekend, and holiday work. sion. As of 2019, the minimum monthly salary of a registered nurse (bachelors level) in the Investments to expand the number of pub- government sector is 7,130 SARs, which is the lic sector training slots in nursing schools are equivalent of US$1,900 (US$22,800 per year). critical. In Saudi Arabia, 26 out of a total of Diploma nurses (reclassified as technicians), 39 nursing schools are public sector institu- which represent the majority of MOH nurses tions under the Ministry of Education (MOE) (see

7 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

FIGURE 6 DEMAND BY SAUDIS FOR NURSING EDUCATION EXCEEDS ABSORPTION CAPACITY: A VERY LARGE PERCENTAGE OF SAUDI NURSES CURRENTLY RECEIVE TRAINING OUTSIDE OF KSA

N N US UK I KSA F S C A G OECD OECD N

Source: OCED (2017); SCFHS (2018). Note: OECD data are for 2015 or most recent year; KSA data are for 2018.

Figure 7 and Appendix 2). Demand for placement or contribute toward the funding of exist- in these schools currently exceeds the absorp- ing nursing schools. If these restrictions were tion capacity of public universities. Partly as a removed, public nursing schools could be estab- result, many Saudi nationals receive their nurs- lished by regions, governates, or future corpo- ing education abroad (Figure 6). Within Saudi rates in addition to the MOE. Local development Arabia, high demand is regulated by increas- funds could be made available to support the ingly stringent university entrance requirements establishment of new nursing schools, or the and low acceptance rates (in line with other uni- expansion of existing ones, where Saudi nurs- versity education). Barriers to the expansion of ing shortages are most pronounced. In addition, Saudi nursing schools include limited funding, increasing collaboration between nursing aca- faculty shortages, and shortages of (available demics and nursing services could help open up and good-quality) clinical sites. more clinical training sites and help make the training more relevant to the realities of care Existing financing restrictions linked to the delivery. establishment or expansion of most public nursing schools in Saudi Arabia should be reconsid- Investments to increase the number of pri- ered. With the exception of the National Guard vate sector training slots should also be consid- University for Medical Sciences (open to the ered, albeit with increased regulatory oversight. public) and the MOD’s Health Sciences Colleges Currently, only 13 out of the total of 39 nurs- (available to military personnel), only the MOE ing schools are private sector nursing schools can establish and fund public nursing schools. (Figure 7). The Ministry of Investment (MOI) and This limits the opportunities to start new ones the MOE could reduce existing barriers to the

8 AVAILABILITY OF NURSES

FIGURE 7 THE NUMBER PRIVATE NURSING SCHOOLS IS VERY LOW

Number of Nursing Schools in 2018, by Sector

Source: SCFHS 2018.

establishment or expansion of private or foreign particularly from private sector schools, experi- nursing schools or satellite campuses. It is well ence difficulty passing the new licensure exam recognized that regulation was the main cause or obtaining a job in the labor market, because of the lack of expansion in the capacity of US they are deemed not to be sufficiently qualified. medical schools for over 20 years (Jenkins and Graduates from private sector schools in par- Reddy 2017). The MOI could also incentivize pri- ticular have limited patient contact during their vate investment in nursing schools, for exam- four years of training, and learn the majority of ple by making available public land, or matching their clinical skills during their one-year intern- private investments with public investments. ship. The solution should not be to make the Moreover, financing could be directed toward licensure exam easier lower recruitment stan- restarting public scholarships to private nursing dards. In fact, a clinical evaluation should be schools, offering quality public sector teaching added to the exam to test for clinical competen- materials to private nursing schools, and mak- cies in addition to theory, as is done in countries ing public hospitals and clinicals available as clin- such as the United Kingdom, and employers ical sites for private nursing schools. Expansion should be encouraged to hire those with the of private sector education capacity would help most developed clinical competencies. This absorb existing demand, but it would need to be does mean, however, that both the licensure combined with an increased focus on regulatory exam and the curriculum should be reviewed capacity and enforcement of quality and accred- for relevance to clinical practice and realigned itation standards. with one another. Other opportunities include integrating nursing schools with clinical sites Opportunities for absorption into the labor better, exposing nursing students to medical market after graduation should be maximized simulation labs and hands-on patient care from by improving the clinical competencies of grad- day one, and offering targeted training courses uates. Many graduates from nursing schools, outside of the nursing school (for example by a

9 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

private company) to prepare students for licens- female nurses, labor market exit is often driven ing exams. by a work structure that is not conducive to family and social obligations. Albolitech (2018) stud- Bonding also presents opportunities to improve ied what changes would most likely cause Saudi absorption of graduates into the labor market. nurses to stay in the field and these included: With bonding, hospitals that need to hire new 1) decreasing working hours, 2) increasing pay nurses make a contractual agreement to pay for non-regular hours, 3) providing support ser- for all or part of a nurse’s education and hire vices such as childcare and transport, 4) decreas- him or her upon graduation, in exchange for ing the workload, and 5) providing opportunities the nurse agreeing to work for the hospital for for continued training and education. Saudi a set number of years. As part of the bonding Arabia has an opportunity to transform the experience, the nursing student may do clini- working environment for nurses and become cal rotations in the bonding hospital so that he more family-friendly by reducing the impact of or she can learn the hospital’s workflow and night shifts, supporting long-term careers, and they can assess his or her quality of care. This reducing individual workload by introducing rel- bonding approach enables hospitals to secure evant support staff. their “supply chain” of high-quality nurses and enables low-income students to afford nurs- Introduction of part-time work, short shifts, and ing school. This model has been used success- surge shifts. The government has already made it fully in some private hospitals in Saudi Arabia. a priority to establish part-time and flexible work It could be considered in addition to a recom- arrangements to make work more family-friendly mendation that most nurses should have one and keep Saudi nationals in the labor market. The year of on-the-job training immediately after Ministry of Civil Service recently made part-time graduation. work legal, although the lack of bonuses or salary allowances do not make this attractive to Re-entry programs for nurses who exited the everyone. More could now be done to reduce labor market could also be considered. Some the length of shifts. Instead of covering a 24-hour nurses, who have been out of the clinical work- period with the traditional two 12-hour shift, for place for several years raising their family or example, a 24-hour period could be covered with doing administrative work, may wish to return three 8-hour shifts or four 6-hour shifts. In addi- to nursing but their skills may be considered tion, during peak work hours (which vary by time out-of-date. Re-entry after such a long period of of year and facility), extra surge shifts of as little professional inactivity can be daunting. For such as four hours can be offered. In the United States, nurses, re-entry programs can update them shorter shift times have been associated with a on the latest advances in nursing, enable them number of positive aspects, including lower rates to practice their nursing skills, and help them of nursing errors and lower rates of occupational regain the confidence needed to start practicing injuries (Ericksen 2016; Witkoski 2003). The pro- again. Such re-entry programs could be subsi- vision of nurses for short shifts or for surge shifts dized by the government or paid for by private could either be handled internally by a hospital’s employers who can bond the nurse to work for HR and nursing departments, or private nursing them for a few years. staffing agencies could be contracted to provide the nurses for these shifts (reducing the administrative burden for the hospital). Opportunities to Reduce Outflow Increasing home health nursing or telehealth nurs- Policies that provide a working environment con- ing. Telenursing has been demonstrated to be ducive to family life are critical to minimize high effective in offering access to high-quality nurs- turnover and labor market exit. In particular for ing care in a variety of settings (Yamayoto 2018).

