Nursing History and Education in Saudi Arabia

Introduction and Objectives

The primary objective of this work is to provide the reader with evidence-based nursing education and practice principles. The goal 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, and this work aims to support nurses and nurse educators in doing so.

The cultural values of the Kingdom of Saudi Arabia are also an important component of this discussion, 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 is to help develop a culture of professional nursing. The aim is 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, suggestions are put forward for a rigorous nursing curriculum; research development and utilization are promoted; and both educators and students are offered new ideas about how to face the difficulties and issues unique to the culture of the Kingdom of Saudi Arabia.

Historical Roots: Nursing in Early Islamic Society

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 — navigating between cultural directives and modern governmental and educational policies. Historically, the nursing profession depended upon the community-based care of local healers, with some noteworthy exceptions, who 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 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 not yet been tapped at the time of its founding. 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, which dated back 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 practice commonly exercised in the Arab world: empathy and compassion were the heart of community-based care.

Compassionate care drove the first nurses, like Rufaida al-Asalmiya, to hone their skill sets and identify best practices to treat the various ailments that patients presented. Considering the often war-torn times of the Middle Ages in which Rufaida lived, it should not be surprising that this type of care emerged. 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) Western Florence Nightingale — a nurse devoted to caring for 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 a historical example of care during the initial Islamic period (Tumulty, 2001).

Combining Ancient Teachings with Nursing Practices 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 impulse of the nurse practitioner to tend to the needs of others — what today is called patient-centered care (Karabudak, Arslan, & Basbakkal, 2013). Arab physicians during the post-Prophetic era 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 a vast body of medical works and treatises. 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, studied, and added to them. The Arabic language became the language of scholarship in the region — for as the Golden Era of Greek civilization fell away, Arab civilization gathered and saved what it deemed worth keeping. From Plato's assessment that one wishing to cure the body must first heal 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 advances in 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 for guidance in approaching 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.

There was also substantial intellectual activity among physicians and nurses during this time. By the 800s AD, an Arab physician named Ibn Rabban at-Tabari was describing in his own book the various maladies and diseases known to affect the working of the brain (Kyziridis, 2005). To assume that no research was being conducted in the Arab world prior to the modern era is to overlook 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). Though direct study of the human body via dissection was forbidden in Arabic culture, Arab researchers put forward working theories on the relationship between the parts of the body — from pores to veins to arteries and lungs. 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).

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

It was 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 embodied the ideals of the community-based nurse through her exercise of 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). Rufaida thus 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 in communities across Arabia (Bryant, 2003). She emphasized the importance of cleanliness, and during military campaigns she led a corps of female nurses who administered to injured soldiers, cleaning their wounds and helping to stabilize their condition until surgery could be conducted. Just as al-Rashid's hospital served as a model for others in the Arab states, Rufaida served as a model nurse for centuries — a woman who respected the patriarchal norms of Islam while tending to the sick.

Rufaida al-Asalmiya: Pioneer of Nursing

Rufaida al-Asalmiya is rightly called the pioneer of nursing in Saudi Arabia because of her devotion to the duties described 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 for the people to support the Islamic state. As a woman, Rufaida could not serve through force, but she could offer her services as a nurse. Not satisfied to labor 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 Battle of Badr in 624 AD by tending to Muslim warriors, giving them water, seeing to their wounds, and removing the dead from the field of battle to prevent contamination and the spread of disease among the living (Rassool, 2014). She 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). 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. 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 consistent with Mohammed's own recognition of Rufaida. 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 expatriate nurses from foreign lands (Almalki, Fitzgerald, & Clark, 2011). Today's nurses also recognize a need to promote better cultural responsiveness within their units: 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 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 Saudi culture, this should come naturally. The reason cultural responsiveness is a problem in the Kingdom is that there are too few indigenous nurses in the profession. Promotion of Rufaida's example as a pioneer of nursing could serve both the nursing profession in the Kingdom and the patient.

Conclusion

The history of nursing in the Kingdom of Saudi Arabia should not be thought of as beginning in 1932 with the official creation of the Kingdom. Rather, the history of nursing stretches back many centuries — all the way to the days of Mohammed the Prophet and Rufaida, his highly praised and highly skilled nurse practitioner, who tended to soldiers and the wounded in the holy wars of that era, much like Florence Nightingale would do centuries later in the West. Rufaida exemplified the ideals of Islam in her character and deportment as well as in the care she showed to her patients. Trained by her father in the craft of nursing, she applied herself to what she believed to be her duty to the Islamic state.

Today's nurses should likewise strive to model themselves after Rufaida's character. The Kingdom offers them a chance to acquire an education in nursing and to practice the profession at a variety of levels. The culture of Saudi Arabia remains somewhat conflicted in terms of what it seeks to promote and what its boundaries will permit. Addressing the issue of boundaries by remembering how the first pioneer of nursing in the Islamic world navigated them would help physicians, social workers, nurses, and patients to better and more fully embrace the idea of nursing in the Kingdom of Saudi Arabia.

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