TITLE: all Saudi Arabian nurses living and working in




1.0       Research

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For many
organizations, no matter what industry they are in, turnover is a major concern
since it can be expensive in relation to recruiting, hiring, and training as
well as the cost of lost productivity. Many studies disclosed the worry of the nursing shortage, and vacancies
in nursing are reported in most countries of the world with turnover being
identified as a main contributor to the shortage of nurses (Ramoo, Abdullah
& Chua, 2013).

             It is even worse when many nurses, especially
from developing countries, migrate or leave their home countries to serve
developed countries (BandhanpreetKaur et al, 2013). Malaysia, similar to other
developing countries, is facing a nursing shortage and employee turnover in
this profession is really a matter of concern (Ramoo et al., 2013). The reasons
behind this phenomenon are aging nursing workforce, an increase in medical
facilities and overseas employment opportunities.

attrition rate is 400 per year and currently about 2,000 Malaysian nurses are
working in countries such as in the Middle East, United State of America,
Australia, New Zealand, Europe, and other Asian countries (Ministry of Health
Malaysia, 2008). This phenomenon is reportedly due to higher pay, less
job-stress and other attractive remunerations (Khatijah Omar, 2012). This
research is to explore the experience of Malaysian nurses working in Kingdom of
Saudi Arabian (KSA) hospital.


2.0       Existing
Evidence of Nursing in Saudi Arabia

This section will discuss four major research
papers based on the reflection of experiences of nurses working in Saudi
Arabia. The first research paper is by Dalena van Rooyen, Collette
Telford-Smith and Johanita Strumpher in 2010. This study explored and described
the experiences of South African nurses residing and working in KSA hospitals.
This study used a qualitative descriptive and contextual phenomological
approach method.

of this study consisted of all Saudi Arabian nurses living and working in the
Kingdom of Saudi Arabia. A purposive sampling was used in determining samples
of this study. Samples was selected based on several criteria of inclusion
which is one must be a registered nurses with South African Nursing Council,
able to speak English and Afrikaans, representing different gender groups,
comes from various cultural groupings in South Africa, resided in KSA for 3 to
6 months and is married, single or divorcee.

            Data was collected by
the main data collection instrument, which was individual interview, and also
from nurses’ personal journal while working there. Data was analyzed using
thematic analysis approach proposed by Tesch (1994). The findings of this study
were classified into 4 identified themes, which is religious/spiritual,
environmental, emotional/phycological and professional experiences of the
nurses. For example, some of the nurses explained the phenomena of religious
intolerance in KSA where there was restriction of belief especially for

            The next paper is
written by Hanan Al-Ahmadi, which this paper was published in the Saudi Medical
Journal in 2002. The objective of this study is to examine the determinant
factors of job satisfaction among nurses working in the Ministry of Health
Hospitals in Riyadh, KSA. This study used a quantitative descriptive research
design where questionnaire was utilized as the main data collection instrument.

            The population of this
study consisted of all nurses working in Ministry of Health hospitals in KSA.
The total number of nurses’ population in Riyadh is 5236 nurses. Among them,
14% are native of KSA. This study adopted a stratified convenience sampling
method where researcher asssumed that population is divided by Saudi and non-Saudi.
A sample of 500 nurses was selected. The questionnaire was developed based on
The Minnesota Satisfaction Questionnaire which consists of 25 items which was
classified into 10 different categories such as utilization of skills, job
advancement, pay, colleagues, recognition, autonomy, job security,
supervision/human factor, supervision/technical factor and work conditions.

            5 Point-Likert Scale
was used to calculate the responses from respondents, which ranged from very
dissatisfied to very satisfy. The internal reliability of the questionnaire was
calculated based on the pilot study condusted (Cronbach’s Coefficient alpha)
and items in questionnaire was also revised several times by panel of judges to
determine its validity. Data was analysed using descriptive statistics, which
includes standard deviations, frequency distribution, t-tests, and one wat
ANOVA, correlation and regression analysis.