10 AVAILABILITY OF NURSES

Examples include post-hospital care, home care allowed and encouraged to use private staffing for seniors, and telephone triage for sick visits. In agencies. Although most Saudis have extended Saudi Arabia, the MOH has already had success family who can care for their children, some with its 937 telemedicine program, and this pro- large metropolitan hospitals may benefit from gram could be extended to nursing. Telenursing having on-site daycare, on-site sick-child care is especially attractive in Saudi Arabia as shifts (both of which could be provided by the facil- can be performed from home and if a sufficient ity), or nurse “floaters” (contracted through a volume of providers is recruited, each provider private nursing staffing agency) who can- pro does not need to commit to specific shifts. For vide coverage if a nurse needs to stay at home example, Teladoc, the largest telemedicine pro- to care for a sick child. vider in the United States, does not hire any providers in set shifts. Instead, providers log on and Reducing the workload by increasing use of off as their schedule suits and see the patients allied health professionals (non-nursing cad- in the queue in the order in which the patients res). High workload, particularly in hospi- joined the queue. Increasing the number of tals in KSA, is often stated as a key reason home health nurses or telehealth nurses thus for nurse dissatisfaction, turnover, and labor would be important. market exit. Opportunities to reduce workload include changing the team composition Introducing extra pay for night shifts and noct- of nurses by adding new nursing professions urnist nurse positions. Facilities could consider or new allied health professionals who sup- offering extra pay for night shifts or creating port and are supervised by nurses. The use “nocturnist” positions for nurses. A nocturnist of non-nurse cadres to be part of the nursing nurse is a nurse who works at night. Nocturnist team should be considered further. The cur- positions have been a successful way of cover- rent non-nurse members of the nursing team ing night shifts and improving retention and job in Saudi Arabia include nursing care assis- satisfaction of health workers (Boodman 2011; tants (usually Philippine nurses who have not Papetti 2013). Establishing nocturnist nurse passed their nursing boards or Saudis with one positions would mean that other nurses would year of training after high school), ward secre- no longer be required to do a certain number taries, and patient care assistants (transport- of night shifts, which would improve retention ers, usually managed centrally). The use of this of female nurses in general and especially in non-nursing clinical team and their training remote areas. programs should be dramatically expanded. Such cadres have a significant role to play in Promoting maternity leave and child care support. reducing nursing workload and in efforts to Because of the large number of female nurses refocus on teams rather than individuals in the of child-bearing age, maternity leave and child- provision of the best quality care. care may need to be further addressed within the nursing community. The Saudi government Providing opportunities for continued educa- offers 70 days of fully paid maternity leave and tion, training, and professional development up to two years of maternity leave on a percent- should be prioritized, and can increase reten- age of salary. However, most health facilities do tion. Opportunities for professional develop- not have a standard mechanism to backfill the ment (e.g., career advancement, opportunity positions of nurses on maternity leave. These for further nursing education, and access to vacancies can cause stress on the remaining continuing education) are often reported as nurses, who now have a heavier work burden, insufficient. This can diminish nurses’ efforts and can compromise quality of care. Health to provide quality care and is a major reason facilities could develop their own system of for job dissatisfaction. Hart (2005) found that backfilling these positions or they could be nurses who were enrolled in an educational

11 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

program were less likely to leave their posi- reflected in the official pay scales. Payand tions than those who were not enrolled in any remuneration of foreign nurses, moreover, var- program. Nurses, as health care professionals, ies greatly by employer and nationality and is seek to continually refresh their knowledge not always transparently shared, nor aligned to and skills to provide quality patient and com- experience, workload, or work risks. Pay scales munity care. Opportunities for continuing edu- can be defined according to objective,- mea cation, including a move from diploma nursing surable factors such as seniority, patient load, to registered nursing (for example through patient complexity, task complexity, shift length part-time efforts), should be a key strategy for and timing, serving in an underserved loca- retention, as much as it should be to ensure tion, and military active duty status, as well as quality, at all levels of the health system. In performance-based bonuses for achieving an addition, online education will make it eas- agreed-upon set of targets. ier for busy nurses or nurses in rural areas to access continued education. Reducing the outflow of nurses to non-clinical nursing positions is also important. Anecdotal Developing and enforcing regulations to min- evidence suggests that an estimated 20 percent imize occupational hazards will also be impor- of Saudi nurses who work for the MOH are not tant. These should be regulations and programs working in nursing jobs. Instead they are per- to minimize stress, improve security of health forming non-nursing tasks including working facilities, improve the treatment of nurses, as secretaries, working in purchasing, and per- improve infection control practices, and reduce forming non-nursing administrative roles. Such injuries, including back injuries. Each of these nurses are improperly receiving the same bene- hazards can contribute toward the exit of nurses fits as nurses working in clinical settings, includ- from a particular job or the labor market more ing in intensive care units (ICUs). This causes generally. Box 2 provides some examples that both a loss of clinical nurses and a financial inef- could mitigate these hazards. ficiency, in addition to leading to demotivation of clinical nurses. Currently job changes are pro- Efforts should also be directed toward - ensur cessed on paper by the HR department in hospi- ing transparency and/or, moreover, pay scales. tals and there is no electronic capture to enable Pay discrepancies breed resentment and cause the process to be regulated or managed. This low morale. In order to introduce greater trans- needs to change, with any transfer of nursing parency into the nursing market, publishing pay to non-nursing work done only as an exception scales and benefits packages should be consid- and then entered and captured by HR electron- ered, so that they are clear to all those enter- ically. In addition to minimizing attrition, such ing the profession. While the harmonized pay rationalization of benefits can free up resources scale for Saudi nurses working in the govern- to enable the MOH to hire more clinical nurses ment sector is widely known and published, or to offer greater benefit packages to existing bonuses for example are not always accurately clinical nurses.

12 AVAILABILITY OF NURSES

BOX 2: EXAMPLES OF STRATEGIES TO MINIMIZE OCCUPATIONAL HAZARDS

Integrate Stress Management into Curriculum: Globally, stress is a major cause of absenteeism among nurses (Shamian et al. 2003). In addition, there is some evidence that addressing the holistic well-being of nurses and patients can improve nurse job satisfaction in Saudi Arabia (Cruz et al. 2018). Stress management techniques could be inte- grated into nursing school curricula and nursing continued medical education. Stress awareness and team stress management could be added to nursing leadership job descriptions and nursing support supervision processes. Health facilities could be required to have stress reduction and management programs and stress levels could be measured during regular employment engagement surveys. Many women in Saudi Arabia do not have easy access to exercise facilities. In fact, Al-Tannir et al. (2017) found that only 60 percent of nurses exercise on a regular basis. Hospitals could make separate workout facilities available to their staff at minimal cost.

Improve Health Facility Security: Some reports have pointed to concerns with facility security, causing nurses to stop working (Alyaemni 2016; Mohamed 2002). Security standards in hospitals and health facilities could be improved to ensure the safety of all patients, families, and workers. The International Association for Hospital Security and Safety has helpful guidelines for making health facilities safer (IAHSS 2019).

Improve Treatment of Nurses: Anecdotal evidence suggests that some nurses in Saudi Arabia report that they have been mistreated, including being yelled at and slapped by patients and patients’ families. On admission, patients and their families can be shown a video on their rights and responsibilities, including their responsibility to treat hospital staff appropriately. In addition, proper interprofessional behavior should be included in job descriptions and performance improvement/support supervision tools. Methods need to be designed to remove the barriers to reporting violence against nurses and professionally address the problem.

Improve Infection Control Training: Alsahafi and Cheng (2016) found that in Saudi Arabia nurses’ “self-reported infection control practices were sub-optimal and overestimated” and that further training of nurses is needed to protect them and their patients and colleagues from hospital-acquired infections such as Middle East Respiratory Syndrome (MERS) or other infectious diseases. Training in personal protection equipment that reduces the risk of infectious disease should also be improved in nursing schools and required as part of nursing continued medical education. Routine infection control training and simulation should be conducted in health facilities. All occupational infectious diseases acquired by health workers should be reported.

Strengthen Bed Mobility Safety: Back pain and injuries from moving patients are major causes of nurse absenteeism and departure from the field. Safe patient mobility standards need to be developed and implemented. Patient mobility aids (patient lifts, patient slides, etc.) need to be purchased and nursing staff need to be trained in the proper procedures for patient transfer, mobility assistance, and assisting a fallen patient to get up. Nurses should be trained in back health and provided access to occupational therapists and back braces as needed.

