Strategies to Enhance Critical Thinking in Saudi Arabia Nursing Education

¶ … 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 has been assumed that the medical professional with the most training in diagnosis was best suited to perform the critical thinking function, and that nurses were to act as caretakers who followed the directions passed down by doctors (Turner, 2005). Unfortunately for the patient, there is a need to have someone immediately available who has "the ability to collect, interpret, analyze, synthesize, and evaluate data" (Maneval, Filburn, Deringer, & Lum, 2011). Critical thinking is important in nursing primarily because the nurse is the healthcare worker tasked with direct care of the patient (Simpson, 2002, 23). The need to make decisions that will impact the health and safety of the patient is of paramount importance in the role of nurse. Education which fosters this ability is critical to nurses and the literature bears out the fact that multiple methods can be used to accomplish this goal (Maneval, Filburn, Deringer, & Lum, 2011; Reese, Jeffries & Engum, 2010; Simpson, 2002, 26).

Strategies to Enhance Critical Thinking in Saudi Arabian Nursing

In the discussion raised by Simpson (2002) is the difference between critical thinking and other types of mental processes which may, at first, seem to be synonymous. The author indicates that critical thinking is not the same as problem solving, decision making or creative thinking (Simpson, 2002, 23). In problem solving, the nurse is not asked to "raise questions and critique the solutions" (23); decision making differs in that it is only concerned with clinical applications (24); and creative thinking often takes a "leap of faith" approach that is not a function of critical thinking (Simpson, 2002, 25). The importance of critical thinking is that the nurse is able to look at a situation, devise possible solutions to the presented problem, and then he or she can evaluate which possible outcome will be the best when applied to the situation. This level of investigation and thought is being taught in Western nursing programs, and it needs to be integrated into the programs in Saudi Arabia.

A great deal of research has been done regarding different methods of teaching critical thinking in different types of programs, but nursing programs, teaching a specific skill set, have devised singular methods to teach this new skill. Among those are problem-based learning, experiential education/learning, active learning, case study, target teaching, group discussion, student centered teaching, concept matching, and simulations. All of these approaches can be used to instill the concept, but determining which would be best suited for nursing students in Saudi Arabia is the educational conundrum.

Saudi culture is relevant to this discussion because how the native nurses in that country have been taught in the past determines how receptive and successful they will be when attempting to use the instruction while on the job (Simpson, 2002, 115). There is a need for nursing educators to try and understand where the connects and disconnects are for this process to be effective. Critical thinking is a needed application in nursing, so it is critical to determine the most effective pathway for Saudi nursing students.

Simpson (2002) evaluated the use of different types of critical thinking pedagogy and their appropriateness when used in Saudi Arabian nursing programs. Questioning is the technique first implemented by Socrates in his work with students. His aim was to teach a subject by making the students think about the questions that arose when they were considering it. This method has its basis in the eastern tradition and is actually very familiar to students in Saudi Arabia because of its basis in that region of the world (Simpson, 2002, 31). A second method that Simpson (2002, 35) mentions is small group technique. Students are encouraged to look at an issue while in a group and each member is encouraged to think about the problem presented independently. Then all of the students are tasked with coming back to the group with their solution, and all are critically analyzed by all members of the team. This technique has been used by medical and nursing students for many years during clinical training. But, the difference here is that students are asked to think critically and ask questions about the approach presented by other in the group. This method is closely akin to debate which is used in a similar small group setting, and students are asked to look at a number of known solutions to a problem and determine which of them is the best for the situation via lively discussion (Simpson, 2002, 36). Another that Simpson investigated was the use of role-play (Simson, 2002, 37). Students are placed into situations that simulate reality and they are asked to act out what they would do in the given situation. The other nurses in the group are tasked with critically evaluating the responses of the actor to the problem. One of the more interesting critical thinking exercises that Simpson investigated was reflective journaling. She stated that students were asked to journal about their clinical experiences and review their thoughts and actions during a typical day in the hospital. This exercise allowed the students to see what had been done by professional nurses and doctors, and then evaluate it based on the practices that they were being taught (Simpson, 2002, 38).