            The result of the study
indicated that majority of the nurses are female and from South East Asian
countries. The overall job satisfaction among respondents showed that nurses
participated in this study has a moderate level of job satisfaction or
‘somewhat satisfied’ with their current job. As for t-test and ANOVA, there are
no significant differences in overall levels of job satisfaction in association
with gender, nationality, age, marital status, job tasks and monthly income. It
is determined that overall job satisfaction is significantly lower among
bachelo’s degree holders than middle college graduated and graduated of Health
institutes. Correlation analysis showed that overall job satisfaction improves
with time on the job. Job satisfaction factor, which received highest score, is
colleagues factor. This means that respondents are more satisfied at work due to
colleagues factor.

            The third research paper,
which will be discussed, is by Ahmad Aboshaiqah. This paper was published under
Journal of Nursing Management in 2015. The main purpose of the study is to
assess and investigate the work environment as perceived and reflected by
nurses in tertiary hospitals in Saudi Arabia. As such, this study used a
quantitative descriptive design involving all service units. Samples were
chosen using convenience-sampling method where a sample size of 1700 nurses was
selected out of 2800 of overall nurses population.

            The sample was selected
from different service/units departments in one of the government-owned
1000-bed tertiary hospitals in Saudi Arabia. Data was collected using
questionnaire adopted from American Association of Critical-Care Nurses (AACN)
Healthy Work Environment (HWE) assessment tool. A panel of experts and
undergone psychometric tests to determine its validity analyzed the original
instrument. In this study, the instrument was used for pretesting without modification.
Data was analyzed using SPSS version 17 to determine the mean score in each
item, the aggregate mean score in each standard interpreted using mean score
interpretation matrix.

            The results indicated
that the aggregate scores for all standards was interpreted as good where
effective decision making scored at 3.76, authentic leadership scored at 3.71,
appropriate staffing scored at 3.65, true collaboration at 3.64, skilled
communication at 3.60 and meaningful recognition at 3.53. The result interpreted,
as there was a good overall aggregate score for the institution equivalent to
good environment as perceived by participant nurses.  In a simpler description, nurses participated
in this study are satisfied with their work environment.

            Phil Halligan writes the
last research paper in 2006, which the paper aimed to describe citical nurses’
experiences in caring for patients of Muslim denomination in Saudi Arabia. This
study adopted a phenomological descriptive qualitative research design method
where in-depth interview was used as the primary data collection instrument.
This study was conducted in large hospital in the Eastern province of KSA.

            Participants were
selected using non-probability purposive sampling method. Th ecriteria of
inclusion includes; non-Muslim male and female senior staff nurses in critical
care unit, willing to take part in the study, able to express their opinions
clearly in English and possessed at least 1 year experience of caring critical
care unit patients in KSA. A total of 6 respondents was selected and was
interviewed individually using open-ended questions. Data was analyzed using
Colaizzi’s (1978) framework. Data gathered through interview were categorized
to identify the significant statements emerged in the responses. Responses as
categorized into themes.

findings showed that three main themes were identified; family and kinship
ties, cultural and religious influences and nurse-patient relationship.
Overall, the nurses experience significant Islamic denomination while working
at critical care unit in KSA includes stress, frustration and tensions
paracticing in an Islamic culture. For example, the connection of the family in
the care of their kin, including the routine visiting of family members,
created pressure for many of the participants. The impact of religion was found
to be all incorporating in the process of caring for their patients in KSA.
Physical touch and patient modesty is an integral part of the nurse–patient
interaction, regardless of the cultural context. This created a difficulty for
the participants when patients or families were given bad news, as the nurses
were not able to ‘touch’ or ‘comfort’ in the common way.


3.0       Evidence Gap and Research Aims

There has been numbers of documented literatures on
the experience of nurses living and working in Saudi Arabia both in private and
public healthcare setting. Examples are the work of Aboshaiqah in 2014 about
work environment in Saudi Arabia. The work of Al-Ahmadi in 2002 talked about
job satisfaction among nurses in public hospitals in Riyadh. Halligan in 2006
research about the overall experience of caring for patients in Saudi Arabia
while Rooyen et al., in their study in 2010 study on the reflections of South
African nurses working in Saudi Arabia.