SKILL MIX OF NURSES 3

The vast majority of Saudi nurses are diploma nurses who will be reclassified as technicians in the near future (SCFHS 2018). In the MOH, around 65 percent of Saudi nurses are diploma nurses (technicians) who have completed a two- or three-year program (Figure 8). The rest of Saudi nurses are registered nurses, who have completed a four-year bachelor’s degree. Many diploma nurses were trained by private sector institutions, with such training previously seen as an initial stop-gap to address the nursing shortage. The government is now in the process of implementing the Nursing Practice Act, which will prevent diploma nurses from providing direct nursing care. Diploma nurses will be re-categorized as technicians. This will further reduce the number of Saudis counted as national nurses.

FIGURE 8 THE VAST MAJORITY OF SAUDI NURSES DO NOT HAVE A BACHELOR’S IN NURSING

Estimated Proportion of Registered vs Diploma Nurses, Ministry of Health

Source: MOH 2019.

15 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

TABLE 1 EXAMPLE OF SAUDI NURSING CATEGORIES

Type of Nurse Training Responsibilities Chief Nursing Officer • No strict requirements. May have • Responsible for all nursing within an institution. master’s degree. Nursing Department Director • No strict requirements. May have • Responsible for nursing within their program or department. and Nursing Program Director master’s degree. Advanced Practice Nurse • Master’s degree (only one program • Serves as a provider with supervision by a physician. in the country). Quality Assurance Nurse • No strict requirements. May have • Responsible for designing, overseeing the implementation master’s degree. of, and evaluating nursing quality protocols. Nurse Manager • No strict requirements. May have • Supervising teams. master’s degree. • Ensuring nursing quality. Nurse Clinical Specialist • No strict requirements. Most have • Focused nursing care. on the job training. Some have • Focused patient and family communication and education. specialty certificates. • Focused communication with other members of the health care team. Bedside Nurse • Bachelor’s degree required. • Classic bedside nursing. • Four years didactic education and • Patient assessment and documentation. one year residency. • Patient care. • Administration of medicines. • Communication with physicians and other members of the health care team. • Communication with patients and families. • Education of patients and families. • Infection control. Primary Health Care Nurse • Usually Diploma Nurses but can • Carry out all tasks and functions at the primary health care also include registered nurses. level.

In KSA, nurses fall into a number of different skills of subspecialty nurses (wound care, hematol- mix categories (see Table 1). They include chief ogy, pain management, palliative care, home nursing officers, departmental nursing -direc health care, etc.) exist in KSA (Bagadood 2016). tors, advanced practice nurses, quality assurance Saudi nurses can obtain specialist qualification nurses, nurse managers, clinical specialists, bed- through the SCFHS’s two-year diploma/certifi- side nurses, and primary health care (PHC) nurses. cate courses offered within training centers in In general, Saudi diploma or bachelor’s degree many of the hospitals, but these programs are nurses get hired into their specialty and nurses not formally accredited by a university. They are largely learn on the job to work, for example, in often used to justify salary increases (within the an intensive care unit. On the other hand, most standard salary scale) and sometimes enable foreign nursing specialists are formally trained nurses to move up the career ladder from spe- specialists (Figure 9). A needs assessment should cialists to senior specialists. Since the introduc- be conducted to determine how many of which tion of the harmonized salary scale, the number type of specialty nurse is needed. of Saudi nurses classified as specialists has grown substantially (Figure 9). Although specialist certification programs exist, they are not currently academically accred- The number of advanced practice Saudi nurses ited, which is the global standard. Various types (master’s level Nurse Practitioners/NPs and

16 SKILL MIX OF NURSES

FIGURE 9 THE NUMBER OF SPECIALIST NURSES HAS GROWN SIGNIFICANTLY IN RECENT YEARS

Growth in Saudi and Non-Saudi Nurses Classified as Specialists

S N S

Source: SCFHS 2018.

other master’s level nurse clinicians), remain very prioritized, following the implementation of the limited, and represent less than an estimated 5 Nursing Care Act. In particular, the MOH, which percent of the overall nursing workforce. Most currently has the highest number of diploma of the advanced nurses and specialty care nurs- nurses in the market, will need to establish ing positions are filled by foreign nurses (such as bridging programs. The availability of greater ICUs, operating rooms, oncology, etc.). One bar- resources in other sectors such as National Guard rier to the training of advanced practice nurses Health Affairs (NGHA) or King Faisal Specialist is the difference of opinion among Saudi nurs- Hospital & Research Centre (KFSH&RC) have ing leaders regarding the number of years of given these sectors an advantage to fund bridg- practical experience a nurse should have before ing programs abroad (for example in the United entering an advanced program. For example, in States, Australia, and Jordan). The government some countries, nurses can go straight through should also review the option of reinstating pub- their training from bachelor’s to doctorate with- lic scholarships for private bridging programs or out practicing, while in other countries, such as encourage the private sector to offer such train- Portugal, practical experience of four years or ing (if adequately regulated and accredited). more is mandated. Moreover, to minimize temporary labor market loss, part-time bridging programs (that focus on clinical training elements) should be considered. Opportunities to Optimize Skill Mix Currently, in order to carry out bridging training or any post-graduate training, a nurse has The scale-up of bridging programs for diploma to exit the profession completely to professions nurses to become registered nurses should be such as sales, management, or IT. Amending

17 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

FIGURE 10 NUMBER OF SAUDI NURSES ENROLLED IN FORMAL SPECIALIST TRAINING PROGRAMS IN 2017

Nurses Enrolled in Formal Specialist Nursing Programs

N N

D N O N C N E N C A C D D D

Source: SCFHS 2018.

the government policy that prohibits employees they are accredited only by the SCFHS), with a from studying while in full-time employment is careful attention to standardization and quality. thus critical. Clarity could also be provided about how such diplomas or certificates can be used toward Efforts should aim to formalize and academically credits to becoming master’s level, Doctorate of accredit the existing specialist certificate pro- Nursing Practice (DNP), or PhD nurses (i.e., for- grams and bring them on par with international mal advanced nurses). standards. Currently, around seven different types of specialist diploma/certification pro- Saudi Arabia has the opportunity to lead the grams exist, designed largely to allow nurses to region in the establishment of accredited advance in their career ladder and move closer post-graduate nurse education, including mas- toward the maximum level within their salary ter’s, DNP, and PhD degrees (advanced nursing). scale. Figure 10 provides an overview of four of There is much room for expansion; currently, them. These diploma programs are usually pro- the total number of students enrolled in the vided by the training centers within hospitals. A post-graduate program in KSA and abroad is first step could be to reform these programs and 956. Within each specialty, the number of nurses reduce their length from two years to one year enrolled and expected to graduate within five or 18 months, as is common globally. The length years is extremely low. Since there is only one of the programs should be benchmarked against master’s-level nurse practioner program in the similar programs in OECD countries. In addition, country at Princess Nourah University, the major- efforts could be made to have the MOE formally ity of Saudi nurses with advanced training have accredit such programs academically (currently obtained their degrees outside the country. The

