nursing education and specifically that completed in Saudi Arabia. The review will what the level of education is in Saudi Arabia now and historically, what efficacy critical thinking has as a component of nursing education and how that component can be enhanced among Saudi Arabian nurses.
Nursing Education in Saudi Arabia
History of Nursing Education
The roots of medical care on the Arabian peninsula can be traced to a single individual, Rufaida Al-Asalmiya, who was engaged by the prophet Mohammed care for soldiers during the holy wars (Aldossary & Barriball, 2008). The women already had significant experience in the medical profession as many of them were traditional healers and were skilled as the nurturing heads of families (Aldossary & Barriball, 2008). There is significant documentation of this period which shows how the practice of nursing was carried out by Rufaida and others, but after that period a history of nursing in the area is difficult to find (Miller-Rosser, Chapman & Francis, 2006).
Nursing was very well defined up until 632 AD, but was rarely spoken of in Arabic texts again until the latter portion of the nineteenth century (Miller-Rosser, Chapman & Francis, 2006). Research indicates that the nursing function was performed by doctors or family members during this time period because corporate means of healthcare were not available (Almalki, Fitzgerald & Clark, 2011; Miller-Rosser, Chapman & Francis, 2006). Small hospitals were constructed by the royal family in a few large outposts and these were available to the royal family and all loyal Bedouins (Miller-Rosser, Chapman & Francis, 2006). These hospitals contained caregivers, who were often family members, and the wards were segregated between men and women with nurses of the same gender caring for the patients (Almalki, Fitzgerald & Clark, 2011). Expatriate nurses and doctors were also brought in as early as 1890 to care for members of the royal family (Miller-Rosser, Chapman & Francis, 2006). Nursing became a priority only after Luffiyah al-Khateeb returned to the peninsula after receiving her diploma from a program in Cairo, Egypt (Miller-Rosser, Chapman & Francis, 2006).
Level of Nursing Education
Khateeb was the first nurse in Saudi Arabia who proposed that nurses be educated to the exacting standards of the West and that more nurses needed to come from within Saudi Arabia to care for its citizens rather than the continued dominance of expatriate healthcare workers (Miller-Rosser, Chapman & Francis, 2006). Since that time nursing education has become more professional in the nation with the introduction of nursing certificate programs in 1958, junior programs in 1965, and the opening of the first Junior College courses in 1992 (Aldossary & Barriball, 2008). During this time the government was also encouraged to open its own college degree programs and to encourage both men and women to join them. Saudi ministers spoke against a complete westernization because they wanted to "embrace those aspects which were beneficial to their society & #8230; [while] discarding those which threaten" (Simpson, 2002, 14). Thus college degree programs were carefully instituted with a BSN first being offered in 1976, followed by MSN in 1987, and the first doctorate program was begun in 1996 (Aldossary & Barriball, 2008). The level of education has improved over this period of time, but the number of Saudis applying to these programs has actually dropped (Miller-Rosser, Chapman & Francis, 2006).
Present Education Situation
According to Aldossary and Barriball (2008), presently "67% of the Saudi nurses graduated from Health Institutes, 30% from Junior Colleges and 3% from BSN programs, while there are also 28 with master's degree and 7 with a doctorate." This is critical to the people of Saudi Arabia who want their programs to produce enough nurses that they can fully stock hospitals with native workers. However, medical education, for both doctors and nurses, is currently inadequate to meet this demand. Another issue is that expatriate nursing educators continue to be needed because there are not nurses who are currently well-trained enough that they can take these positions.
This is a concern because the people of Saudi Arabia have been conditioned, in many ways, to mistrust expatriate workers (Simpson, 2002, 13), so there is an urgent need to switch to native workers and educators. Saudi nationals have the advantage of being able to instruct the people in the ways of modern medicine that is difficult for the expats. In many regions of the country, "the use of folk medicine is still practiced in this society" (Simpson, 2002, 13). Native nurses are thus needed to both make patients more comfortable and to educate them as to the improved efficacy of modern medicine.
State of Nursing
The level of available medical care and the fact that it is free to all citizens of the country has made Westernized practices much more accepted among Arab natives of the country. However, there remains a distrust of foreign workers (Simpson, 2002, 14) that is difficult to overcome. Since "medicine was largely based on folk remedies that were passed down from one family member to another (Simpson, 2002, 13), many people still do not believe that the invasive nature of modern medical techniques is preferable to what they have practiced for thousands of years. But, because the people of the country are becoming more accustomed to the benefits of this new medical knowledge, they are changing that belief system.
This reliance on past methods has also been pervasive in nursing education (Aldossary & Barriball, 2008). Nursing education, throughout the world, had long been focused on disease and curing the symptoms of the illness that presented itself. Unfortunately, this reactionary approach to medicine does not prevent people from getting the diseases in the first place, and is damaging to the health of a population. This curative model of medicine was brought to Saudi Arabia by the educators who first brought nursing instruction to the Kingdom. However, that paradigm has been found to have significant flaws, so the nursing education community in the West has adopted a more preventive focus in education which has been forwarded to nations which employ expatriate Western nursing educators (Aldossary & Barriball, 2008).
The education of Saudi Arabian nurses has also become more oriented toward the whole family model rather than focusing specifically on the individual patient (Almalki, Fitzgerald & Clark, 2011). This is both a reflection of the traditional structure of the Saudi culture and the present thrust of nursing education. According to Brown (2006);
"The family and close friends is the most important social group in Saudi Arabia, with the oldest male being the patriarch. Younger members of the family highly respect and take care of their elders ... Most Saudi families tend to be large in size, a great factor that is also influenced by economics."
This family mentality is common to Eastern societies (from which Arab society derived), and less likely to be practiced in the West. Thus, the change for Saudi nurses is not an issue because of the atmosphere that they have grown to expect their entire lives.
Hospitals are being constructed with a view to this orientation (Brown, 2006), and families are encouraged to be members of the care-taking team. Moving from the individual-focused to a family-focused model is a natural progression and may make it easier for nursing educators to convince more young women and men to apply for nursing courses. However, this very family structure is a reason why many do not.
Family and close relationships are important in this culture, so what an individual's family and friends think about one's chosen profession also matters a great deal. The nursing profession does not carry the prestige in Saudi Arabia that it does in the West. Simpson (2002, 11) mentions that men and women who choose nursing as a profession are looked down on in Saudi society because it is thought that they occupy the position of a maid. Saudis do not understand the gravity of a nursing education so this keeps many from entering the profession. The latest figures show that only 22% of the nursing workforce in Saudi Arabia is native (Aldossary & Barriball, 2008), but that figure continues to grow slowly.
Role Of Critical Thinking in Nursing Education
Nursing education emphasizes many aspects of the profession, but it was not until recently that the role of critical thinking has been prominently featured in degree and certificate programs. For nurses, it was determined that the skills were the most important components of a proper education. Nurses who entered BSN programs were more likely to receive the rudiments of a critical thinking paradigm, but the importance of the practice did not become apparent until recent research demonstrated the need for this type of instruction in nursing programs.
Simpson (2002) said that "critical thinking is not a method to be learned, but rather a process and orientation of the mind and so includes both the cognitive and affective domains of reasoning." For many years, the skill focus of nursing precluded, apparently, the need for critical thinking education. It…