03 December 2015

Sandstorms and traffic in Riyadh

RIYADH, Saudi Arabia—Arriving at King Khalid International Airport in Riyadh in the early hours of last Sunday impressed on me just how different this place is from anywhere else I go. The streams of young ladies in various queues are stopped past immigration and have their passports confiscated. This violation of human rights means they are the indentured maids of Saudi families. Misbehaviour of any kind ends in corporal punishment, or worse.

Yours Truly with Assistant Professor of
Nursing Joel Gonzales Patalagsa, RN,
of King Saud University.
The other side of Saudi Arabia becomes visible when my Indian driver shakes my hand, this followed by a charming young man in full Arab dress who also welcomes me to Riyadh. The latter is Fayez, the unfortunate member of the teaching staff at King Saud University who has been tasked to meet me. It is 3 a.m. before I arrive at my hotel. Fayez is clearly getting the rest of the day off; I am not. Three and a half hours later, I am up and off to meet the dean of nursing. I had my revenge on poor Fayez, however. My driver had no idea where to take me—nobody gave us instructions. We took in a great deal of Riyadh before I phoned Fayez, waking him up to get directions.

The dean is Associate Professor Ahmad Aboshaiqah, PhD, RN, whom I met earlier this year on a previous visit to Riyadh. Aboshaiqah, who lived in the United States for 10 years and whose doctorate was supervised by a mutual colleague, Marilyn Oermann, PhD, RN, FAAN, commiserates on the loss of my good friend here, Professor James Ware, FRCS, who died a few weeks back. I knew Ware in Hong
Professor James Ware,
8 July 1941 – 9 October 2015
Kong, his death was sudden and, as everyone here confirms, a great loss. He led the team responsible for medical examinations at the Saudi Commission for Health Specialties and also established the Journal of Health Specialties. I wrote his obituary for the journal, and that will be published soon.

Where are the women?
I am on my first visit to King Saud University to advise staff members on writing for publication. Everything is done twice, as there is strict separation of male and female students and, therefore, male and female staff members between the main campus and the “girls’” campus. Apart from the Arab dress and Arab manners—ultimate politeness to visitors and brusque orders to junior staff—everything is quite normal with the men.

To enter the girls’ campus is to enter another world. There is not a glimpse of an undergraduate student and no view of the actual campus, which is behind high walls and large double doors at the end of long corridors. I am in an outer sanctum where men may wander freely and only staff members and masters’ students may venture. Most women—staff and students—are in the hijab, with only eyes visible, which makes it very hard to know who is speaking.

There are few non-verbal clues to indicate what they are thinking. I also keep introducing myself to people—without a handshake—who tell me that I had already introduced myself. There is continual and distracting adjustment of the abaya, the yashmak, and the headdress and, as Arab women do not project their voices, I am both confused and exhausted by the end of two days. However, in two-to-one consultations—no female meets you alone—I was able to advise on research projects and manuscripts and answer questions about master’s and doctoral study at my university.

There is virtually nothing to do in Riyadh. Where alcohol might take the edge off a long evening for me elsewhere, it is not available here. To pass the time, you work your way through a series of tooth-rotting and waist-expanding sickly sweet fruit drinks and mountainous plates of food. Walking is virtually impossible. Pavements—where they exist—are badly kept and where there is construction, piles of bricks, tiles and sand block your way. Magnificent buildings tower into the night sky, but getting to them on foot is impossible and an incipient sandstorm makes being outdoors unpleasant. Crossing the road to get to something that looks interesting is life threatening, as indicated in this podcast clip. There was a gym at the hotel, so I managed to burn a few calories in the evening.

I will be in Saudi at least three times this next year, with one of those visits to King Saud University. I visit Oman in January and Qatar in February, so it seems that the Far East is becoming less of a venue for me as the Middle East becomes more prominent. With the world the way it is now, I am frequently asked about my personal safety. People unfamiliar with the region cannot distinguish between Arab and terrorist, between Moslem and Islamic extremist. The religion may seem incomprehensible and aspects of the culture repellant, but every person who declines contact isolates the region further. As for personal safety, if I change my schedule or the places I visit, I hand a minor victory to the merchants of death.

Good news and bad news
As the joke goes, do you want the good news or the bad news first? The UK government has decided to do two things with nursing education that make perfect sense to me, one of which I have long advocated. Nursing students are paid bursaries by the National Health Service (NHS) to study nursing, and this will end. Despite progress made in moving nursing to universities and the move to all-graduate entry to the profession, we have never completely broken the link to the idea of the hospital apprenticeship model of training. Most other students have to fund themselves or take out loans, which are repaid when they enter employment. The UK is unique. In the United States and Australia, nursing students have to finance their studies at university like any other student. There is evidence—admittedly anecdotal—that some students come into nursing only to be paid the bursary, with a low commitment to the profession. These reports come from fellow students. It has always seemed wrong to me that, in a situation where we are heavily oversubscribed to nursing programmes, that we may be turning away people with a genuine commitment in favour of people doing it for the bursary.

The other thing that will change, mainly as a result of this change in funding, is that the cap on nursing places in universities will be lifted, as it has been lifted for other subjects. Universities can now take as many nursing students as they can manage. These moves are proposed as a response to nursing shortages and the high levels of non-UK nurses working in the NHS. These proposals were raised in a report titled "Supplying the demand for nurses" by Edmund Stubbs, whose credentials include four years working as a health care assistant. When I downloaded my copy, I opened it with relish. Thus ends the “good news.”

Expecting to find a good read, I was horrified to find language that was highly insensitive toward non-UK nurses, inappropriate nationalism, and complete misunderstanding of how nursing education is organised. The insensitive langauge came in the form of negative stereotyping of non-UK nurses who work in the NHS. Stubbs describes how many go home after working for a few years, as if they were to blame for being recruited, many leaving the poverty of their country to earn money elsewhere and support their families. This seems like a very acceptable form of foreign aid to me. 

The nationalism was apparent in the suggestion that, while those who choose to work in the NHS should have their loans repaid, those who work abroad should not. There is no logic to the NHS repaying the loans. I fail to see how this represents a cost-saving (which is at the heart of the report), and it continues to set nursing students aside from other students. Bribing nurses to remain in the NHS by creating a financial differential is just wrong. If we want to encourage nurses to work in the NHS, we must make it a better place to work, and if we want to stop nurses from working overseas, then what about our contribution to global nursing and how do we ensure that nurses gain international experience that they can bring back to the UK?

Finally, the report suggests that increasing the number of nursing students will be beneficial to the NHS as cheap labour. This is ludicrous and, in any case, nursing students have been “supernumerary” for nearly 20 years and are not included as part of the nursing workforce. The author makes no mention of this or about how nursing students will receive adequate supervision in clinical practice. I assume he is unaware of the issues. I wish I could end on a higher note, but, but except for this blog and podcast, where I describe fully what I think of this and some recent research on non-UK nurses working in the NHS, I find myself—finally—lost for words.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

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