18 SKILL MIX OF NURSES

first priority for the post-graduate education of Saudi nurses will be to train them to replace the Advanced Practice Nurses in KSA: The intro- existing foreign specialty nurses. This will include duction of advanced practice nurses (APNs) is establishing training programs for OR nurses an ongoing reform effort in Saudi Arabia. The and intensivist nurses (ICU, CICU, SICU, PICU, and SCFHS has permitted the introduction of fam- NICU). Saudi senior nursing leadership is cur- ily nurse practitioners (NPs) in government Primary Health Centers (Bagadood 2016) rently considering requiring a minimum num- with pilots underway. The scope of practice ber of years of clinical experience before nurses and educational qualifications of the NPs are can enter advanced nursing degree programs. still being defined. Bagadood (2016) reports Currently, Princess Nourah University allows that the reason for the delay in the rollout of nurses to enter advanced nursing training pro- APNs is the disagreement within nursing on grams directly after graduating with their regis- the overall vision for Saudi nursing as well as tered nurse degree. Requiring minimum clinical the role of APNs. experience before entering post-graduate education will ensure that nurses are making the right decision for themselves and that they have the experience and maturity to make the most out of the post-graduate program. Opportunities for The salary levels for specialist nurses need part-time education should be provided for more to be revisited as well. Since many special- senior nurses to receive advanced qualifications ist nurses or nursing professionals earn the with minimum disruption to their work schedule. same as non-specialty RNs (everyone is on the same, unified salary scale, with the exception of The development of a regulatory framework for KFSH&RC), there is little incentive to pursue the advanced nursing should be considered. The additional training, which may come at the cost establishment of advanced nursing programs of course fees and lost wages. Currently there will require setting standards for competencies, are no salary differentials even between regis- length of training, balance between theoreti- tered nurses working in specialist roles and reg- cal and practical training, faculty requirements istered nurses working in non-specialist roles. (number, profession, degrees, etc.), and clin- The existing two-year specialist/diploma pro- ical site requirements. Moreover, as the grams or an advanced nursing degree may only post-graduate nursing education system devel- allow nurses to move slightly further toward the ops, it is important to phase-in standards and upper ceiling of their salary grade. But these not overregulate and cause nursing shortages increases are insufficient to account for the dif- due to unrealistic standards. ferences in skills needed.

DISTRIBUTION OF NURSES 4

The following provides an overview of the key challenges and opportunities linked to the fragmentation of the nursing workforce in KSA, mainly the distribution of the workforce across sectors, geographical divisions, and level of care.

The nursing labor market is fragmented across considered as good. The uniform salary scale various subsectors/employers, with MOH in government sectors largely resulted in a con- facilities home to most of the Saudi nurses siderable increase for MOH nurses (many of (Figure 11). The various sectors/employers cre- them diploma nurses) in particular. However, ate a number of almost completely different nurses in other sectors saw their salaries cut, nursing labor markets and it is unusual for a especially when many of them were hired on nurse to transfer from one employer to another. the basis of international rates of international Saudi nurses tend to be clustered in MOH facili- rates; for example, nurses who received their ties whereas the other sectors, including the pri- training in the West). Other sectors generally vate sector, is staffed more by foreign nurses. offer better benefit packages and allowances, MOH facilities, which hold the largest share and their working environment is considered of Saudi compared to foreign nurses, employ more favorable. 59 percent of Saudi nurses compared to 41 percent of foreign nurses. In all the other govern- Nurses are also distributed unevenly across ment sectors combined, Saudi nurses represent geographical divisions. Figure 12 shows the around 17 percent of the workforce, compared uneven distribution across regions. In addi- to 83 percent foreigners. Saudi nurses repre- tion, the vast majority of Saudi nurses are clus- sent around 4.9 percent of nurses in the private tered in facilities in urban locations, with rural sector. locations largely staffed by foreign staff. When counting only registered and advanced Saudi The clustering of Saudi nurses in MOH facilities nurses in rural areas, combined their ratio is has less to do with the attractiveness of the sec- less than 0.1 per 1000 population. The short- tor than with the difficulty Saudi nurses experi- age of Saudi nurses in more remote locations ence in getting a job in other sectors. In fact, for is largely driven by poor living and working con- many Saudi nurses, the most attractive sector is ditions, which are particularly pronounced for the NGHA, Ministry of Defense (MOD), Ministry nurses who do not come from remote areas of Interior, and KFSH&RC, with MOH generally and are not used to them. Some of the fac- considered less attractive. The private sector is tors that make remote postings less attrac- also often considered a less attractive alterna- tive for nurses include: 1) salaries that don’t tive, with pay, work hours, and conditions not cover the opportunity cost of living in a rural

21 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

FIGURE 11 EMPLOYMENT OF NURSES, SAUDI AND NON-SAUDI, BY SECTOR

Nurses Employed in Different Sectors

P S

O G S

S NS

Source: MOH 2018.

area, 2) inadequate housing, 3) fewer oppor- education. PHC services provide a large part tunities for continued education, and 4) fewer of the basic health care to the Saudi commu- work opportunities for spouses. Despite the nity. According to the MOH, 82 percent of the shortage of Saudi nurses in rural areas, unem- total visits to MOH institutions occurred in PHC ployment rates of populations in rural areas centers. Although a larger proportion of Saudi are particularly high, due to lower educational nurses work at the hospital level than the pri- achievements and stronger conservative and mary care level, the majority of nurses within patriarchal social norms. the primary care level are Saudi nurses. Only a few non-Saudi nurses are found at the primary Finally, nurses are also unevenly distributed level (see Figure 13). across service delivery levels. The vast majority of nurses at the primary level in KSA are Whereas the attractiveness of working at the Saudi nationals, whereas non-Saudi nurses hospital level is clearer, the reason for Saudi dominate employment at the hospital level. In nurses being employed at the primary level are KSA, the PHC center is recognized as the basic multi-fold: 1) PHC centers are said to provide health unit or the first point of contact between working conditions that are more in line with the community and the health care system. It family life and priorities (for example, no night provides a set of health care services includ- shifts as needed in hospitals), which includes ing prevention programs, treatment of simple less supervision and accountability along with a diseases, chronic care management, maternal salary that is the same as that of a nurse working and child health services (including immuniza- in a hospital; 2) Many Saudi nurses, in particular tion), environmental health, and public health diploma nurses, end up in PHC facilities because

22 DISTRIBUTION OF NURSES

FIGURE 12 PROPORTION OF NURSES TO THE POPULATION ACROSS REGIONS

Total Nurses per 1,000 Population across Different Regions

N N

H A T A R N E AB N B N A

Source: MOH 2018.

they find it more difficult to be recruited at the and often not needs-based. Recruitment occurs hospital level—hospitals across sectors are through the Ministry of Civil Service or Ministry reluctant to hire diploma nurses (unless they are of Labor and deployment through the MOH. This hired as technicians). A survey of primary care is a long process, in which facilities are often nurses in the Jazan region identified existing staffed with nurses who do not meet the facili- challenges at the primary level, including weak ty’s needs. Recruitment in the non-MOH sectors management and supervision practices and lack in turn is highly selective, with MOH ending up of professional development opportunities. The hiring those nurses who were not recruited else- survey also identified that the majority of nurses where. This also helps explain why a large pro- were satisfied with their co-workers, satisfied to portion of nurses in the MOH are diploma nurses be nurses, and had a sense of belonging in their (as opposed to registered nurses). The situation workplaces (Almalki et al. 2012). is further complicated by the fact that each of the sectors are in a different stage of reform and many policies are in the process of changing. Opportunities to Improve Sectoral Distribution The plans to divide the country into five corporates with clusters underneath is expected to The MOH currently has a disadvantage relative improve the hiring capacity of the MOH, as well to the other sectors in terms of recruiting and as improving the attractiveness of the MOH to attracting the highest caliber staff in a timely higher caliber staff. Reform efforts will decen- manner and according to need. MOH recruit- tralize and provide autonomy to the corporate ment is highly bureaucratic and centralized holding companies to finance, plan, recruit, and

23 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

FIGURE 13 THE DISTRIBUTION OF NURSES ACROSS LEVELS OF CARE

MOH Nurses in Primary Care Centers and Hospitals

P C C

S NS

Source: MOH 2018.

