Developing culturally appropriate leadership for nursing in Saudi Arabia

382 Pages·2017·5.13 MB·English

by  Daniel Kelly

Cardiff University
School of Healthcare Sciences
Eastgate House Campus, 35-43 Newport Road, 12th Floor, Cardiff, CF24 0AB
South Wales, United Kingdom

Developing culturally appropriate leadership for
nursing in Saudi Arabia

Thesis submitted in partial fulfilment for the degree of Doctor of
Philosophy.

Abdulrahman A Aldawood
Student Number D1155438
December 2017

Supervised by
Professor Daniel Kelly
Professor Dianne Watkins
DECLARATION
This work has not been submitted in substance for any other degree or award at this or any other
university or place of learning, nor is being submitted concurrently in candidature for any degree
or other award.
Signed……………………………… (candidate) Date ………20/12/2017……………
STATEMENT 1
This thesis is being submitted in partial fulfilment of the requirements for the degree of
PhD.
Signed……… ……………………………… (candidate) Date ……20/12/2017……
STATEMENT 2
This thesis is the result of my own independent work/investigation, except where
otherwise stated, and the thesis has not been edited by a third party beyond what is
permitted by Cardiff University’s Policy on the Use of Third Party Editors by Research
Degree Students. Other sources are acknowledged by explicit references. The views
expressed are my own.
Signed……………………………………… (candidate) Date …… 20/12/2017…………
STATEMENT 3
I hereby give consent for my thesis, if accepted, to be available online in the University’s
Open Access repository and for inter-library loan, and for the title and summary to be
made available to outside organisations.
Signed……………………………… (candidate) Date ………20/12/2017……………
STATEMENT 4: PREVIOUSLY APPROVED BAR ON ACCESS
I hereby give consent for my thesis, if accepted, to be available online in the University’s
Open Access repository and for inter-library loans after expiry of a bar on access
previously approved by the Academic Standards & Quality Committee.
Signed……… ……….……………… (candidate) Date……20/12/2017………………
I
CONTENTS
LIST OF TABLES .................................................................................................................... IX
LIST OF FIGURES .................................................................................................................. IX
ABSTRACT .............................................................................................................................. XI
ACKNOWLEDGEMENTS .................................................................................................... XIV
DEDICATION ........................................................................................................................ XIV
CHAPTER ONE: Introduction ...................................................................................................... 1
1.1 Introduction .......................................................................................................................... 1
1.2 Background .......................................................................................................................... 3
1.3 Statement of the Problem ..................................................................................................... 7
1.4 Aims and Objectives of the Study........................................................................................ 8
1.5 Rationale of the Study ........................................................................................................ 10
1.6 Nursing Leadership and Management ............................................................................... 13
1.7 Nursing Leadership Training and Development ................................................................ 16
1.7.1 The Need for Nursing Leadership Training ................................................................ 16
1.7.2 Promoting and Maintaining Nursing Leadership Development in Practice ............... 17
1.8 Islamic Leadership ............................................................................................................. 19
1.9 Summary ............................................................................................................................ 21
CHAPTER TWO: Contextual Background ................................................................................. 22
2.1 Introduction ........................................................................................................................ 22
II
2.2 Overview of Saudi Arabia.................................................................................................. 22
2.3 Tribal Affiliation in SA ...................................................................................................... 24
2.4 Saudi Arabian Healthcare System ...................................................................................... 25
2.5 Healthcare privatization in Saudi Arabia ........................................................................... 27
2.6 The Nursing Profession in Saudi Arabia ............................................................................ 28
2.7 The Nursing Workforce ..................................................................................................... 31
2.8 Nursing Practice in SA ....................................................................................................... 32
2.9 Communication Barriers .................................................................................................... 33
2.10 Culture and Gender Segregation in Saudi Arabia ............................................................ 34
2.11 Summary .......................................................................................................................... 37
CHAPTER THREE: Literature Review ...................................................................................... 38
3.1 Introduction ........................................................................................................................ 38
3.1.1 Literature Search Strategy and Keywords................................................................... 40
3.1.2 Inclusion and Exclusion Criteria ................................................................................. 41
3.1.3 Organization of the review .......................................................................................... 41
3.1.4 Critique of relevant Middle Eastern Empirical Research Studies ....................... 43
3.1.5 Summary of relevant Middle Eastern Empirical Research articles ............................. 51
3.2 Defining Leadership ........................................................................................................... 53
3.3 Leadership Theories ........................................................................................................... 62
3.3.1 Great Man Theory ....................................................................................................... 62
III
3.3.2 Trait Theory ................................................................................................................ 63
