Introduction Background The Kingdom of Saudi Arabia has committed vast resources by allocating more than 13 percent of its annual budget in improving the Kingdom's medical care system, with the ultimate goal of providing free medical care for everyone. This commitment has been translated to more than 330 hospitals operated by the government and the private sector, with a capacity of more than 50, 000 beds. Of these hospitals, 184 are run by the government, with more than 16 thousand doctors, 40 thousand nurses, and more than 25 thousand assistant nurses according to the Ministry of Health (2003). Based on these figures and the Saudi population of 20 million people, to satisfy and maintain the current health care standard, one out of every two hundred Saudi nationals and residents should work within the Saudi medical sector. This number would not include all other personnel working within the private medical sector or other personnel working behind the scenes; where all managerial and logistical decisions are being made. This task of maintaining the current standard is hard, especially at the nursing level.
With a country that has a young history, young education system, and young population with more than 50 percent of its citizens under the age of 18 years old. With these facts, having enough nurses seems to be an impossible task to be achieved. Other factors as long working hours and working night shifts in a country that is over protective of its wives and daughters are also factors that contribute to hardening the task. Due to these issues among others, Saudi Arabia has become one of the most nurse importing countries in the world, if not the most, with over 80 percent of its nurses are non-Saudi nationals. The Shortage: To understand the Saudi shortage in nurses, one has to understand the Saudi dependence on foreign nurses. In a country as young as Saudi Arabia; going from the tribal age to the informational age in less than 70 years was and still considered a dream come true for many people.
With a low literacy rates, 15 percent for men and less than 2 percent for women in 1970, Saudi Arabia with its new untapped oil reserved was committed in producing and providing the best for its citizens; schools, hospitals, communities, industries, and jobs. As result, Saudi Arabia has decided that it would import all means and personnel in need to produce a better society. For some time, importing everything was the only solution to the Saudi lack of all modern life necessities, but with the new education system, placed in the mid 60 s, Saudi Arabia started collecting its harvest of educated citizens. Unfortunately, the Saudi education system has only focused on high paid, prosperous, and prestigious jobs like doctors, engineers, and lawyers and left basic yet complementary job as nursing way behind.
This lack of attention to necessary and complementary jobs, has led the Saudi education system in creating less than 20 percent of the nursing staff working in Saudi today, which in return led into today's significant shortage in qualified and competent Saudi nurses and to high rate of imported nurses (Sadeeq, 2003). Even with a limited nursing teaching facilities, the Saudi social perception of nurses was a major factor in the nurse shortage in the country today. First, being low paying job, nursing is considered a middle to low class job, in contrast with it counterpart of being a physician. Secondly, with long working hours and night shifts, Saudi female nurses have had hard time in practicing their jobs due to strict social traditions. Last but not the least, the people's perceptions of being the nurse of nothing more than a maid; who has to follow the physician's orders and the patient's needs, has ruined the nurse image completely. As hospitals across the country face a shortage in nurses, King Abdulaziz University Hospital (KAUH) as most other Saudi hospitals have chosen the path of importing professional labor to satisfy its needs of necessary nurses.
Yet, with a nurses turnover of almost 30% a year, importing nurses has become a constant headache to hospital staff and management. Work overload due to nurse shortage, low salaries and additional factors as expected nurse conduct and behavior standards, in addition of competition with other recruitment countries have made recruitment and marinating the right nurse with the right qualification harder every year. Therefore, within this review we would examine causes that lead to this high turnover and try to provide effective solution for each cause. Variables of Concern: Through this review we will examine some of the variables that lead to the high rate of turnover in the King Abdulaziz University Hospital and how this number can be reduced significantly with few marginal adjustments to the recruiting policy: Behavior & Conduct Standers As most foreign nurses come to Saudi Arabia from countries like the Philippines and India, living the Saudi different culture and tradition becomes a daily ritual of these nurses' lives. Due to its pride in the Arabic and Islamic heritage, the Saudi Arabian customs and traditions sometime impose stricter rules and specific behaviors other than nurses have been accustomed to. Due to these differences in customs, imported nurses have a hard time to adjusting with Islamic & Arabian customs and traditions.