manage staff for their clusters based on need Opportunities to Improve and move away from the centralized recruit- Geographical Distribution ment and hiring currently in place in the MOH sector. This will eliminate the current process of Efforts to increase salary and non-salary incen- nurses applying to the Ministry of Civil Service tives for working in rural areas are a step in the and Ministry of Labor and then having to wait for right direction. Currently, some limited incen- the MOH to deploy staff. Corporate holding com- tives are in place to attract a greater number of panies will be able to hire directly per their need. nurses to rural areas. These incentives are currently relatively low (about a 5 percent increase The ongoing reform will put the MOH sector on in salary) and do not fully cover the opportu- par with the other government sectors, such nity costs nurses experience from moving to as the NGHA and the Ministry of Interior, and rural areas. Rural hiring authorities may wish to: also the private sector. This will also include a 1) increase rural salary incentives and other ben- transition from hiring workers as civil servants, efits such as preferred access to post-graduate in which there is little flexibility to hire and fire, education and promotion, 2) build housing on or to contractor hiring, in which the workforce can near medical facilities, 3) provide support to find more readily be expanded and contracted based work for accompanying spouses, and 4) address on need. The added autonomy in the MOH sec- security concerns. While these steps are in the tor is expected to result in greater quality and right direction, monetary and non-monetary quantity of services in part through incentiviz- incentives alone are unlikely to be sufficient to ing needs-based hiring of nurses, and is seen convince nurses to accept rural over urban posts. as a much-needed reform to attract higher caliber staff, including advanced nurses, to the Further investment is needed in telehealth and MOH sector. The role of the central MOH will be e-learning opportunities to reach patients and restricted to its regulatory function. nurses in remote areas. With the Kingdom of

24 DISTRIBUTION OF NURSES

Saudi Arabia’s embrace of technology, its large important cost-effective strategy to staff rural geographic size, its large numbers of rural and facilities (Mbembe et al. 2013). Students who remote communities, its cultural preference for come from rural areas and are trained in rural some female nurses to work from home, and the areas are often more willing to work in rural areas. preference of female patients to receive treat- Decentralization of training would involve estab- ment at home rather than at a facility, telemedi- lishing branches of nursing colleges in rural com- cine has an unprecedented opportunity in Saudi munities and training and recruiting young people Arabia. Opportunities for telehealth hold poten- from these communities. These branch campuses tial to reach rural communities, and e-leaning would fall under the licensing and accreditation opportunities hold potential to provide continu- of existing schools and could leverage their fac- ing professional development and learning for ulty as well. These branch campuses could be pri- nurses already employed there. It is imperative oritized for rural and remote governorates. This that frontline working nurses are involved in the would enable students from these underserved design of telemedicine programs. It is widely populations to enroll, and would allow the stu- recognized that one of the main causes of the dents access to these clinical sites that currently failures of electronic medical records was the do not have student clinical rotations. Nursing almost complete absence of involving working schools in underserved governorates could also health professionals in their design. provide the infrastructure to offer continuing education opportunities to existing staff, which Increasing the enrollment of Saudis from under- can reduce attrition of nurses once employed. served communities in nursing schools should also be considered. Global evidence has shown that students who come from rural areas are Opportunities to Improve Service- more likely to be willing to work in rural areas. Level Distribution The number of Saudi nursing education slots is estimated to be limited compared to the num- Further scale-up of Saudi nurses at the primary ber of qualified Saudi applicants. Due to this level would require addressing a number of mismatch, applicants from rural communi- existing challenges. These efforts should include ties must compete with applicants from urban interventions to develop sufficient facilities areas. A number of barriers exist for rural appli- for nurses, provide continuous improvements cants. Often rural applicants may have gradu- for nurses to balance work with family needs, ated from high schools that are of lower quality improve staffing including support staff, improve than urban high schools. In addition, rural appli- management of supervision practices, provide cants are more likely to be the first in their fam- professional development opportunities, and ily to apply to college and therefore do not have improve the working environment in terms of family members with college experience to sup- security, patient care supplies and equipment, port them through the process. Students in and recreation facilities (break areas). rural and remote communities may even have trouble obtaining information about nursing Attracting a greater share of Saudi nurses to programs and their application process. Efforts the hospital level requires efforts to generate should target rural applicants to provide them more hospital demand for the recruitment of with additional financial and educational sup- Saudi over foreign nurses. Indeed, the single port to ensure their entry into nursing schools. most important interventions to increase the number of Saudi nurses at the hospital level Decentralizing training itself to rural areas is would be to transform Saudi diploma nurses a particular opportunity to maximize staffing. into registered nurses (through training and Globally, evidence has shown that decentral- bridging as discussed previously), and to izing the training of nurses to rural areas is an increase opportunities for advanced nursing.

25 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

Currently, Saudi hospitals do not hire diploma work in the other levels of care, it is essential that nurses, and support is needed to provide these issues be addressed. Specific solutions to diploma nurses with the qualifications and increase the number of nurses for the hospi- competencies that would make them competi- tal level could include: 1) increasing the pay for tive with foreign nurses. hospital shifts given the more complex patients and greater occupational risks, 2) reducing hos- A second intervention will have to be imple- pital shift times from two 12-hour shifts to three mented to increase the willingness of Saudi 8-hour shifts or four 6-hour shifts, 3) improv- nurses to work at the hospital level by improving ing career paths within hospitals, 4) addressing working conditions, including potentially higher other hospital-based nursing concerns such as salaries or additional incentives. The working workload, safety, and stress levels, and 5) cre- conditions in hospitals (shift work, long hours, ating hospital entry programs for new gradu- etc.) are less compatible with Saudi family life. ates (as has already been done in KFSH&RC and In order to ensure that more Saudi nurses will National Guard Hospitals).

26 PERFORMANCE OF NURSES 5

Despite the high caliber of foreign nurses in the country, and their dedication and effort to contribute to the well-being of the population of Saudi Arabia, the current dependency on foreign nurses has also been argued to be a structural barrier to the provision of quality care. Foreign-trained nurses can pose potential quality risks in the areas of: 1) language, 2) cultural and religious understanding, 3) quality of pre-service education, 4) variation in pre-service education, and 5) length of service/turnover. As long as Saudi Arabia relies on foreign nurses, it will have limited control over the consistency and quality of their pre-service education and prior work experience. For example, a nursing team on a single ward com- posed of foreign nurses may have nurses from four countries who attended nursing schools with different priorities and who have radically different ideas of proper nursing practice.

The dependency on foreign nurses is partly a updated in the past 10 years, gaps remain in result of some of the challenges related to the areas such as pediatrics, mental health, geriat- performance of Saudi nurses. Workforce per- rics, professionalism, ethics, legal liability, tele- formance can be categorized as a function of: medicine, and career management. In many 1) competencies and skills of the nurses (linked schools, training continues to be largely theoret- to education and training-related factors); and ical with little exposure to practical training until 2) the extent to which nurses exert effort in the internship phase. On the workplace side, their work—lack of productivity or excessive management weaknesses are reflected in the absences—which are often linked to the avail- fact that on-the-job training opportunities are ability (or lack of) supportive policies as well as often limited, and many nurses are deployed to supervision and accountability mechanisms. All posts in which other more specifically trained the elements of performance are thus influenced cadres would be more suitable. Career advance- by both the education of nurses as well as the ment opportunities are generally sparse. management of nurses in the workplace and can Management profiles are often questionable. further be influenced by regulation and licensing. Managerial authority to enforce accountability, particularly over civil servants (who can- A number of education and workplace-related not be fired), can be limited. In addition, salary challenges exist in Saudi Arabia, but not all of increases are not linked to performance. them are discussed here. On the education side, some of the critical ones to mention are related The nursing licensure examination was recently to curricula and clinical sites. Although many introduced to identify non-performers and give of the curricula of nursing schools have been them time to retrain before they start practicing.

