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THE DEVELOPMENT OF CRITICAL
THINKING IN SAUDI NURSES: AN
ETHNOGRAPHICAL
APPROACH
ELAINE SIMPSON
RN, BAppSc (AdvNsg), GradDipRehabSt, CertGeront, MHlthSc.
QUEENSLAND UNIVERSITY OF TECHNOLOGY
CENTRE FOR NURSING RESEARCH
SCHOOL OF NURSING
FACULTY OF HEALTH
SUBMITTED IN FULFILMENT OF THE REQUIREMENTS
FOR THE DEGREE OF PHD
2002
iii
DECLARATION OF ENROLMENT
I, Elaine Simpson, a candidate for the degree of Doctor of Philosophy at Queensland
University of Technology, have not been enrolled for another tertiary award during the term
of my PhD candidature without the knowledge and approval of the University's Research
Degrees Committee.
Candidate's Signature
/ /
Date
iv
v
KEYWORDS
Critical thinking skills
Critical thinking strategies –role-play, debate, questioning, small group activity,
journaling
Saudi Arabia
Saudi nurses
Nursing education
Critical thinking model
Clinical instructors
Ethnography
Fieldwork
Participant observation
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ABSTRACT Introduction Saudi Arabia is the largest country in the Middle East occupying the majority of the
Arabia Peninsula. In 1934 the exploration of oil propelled this country from one of
the poorest to one of the highest in per capita income. Islamic law forms the basis of
Saudi Arabia’s constitution, its civil and penal codes and guides the Saudis in their
daily and family lifestyles, governing morals, dress, eating habits and business
dealings. Between 1970 and 1980, there was a sharp increase in the rate of
population. Currently the population is estimated at 20.8 million with a projected
increase to 44.8 million by the year 2025, with approximately 49% under the age of
20. This rise in population has implications for the health care industry, of which
expatriates make up more that 85% of the country’s health care system.
Purpose The purpose of the study was to examine the social and cultural experiences
associated with living and working as a registered nurse in a major teaching hospital
in Saudi Arabia and to identify and understand how to develop critical thinking skills
in Saudi nurses during a nursing education/intervention program in Saudi Arabia.
Methodology
The researcher reviewed the literature on critical thinking, which allowed the
construction of a conceptual model (Appendix 1) to guide teaching and evaluation of
critical thinking skills and maintained the focus on dialogue to stimulate interaction
and participation in order to promote critical thinking abilities in Saudi nurses. This
study adopted ethnography as a methodology and utilised Spradley’s (1979)
ethnographic research cyclical tasks for data collection and analysis, which are
explained in the exploratory, descriptive and explanatory phases of the research. The
researcher was a participant observer and collected ethnographic data in the social
situation. A variety of data collection methods were employed, which included
observation of students and clinical instructors, evaluation of clinical instructors
teaching techniques in utilising critical thinking strategies, evaluation of students’
responses in the use of critical thinking strategies, focus group interviews of students
and clinical instructors and informal interviews conducted within the hospital setting
with relevant informants. The use of multi-methods provided the opportunity to
viii
examine more fully the richness and complexities of the culture, by gathering data
from various sources to validate the consistency of information to reflect the multiple
realities of this cultural group. Cultural domains were identified after examining
field notes and interviews for terms and clues repeatedly verbalised by informants, in
particular students. The researcher organised the domains to formulate taxonomies,
leading to cultural themes, which are answered within the research questions in
Chapter 8. The research questions for this study are as follows:
Research questions
1. What are the issues related to the implementation of critical thinking in a
Professional Development Program to improve critical thinking in Saudi nurses?
2. What major elements are involved in creating and sustaining the Saudi Arabian
nursing profession?
3. How might Saudi culture be used to support the development of professional
nursing identity?
Implications for the study
This study has the potential to make a significant contribution to nursing education in
Saudi Arabia in promoting critical thinking in nurses and in curriculum development
for the following reasons. First, didactic instruction was replaced with an interactive
approach by utilising critical thinking strategies and devices to facilitate the
development of critical thinking abilities. Second, working with a conceptual
framework or model made it easier to manage complex multifaceted concepts, such
as critical thinking. The model maintained the focus on dialogue and experiential
learning thereby assisting students and staff to integrate theory and practice. This
model was effective for the program and if duplicated by other programs, could
create a learning environment that would allow the effective development and
evaluation of critical thinking. The model is reflected in Appendix 1.
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Recommendations for the nursing profession in Saudi Arabia • To establish the Nursing Practice Act which subsequently leads to the formation
of a National Nursing Registration Board.