Life luxuries substance as alcohol, sexually suggestive magazines, and narcotics among other things including any and all additives are not available in Saudi. Plus, the separation in the Saudi life between single men and women has made the lives of some a little bit harder. According to Post (2003) "All Saudi Arabian social life functions are separated into male and female. The position of women in Saudi Arabia is very different from that in Western countries. In public, a Saudi woman is completely covered from head to toe. From an early age women live in extreme privacy, and are not normally seen by other men except for their husbands and close male relatives.
Single Western males and females are not allowed to mix socially except in the presence of a married couple. Islam and deep-rooted traditions play an important role in Saudi Arabia." This way of expected social conducts has made it hard for foreign nurses to adjust to the Saudi Arabian living standard, especially as some foreign workers see working abroad is an opportunity to meet people and learn more about other cultures. Life Expectations & Recruiting Competition In addition to behavior and conduct standers which are expected from all foreign workers in Saudi Arabia, other Saudi residential rules and regulation have made living in Saudi harder for foreigners than one would expect. For a country that was built with the help of people who came from all around the world, the Saudi government have made sure that when this country is up and running, only a hand full of needed foreign nationals would be here to benefit from what they help achieving.
The government also made sure that Saudi citizens should be able to carry out the task when foreign workers are leave back home. Lack of granting foreigners a permanent residential status or the ability of purchasing a real estate has kept nurses from considering Saudi Arabia a home to them especially, for married foreigners with more than one source of income. These families would save as much money as they can to spend it back home. Yet, other countries as Britain, the United States, and Canada, which have aggressive recruiting programs, have provided another good alternative to Saudi Arabia. And as Saudi sees other third world countries as good place to recruit nurses, nurses see Saudi Arabia as the first step to the western world. As Saudi recruits a nurse and trains him / her into how to handle patients and how to use new advanced machinery, the nurse starts after few years of working in looking for another opportunity in a western country, specially, that the new western recruiting programs have been encouraging nurses to use Saudi Arabia as bridge and a first step to the western world.
Countries as United Kingdom and the United States see Saudi Arabia as fertile ground of importing already imported highly trained cheap labor which in turn increases the Saudi turnover numbers. Work Expectations As Saudi Arabia is experiencing severe shortage in nurses and a high dependency on imported labor, the limited number of nurses in hospitals is expected to be at their highest performance to carry out the duties assigned on the way to achieve and maintain health within the country. Unfortunately, with a ratio of 8-10 patients per nurse, maintaining good service for patients becomes a very hard task to achieve. That is not including periods when a nurse have to accompany one of his / her patients to the X-ray room, at that time his / her load of patients is assigned to other nurses on the floor; which in turn, changes the patient to nurse ratio to 12-14 patients per nurse. This patient to nurse ratio leads to reducing time spent to take care of each patient and leads to more of patient complaints. These complaints in the end lead to patient insistence on having a family member to accompanies him / her in the room and more work load is added to the nurse, since he / she are serving two instead of one.
This patient to nurse ratio also leads to nurses delaying their break, prayers, and eating times which lead to exhaustion and burnout among nurses. Other administrative factors do sometimes add to work expectation burden. To meet the goal of providing an adequate, safe, and effective care, King Abdulaziz University Hospital has maintained a minimum of 50 working hours a week, and a maximum of 45 days of annual leave to keep enough nurses on the floor. Yet, personal and unaccounted factors as nurse pregnancy might complicate all prearrangement. These personal issues can disintegrate any plans that a hospital like KAUH has to utilize its resources to the end and make the working environment less than expected by the KAUH nurses. Financial Aspects: Hospitals are crucial part of our health care system, which largely provides curative health care service.