27 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

In line with concerns in other countries, how- Improving the accessibility and quality of clini- ever, the following points on the relevance of cal sites for nursing is also particularly critical. the licensure examination should be taken into Clinical sites for students are a limiting factor consideration. In the United States,, there have in most nursing school systems, in particular been concerns among some professions that for private schools and those located in more some examinations serve no purpose because remote parts of the country. This clinical site the vast majority of graduates pass the exams. shortage exists for both pre-service educa- This is especially the case in which the level of tion as well as for post-graduate training (nurs- professional education is quite good and very ing diploma, bachelors, masters, and doctoral few students fail the examinations. In such programs). Saudi Arabia has the opportunity cases, examinations are primarily viewed as to require all clinical sites to receive nursing time burdens for graduates with little benefit to students. Clinical sites need to be expanded patients or the profession. Creating fair, secure both to private hospitals and to all levels of the exams can be quite difficult and expensive, but public health system. In order to ensure high- well worth the effort. quality clinical practice in these new clinical sites, a number of measures need to be taken:

Opportunities to Address Education y Education mandate: All public health facil- Constraints ities and all private health facilities of a certain size or referral level, or level of tech- Efforts should primarily focus on regular reviews nical advancement (e.g., having an MRI scan- and adjustments of nursing school curricula. ner) should be legally required to accept Saudi Arabia has an opportunity to create a more health professional students. Private facili- detailed mandatory outline of curricula for nurs- ties that do not wish to participate in health ing schools. Nursing school curricula need to worker education can pay a reasonable per be updated at a minimum of every five years to bed fee each year. This fee will be directed remain relevant. However, updating curricula can toward scholarships for health professional cost hundreds of thousands of dollars and pull students. faculty away from teaching and other responsibilities. By creating and updating a universal nurs- y Patient rights and responsibilities: All ing curriculum centrally, KSA will not only keep health facilities that have practicing stu- all its nursing schools (public and private) teach- dents should provide patients who arrive ing the highest quality curriculum, but it will also and register at the hospital with a copy of decrease the cost model of nursing schools and their patient rights and responsibilities. The potentially decrease the cost of tuition of nurs- rights and responsibilities will explain that ing schools. This is also an opportunity to shift the facility is a teaching facility and that the nursing schools to a competency-based cur- teaching is an essential part of its work and riculum, which will better equip nurses to provide that it is the responsibility of the patient to direct care to patients. Schools would always be help in the education of the next generation free to adapt the central curriculum to meet their of health workers. It will be explained that, local needs. KSA can also make the curriculum in extreme cases, patients have the right to available to other nursing schools around the request not to be seen by students or by world that struggle to keep their curricula up to male students, but that is expected to be the date. This will help Saudi Arabian nursing estab- rare exception. lish itself as a leader in the field. The curriculum could start with topics that are frequently weak in y Case-based teaching: In order to ensure many nursing schools, including pediatrics, men- that the nursing staff at the new teach- tal health, geriatrics, leadership, and research. ing sites are able to teach and mentor the

28 PERFORMANCE OF NURSES

students properly, KSA should provide them include elements such as the qualifications of the with case-based teaching (often called bed- person supervising the trainee, mentor training side teaching) and clinical mentoring. for the supervisors, the total number of hours, the expectations for direct care versus observed y Clinical practica curricula: Since tradition- care, and hours and content of direct teaching. In ally students receive some lectures during addition, the trainee should keep a standardized clinical practica, KSA can ease the transi- record signed by their supervisors of the differ- tion of new clinical sites by providing curri- ent types of patients they care for (e.g., cardiac, cula and lecture materials. For some topics, pediatric, oncology, mental health) and the pro- the government may want to provide inter- cedures they performed (e.g., straight catheriza- active webinars or taped lectures. These will tion, wound care, ostomy care, chest tube care, be especially helpful in clinical sites that have care of patients in restraints). large numbers of patients but few specialists. Efforts should also be directed toward the y Documentation of clinical experience: To redesign of the nursing team to maximize qual- ensure that each student sees a sufficient ity and efficiency. Such a redesign would add volume and diversity of patients and has suf- new members to the conventional nursing ficient opportunity for hands-on experience team, including APN (master’s level NPs and (including procedures such as suturing and other master’s level nurse clinicians), nurse performing lumbar punctures, etc.), metrics specialists (wound care, ostomy, and other spe- need to be agreed upon for each program cialists), and nurse care coordinators, as well as and a common methodology for document- new non-nurse members, such as nursing care ing the experience. This can be as simple as assistants (usually one year training post-high a paper booklet in which the student doc- school), patient care assistants (transporters, uments cases and the supervising health usually managed centrally), and ward secre- worker signs, or more sophisticated apps or taries. For such a redesign to be successful, it websites. needs to be based on data about how nurses in a particular facility spend their time: their y Transportation and accommodation: As most high-risk activities, their most common students start learning in sites outside pub- activities, and the most common reasons for lic academic centers, many of these centers patient calls and for patient dissatisfaction. A will be at a great distance from the nursing redesign would enable nurses to practice at the schools. Schools should then be obliged to top of their license and focus on the complex, provide transportation when the distance high-risk tasks, while enabling other members is commutable from the base school. If the clinical site is too far away to be commutable, the school should provide free or affordable Multidisciplinary Teams: One care model housing near the clinical site. that looks increasingly attractive for Saudi Arabia is multidisciplinary teams. There are dozens of variations of this model. However, Opportunities to Address Workplace the basic version has nurses performing the Constraints intake history and physicals, followed by physicians doing focused history and physicals. Guidelines for on-the-job-training should be stan- Once the physician makes the diagnosis, the dardized. They should be developed and enforced nurse follows up with the patient in between to ensure high-quality on-the-job training, thereby appointments, ensures compliance, and edu- allowing each facility to improve its nursing qual- cates the patient (Bagadood 2016). ity of care. The standardized guidelines should

29 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

of the team to take patient calls, help with bed improvement of nursing performance. Current mobility, and so on. Such a redesign would also efforts to reform the MOH into five corporates help other members of the clinical team, espe- that will manage clusters (hospitals and primary cially physicians, better understand the roles care centers) is a step toward decentralizing and responsibilities of nurses and reduce con- management and providing greater manage- flicts between physicians and nurses. ment autonomy with incentives on efficiency and quality over the workforce. This will be Improving career mobility and establishing linked to the phasing out of civil servants—until career ladders for nurses and clear criteria for now facility managers had limited autonomy to employment in management positions is also hold staff accountable. critical. A career ladder can be created in which nurses have increasing technical and mana- Finally, KSA should consider linking salary gerial responsibilities. The career pathway by increases to performance evaluation outcomes. which nurses can advance within their profes- While the salary scale has been harmonized, sion should be clarified, including a move from a currently there are upper limits in this scale junior nurse to a senior nurse (see how done in that are not always linked to seniority or per- UK banding system), or toward a middle manage- formance. Clarity should be provided on how ment or director position. This must be accompa- to advance within categories of the salary scale. nied by leadership and mentoring programs to Advancement toward the upper limits of the help identify and support high potential nurses. scale should be linked to the outcome of performance evaluations of nurses (as has already A leadership or management position should been done regularly in sectors such as the not be obtained without sufficient seniority and NGHA), with better performers advancing within experience obtained in the labor market, includ- their salary category or receiving a performance ing a sufficient number of years in clinical- prac bonus based on their performance evaluation. tice. Furthermore, while post-graduate education can lead a nurse toward a management career pathway, the obtained degrees should be directly Opportunities to Optimize Licensure relevant to clinical care. A master’s or PhD in global health, for example, or others that are A number of innovative interventions have purely theoretical, may not be sufficient for clin- already been implemented on licensure. The ical advancement. Programs such as Doctor of Saudi government has moved to improve qual- Nursing Practice (DNP), which have shown else- ity of care and data on health workers by reduc- where to prepare nurses well for management ing the length of time that clinical licenses are posts, do not currently exist in KSA and could be valid from five years to two years. This will considered for introduction or scholarship tar- enable the government to require timely con- geting. More attention also needs to be paid to tinuing professional development (such as offering women more opportunities to receive courses on MERS) and will enable the collec- post-graduate training and clinical experience tion of more up-to-date data on who is practic- and then assume leadership positions. Many of ing and where they are practicing. Furthermore, the nursing leadership and management posi- it is important to ensure that licensure exams tions today are filled by males, who represent just appropriately reflect the realities of nursing a small minority of the nursing workforce in KSA. practice and improve the performance of the profession without unnecessarily weeding out Greater autonomy and decentralized manage- graduates who would be good nurses but are ment of the nursing staff will be critical for the not strong test takers.