            Among the literatures
studied and analyzed, there is no specific study about Malaysian nurses
experiences working in Saudi Arabia. Despite Malaysia being one of the major
nurses exporter country in Asia (Ministry of Health Malaysia, 2011), there is
still not much written about the experiences of nurses who quit job at the
local hospitals to work at Saudi hospitals and Malaysian nurses who were sent
to study clinical practices at Saudi hospitals as part of transfer-exchange
program. This is the identified gap of knowledge in this study. Thus, the study
meant to explore Malaysian nurses experiences of working in Saudi Arabia


4.0       Research Question/Hypothesis

The underlying question in this study is to
examine, investigate the experience of Malaysian nurses working in Saudi Arabia
hospitals. This experience includes several dimensions for example the aspect
of culture, gender, time zone, language etc. Even though Malaysia is an Islam
majority state, there is also other culture and religion co-existed. Nurses are
not only a work function partcipated by majority Malays who are Muslim but also
Chinese, Indian, Kadazan, Ibanese and others who are Non-Muslims. The clash of
experience between Malaysian nurses working in Saudi Arabia and local Saudi
nurses in Saudi hospital setting is very important to be documented in order to
determine the gaps.


5.0       Research Paradigm

Proposed research paradigm in this study is qualitative interpretative
phenomological analysis (IPA) approach. This is due to three main reasons, that
is the method being naturalistic, subjective and small-scale in-depth study,
which is very suitable for smaller group of identified respondents. IPA is
phenomenological, attempting to understand how participants relate to their
experiences (it does not assume that participants’ interpretations refer to
some verifiable reality) but it recognises that this involves a process of
interpretation by the researcher (Smith, Flowers & Larkin, 2009).

            It is an methodology
popular in psychology and in some field of nursing (Eatough & Smith, 2008).
The data are accounts, which researchers then code for emergent themes, look
for connections, and construct higher order themes example “depersonalisation” ascends
as a consequence of illness. Thus, qualitative IPA is chosen as the most
suitable approach for this study.


6.0       Research Design

A phenomenological
qualitative study will be conducted as a method of analysis for this study.
Qualitative studies will be use to reach a deeper understanding of, and find
explanations for people’s behaviour under specific conditions, such as disease
(Cypres, 2015). The key characteristic of this qualitative methodology is that
the researcher is closely involved in data collection and analysis; data
collection demands the researcher to interact with the study participants and
their social setting (Cypres, 2015). In the ground of qualitative studies, phenomenology attempts to understand
individuals voices of their own opinion on the basis of the meanings used by
them, in other words it looks through a window into other people’s experiences (Matua,

purpose of phenomenological studies is to identify the core of living this
experience and also in-depth lived experienced in subjective reflection
described by  subjects in situations or
events in a specific geographical, social and cultural environment. This
experience always has a meaning for the person who lived it (Matua, 2015).
Qualitative phenomenological studies are using first-person narratives from the
participants themselves as data source. In-depth interview using open-ended
questions will be employed to gather data.

of participants is through snowball method. Snowball sampling is defined as a
technique for finding research subjects. One subject gives the researcher the
name of another subject, who in turn provides the name of a third, and so on (Gile,
2008). This strategy can be viewed as a response to overcoming the problems
associated with sampling concealed populations such as the criminal and the
isolated (Gile & Hancock, 2010). Snowball sampling can be placed within a
wider set of link-tracing methodologies, which seek to take advantage of the
social networks of identified respondents to provide a researcher with an
ever-expanding set of potential contacts.

process is based on the assumption that a ‘bond’ or ‘link’ exists between the
initial sample and others in the same target population, allowing a series of
referrals to be made within a circle of acquaintance (Gile, 2011). Samples will
be chosen according to the recommendation of the initial identified samples.
Around 10 respondents will be identified to take part in this study. The
inclusion factor to be participant of this study is respondents must be
currently registered with Malaysian Nursing Board and have resided in Saudi
Arabia for a period between 6 to 12 months. This mean that only Malaysian
current registered nurses working in Saudi will be selected as samples,
excludes Malaysian nurses who have resigned from local hospitals and have been employed
by Saudi hospitals.

