Saudi Arabia and Nursing

Future of Nursing Education in the Kingdom of Saudi Arabia

The primary objective of this book is to provide the reader with evidence-based nursing education and practice principles. The goal of this work is to help nursing educators and nurse practitioners develop evidence-based nursing education standards and curriculum while providing nurses with effective examples of patient-centered care that is both high quality and cost effective. Patients and family members in Saudi Arabia have needs and expectations that nurses should seek to meet and fulfill. To that end, this book aims to support nurses and nurse educators.

The cultural values of the Kingdom of Saudi Arabia are also an important component of this work, as it is the culture of this country that supports and advances the aims of the nursing profession. This is seen in every aspect of the nursing profession -- from the earliest days of the first nursing pioneer to now, as the nation seeks to define itself and forge a path forward in the 21st century.

The secondary objective of this book is to help in developing a culture of professional nursing. It aims to provide a professional nursing model that can be utilized by nursing educators and clinicians, enabling them to strive professionally towards demonstrating the values, ideals, aims, and skills of the nurse practitioner. To that end, this book puts forward suggestions for a rigorous nursing curriculum, promotes research development and utilization, and provides both educators and students with new ideas about how to face the difficulties and issues that are unique to the culture of the Kingdom of Saudi Arabia.

It is my sincere hope that you find this book useful and appropriate as you partake in the advancement of the nursing profession in Saudi Arabia.

Chapter 1: Historical Perspective of Nursing in the Kingdom of Saudi Arabia

Compassionate care served as the basis for the first nurses in the Arab world. From the very first days of Islam to now, this has been the primary driver of nursing in what is now known as the Kingdom of Saudi Arabia. Because of strict rules and observances regarding the roles of men and women in Arab culture, the nursing profession has had to develop almost organically in between cultural directives and modern governmental and educational policies. Historically, the nursing profession has depended upon the community-based care of local healers, with some noteworthy exceptions, who have pioneered the nursing profession.

In 1932, the Kingdom of Saudi Arabia was formed. The unification of the Hejaz and Nejd under Abdul-Aziz bin Saud resulted from a series of battles and wars fought throughout the first part of the 20th century. The region over which Saud exerted control was exceedingly poor -- a desert landscape where civilizations had existed in clusters for thousands of years. What would become the Kingdom's lucrative oil fields had, at the time of its founding, not yet been tapped. As a society, the Kingdom stood at the very beginning stages of development and yet, compared to the Western world, rooted in a very old culture -- Islam -- with a Wahabbi slant. The conditions required for modern, research-based nursing were virtually non-existent. Health care in the early days of the Kingdom was primarily community-based rather than research-based.

6th to 7th Century AD: The Islamic Period

The community-based practices of the Kingdom stemmed from the regional and cultural traditions of the Arab population. This population dated back for centuries -- even to the earliest days of Islam. The first major Muslim nurse was in fact a contemporary of Mohammed: her name was Rufaida Al-Asalmiya (Miller-Rosser, Chapman, Francis, 2006). Rufaida al-Asalmiya demonstrated a number of skills -- those of nurse, surgeon and social worker (Jan, 1996). This combination of medical knowledge, compassion, and full spectrum service corresponds with the concept of community-based practices commonly exercised in the Arab land: empathy and compassion were the heart of community-based care. Compassionate care drove the first nurses, like Rufaida al-Asalmiya, to hone their skill-set and identify best practices to treat the various ailments that patients would present. Considering the often war-torn times of the Middle Ages when Rufaida lived, it should not be surprising that this type of care was provided. Necessity outweighed formal practice and Rufaida's response to the needs of wounded warriors was based on her role both as a woman in Islamic society and as a leader, identified as such by Mohammed himself.

Rufaida was essentially an early Arabic version of the (much later to come) Western Florence Nightingale -- a nurse devoted to caring for the fallen soldiers who fought in the holy wars. Rufaida and her attendant nurses were women who sought to give comfort and emotional assistance to Mohammed's soldiers. Their roles helped to set the stage for future nurses by providing an historical example of care during the initial Islamic Period (Tumulty, 2001).

