Saudi Arabia, Part 3

RIYADH, Kingdom of Saudi Arabia—This is the end of my Saudi Arabia trilogy, although an addendum will be posted in May when I come back to speak at a conference. (I suppose I could identify the now four-part series as a tetralogy or quadrilogy.) My visit to Jeddah was over too quickly. For the first three days back in Riyadh, with teaching and other presentations from early morning until late afternoon, I barely had time to think. Now, I have two days to reflect and clear up loose ends before I return to the UK.

Presentation time with Juliana D'Sa and
Raeid A. Faqehi.

My first day back in Riyadh was spent partly in the College of Nursing (male) with Master in Nursing students and partly in the Medical College, where I gave a lecture about detecting similarity in manuscripts (available on podcast). The next day was spent at the leading hospital in Riyadh, King Faisal Specialist Hospital & Research Centre (KFSH), teaching on writing for publication and evidence-based practice. That day was hosted by Marinha Macedo, RN, nursing research senior specialist. By coincidence, I met her counterpart, Gillian Sedgewick, RN, at the Jeddah King Faisal hospital on the weekend. Both KFSHs are Magnet hospitals, the first in the Middle East. The third day was spent teaching at the General Directorate of Health Affairs, Riyadh on research and publishing. It was a thoroughly enjoyable day, but I was glad when it ended, as I was exhausted.

Jeddah memories: Yours Truly with, l-r, Wafaa
Al-Johani, Shadia Abdullah Hassan Yousuf,
Hannah Erfan Banjar, and Ahlam Eidah Al-Zharani.

The day finished back at the Ritz Carlton at a dinner hosted by my former University of Sheffield student, Mansour Al-Yami, PhD, RN, now general director, training and scholarship, at the Saudi Ministry of Health, along with several colleagues from the Saudi Ministry of Health. You know you’re a frequent visitor to a place when you get tapped on the shoulder and turn round to see someone you know. Mustafa Bodrick, PhD, RN, of King Saud bin Abdulaziz University (blog passim) was also dining, and he introduced me to Gwen Sherwood, PhD, RN, FAAN, University of North Carolina at Chapel Hill, with whom I will be dining tonight. Leaving the Ritz, I almost bumped—literally—into Joseph Westphal, U.S. ambassador to the Kingdom of Saudi Arabia. Any closer, and I think the security detail would have “taken me out.” I wonder if he was making arrangements for U.S. President Obama, who arrives today.

Reflections on Saudi Arabia

I have mentioned before in this blog that I am often asked about my safety when travelling to the Middle East. When I ask people to specify more precisely what they mean—I understand the question but am tired of it—they never can. There is an association in people’s minds between Arabs and terrorists. The association is understandable, given press portrayal of the situation in some parts of the region. The same kind of association applied to Northern Ireland for a prolonged period, now euphemistically referred to as “the troubles.”

However, I have also noted a frequent question here—almost daily—in my meetings about my impressions of Saudi Arabia. My answer depends on the question. If I am asked, “Do I like Saudi Arabia?” I find it hard to say yes, simply due to the visual impact of women peeping out over niqabs, an image I find hard to accept. However, while the positional disparity of men and women runs deep in Saudi society, I realise this cannot be a barrier to cooperation and collaboration. I find the women charming, self-deprecating, funny, and easy to work with. This is not my country, and I am a guest.

On the other hand, I was asked if my view of Saudi Arabia was positive or negative, and I replied without hesitation that it is positive. To someone from the West, the intrusive nature of religion is alien. However, I have been coming here since 1991, albeit with a significant gap in time, and things are changing. This is a highly developed society with the best hospitality and the most respectful people I have ever met. As I have said before, we turn our backs on the Middle East at our peril.

Exercise

Running has not been possible here, as there is not enough pavement to accommodate it in the part of Riyadh where I have been staying, so it has been the treadmill for two weeks. My various injuries are starting to resolve, and I can do a full-length pull-up without screaming. This indicates that, if I continue to improve, I should be able to start climbing again.

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.

Saudi Arabia, Part 1

HULL, United Kingdom—Absence of a blog post from me for several weeks should not be interpreted to mean that I only write when I am on my travels. Occasionally, I post entries from Hull, where I have been for the past three weeks, but these weeks have been packed with long days, many meetings, learning about new processes, and catching up on supervision of doctoral students. As I remarked to my wife: “It’s almost like having a real job. I’ll be glad to get away for a rest.”