excluded from being selected as sample in this research apart from previous
mentioned characteristic, would also be those who resided in Saudi Arabia for
less than 6 months and those who resided for more than 12 months. The reason of
selecting respondents with 6 to 12 months working experience is due to the fact
that these are the times of adjustments where newly appointed nurses have adequate experience to maintain a standpoint, but
have not become too submersed in their condition, it is too early for a person
to gain experience of living in the KSA in three months, but, after six months,
may have grown used to the changes in lifestyle.

as mentioned before will be using in-depth interview using semi-structure
questions on the experience of nurses working in Saudi hospitals. The participants will be interviewed in their private
quarters whenever between their off duty as agreed by both party. The
researcher adhered to phenomenological interviewing techniques, as described by
Gile (2011). Field notes and the participants’ personal journals further served
as methods for data collection.  Personal
journals will be kept for two years after the interview (Gile, 2008). The
information was integrated when the final themes were identified.

            The following
general opening question will be pose to the participants: ‘What are your
experiences with regard to living and working in Saudi Arabia?’ Then the
following sub-question will be directed to the participants: ‘How can a
registered nurse be assisted to function effectively in Saudi Arabia?’. In-depth
phenomenological interviews will be conducted with the participants that each
lasting between 45 and 60 minutes. After which ‘data saturation’ was achieved,
in that the themes that emerged became recurrent (Gile & Hancoco, 2010).

            Data analysis can be
described as a search for patterns in data-recurrent behaviours, objects or a
body of knowledge. The recorded interviews were transcribed and analysed, along
with the field notes and personal journals. The data will be analysed using a
thematic analysis approach. According to the principles of phenomenological
research, the researcher made use of intuiting, bracketing, analysing the data
and describing the results.


7.0       Ethical

This relates to moral standards
that the researcher should consider in all research methods in all stages of
the research design. After approval from the selected hospital was obtained to
conduct the study, permission was obtained from the ethics committee of the Malaysian
Nursing Association. The researcher will be following three principles of
ethics namely beneficence, respect for human dignity as well as justice.

Principle of beneficence

This principle means, “above all
do no harm”. This principle contains broad scopes such as freedom from harm and
exploitation as well as the researcher’s duty to evaluate the risk/benefit

7.2       Freedom
from harm

In this study physical harm was
not to be considered, however, the researcher need to bear in mind that the
psychological consequences needed sensitivity. The researcher must being sensitive
to the participants’ emotions when probing questions that could psychologically
harm the participants. The researcher will inform the participants that they
are allowed to withdraw from the study or choose not to answer the questions if
they felt that the interview session were too much for them.

7.3       Freedom
from exploitation

Participants in a study will be
protected from any potential adverse situations. They will be assured that
information that they provide to the researcher or their participation will not
be used against them. The researcher-participant relationship should not be
exploited and confidentiality maintained. The tapes and written narratives were
safely stored in password/locked-protected file and were destroyed after the

7.4       Right
to self-determination

This principle means that the
selected participants will not be forced in involving toward this research and
they are allowed to withdraw from taking part in this study without any
consequences. Participants have the right to opt whether to participate without
encountering any penalty. Participants will be briefed and the purpose of the
study explained. No compensation will be offered and they were informed of the
opportunity to withdraw at any stage of the research. Verbal and written consent
will be obtained. Individuals involving in this research are on voluntary based
and no forced.

7.5       The
right to privacy

This means that the data provided
by participants will not be shared without their permission and consent and
will be kept only within the research team. As the study was conducted in the
participants’ natural setting; there was no intrusion of privacy with regard to
information provided. Anonymity will therefore be endorsed. Anonymity is the
inability to link information to participants. This was achieved by
tape-recording the interview conducted. The participants were assured of confidentiality
verbally and in the written consent form.