1.0 ResearchFocusFor manyorganizations, no matter what industry they are in, turnover is a major concernsince it can be expensive in relation to recruiting, hiring, and training aswell as the cost of lost productivity. Many studies disclosed the worry of the nursing shortage, and vacanciesin nursing are reported in most countries of the world with turnover beingidentified as a main contributor to the shortage of nurses (Ramoo, Abdullah& Chua, 2013). It is even worse when many nurses, especiallyfrom developing countries, migrate or leave their home countries to servedeveloped countries (BandhanpreetKaur et al, 2013). Malaysia, similar to otherdeveloping countries, is facing a nursing shortage and employee turnover inthis profession is really a matter of concern (Ramoo et al., 2013). The reasonsbehind this phenomenon are aging nursing workforce, an increase in medicalfacilities and overseas employment opportunities.
Theattrition rate is 400 per year and currently about 2,000 Malaysian nurses areworking in countries such as in the Middle East, United State of America,Australia, New Zealand, Europe, and other Asian countries (Ministry of HealthMalaysia, 2008). This phenomenon is reportedly due to higher pay, lessjob-stress and other attractive remunerations (Khatijah Omar, 2012). Thisresearch is to explore the experience of Malaysian nurses working in Kingdom ofSaudi Arabian (KSA) hospital.
2.0 ExistingEvidence of Nursing in Saudi ArabiaThis section will discuss four major researchpapers based on the reflection of experiences of nurses working in SaudiArabia. The first research paper is by Dalena van Rooyen, ColletteTelford-Smith and Johanita Strumpher in 2010. This study explored and describedthe experiences of South African nurses residing and working in KSA hospitals.
This study used a qualitative descriptive and contextual phenomologicalapproach method. Populationof this study consisted of all Saudi Arabian nurses living and working in theKingdom of Saudi Arabia. A purposive sampling was used in determining samplesof this study. Samples was selected based on several criteria of inclusionwhich 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 to6 months and is married, single or divorcee.
Data was collected bythe main data collection instrument, which was individual interview, and alsofrom nurses’ personal journal while working there. Data was analyzed usingthematic analysis approach proposed by Tesch (1994). The findings of this studywere classified into 4 identified themes, which is religious/spiritual,environmental, emotional/phycological and professional experiences of thenurses. For example, some of the nurses explained the phenomena of religiousintolerance in KSA where there was restriction of belief especially fornon-Muslim. The next paper iswritten by Hanan Al-Ahmadi, which this paper was published in the Saudi MedicalJournal in 2002. The objective of this study is to examine the determinantfactors of job satisfaction among nurses working in the Ministry of HealthHospitals in Riyadh, KSA. This study used a quantitative descriptive researchdesign where questionnaire was utilized as the main data collection instrument. The population of thisstudy 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 samplingmethod where researcher asssumed that population is divided by Saudi and non-Saudi.A sample of 500 nurses was selected.
The questionnaire was developed based onThe Minnesota Satisfaction Questionnaire which consists of 25 items which wasclassified into 10 different categories such as utilization of skills, jobadvancement, pay, colleagues, recognition, autonomy, job security,supervision/human factor, supervision/technical factor and work conditions. 5 Point-Likert Scalewas used to calculate the responses from respondents, which ranged from verydissatisfied to very satisfy. The internal reliability of the questionnaire wascalculated based on the pilot study condusted (Cronbach’s Coefficient alpha)and items in questionnaire was also revised several times by panel of judges todetermine its validity. Data was analysed using descriptive statistics, whichincludes standard deviations, frequency distribution, t-tests, and one watANOVA, correlation and regression analysis. The result of the studyindicated that majority of the nurses are female and from South East Asiancountries. The overall job satisfaction among respondents showed that nursesparticipated in this study has a moderate level of job satisfaction or’somewhat satisfied’ with their current job. As for t-test and ANOVA, there areno significant differences in overall levels of job satisfaction in associationwith gender, nationality, age, marital status, job tasks and monthly income.
Itis determined that overall job satisfaction is significantly lower amongbachelo’s degree holders than middle college graduated and graduated of Healthinstitutes. Correlation analysis showed that overall job satisfaction improveswith time on the job. Job satisfaction factor, which received highest score, iscolleagues factor. This means that respondents are more satisfied at work due tocolleagues factor. The third research paper,which will be discussed, is by Ahmad Aboshaiqah. This paper was published underJournal of Nursing Management in 2015.
The main purpose of the study is toassess and investigate the work environment as perceived and reflected bynurses in tertiary hospitals in Saudi Arabia. As such, this study used aquantitative descriptive design involving all service units. Samples werechosen using convenience-sampling method where a sample size of 1700 nurses wasselected out of 2800 of overall nurses population. The sample was selectedfrom different service/units departments in one of the government-owned1000-bed tertiary hospitals in Saudi Arabia. Data was collected usingquestionnaire adopted from American Association of Critical-Care Nurses (AACN)Healthy Work Environment (HWE) assessment tool.