Yours Truly with Mustafa Bedrock.

I have just returned to the UK from Saudi Arabia, the first of three visits scheduled in quick succession. At the invitation of Mustafa Bodrick, PhD, RN, director, Center of Nursing Education, King Abdulaziz Medical City, I have been at the King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), where I attended and presented—keynote, workshop, and plenary—at the 2nd International Conference in Nursing & Health Sciences. We arrived in a dust storm and searing heat, which were followed by torrential rain that cleared the air and cooled things down considerably.

There were about 2,000 delegates at the conference, and I was one of five international speakers, all of whom worked hard each day to fulfill their obligations. I was delighted, for the second time this year, to meet Afaf Meleis, PhD, RN, FAAN, who is now dean emeritus at the University of Pennsylvania School of Nursing. We first met in Tainan, Taiwan. She is sparkling company, and her fluency in Arabic helped us all in several situations.

Yours Truly with local colleagues, Afaf Meleis (in
turquoise), and Shirley Moore (second from left).

I was also glad to renew acquaintance with Janye Smitten, PhD, RN, health administration tutor, Athabasca University, Canada’s Open University and Muntaha Gharaibeh, PhD, RN, former dean of nursing, Jordan University of Science and Technology. I met Smitten the first time a few years ago at the University of Alberta in Edmonton, Canada, and Gharaibeh two years ago in Saudi Arabia. At the conference, I was also very pleased to get to know Shirley Moore, PhD, RN, FAAN, The Edward J. and Louise Mellen Professor of Nursing at Case Western Reserve University, Cleveland, Ohio, USA, and associate dean for research at that school.

I was able to squeeze in a meeting one evening with Ahmad Aboshaiqah, PhD, RN, dean of nursing, King Saud University (KSU), Riyadh, and a prospective doctoral student to discuss admission processes at the University of Hull and the possibility of pioneering an external joint supervision programme between Hull and KSU. There was no great pressure to finalise arrangements, as I will return to KSU at the end of next week. All I have to do between now and then is secure a visa, visit Dublin and Edinburgh, and get back to London Heathrow.

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.

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.

Another side of Saudi Arabia

JEDDAH, Kingdom of Saudi Arabia (KSA)—At 2 a.m. the morning after my arrival, Saudi Arabia’s health minister, Abdullah al-Rabeeah, was removed from office by King Abdullah for claiming he did not know why the number of people with MERS (Middle Eastern Respiratory Syndrome) was increasing, thereby admitting he had been unable to address the problem. 

The unfortunate turn of events for al-Rabeeah meant I was one of the first people to meet his interim replacement, His Excellence Acting Minister for Health Adel Faqih, Saudi Arabia’s labor minister, who now serves in both roles. Faqih presented me, later that morning, with my “hadyyah” (gift) for presenting at The Second International Health Specialties Conference in Riyadh, KSA, sponsored by the Saudi Commission for Health Specialties.

Apparently some folk
think I'm OK! 
(Click photo to read text.)

According to colleagues here, the sacked minister, an engineer by background, was popular and had made a good impression on my nursing colleagues, some of whom met him. However, politics is politics the world over, and, frankly, honesty does not pay if you wish to keep your job.

International conference

My paper at the conference was on the difference ethics can make to health care, but I also gave a preconference workshop to 150 nurses and physicians on getting papers published. Among the attendees was my former PhD student, Mansout Alyami, who works at the Ministry for Health. The workshop was the most popular of the two sessions, with an additional 150 people being turned away.

This was especially surprising as I was competing for participants with such luminaries as Geoff Norman, PhD, of McMaster University who, I now realise, is one of the world’s foremost experts on medical education. I was very pleased to get to know Norman over the course of the conference, and his presentation on myths in medical education reinforced many of the things I had long held doubts about, such as learning styles, self-assessment, high-fidelity simulation (essentially a waste of money), and the predictive value of multiple-choice tests (turns out they’re pretty good). Norman, who backs all this up with evidence, has already sent me his portfolio of research papers and reviews on these issues.