Although hospitals seem to occupy a very small part in the overall health care system in term of numbers, they in fact take the major chunk of the Ministry of Health's annual expenditure. Since costs in the healthcare sector have increased significantly throughout the past 20 years or so, most developed or developing countries around the world have chosen to import foreign nurses out of other countries mainly third world countries. On one hand, this importing has helped a country like Saudi Arabia to maintain health among its citizens at the lowest costs, but, on the other hand, it kept salaries at barley minimum that Saudis were not interested in penetrating into this field. Undoubtedly, foreign nurses from countries as Philippines, Indonesia, and India among others saw working in Saudi as a chance and an opportunity to improve their living standard by making large amount of money since currency exchange works in their favor. For example, imported nurses would costs a hospital as King Abdulaziz University Hospital about the third of what a Saudi nurse would cost.
Solutions In contrast to the other countries that are looking for cheap labor, Saudi Arabia faces a real shortage in its medical care service. This shortage is significant within the nurses' level, it is due to limited nursing schools and colleges, only 15 thousand nurses have graduated from the Saudi education system in the last seven years (Sadeeq, 2003). However, in other countries, shortage in nurses is more of an economical shortage than human shortage. According to Sergeant "There are, however, more trained nurses in Britain not working than there are still in the profession.
Instead of making a return to work attractive with better pay, flexible hours (many are women with children) and better conditions, the British National Health Service (NHS) recruits nurses from Third World countries" (2002). This shortage in the Saudi Arabian qualified nurses can be solved by nurse recruiting programs, yet not as old recruiting ones, since a high turnover rates would make recruiting costly and inefficient in most cases. Therefore, human resources personnel within the KAUH should recognize that recruiting the right nurse is essential to achieve the anticipated level of patient's health care. First, recruiting Muslim nurses, for example, would solve the behavior & conduct standers problems, which are expected out of foreign nurses working in Saudi.
As Muslim nurses would not try to participate in activates as consuming alcohol, sexually suggestive magazines, or narcotics in following of the Islamic doctrine. However, these nurses would be wearing the Hijab, the Islamic veil, and would fit easily among other Saudi women. Secondly, recruiting nurses over the age of 38 year old would also help in having more financial and emotional stability among hospital personnel, which in turn would not be looking for an alternative path for his / her life as future plans of moving out of Saudi Arabia or having another kids for married couples. This kind of decision would have been made previous to a nurse coming to Saudi. A third solution that Human Resources can implement is recruiting more of nurse assistant to meet easy tasks and add a balance to the patient to nurse ratio.
This balance in the Patient to nurse ration, will approve the working environment and reduce complaints of the nurses and the patients. Last but not the least, to really solve the foreign labor shortage, one point should be considered by the Human Resource Mangers within the KAUH is to encourage Saudis to work as nurses. By improving the nurses' image; starting by escalating levels of respect for them within the hospital. This starting respect would quickly be reflected to the outside world and the nursing profession would have more than a maid image. In addition, the Human Recourses Mangers should look into improving the nurses' living standard by increasing Saudi nurses pay. These decisions can encourage more Saudis to join the nursing field which would reflect in reducing KAUH dependency on foreign nurses as more Saudis join the field.
Conclusion Today, King Abdulaziz University Hospital is having a hard time in providing quality care to its patients due to nurse shortage that it the hospital is experiencing. Yet, with some minor adjustment within the hospital's recruitment program, one can be assured and certain that these programs would do what it meant to do. Until the huge investment that the Saudi Arabia is inputting within the Saudi education system pay, dependency on foreign nurses would be an essential part of the Saudi health care system. References Mi story of Health, (2003), web C. (2003), web forum / show flat. php/Cat/0/Number/3790/page/4/view / collapsed /sb/9/o / all /f part/1 Sadeeq, M.
, (2003), Nursing Jobs for Saudis, web Issue 2298. Sergeant, H. , (2002), Labour's asylum policy is to fool the public that all is well, Telegraph. co. uk, (Filed: 16/12/2002)..