A panel of experts andundergone psychometric tests to determine its validity analyzed the originalinstrument. In this study, the instrument was used for pretesting without modification.Data was analyzed using SPSS version 17 to determine the mean score in eachitem, the aggregate mean score in each standard interpreted using mean scoreinterpretation matrix. The results indicatedthat the aggregate scores for all standards was interpreted as good whereeffective decision making scored at 3.76, authentic leadership scored at 3.71,appropriate staffing scored at 3.
65, true collaboration at 3.64, skilledcommunication at 3.60 and meaningful recognition at 3.
53. The result interpreted,as there was a good overall aggregate score for the institution equivalent togood environment as perceived by participant nurses. In a simpler description, nurses participatedin this study are satisfied with their work environment.
Phil Halligan writes thelast research paper in 2006, which the paper aimed to describe citical nurses’experiences in caring for patients of Muslim denomination in Saudi Arabia. Thisstudy adopted a phenomological descriptive qualitative research design methodwhere 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 wereselected using non-probability purposive sampling method.
Th ecriteria ofinclusion includes; non-Muslim male and female senior staff nurses in criticalcare unit, willing to take part in the study, able to express their opinionsclearly in English and possessed at least 1 year experience of caring criticalcare unit patients in KSA. A total of 6 respondents was selected and wasinterviewed individually using open-ended questions. Data was analyzed usingColaizzi’s (1978) framework. Data gathered through interview were categorizedto identify the significant statements emerged in the responses. Responses ascategorized into themes.
Thefindings showed that three main themes were identified; family and kinshipties, cultural and religious influences and nurse-patient relationship.Overall, the nurses experience significant Islamic denomination while workingat critical care unit in KSA includes stress, frustration and tensionsparacticing in an Islamic culture. For example, the connection of the family inthe care of their kin, including the routine visiting of family members,created pressure for many of the participants. The impact of religion was foundto 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–patientinteraction, regardless of the cultural context.
This created a difficulty forthe participants when patients or families were given bad news, as the nurseswere not able to ‘touch’ or ‘comfort’ in the common way. 3.0 Evidence Gap and Research AimsThere has been numbers of documented literatures onthe experience of nurses living and working in Saudi Arabia both in private andpublic healthcare setting. Examples are the work of Aboshaiqah in 2014 aboutwork environment in Saudi Arabia.
The work of Al-Ahmadi in 2002 talked aboutjob satisfaction among nurses in public hospitals in Riyadh. Halligan in 2006research about the overall experience of caring for patients in Saudi Arabiawhile Rooyen et al., in their study in 2010 study on the reflections of SouthAfrican nurses working in Saudi Arabia. Among the literaturesstudied and analyzed, there is no specific study about Malaysian nursesexperiences working in Saudi Arabia. Despite Malaysia being one of the majornurses exporter country in Asia (Ministry of Health Malaysia, 2011), there isstill not much written about the experiences of nurses who quit job at thelocal hospitals to work at Saudi hospitals and Malaysian nurses who were sentto study clinical practices at Saudi hospitals as part of transfer-exchangeprogram. This is the identified gap of knowledge in this study. Thus, the studymeant to explore Malaysian nurses experiences of working in Saudi Arabiahospital.
4.0 Research Question/HypothesisThe underlying question in this study is toexamine, investigate the experience of Malaysian nurses working in Saudi Arabiahospitals. This experience includes several dimensions for example the aspectof culture, gender, time zone, language etc.
Even though Malaysia is an Islammajority state, there is also other culture and religion co-existed. Nurses arenot only a work function partcipated by majority Malays who are Muslim but alsoChinese, Indian, Kadazan, Ibanese and others who are Non-Muslims. The clash ofexperience between Malaysian nurses working in Saudi Arabia and local Saudinurses in Saudi hospital setting is very important to be documented in order todetermine the gaps. 5.0 Research ParadigmProposed research paradigm in this study is qualitative interpretativephenomological analysis (IPA) approach. This is due to three main reasons, thatis the method being naturalistic, subjective and small-scale in-depth study,which is very suitable for smaller group of identified respondents.
IPA isphenomenological, attempting to understand how participants relate to theirexperiences (it does not assume that participants’ interpretations refer tosome verifiable reality) but it recognises that this involves a process ofinterpretation by the researcher (Smith, Flowers & Larkin, 2009). It is an methodologypopular in psychology and in some field of nursing (Eatough & Smith, 2008).The data are accounts, which researchers then code for emergent themes, lookfor connections, and construct higher order themes example “depersonalisation” ascendsas a consequence of illness. Thus, qualitative IPA is chosen as the mostsuitable approach for this study.
6.0 Research DesignA phenomenologicalqualitative study will be conducted as a method of analysis for this study.Qualitative studies will be use to reach a deeper understanding of, and findexplanations for people’s behaviour under specific conditions, such as disease(Cypres, 2015).
The key characteristic of this qualitative methodology is thatthe researcher is closely involved in data collection and analysis; datacollection demands the researcher to interact with the study participants andtheir social setting (Cypres, 2015). In the ground of qualitative studies, phenomenology attempts to understandindividuals voices of their own opinion on the basis of the meanings used bythem, in other words it looks through a window into other people’s experiences (Matua,2015). Thepurpose of phenomenological studies is to identify the core of living thisexperience and also in-depth lived experienced in subjective reflectiondescribed by subjects in situations orevents in a specific geographical, social and cultural environment. Thisexperience always has a meaning for the person who lived it (Matua, 2015).Qualitative phenomenological studies are using first-person narratives from theparticipants themselves as data source.