Jeddah

After three days in the oppressive heat, oppressive atmosphere (especially for women), and dry dust of Riyadh, I flew to Jeddah on the coast to participate in a scientific forum at Fakeeh College of Nursing & Medical Sciences, where I presented three papers over two days. Another former PhD student, Wafaa Aljohani, who is a faculty member at the school, facilitated my visit. I also met former PhD student Samira Alsenany, who works at King AbdulAziz University, the oldest university in KSA.

A preserved building in the old town of Jeddah,
included in UNESCO’s World Heritage List. 

Compared with Riyadh, Jeddah is a coastal paradise. In addition to the weather being cooler, it is less dusty and less oppressive in many ways than Riyadh. The population is cosmopolitan, and, because the city is close to the holy cities of Mecca and Medina, it is a tourist destination. This was my first sight of the Red Sea where, as the Old Testament describes, Moses parted the water and crossed from Egypt to the Promised Land. I can imagine that, all those thousands of years ago, this place did not look very promising.

International family

The Watson family is scattered across the globe. Another contingent is in Florida, where Mrs. Watson and our youngest daughter arrived this week. Our daughter is taking part in a street-dancing competition at Daytona Beach, and Mrs. Watson will continue training for the London Marathon.

My ambitions are modest by comparison. I am training for a 10-kilometre race, and managed to run 13 miles over four days along the seafront in Jeddah. My next visit to the Middle East is in May, when I go to Bahrain, but a visit to Genoa, Italy comes before that.

Podcasting continues, if you want to listen to my daily reflections on Jeddah. With my new Veho MUVI Mini Cam, claimed to be the smallest video camera in the world, I posted on YouTube a compilation of video segments, all in one 48-minute clip, that range from Hull to Riyadh. Persevere—or fast-forward—to take a cultural tour of Riyadh and hear the call to prayer going out.

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.

Examining in the Kingdom of Bahrain

MANAMA, Kingdom of Bahrain—The last time I visited Bahrain, I arrived on a Sunday night and took a taxi to the nearest Catholic church to attend Mass. This proved to be a mistake. The “five minutes” from the hotel, as estimated by the hotel receptionist, turned into a considerable taxi ride, miles from the Diplomatic Area (DA) where I was staying. The class of housing dropped and the width of the streets steadily reduced and, eventually, I found myself downtown, where the walls had slogans in English and Arabic. This was immediately following the Arab Spring risings, which had reached the Kingdom and the television screens. My hosts, my employers and my wife would have had a collective fainting fit if they had seen me.

I attended Mass, the only westerner, and then tried to hail a taxi. Plenty went past, but none would stop. As a mild sense of anxiety set in about my predicament—lost, dark, miles from my hotel, and in an area of obvious unrest—I was rescued by a diminutive Indian gentleman, clearly amused at my attempts to hail a taxi in that area. He promised, and duly fulfilled his promise, to lead me to safety. My escape took me through a series of back alleys and past some dubious looking local characters to an area where taxis were available. I hailed one, and my saviour disappeared down one of the alleys from which we had emerged, hardly stopping for thanks.

This is my second visit to the Middle East this year (blog passim) and my second time here as an external examiner at the Royal College of Surgeons in Ireland-Medical University of Bahrain (RCSI-MUB). I have not ventured beyond the DA and, apart from a five-kilometre run that I worked out for the early mornings (30 degrees Celsius; 86 degrees Fahrenheit) before the temperature rises to a searing 40 degrees C (104 F), I have only been to the college and restaurants. The RCSI-MUB was established in 2005 and represents one aspect of the work of the RCSI in Dublin to expand and find business in this region. As such, the RCSI is both innovative and entrepreneurial and has established a very good name for itself in Bahrain and Saudi Arabia.

The RCSI-MUB runs a School of Nursing and Midwifery here that provides undergraduate programmes, including a bridging programme for local diploma-educated nurses and a master’s programme. I examine the bridging programme and the master’s programme and, as my reports to the college have indicated, have been impressed with the standard of work and, in particular, by some of the master’s students, who have to present their work to members of the school in my presence. I predict that the School of Nursing and Midwifery here will become a powerhouse for academic and clinical nursing in the region.

