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Saudi Arabia has a chronic shortage of Saudi healthcare professionals, especially nurses, which is accompanied by a high level of turnover (Abu-Zinadah, 2004; 2006a). Expatriate nurses form a large proportion of the nursing staff in the Saudi healthcare facilities (MOH,

2008a; WHO, 2006a). Statistics of the MOH (2008a) showed that the total number of nurses in all healthcare sectors was approximately 101,298, yet only 29.1% of them are Saudis. This dependence on expatriate nurses worsens in the private health sector where local nurses comprise only 4.1% (see Table 3.1).

Table ‎3.1

Nursing personnel in the healthcare sectors in Saudi Arabia (2008)

Sector No. Saudis (%) Non-Saudis (%)

Ministry of Health 55,429 24,689 (44.5) 30,740 (55.5) Other Govt. Facilities 23,536 3,908 (16.6) 19,628 (83.4)

Private Sector 22,333 909 (04.1) 21,424 (95.9)

Total 101,298 29,506 (29.1) 71,792 (70.9) Source of data: Ministry of Health (2008a) Health statistical year book. Ministry of Health, Riyadh.

In the MOH, which is the main provider of health care in Saudi Arabia, nurses numbered 55,429 (55.2%) of the total health workforce. Of these, 24,689 (44.5%) are Saudis, while the rest are expatriates (MOH, 2008a). The majority work in public hospitals (73.1%), while the rest operate the PHC centres and other related departments. The percentage of Saudi relative to expatriate nurses working in the healthcare sectors grew from 9% in 1996 to 21.5% in 2002 and 29.1% in 2008 (see Figure 3.1) (Aldossary et al., 2008; 2002; MOH, 2008a). However, this growth, while noteworthy, is not compatible with the actual need. Recent statistics by the MOH (2008a) showed that the ratio of nurses, including expatriates at the MOH facilities, is 22.3 nurses/10,000 (one nurse for 473 people). This ratio drops critically at the PHC services to 5.2 nurses/10,000 people. The overall ratio of nurses in the different health sectors in Saudi Arabia is 40/10,000 people. While this rate is

and Jordan (32), it is still lower than other regional and developed countries such as Bahrain (61), Qatar (60), Australia (97), Japan (95), and France (80) (WHO, 2011).

Figure ‎3.1. Nursing workforce in all healthcare sectors in Saudi Arabia, 1996-2008.

Source of data: Aldossary, A., While, A., & Barriball, L. (2008). Health care and nursing in Saudi Arabia. International Nursing Review, 55, 125-128; Ministry of Health (2002, 2008a). Health statistical year book. Ministry of Health, Riyadh.

Part of the problem of the nursing shortage in Saudi Arabia is the high dependency on expatriate nurses (Al-Ahmadi, 2006). The majority of expatriates use the Saudi healthcare facilities as a temporary location to obtain training and experience. Then they move with marketable skills to developed countries such as the USA, the UK, Canada, and Australia (Alamri et al., 2006; Alhusaini, 2006). Unfortunately, there are no published statistics regarding this critical issue, although expatriate turnover is a major concern for managers of healthcare facilities (Almalki et al., 2011b). Other factors that are blamed for the nursing shortage in Saudi Arabia include the lack of awareness about nursing opportunities among high school students, the nature of nursing work that conflicts with the family and personal

life (high workload, long working duties, night shifts, and working over public holidays and weekends), low payment compared with other jobs, lack of professional growth, and lack of support for working mothers (Abu-Zinadah, 2004; Al-Sa’d, 2007). However, the common blamed factor for the nursing shortage in Saudi Arabia is the poor image of nurses (Abu-Zinadah, 2004). Due to its importance, this factor will be discussed in detail in the following section.

3.6.1 Low status of nursing as a profession

The Saudi youth generally do not prefer nursing as their future career. A number of health studies undertaken during the 1990s in Saudi Arabia indicated a high opposition of students and their parents to study and have nursing as a job. In 1991, Jackson and Gary conducted a survey study to explore the attitudes and perceptions towards nursing as a profession of 1,131 secondary and university students in Saudi Arabia. The findings indicated that the low impressions of nursing and cultural and communal values were identified as the main causes that prevent the Saudi nationals from entering the nursing profession. Likewise, a survey study of university students and their parents in Riyadh showed that students were reluctant to enrol in nursing, and that both students and their parents hold incorrect knowledge and negative images of the nursing career. Reasons given for not choosing nursing included the image of nursing, long working hours, and mixing with the opposite gender (Mansour, 1992).

Several years later, another study was conducted by Hamdi and Alhyder (1996) to examine the factors that influence Saudi females’ choice of nursing as a profession. The findings demonstrated that female students of both high schools and health institutes have

ranked nursing as fourth among three other jobs of teacher, physician and social worker, respectively. Reasons for avoiding nursing by Saudi females include family disagreement, cultural values, low chance of marriage, poor image of nursing, gender desegregation, dissatisfaction with job salaries, lack of job progress opportunities, job nature, high level of patient-related stress, long working hours, night shifts, and the requirement of a good level of English.

During the 2000s, the situation is not far from previous years. Aljawhari (2000) reported a common agreement between Saudi female students of high school and their families regarding the inappropriateness of nursing as a future career. They ranked nursing as last among nine other jobs. The results also showed that about 80% of the participants do not desire to work in nursing. Major reasons that prevent Saudi females from studying nursing include working with males at the same place, unsuitable rotation schedules, values and beliefs of the community, difficulty of nursing tasks, and the low image of nursing as a profession. In addition, the majority of male university students felt discouraged to marry a female nurse for the same reasons (Aljawhari, 2000).

Similarly, Al-Omar (2004) conducted a survey study to determine the knowledge, attitudes, and intention among the Saudi high school students in Riyadh towards the nursing profession. The findings established that only 5.2% of the examined students indicated nursing as their preferred future job. Inferential data analysis showed that attitude, having or not having a nurse friend and knowledge were found to have a significant positive influence on high school students’ intention, while long working hours and enormous workload compared to other jobs were found to have a significant negative influence. This study concluded that Saudi health decision-makers need to increase

positive attitudes regarding the nature and encouraging characteristics of modern nursing and its increasing esteem as a skilful career for high school students.

Al Thagafi (2006) investigated the attitudes of grade one students at Al Sebaei Health Institute in Altaif city, Saudi Arabia, towards the nursing profession. The findings of the study showed a negative attitude. Significant differences in students’ attitudes towards nursing due to personal opinion, future profession and societal opinion were observed (α = 0.05). However, these negative attitudes towards nursing were successfully managed by implementing a particular planned educational program.

To minimise the effect of nursing shortages and related factors, including the poor image of nurses, health and nursing long-term plans are needed to recruit more local nurses and to retain the current expatriate workforce. High priority in such strategies should be given to the role of the media in educating local people about nursing and its important role in the provision of health care. In fact, Saudi nurses are more eligible to work with local patients since they know the language, culture and customs, and are well versed in the common socioeconomic problems (Abu-Zinadah, 2006; Alamri et al., 2006).