• To transfer nursing into the higher education sectors, to be on par with their
Western counterparts. To foster career incentives for men to meet the cultural
needs of the people, increase Saudi nurses in the workforce and to raise the image
of nursing.
• To enact Saudiisation policy.
• To incorporate Islamic nursing history into diploma nursing and other nursing
educational programs and implemented into the workplace, government policy
and the media.
• To construct separate male and female hospitals to solve the gender issues.
• To systematically collect, collate and analyse nursing data.
• To develop continuing education programs to meet educational needs of nurses.
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TABLE OF CONTENTS
KEYWORDS ............................................................................................. v
TABLE OF CONTENTS..........................................................................xi
LIST OF TABLES .................................................................................xvii
LIST OF FIGURES.................................................................................xix
STATEMENT OF ORIGINAL AUTHORSHIP....................................xxi
ACKNOWLEDGEMENTS ..................................................................xxiii
CHAPTER ONE ........................................................................................ 1
Introduction ................................................................................................ 1 1.0. Preamble............................................................................................................ 1
1.1. Significance of the study................................................................................... 3
1.2. Overview of the methodology........................................................................... 5
1.2.1. Limitations of the study ...................................................................... 6
1.3. Overview of Saudi Arabia................................................................................. 7
1.4. Islam and culture ............................................................................................. 10
1.5. Summary ......................................................................................................... 13
CHAPTER TWO ..................................................................................... 16
Review of the literature on Critical Thinking .......................................... 16 2.0. Introduction ..................................................................................................... 16
2.1. Towards a definition of critical thinking......................................................... 17
2.2. Critical thinking in nursing literature.............................................................. 23
2.2.1. Critical thinking versus problem solving.......................................... 23
2.2.2. Critical thinking versus decision making ......................................... 24
2.2.3. Critical thinking and creative thinking ............................................. 25
2.2.4. Critical thinking in nursing education and evaluating critical thinking skills.................................................................................... 26
2.3. Instructional methods to develop critical thinking in nursing......................... 30
2.3.1. Questioning....................................................................................... 31
2.3.2. Small group technique ...................................................................... 35
2.3.3. Debate ............................................................................................... 36
2.3.4. Role-play........................................................................................... 37
2.3.5. Reflective journaling ........................................................................ 38
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2.4. Rapidly changing healthcare environments .................................................... 38
2.5. Critical thinking instruments used to evaluate critical thinking...................... 41
2.5.1. The Watson-Glaser Critical Thinking Appraisal (WGCTA)............ 41
2.5.2. California Critical Thinking Skills Test (CCTST) ........................... 42
2.5.3. The California Critical Thinking Disposition Inventory (CCTDI)... 44
2.5.4. The Cornell Critical Thinking Test (CCTT)..................................... 44
2.5.5. The Ennis-Weir Critical Thinking Essay Test (EWCTET) .............. 46
2.6. Summary ......................................................................................................... 47
CHAPTER THREE..................................................................................49
Methodology ............................................................................................49 3.0. Introduction ..................................................................................................... 49
3.1. Qualitative (naturalistic) and quantitative (experimental-type) research ........ 50
3.2. Exploratory, descriptive and explanatory phases of research ......................... 51
3.3. Justification for selecting ethnography ........................................................... 52
3.3.1. Naturalistic Inquiry: Phenomenology............................................... 53
3.3.2. Naturalistic Inquiry: Grounded theory.............................................. 54
3.3.3. Naturalistic Inquiry: Ethnography .................................................... 55
3.3.4. Justification of methodology ............................................................ 56
3.4. Sampling.......................................................................................................... 57
3.5. Origins of ethnography.................................................................................... 58
3.5.1. Ethnography...................................................................................... 59
3.5.2. Ethnography as science..................................................................... 63
3.5.3. Features of ethnography.................................................................... 63
3.5.4. Orientations of ethnography ............................................................. 64
3.6. Triangulation ................................................................................................... 69
3.7. Validity in ethnography................................................................................... 70
3.8. Reliability in ethnography............................................................................... 71
3.9. Trust and integrity in ethnographic research................................................... 72
3.10. Ethical principles............................................................................................. 72
3.11. Data collection methods .................................................................................. 73
3.11.1. Fieldwork .......................................................................................... 73
3.11.2. Participant observation ..................................................................... 75
3.11.3. Questioning and interviewing........................................................... 78
3.11.4. Questionnaire .................................................................................... 81
3.12. Summary ......................................................................................................... 83
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CHAPTER FOUR.................................................................................... 84
Research Design....................................................................................... 84 4.0. Introduction ..................................................................................................... 84
4.1 Five tasks in ethnographical research design .................................................. 84