3.3.3 Contingency Theory .................................................................................................... 65
3.3.4 Transformational Theory ............................................................................................ 66
3.3.5 Servant Leadership Theory ......................................................................................... 67
3.4 The difference between Leadership and Management ....................................................... 68
3.5 Change Management and Leadership Style in the Middle East ........................................ 69
3.6 Defining Culture ................................................................................................................ 71
3.7 Nursing Leadership and culture ......................................................................................... 79
3.7.1 Why culture matters .................................................................................................... 79
3.7.2 Confirming the relevance of culture ........................................................................... 79
3.8 Leadership and Management in Nursing ........................................................................... 82
3.9 Leadership Styles in Nursing ............................................................................................. 83
3.9.1. Transformational Leadership in Nursing ................................................................... 84
3.9.2 Transactional Leadership in Nursing .......................................................................... 84
3.9.3 Differences between transformational and transactional leadership ........................... 85
3.9.4. Laissez-Faire Leadership in Nursing ......................................................................... 87
3.9.5. Effective Leadership in Nursing ................................................................................ 88
3.10 Leadership Practice in Multicultural Environments ........................................................ 88
3.10.1 Multicultural Environments ...................................................................................... 89
3.10.2 Nursing Leadership in a Multicultural Workforce .................................................... 90
IV
3.10.3 Transformational Leadership in a Multicultural Workforce ..................................... 91
3.11 Summary .......................................................................................................................... 94
CHAPTER FOUR: Methods ........................................................................................................ 95
4.1 Research Methodology ...................................................................................................... 95
4.2 Theoretical Framework and Research Questions ............................................................... 96
4.2.1 Research Questions ................................................................................................... 100
4.2.2 Employment of Cultural Competence Model to SA nurse leaders ........................... 100
4.3 Research Methods ............................................................................................................ 101
4.4 Study Setting .................................................................................................................... 102
4.5 Sampling .......................................................................................................................... 103
4.5.1 Data Collection ......................................................................................................... 105
4.6 An inductive strategy ....................................................................................................... 106
4.6.1 In-depth interviews ................................................................................................... 108
4.6.2 Focus Groups ............................................................................................................ 109
4.7 Data analysis .................................................................................................................... 114
4.7.1 Analysis and writing approach: Thematic analysis ................................................... 115
4.8 Ethical considerations ...................................................................................................... 119
4.8.1 Confidentiality .......................................................................................................... 122
4.8.2 Reflexivity ................................................................................................................. 122
4.8.3 Research validity and reliability................................................................................ 123
V
4.9 Limitations ....................................................................................................................... 124
4.10 Conclusion ..................................................................................................................... 125
CHAPTER FIVE: Findings ....................................................................................................... 127
5.1 Introduction ...................................................................................................................... 127
5.2. First main theme: Gendered Aspects of Nursing in Saudi Arabia .................................. 129
5.3 Second Main theme - Unique personal leadership qualities ............................................ 160
5.4 Third main theme: What Works? ..................................................................................... 198
5.5 Summary .......................................................................................................................... 230
5.5.1 Summary of Findings to Research Questions: .............................................................. 231
CHAPTER SIX: Discussion ...................................................................................................... 240
6.1 Introduction ...................................................................................................................... 240
6.2 Papadopoulos cultural competence model ....................................................................... 242
6.2.1 Cultural awareness and nursing leadership in SA ..................................................... 245
6.2.2 Cultural knowledge of nurse leaders in Saudi Arabia ............................................... 247
6.2.3 Cultural competence of nurse leaders ....................................................................... 248
6.3 First theme: Cultural diversity challenges and gendered aspects of Nursing in Saudi
Arabia ..................................................................................................................................... 250
6.3.1 Cultural influence and diversity ................................................................................ 250
6.3.2 Challenges facing nurse leaders in SA ...................................................................... 252