Combining the Teachings of the Ancients with the Ideas and Nursing Practices of Physicians in the Post-Prophetic Era

This early period of history was not without some degree of research-based understanding of medicine. Islamic physicians often provided nursing care to patients that combined the learning of the Greeks with the compassionate care demonstrated by Rufaida. Rufaida's nursing style was, moreover, an extension of the natural and organic impulse of the nurse practitioner to tend to the needs of others -- which today is called patient-centered care (Karabudak, Arslan, Basbakkal, 2013). Thus, Arab physicians during the post-Prophetic Era in Arabian history, drew both upon the works of Mediterranean scholars and the cultural imperatives passed on to them by Mohammedan society. Caring was very much a spiritual act (Rassool, 2014) that nonetheless drew on the medical knowledge of the ancients (Kyziridis, 2005).

The Arab world had, after all, inherited the vast body of medical works and treatises written by the Greeks. As Lin (2008) notes, "The knowledge of the earlier Greek medical teachings came to Islam through Nestorian Christians driven out of Byzantine and settling in Persia" (p. 41). The Arabs not only preserved the Greek writings and teachings, but translated them, studied them and added to them. The Arabic language became a the language of scholarship in the region -- for as the Golden Era of Greek civilization fell away under the ashes of time and history the Arab civilization gathered and saved that which it deemed worth keeping. From Plato's assessment that if one wished to cure the body he must first start by healing the soul, to Galen's second century AD finding "that mental diseases could be the result of a disorder in the brain or the secondary result of the disorder of another organ" (Kyziridis, 2005, p. 43), the Greeks had made significant penetrations into the world of medical science and nursing from both a spiritual and a biological perspective. The Arab world was much indebted to the work of Galen in Rome, who extended and deepened the work begun on the Greek island of Kos, where Hippocrates laid the foremost teachings for physicians under Pericles (Holmes, 1997). The Arab world also drew on its own deep spirituality to provide guidance in terms of how it approached the practice of nursing. As Rassool (2014) points out, "the history of nursing in Islam grounds the nursing identity in the religious values shared between nurses and patients" (p. 36). Thus it was that Rufaida found such favor with Mohammed: she represented to him and his followers exactly the type of compassionate community-based care that a devout Muslim should show towards others who were suffering and in need. Al-Osimy (2005) states as much when he quotes the Quran as teaching that "whoever works righteousness, whether male or female, while he (or she) is a true believer (of Islamic Monotheism) verily, to him We will give a good life" (p. 1). In other words, if Rufaida set the stage for nurses in Saudi Arabia, Mohammed provided the spiritual guidance and support for their commission.

Yet, there was much intellectual activity among physicians and nurses during this time as well. By the 800s AD, even as Charlemagne was uniting the European tribes under the banner of Rome, an Arab physician named Ibn Rabban at-Tabari was busily describing in his own book the various maladies and diseases known to affect the working of the brain (Kyziridis, 2005). Thus, to assume that no research was being conducted in the Arab world prior to the modern era is to miss out on a number of substantial facts. The Arab peoples of the past were thoroughly interested in deepening the vast body of knowledge on medicine, pharmacy, therapy, chemistry, and nursing techniques that could be used to help patients experiencing a wide variety of symptoms (Saad, Said, 2011). And though direct study of the human body (via dissection) was forbidden in the Arabic culture, Arab researchers certainly put forward working theories on the relationship of the parts of the body: everything from pores to veins to arteries and lungs was seen as having an integral, relational role to play in the life of the body. These theories were based on Arabic readings of the works of Galen and Hippocrates -- translated by the Arabic scholar Hunain ibn Ishaq, recognized today as the most important translator of the Greeks and preserver of Greek medicine (Saad, Said, 2011). Thanks to these works and their preservation in Arabic culture, nurses and physicians have been able to base their work on more than just the incentive to care given them by their Creator. They have been able to base it on research as well. Today, that base is larger than it ever has been in human history.