30 MAXIMIZING CURRENT NURSING INITIATIVES 6

KSA is currently working on developing the implementation strategy of initiatives to improve the nursing situation in Saudi Arabia. Following the working sessions with Saudi nursing leaders in early 2018 (linked to the national conference on Human Resources for Health [HRH]), 17 initiatives to improve existing challenges were identified. While taking into account the previously discussed challenges, the current 17 initiatives hold some potential to improve the availability and skill mix, as well as the distribution and performance, of nurses. Table 2 lists the 17 initiatives and provides key recommendations on how to maximize impact on each of these areas.

31 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

TABLE 2 RECOMMENDATIONS TO MAXIMIZE IMPACT OF CURRENT INITIATIVES ON NURSING

Potential Impact on Potential Impact on Potential Impact Potential Impact on Intervention Availability Skill Mix on Distribution Performance Support public and private High Depends on what types Schools must Positive impact if shared nursing schools to increase of schools are opened be opened in resources are created. enrollment underserved Negative impact if insufficient communities. investments are made or regulation is poor. Support private investment in Same as above Same as above Same as above Same as above nursing schools Separate nursing schools Unclear. May increase Unclear Unclear. If costs Unclear from Allied Health Schools the operational costs increase, may limit into separate nursing colleges and tuition costs the enrollment to have direct entry nursing and therefore limit of students from degrees (without undergoing enrollment. May underserved the general foundation year) reduce 1st year drop communities. out rate. Increase male enrollment High Male nurses may Male nurses Unclear be more likely to may be more pursue post-graduate likely to work education. in underserved communities. Increase scholarships for High, especially Unclear. If scholarships Unclear. Unclear study within Saudi Arabia for students from are earmarked for post- Scholarships could underserved graduate education be targeted to communities. (PGE), then the nurse students from skill mix impact will be underserved large. communities. Create partnerships with Moderate. Faculty High, especially if the Unclear High, especially in international nursing colleges sharing may enable partnerships focus on traditionally weak areas such Saudi schools to the creation of PGE as pediatrics, mental health, expand. Improved programs. geriatrics, and oncology. management may reduce student dropout. Reform national framework Moderate. Both Unclear Unclear High. Saudi nursing schools, for academic accreditation curricula and like most nursing schools, toward competency-based licensing exams must focus too much on theory at teaching be aligned to be the expense of practice. competency-based. Found clinical nursing post- High. Likely to improve High. PGE creates skill Unclear. Globally High graduate education career retention. mix within the nursing APNs tend to labor market. cluster in urban areas. Expand and accredit the Same as above Same as above Same as above Same as above seven advanced nursing diploma programs (which enable a nurse to move up the career ladder from specialist to career specialist) (continued on next page)

32 MAXIMIZING CURRENT NURSING INITIATIVES

TABLE 2 RECOMMENDATIONS TO MAXIMIZE IMPACT OF CURRENT INITIATIVES ON NURSING (continued)

Potential Impact on Potential Impact on Potential Impact Potential Impact on Intervention Availability Skill Mix on Distribution Performance Add clinical evaluation (e.g., Unclear None None High. Will incentivize Objective Structured Clinical schools to focus on clinical Examination/OSCE) to competencies. the Saudi Nursing Council Licensing Exam Integrate career awareness High. Will increase Moderate. May help Unclear Moderate. May motivate and planning into the nursing retention in labor nurses plan to pursue nurses to perform better in curriculum market. PGE order to advance their careers. Support private hospitals High. Likely to improve High. PGE creates skill Unclear. Globally High to host more nursing post- career retention mix within the nursing APNs tend to graduate education programs labor market. cluster in urban areas. Could have benefit if rural areas are prioritized. Establish day care facilities in High. Likely to improve Unclear. May facilitate Moderate. Rural High. Likely to reduce hospitals retention. nurses to pursue PGE facilities could absenteeism. receive priority programs Develop a way to license Moderate. Will reduce Moderate. Will create a Unclear Moderate. The new cadre RNs who have not passed the risk of pursuing a new cadre. will support the performance the licensing exam as nursing career. Will of RNs. “technicians” make more health workers available. Encourage all employers to Moderate. Will reduce Unclear Unclear. Should Moderate. Will better prepare create one-year training and nurse dropout in the prioritize programs new graduates for clinical development contracts for first year of work. Will in rural health practice. new graduates also ensure faster facilities. absorption of Saudi graduates into labor market. Establish part-time and High. Will enable Unclear High. Flexible High. Potential to reduce flexible work arrangements nurses to stay in the work arrangement fatigue and burn-out. labor market. may be more necessary in more conservative, rural communities. Establish bonuses or special High. Will incentivize High. Will incentivize Unclear. Priority High. Will incentivize nurses to payment schemes for nurses to stay in the job nurses to pursue PGE. programs should improve their skill set. specialty nurses market. be placed in rural health facilities.

GOVERNING THE MARKET FOR NURSES 7

Planning and policy at the national level remains fragmented across sectors. Currently, there is no national HRH plan or comprehensive and cross-sectoral planning that includes the nursing profession—each sector is engaged in its own planning and management activities. In addition, there is often no link between the health sector and the education sector, meaning that the education sector is engaging in activities that do not meet the needs of the health sector.

There have been calls for updating nursing leg- for Saudi nurses that aim to decrease turn- islation and policy (Bagadood 2016). The lack over, improve retention, and improve produc- of sufficient legislation, for example, has been tivity and quality of Saudi nurses can generate one key cause of the delay in rolling out APNs greater efficiencies and be more cost-effective in KSA. Efforts are being made to strengthen than using foreign workers. the national nursing leadership. For example, the SHC has recently established a National Committee for Nurses. This new committee will Opportunities to Optimize be able to draw attention to the needs of nurses Governance and propose solutions. The development of a national health workforce The costs of referrals abroad and the turnover plan or strategy that cuts across all sectors and of foreign nurses is high. There is a need to lays out a clear vision on how to improve work- generate greater efficiencies and reduce cost. force challenges, including nursing, is a critical The current model of relying on foreign nurses necessity for KSA. National and sub-national increases the cost of nursing due to 1) the need sectors should work with the leadership of dif- to pay higher wages, 2) the need to pay for ferent professional categories, including nurs- accommodation and transport, and 3) the costs ing, to design and implement a process to reach of recruitment and onboarding, especially in the consensus on the future vision and plans for context of low retention/high turnover. There is the health workforce. All the main sectors and often the implicit assumption that it is cheaper stakeholders should be involved in this plan, to use foreign-trained workers (especially in including the MOE and the Ministry of Finance. rural and remote facilities) because Saudi Arabia does not pay for their pre-service education. Encouraging and funding nursing research However, there are hidden costs in the use of to support planning is critical. Planning and foreign workers. Carefully designed programs reforming the nursing model or workforce and