In-depth interview using open-endedquestions will be employed to gather data. Selectionof participants is through snowball method. Snowball sampling is defined as atechnique for finding research subjects. One subject gives the researcher thename 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 problemsassociated with sampling concealed populations such as the criminal and theisolated (Gile & Hancock, 2010). Snowball sampling can be placed within awider set of link-tracing methodologies, which seek to take advantage of thesocial networks of identified respondents to provide a researcher with anever-expanding set of potential contacts.
Thisprocess is based on the assumption that a ‘bond’ or ‘link’ exists between theinitial sample and others in the same target population, allowing a series ofreferrals to be made within a circle of acquaintance (Gile, 2011). Samples willbe chosen according to the recommendation of the initial identified samples.Around 10 respondents will be identified to take part in this study. Theinclusion factor to be participant of this study is respondents must becurrently registered with Malaysian Nursing Board and have resided in SaudiArabia for a period between 6 to 12 months. This mean that only Malaysiancurrent registered nurses working in Saudi will be selected as samples,excludes Malaysian nurses who have resigned from local hospitals and have been employedby Saudi hospitals. Thoseexcluded from being selected as sample in this research apart from previousmentioned characteristic, would also be those who resided in Saudi Arabia forless than 6 months and those who resided for more than 12 months.
The reason ofselecting respondents with 6 to 12 months working experience is due to the factthat these are the times of adjustments where newly appointed nurses have adequate experience to maintain a standpoint, buthave not become too submersed in their condition, it is too early for a personto gain experience of living in the KSA in three months, but, after six months,may have grown used to the changes in lifestyle. Dataas mentioned before will be using in-depth interview using semi-structurequestions on the experience of nurses working in Saudi hospitals. The participants will be interviewed in their privatequarters whenever between their off duty as agreed by both party. Theresearcher adhered to phenomenological interviewing techniques, as described byGile (2011).
Field notes and the participants’ personal journals further servedas methods for data collection. Personaljournals will be kept for two years after the interview (Gile, 2008). Theinformation was integrated when the final themes were identified.
The followinggeneral opening question will be pose to the participants: ‘What are yourexperiences with regard to living and working in Saudi Arabia?’ Then thefollowing sub-question will be directed to the participants: ‘How can aregistered nurse be assisted to function effectively in Saudi Arabia?’. In-depthphenomenological interviews will be conducted with the participants that eachlasting 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 bedescribed as a search for patterns in data-recurrent behaviours, objects or abody of knowledge. The recorded interviews were transcribed and analysed, alongwith the field notes and personal journals. The data will be analysed using athematic analysis approach. According to the principles of phenomenologicalresearch, the researcher made use of intuiting, bracketing, analysing the dataand describing the results.
7.0 EthicalConsiderationsThis relates to moral standardsthat the researcher should consider in all research methods in all stages ofthe research design. After approval from the selected hospital was obtained toconduct the study, permission was obtained from the ethics committee of the MalaysianNursing Association. The researcher will be following three principles ofethics namely beneficence, respect for human dignity as well as justice.
7.1 Principle of beneficence This principle means, “above alldo no harm”. This principle contains broad scopes such as freedom from harm andexploitation as well as the researcher’s duty to evaluate the risk/benefitratio.7.2 Freedomfrom harmIn this study physical harm wasnot to be considered, however, the researcher need to bear in mind that thepsychological consequences needed sensitivity. The researcher must being sensitiveto the participants’ emotions when probing questions that could psychologicallyharm the participants. The researcher will inform the participants that theyare allowed to withdraw from the study or choose not to answer the questions ifthey felt that the interview session were too much for them.
7.3 Freedomfrom exploitationParticipants in a study will beprotected from any potential adverse situations. They will be assured thatinformation that they provide to the researcher or their participation will notbe used against them.
The researcher-participant relationship should not beexploited and confidentiality maintained. The tapes and written narratives weresafely stored in password/locked-protected file and were destroyed after thestudy.7.4 Rightto self-determinationThis principle means that theselected participants will not be forced in involving toward this research andthey are allowed to withdraw from taking part in this study without anyconsequences. Participants have the right to opt whether to participate withoutencountering any penalty.
Participants will be briefed and the purpose of thestudy explained. No compensation will be offered and they were informed of theopportunity to withdraw at any stage of the research. Verbal and written consentwill be obtained. Individuals involving in this research are on voluntary basedand no forced.7.5 Theright to privacyThis means that the data providedby participants will not be shared without their permission and consent andwill be kept only within the research team.
As the study was conducted in theparticipants’ natural setting; there was no intrusion of privacy with regard toinformation provided. Anonymity will therefore be endorsed. Anonymity is theinability to link information to participants. This was achieved bytape-recording the interview conducted. The participants were assured of confidentialityverbally and in the written consent form.