This veneration for medicine, science and the practice of health care demonstrated by early Muslims fed into the Arab world's desire for to support public health. For instance, the centuries long Abassid Caliphate was instrumental in taking the medical knowledge preserved by these scholars and applying it in everyday life. Harun al-Rashid provided the first hospital to the north of the Arabian Peninsula in the early 800s (Saad, Said, 2011), thus establishing for Arabs a model facility that would be followed for centuries wherever possible. The Abassid in Egypt did exactly that with its own hospital -- and others were founded as well, in Damascus, Tunisia, Mecca and Medina. Arab hospitals in the Middle Ages were places where medicine was both taught and practiced.

It was here in the deserts of the Arabian Peninsula, where medieval wars were common, that the work of Rufaida al-Asalmiya was oriented to meet the needs of patients at that time. As Rassool (2014) observes, Rufaida could be said to have embodied the ideals of the community-based nurse through her exercise of her duties -- described as: "duty to God, duty of the Muslim to himself, duty of Muslim nurses to increase knowledge of science and nursing and the need to connect the past and present" (p. 31). Thus, Rufaida united her heart to the needs of others through her commitment to the religion propagated by Mohammed: she developed mobile care units that could be easily and quickly transferred among patients of the communities in Arabia (Bryant, 2003). Rufaida emphasized the importance of cleanliness and during military campaigns she acted as the leader of a corps of female nurses who administered to injured soldiers, cleaning the wounded and helping to stabilize their status until surgery could be conducted. Just as Al-Rashid's hospital served as the model for others in the Arab states, Rufaida served as a model nurse for centuries -- a woman who submitted to the patriarchal norms of Islam and tended to the sick.

The Pioneer of Nursing

Rufaida al-Asalmiya is rightly called the pioneer of nursing in Saudi Arabia because of her devotion to the duties depicted above. Even before she became a Muslim, she had devoted herself to learning nursing skills from her father Saad al-Asalmi -- a local physician from Yathrib (today known as Madinah) (Rassool, 2014). Holy wars were frequent in the region and there were many calls from all directions for the people to support the holy wars and the Islamic state. As a woman, Rufaida could not serve the Islamic state through force, but she could offer up her services as a nurse. Not satisfied to endeavor alone, Rufaida organized a group of women and trained them in the skills of nursing, teaching them about the importance of proper hygiene, the power of emotional support for those in need, and the art of dressing wounds and stabilizing patients.

Together, Rufaida and her nurse corps assisted at the Badr invasion in 624 AD by tending to Muslim warriors, giving them water, seeing to their wounds, and removing the dead from the field of battle in order to prevent contamination and the spread of disease among the living (Rassool, 2014). It was she who essentially established what could be called the very first health clinic in the Islamic state: "a tent in the Prophet's mosque where health education to the community was delivered" (Rassool, 2014, p. 30). Rufaida was as devoted to spreading positive information about health care and nursing to the Islamic community as Mohammed was about spreading the faith. In fact, both went hand in hand, as Al-Osimy (2005) has shown. Their duties were reciprocal and mutually beneficial.

Rufaida went on to establish Islam's very first nursing school and devised a code of ethics for her nurses (Jan, 1996). The theme that emerges from her teachings is that nursing was a way for individuals to practice Islam (Rassool, 2014). What this means is that the objective of the nurse is consistent with the objectives of the Muslim religion, for in the practice of nursing is the achievement of what Islam calls each individual Muslim to do for his brother and sister in the faith: care for them. Likewise, Rufaida taught nursing in order to promote its spread and acceptance within the Islamic state. Jan (1996) notes that "Rufaida is a great role model for us today. We, who are Muslims, should not forget our historical tradition and the example of Rufaida -- our first nurse, nurse educator, nurse leader, and founder of our first nursing school and clinics" (p. 268). This high praise is in fact consistent with that of Mohammed's for the same Rufaida. It was after all the Prophet who noted her exceptional character, skill and role in the war against the infidel: Al-Osimy (1994) writes that the "status of the women participating as nurses in the wars was so highly honored by the Holy Prophet that he considered their effort as a form of Jihad in the cause of Allah. He used to give them their share of the war loot just as he gave men theirs" (p. 18). Clearly, Rufaida was the pioneer of nursing in the Islamic state -- and as such can be viewed as the patroness of nursing in the Kingdom of Saudi Arabia today.