6.3.3 Expatriate Versus Local Nurses ................................................................................ 253
6.3.4 Managers’ solutions .................................................................................................. 259
VI
6.3.5 Gendered aspects in SA ............................................................................................ 261
6.4 Second main theme: Unique personal leadership qualities .............................................. 264
6.4.1 Personal leadership qualities ..................................................................................... 264
6.4.2 Effective communicator ............................................................................................ 267
6.4.3 Respectful and Trustworthy ...................................................................................... 270
6.4.4 Challenger ................................................................................................................. 271
6.4.5 Motivational .............................................................................................................. 272
6.4.6 Visionary ................................................................................................................... 273
6.4.7 Role model ................................................................................................................ 274
6.5 Third main theme: What works? ...................................................................................... 275
6.5.1 Cultural Training ....................................................................................................... 277
6.5.2 Communication and culture interaction .................................................................... 278
6.6 Summary of discussion chapter ....................................................................................... 280
6.7 Limitations of the research ............................................................................................... 287
CHAPTER SEVEN: Conclusion ............................................................................................... 288
7.1 Conclusion ....................................................................................................................... 288
7.1.1 Summary of the study findings ................................................................................. 289
7.2 Recommendations ............................................................................................................ 292
7.2.1 Recommendations for future research ...................................................................... 294
7.3 Recommendations for Saudi MOH .................................................................................. 295
VII
7.3.1 Characteristics and selection criteria of effective nurse leaders ............................... 296
7.3.2 Professional development ......................................................................................... 296
7.3.3 Recognition of nursing profession ............................................................................ 297
7.3.4 Professional learning of the nurse leader .................................................................. 298
7.4 Suggested leadership training programme ....................................................................... 298
7.5 Contribution and impact of the study ............................................................................... 299
7.6 At the End ........................................................................................................................ 300
7.7 A final personal reflection ............................................................................................... 300
REFERENCES ......................................................................................................................... 303
APPENDIX A – Invitation Letter .............................................................................................. 324
APPENDIX B – Participants Information Sheet ....................................................................... 325
APPENDIX C – Interview Consent Form ................................................................................. 329
APPENDIX E – Questions Prompt for Interviews and Focus Groups ...................................... 331
APPENDIX F - Ethical Approval from Ministry of Health, Saudi Arabia (Arabic). ................ 333
APPENDIX G - English Translation of MOH Ethical Approval .............................................. 334
APPENDIX H - KSMC Research Approval .............................................................................. 335
APPENDIX I – Cardiff University Ethics Approval ................................................................. 336
APPENDIX J – Sample Transcript Extract ............................................................................... 337
APPENDIX K– Sample Interview Transcript Thematic analysis ............................................. 343
APPENDIX L – Proposal for a Culturally Competent Nurse Leader Training Programme in
Saudi Arabia (CCNLTP) ............................................................................................................ 353
VIII
APPENDIX M – Curriculum Outline ........................................................................................ 360
APPENDIX N – Training Completed ........................................................................................ 363
APPENDIX O – First Prize Winning Scientific Poster………………………………………..365

LIST OF TABLES
Table 1 Nursing Personnel in SA ………………………………………... 32
Table 2 Critique of relevant Middle Eastern Empirical Research Studies... 43
Table 2 Biographical data of the sample ................................................... 104

LIST OF FIGURES
Figure 1. Map of Saudi Arabia ................................................................... 23
Figure 2. Medical centers and hospitals in SA ........................................... 26
Figure 3. Summary of challenges ............................................................... 29
Figure 4. Workforce in GCC countries ....................................................... 31
Figure 5. Female to male terms in SA economy ........................................ 35
Figure 6. Literature Review Themes …...................................................... 39
Figure 7. Core qualities of leader ................................................................ 54
Figure 8. Trait theories of leadership .......................................................... 64
Figure 9. Global distribution of healthcare nurses ..................................... 83
Figure 10. Transcultural leadership ............................................................ 85
Figure 11. Cross- cultural leadership Tips for the middle-east …….......... 92
Figure 12. Cultural Competence Model ...................................................... 98
Figure 13. Themes and sub themes to research questions ..........................128
Figure 13. First main Theme (Gendered aspects in SA) ............................ 130
IX