In my previous entry from Finland, I promised to let you know if any of my colleagues have been invited to become fellows of the American Academy of Nursing (FAAN). I am happy to report that Sally Chan, the subject of a previous post, has been selected; also Mark Hayter, my Hull colleague and fellow editor of Journal of Advanced Nursing. The contingent of FAAN international fellows is growing, and I am very happy to be part of that group. I always look forward to my visits to Washington, D.C., but I predict that this year is going to be more fun than usual. If you see me there in October, please say hello.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Return to Riyadh

RIYADH, Kingdom of Saudi Arabia—Listening to “Brothers in Arms”—loud—on the Emirates Airline entertainment system as the Boeing 777 descended into King Khalid International Airport (KKIA), Riyadh, Saudi Arabia, I brushed away several tears. During the First Gulf War, I used to listen to this haunting and emotional song on headphones to drown out the overhead roar of American B-52 bombers, accompanied by massive refuelling planes, as they took off from the military airport in Riyadh to rain down fire and death on forward lines of Iraqi troops.

The bombers were so laden with weaponry that they took off underfuelled. After takeoff, and before proceeding to the Kuwaiti border to lighten their loads, the bombers’ fuel tanks were topped off nearby, in midair, enabling them to proceed to their target and create “fields of destruction,” a phrase from Dire Straits’ song, “Brothers in Arms.” These takeoffs were always followed by the release of a Scud missile in our direction, to which we replied with a Patriot missile from the front gate of our compound. The sickening shockwave, as it broke the sound barrier at ground level, used to make my chest reverberate.

My first visit to Saudi Arabia was courtesy of Her Majesty’s Armed Forces in which I played a small role as a nursing officer in the Royal Army Medical Corps. This time, upon exiting the plane at the airport terminal, I recognised the underground car park where, a couple decades earlier, we had established a 1,000-bed military hospital and set up our evacuation ward. And on my journey home, I walked through shops and lounges where, more than 20 years before, we set up operating theatres and general wards in what was then a newly built, but deserted, building.

This visit was entirely peaceful. I was in Riyadh at the invitation of the General Directorate of Nursing Affairs at the Saudi Ministry of Health to address the Saudi International Conference of Excellence in Patient Care  (SIEPC 2013) on the topic of writing for publication. The conference was attended by “local” nurses from the Gulf states and Jordan, as well as Europeans, Australians, and Americans. The theme of the conference, ostensibly, was about hospitals in the region achieving Magnet status, but it was an opportunity to learn about nursing and, especially, nursing education in Saudi Arabia and Jordan. If the words “Europe” or “United Kingdom” had replaced “Saudi Arabia” or “Jordan” on the program, the discussion would have been much the same.

We share many of the same problems, such as shortages of nurses and nursing faculty, and the employment of immigrant nurses, with the Philippines being a major provider. One difference in Jordan from the rest of the world is the higher proportion of men in nursing, a remarkable 60 percent. It’s actually an issue they would like to address, as it is a symptom of very high unemployment among Jordanian men. There is a deliberate strategy in Saudi Arabia toward “Saudi-ization”—the education, training, and employment of Saudi nationals in a range of professions—including nursing. The initiative is still, however, in its early days.

Meantime, many Saudi nurses visit the United Kingdom and North America to pursue master’s degrees and doctoral education. I have personally benefitted from this. I was met at the airport by Mansour Al-Yami, in full Arab dress, whose studies I supervised at the University of Sheffield. Worth following on Twitter, Al-Yami is involved in his role at the Ministry of Health in recruiting nurses to Saudi’s workforce. Soon, he defends his doctoral thesis in Sheffield.

Yours Truly with Mansour Al-Yami, former student of
mine who is now at the Saudi Ministry of Health.

At the fabulous Four Seasons Hotel, I had dinner with Professor James Ware, director, Medical Education and Postgraduate Studies, the Saudi Commission for Health Specialties, along with Wafaa Al-Johani, who works in nursing education in Jeddah. Al-Johani is one of my former doctoral students, and she made the journey especially to see me.

Wafaa Al-Johani, one of my former doctoral students.

My time in Saudi has been informative, enjoyable and, as I alluded to above, moving. I have three children and a future son-in-law in the military. One daughter returns from Afghanistan soon; she was preceded by her fiancé. Her older sister, a nursing officer in Queen Alexandra’s Royal Army Nursing Corps, leaves for Afghanistan next week. My daughters complete four generations of Watsons who have gone to war.

I often end these entries on a light note, related to my current location or next flight (Rome in May, as it happens), but I must end this one with a rhetorical question: Will the madness of war ever end?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.