Today, the Kingdom of Saudi Arabia is struggling to meet the healthcare needs of a growing population (Tumulty, 2001): the nursing profession is shrinking and is ever-more dependent upon the arrival of expatriate nurses from foreign lands (Almalki, Fitzgerald, Clark, 2011). Today's nurses also recognize a need to promote better cultural responsiveness within their units, as with so many foreign nurses providing care to Muslim patients in the Kingdom too many cultural cues are being lost in translation (Roberts, Moussa, Sherrod, 2011). One of the most important lessons for nurses in the Kingdom to realize today is that "cultural responsiveness requires organizations and individuals to be aware of cultural baselines and diversity in patients, allow and respect patients' cultural perspectives, and collaborate with patients to deliver culturally congruent care" (Roberts, Moussa, Sherrod, 2011, p. 52). For Saudi nurses familiar with the Saudi culture, this should come naturally. The reason that cultural responsiveness is a problem in the Kingdom is there are too few indigenous nurses in the profession. The Kingdom's culture has forgotten the shining example that Rufaida gave to men and women in the Islamic state. Promotion of her example as a pioneer of nursing could serve both the nursing profession in the Kingdom as well as the patient.

Pioneers of the Modern Era

In the modern era, the early days of the Kingdom of Saudi Arabia differed in no substantial way from how life had been lived in centuries past: the same traditional Islamic culture existed -- and, prior to Abdul-Aziz bin Saud's victories in the 20th century, the same fighting among tribal leaders. The Saudi dynasty, the rise of which began in the 18th century near Riyadh, merged with the Wahhabis to promote a fundamentalist type of Islam: it promoted the traditional patriarchal system in which the modern era nurses who modeled themselves after Rufaida would strive to fulfill their nursing duties.

By the 1940s, when oil became the Kingdom's new natural resource -- with enormous reserves found in the late 1930s and pumped out of the ground with assistance from the West -- the Kingdom's economy boomed and new life was breathed into the region. As a result, new inroads to nursing could be made, thanks to the tireless efforts of leaders like Lutfiyyah al-Khateeb and Samira Islam (Miller-Rosser, Chapman, Francis, 2006). As El-Sanabary (2003) observes, Lutfiyyah al-Khateeb has long be recognized by local Saudis as a notable leader in nursing for her support of health institutes and the positive impact that education can have on women's lives. Samira Islam is also viewed as a pioneer for her role in demonstrating how a nurse in Saudi Arabia should conduct herself within the Islamic paradigm and Saudi culture (El-Sanabary, 2003). Samira Islam has helped to raise awareness about issues that nurses face in the Kingdom: her own personal experience of being "looked down upon" by physicians who studied alongside her in her classes indicates that the medical industry in the Kingdom views nurses as inferior to other healthcare professionals (Miller-Rosser, Chapman, Francis, 2006). The medical culture in Saudi Arabia is such that those who seek "power" and "prestige" typically hold nurses as servants and do not relegate to them the kind of honor that Mohammed showed to Rufaida. Fortunately, this type of prejudice has reared its head in other cultures -- notably in both the West and the East -- and in both it has been overcome through education, promotion of the nursing profession as worthy of respect, and proper consideration given towards adjusting the cultural aspects of society that encourage prejudicial and biased thinking of this order (Miller-Rosser, Chapman, Francis, 2006). With this in mind, there is no reason to believe that the nursing profession cannot overcome the hurdles facing it in the Kingdom today. As Samira Islam has shown, the path forward depends upon Saudis appreciating their heritage and looking backward to the shining example that Rufaida was for women and for nurses -- and indeed for all Islam.