35 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

rently, the primary representation for nurses Incentivizing or mandating nursing re- at the national level is the Saudi Professional search: One opportunity that exists to im- Nursing Council and the Saudi Scientific Nurs- prove the image of nursing, improve nurse ing Council under the umbrella of the SCFHS retention, and improve quality of care is to in- (i.e., reporting to a physician). KSA has recently centivize or mandate nursing research. This established the Nursing Association, which research can be as practical as quality assur- needs additional resources to be more active. ance operations to improve nursing-sensitive If it had adequate resources, the Nursing Asso- indicators. In more advanced settings, such ciation could conduct valuable activities such as academic hospitals, it can include origi- as advocating for the nursing profession, nal Institutional Review Board (IRB) research improving the image of nursing, promoting that results in peer reviewed publications and ethical standards, offering educational pro- pushes the nursing field forward. Aljezawi et grams, offering mentoring programs, helping al. (2018) identified clinical setting factors that design career pathways for nursing, and gener- served as barriers to the implementation of ating ideas and energy around nursing in KSA. new nursing best practices (the bench to prac- In addition, the SHC could host a nursing com- tice challenge), and presented how these bar- mittee comprised of key representatives across riers can be systematically addressed. Abos- the sectors for decision-making that cuts haiqah et al. (2014) found that lack of time, across the different sectors. Nursing represen- knowledge, and authority were the main bar- tation through any of these bodies should be riers to nurses utilizing research and translat- transparently selected and/or elected and be ing new knowledge into positive changes in sufficiently representative in terms of female/ patient care. These issues can be addressed male representation. Vision 2030 is seeking to by integrating research and research utiliza- empower females in the labor force, and it will tion into nursing job descriptions and support be critical that females are adequately repre- supervision processes. sented in representative bodies in a nursing market where the vast majority of nurses are female.

developing of policies and solutions need to be Further strengthening the link between uni- based on evidence. Workforce plans should be versities and the health sector is impor- continuously updated based on the evidence tant. Although some of the nursing schools available. Nursing research in Saudi Arabia is have enterprise-wide university data systems currently very limited but can be encouraged that track students and help manage school through a variety of different means. The Saudi resources, there is room for improvement and Scientific Nursing Council could publish a list of better sharing of data with the SHC or MOH, and the 10 most important research questions in the MOE. Many nursing schools are still man- Saudi nursing. Nursing teams (who have access aged on paper or via Excel or Microsoft Word. to patients and data) could be encouraged to Switching to appropriate digital school manage- work with nursing professors (who have the ment systems in all schools will help improve knowledge of how to design research protocols the efficiency of the schools and sharing of data and analyze data). In addition, all clinical nurs- needed for planning and policy making. Nursing ing teams can be encouraged to perform oper- school software can help track, manage, and ational research and track nursing-sensitive evaluate students, staff, curricula, clinical sites, indicators. and compliance.

Strengthening the nursing representation The development and enforcement of regula- across sectors requires more attention. Cur- tions for nursing schools are needed, but it will be

36 GOVERNING THE MARKET FOR NURSES

important not to over-regulate. Given the antici- that some regulatory bodies serve as “guilds” pated expansion in nursing schools, especially pri- that do more to protect and advance the pro- vate nursing schools, the capacity of the MOE to fession than to improve quality and productiv- regulate nursing schools needs to be expanded. ity of the health system and patients’ access to The regulator should take up a supportive role, health care. There have been calls that no major identifying gaps and helping to fill them, rather HRH regulatory change should be made unless than a policing role of automatically shutting it can be shown that there will be a net beneficial down schools that do not meet standards. The effect on patients and the health system. In light regulator can also be supportive as mentioned of the increasing clinical autonomy of nurses, above by setting up networks that support vari- medical malpractice reform may be needed in ous roles within nursing schools, such as deans, Saudi Arabia. Saudi Arabia currently has low admissions officers, or clinical rotation directors, rates of medical malpractice lawsuits, which, for example. Such networks will help improve the when filed, rarely focus on the nurse. However, performance of nursing schools. with increasing nurse autonomy and increasing numbers of APNs, lawsuits that include nurses The development and enforcement of reg- can be expected to rise. Therefore, the policy ulations for the nursing profession are also around nurse legal liability and nurse malprac- needed. It is clear in the field of HRH in general tice insurance may need to be reformed.

CONCLUSION 8

This discussion paper was designed to help inform efforts for more rigorous analyses of the workforce and to help inform discussions around the development of health workforce plans, policies, and strategies in KSA. It was not designed as a rigorous analysis of the national nursing labor market, but as an initial document to pull together some of the perceived challenges and opportunities for nursing in KSA. The paper was informed by the existing literature on the nursing profession, and more directly by the inputs of a select number of key stakeholders of the nursing profession in Saudi Arabia (including the President of the National Nursing Association, the Head of the Professional Council of Nurses, and the Head of the Scientific Council of Nurses). Any potential bias and subjectiv- ity of the information provided by individuals representing different interests and sectors should be taken into consideration.

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Appendixes 1–3: Relevant Organizations, Nursing Schools, and Advisory Group Members

Appendix 1: Table of Organizations Relevant to Saudi Nursing and their Roles

Organization Role Saudi Health Council • Coordinates health-related policy over all ministries that have a health role, including the MOH, the MOD, the MOE, the MOI, etc. Saudi Commission for • Sets the standards for nursing in Saudi Arabia Health Specialists • Decides what cadres of nursing are recognized and their scope of practice • Designs and administers nursing exams Saudi Professional Nursing • Within the Saudi Commission for Health Specialists (SCFHS), responsible for advancing policies related Council to the improvement of the nursing profession Saudi Scientific Nursing • Within the SCFHS, responsible for engaging in education and academic advancement of the nursing Council profession Saudi Nursing Association • Represents the nursing profession National Committee for • Advises the SHC on the nursing profession Nurses Nursing Deans’ Committee • Advises the MOE on nursing school matters • Enables the sharing of best practices and lessons learned among nursing school deans

47 THE NURSING WORKFORCE IN SAUDI ARABIA – CHALLENGES AND OPPORTUNITIES

Appendix 2: Number of Public and Private Nursing Schools, by Geographical Area

Name of the University Type of the University Area 1 King Saud University Public The Central Area 2 King Abdulaziz University Public The Western Area 3 Imam Abdulrahman Bin Faisal University Public The Eastern Area 4 King Khalid University Public The Southern Area 5 University of Ha’il Public The Northern Area 6 Umm Al-Qura University Public The Western Area 7 Prince Sattam Bin Abdulaziz University Public The Central Area 8 Taibah University – Madinah Public The Western Area 9 Yanbu University Public The Western Area 10 Taibah University – Ula Public The Western Area 11 Shaqra University Public The Central Area 12 Najran University Public The Southern Area 13 Jazan University Public The Southern Area 14 Taif University Public The Western Area 15 Al-Baha University Public The Southern Area 16 Jouf University Public The Northern Area 17 Bisha University Public The Southern Area 18 Majmaah University Public The Central Area 19 King Faisal University Public The Eastern Area 20 King Abdulaziz University Public The Western Area 21 King Saud Bin Abdulaziz University – Jeddah Public The Western Area 22 King Saud Bin Abdulaziz University – Al Ahsa Public The Eastern Area 23 Princess Nourah University Public The Central Area 24 Qassim University Public The Central Area 25 Hafr Al Batin University Public The Northern Area 26 Northern Border University Public The Northern Area 27 Al Ghad National Colleges Private The Central Area 28 Al Ghad National College – Jeddah Private The Western Area 29 Al Ghad National Colleges – Dammam Private The Eastern Area 30 Al Ghad National Colleges – Madinah Private The Western Area 31 Al Ghad National Colleges – Tabuk Private The Northern Area 32 Al Ghad National Colleges – Abha Private The Southern Area 33 Al Ghad National Colleges – Najran Private The Southern Area 34 Buraidah National College Private The Central Area (continued on next page)

48 Appendixes 1–3: Relevant Organizations, Nursing Schools, and Advisory Group Members

Appendix 2: Number of Public and Private Nursing Schools, by Geographical Area (continued)

Name of the University Type of the University Area 35 Almaarefa Colleges Private The Central Area 36 Fakeeh College for Medical Sciences Private The Western Area 37 Al Ghad National College – Riyadh Private The Central Area 38 Inaya Medical College Private The Central Area 39 Riyada College Private The Western Area

Appendix 3: Advisory Group Members y Nabeeha Tashkandi y Mohammed Alghamdi y Fahd Albalawi y Taqwa Omar

The Saudi Health Council 6293 Olya Rd Riyadh 3161-13315 Kingdom of Saudi Arabia www.shc.gov.sa