Still, these two modern pioneers of nursing in the Kingdom -- Lutfiyyah and Samira -- have not been admired by all in Saudi Arabia; the Kingdom is essentially conflicted in terms of how it views the role of woman in society. On the one hand, the Kingdom is more modern than it has ever been. On the other, it is still very old in that it clings to its religious and social traditions, including its patriarchal system, wherein women are best seen as contributing positively to society by remaining in the home (El-Sanabary, 2003). For this reason, nursing even still is not wholly embraced by the Kingdom and the majority of the nurses in Saudi Arabia are expatriates from other lands (Almalki, Fitzgerald, Clark, 2011). The nursing profession is still considered a very low-status position for women, because the socio-cultural teaching in the Kingdom is that women should not work outside the home unless they absolutely have to. The model spirit of Rufaida and her focus on simple, compassionate, community-based nursing is in many ways lost on the modern, Wahabbi-driven Saudi mindset.

Past Nursing Practice -- Community Based

In the first half of the 20th century, before the Kingdom was unified, most health issues were referred to local healers, who recommended recitation of the Quran along with the ingestion of particular herbs when treating various ailments such as back pain, depression or infertility (Al-Hashem, 2016). This served as the essence of community-based nursing in Saudi Arabia: a traditional and customary focus on healing via nursing the patient with a faith-based focus and a holistic medicinal approach.

King Abdul-Aziz attempted to regulate and contemporize the healthcare setting in Saudi Arabia. While ruling over the Hejaz region, King Abdul-Aziz instituted the Directorate of Public Health in Makkah; from there, the promotion of public health and safety was performed. This would prove an important step for Saudi Arabia, as the Hajj season was one in which thousands of pilgrims trekked to Saudi Arabia to celebrate their faith -- and outbreaks of disease were common (Memish, 2010). Abdul-Aziz created the Health and Emergency Department in 1926, a decade before the Kingdom was established. It allowed hospitals and healthcare systems to be created and managed -- and over the next 25 years, 11 hospitals would be founded across Saudi Arabia (Al-Hashem, 2016). Health education continued to be poorly provided, however, and it was not until nearly the end of the 20th century that health education and preventative services provided by physicians and nurses really began to be more effectively administered throughout Saudi Arabia (Al-Hashem, 2016).

Thus from the beginning of the Kingdom of Saudi Arabia to now, the idea of community-based nursing remained the most common practice. Today's current nursing environment is steadily increasing its focus, however, on more research-based practice, with nurses being more highly educated in Saudi Arabia than ever before. Still, issues remain regarding the promotion of nursing as a serious profession: marriage remains a high priority in the Kingdom for women, and few men view nursing as an ideal profession for marriageable women (Miller-Rosser, Chapman, Francis, 2006). In order for this to change, the perception of nursing as a less than ideal profession for women must undergo a transformation in Saudi culture.

Contemporary Nursing in Saudi Arabia

In spite of the advancements made in the Kingdom towards establishing a more highly proficient nursing educational system, by the 1990s most nurses continued still to come from outside Saudi Arabia (Jackson, Gary, 1991) -- which has proven problematic for Saudi patients because expatriate nurses administering care to them are not always the most culturally sensitive (Aldossary, While, Barriball, 2008). Thus, researchers still call for more indigenous nurses to provide holistic care in Saudi Arabia. In order for this to be achieved, the Kingdom would have to transform the way its society views nursing as a profession (Alyami, Watson, 2014).

However, it is also important that nurses not have unreal expectations about the cultural boundaries that should be respected in the Kingdom. As Rufaida serves as the model nurse in the Saudi Arabia, it is appropriate that the boundaries that she respected be studied. For example, she appreciated the cultural rules regarding segregation of the sexes, modesty of dress for women, and the subordinate role that women play both in private and in public life in the patriarchal system of the Islamic state. Rufaida excelled at showing respect for these boundaries and the modern nurse in the Kingdom should endeavor to do so too.