4.1.1. Selecting a problem .......................................................................... 84
4.1.2. Collecting cultural data..................................................................... 85
4.1.3. Analysing cultural data ..................................................................... 86
4.1.4. Formulating research questions/hypothesis ...................................... 89
4.1.5. Writing the ethnography................................................................... 89
4.2. Explorative phase of the research design ........................................................ 90
4.3. Descriptive phase of the research design ........................................................ 92
4.4. Explanatory phase of the research design ....................................................... 95
4.5. Summary ......................................................................................................... 95
CHAPTER FIVE...................................................................................... 97
Health Services in Saudi Arabia: Explorative Phase ............................... 97 5.0. Introduction ..................................................................................................... 97
5.1. The general problem ....................................................................................... 98
5.2. Evolution of the Saudi health care delivery system and current trends ........ 101
5.3. Status of nursing within Saudi Arabian National Guard-Health Affairs (SANG-HA) .................................................................................................. 105
5.3.1. Overview of SANG-HA ................................................................. 105
5.3.2. Overview of King Fahad National Guard Hospital (KFNGH)....... 108
5.4. Data collection and analysis.......................................................................... 111
5.4.1. Direct observation........................................................................... 111
5.4.2. Unstructured interviews.................................................................. 112
5.4.3. Literature, journaling, field notes, a questionnaire and document analysis ........................................................................................... 115
5.5. Cultural domains in the explorative phase .................................................... 115
5.6. Summary ....................................................................................................... 120
CHAPTER SIX ...................................................................................... 122
The development of the nursing profession in Saudi Arabia: Descriptive Phase ................................................................................... 122 6.0 Introduction ................................................................................................... 122
6.1 Nursing in the Prophet Mohammed’s period (579 AD)................................ 122
6.2. Nursing in the post-Prophet Mohammed period (590 AD) to the present.... 123
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6.3. Image of nursing in Saudi Arabia ................................................................. 124
6.4. Nursing education in Saudi Arabia ............................................................... 127
6.4.1. Evolution of nursing education under the MOH ............................ 128
6.4.2. Nursing education under the Ministry of Higher Education........... 130
6.5. History and current status of the National Nursing Registration Board in Saudi Arabia.................................................................................................. 132
6.6. The Professional Development Program at Saudi Arabian National Guard-Health Affairs..................................................................................... 133
6.6.1. Early beginnings ............................................................................. 134
6.6.2. The second group - Study group..................................................... 138
6.6.3. Implementation of critical thinking strategies in the classroom and clinical field.............................................................................. 143
6.6.4. Setting the scene to improve critical thinking................................. 144
6.7. Data collection............................................................................................... 145
6.7.1. Direct observation: Questioning ..................................................... 145
6.7.2. Direct observation: Small groups ................................................... 148
6.7.3. Direct observation: Debate ............................................................. 149
6.7.4. Direct observation: Role-play......................................................... 149
6.7.5. Direct observation: Preparation for the clinical field...................... 150
6.7.6. Materials: Reflective journal documentation.................................. 151
6.7.7. Direct observation: Evaluation of Clinical Instructors’ teaching ... 153
6.7.8. Focus group interview with Clinical Instructors............................. 154
6.7.9. Use of questionnaire: Evaluation of students' responses towards critical thinking strategies ............................................................... 156
6.7.10. Focus group interviews with students............................................. 157
6.8 Data analysis ................................................................................................. 160
6.9. Summary ....................................................................................................... 164
CHAPTER SEVEN................................................................................165
Critical Thinking in the social learning environment: Explanatory Phase ..................................................................................165 7.0. Introduction ................................................................................................... 165
7.1. Data collection and analysis.......................................................................... 166
7.1.1. Direct observation: Functioning as a nurse in Saudi Arabia......................... 166
7.1.2. Direct observation and interviews: Importance of Saudi nurses in the workplace ...................................................................................................... 170
7.3. Overview of data analysis ............................................................................. 179
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7.4. Summary ....................................................................................................... 182
CHAPTER EIGHT................................................................................. 184
Conclusion.............................................................................................. 184 8.0. Introduction ................................................................................................... 184
8.1. Methodological approach.............................................................................. 184
8.2. Research questions for this study.................................................................. 186
8.2.1. Question 1: What are the issues related to the implementation of critical thinking in a Professional Development Program (PDP) to improve critical thinking in Saudi nurses? ................................. 186
8.3.2. Question 2: What major elements are involved in creating and sustaining the Saudi Arabian nursing profession?.......................... 191
8.4.3. Question 3: How might Saudi culture be used to support the development of professional nursing identity?............................... 195
8.5. Implications of the research for nursing in Saudi Arabia and internationally ............................................................................................... 196
8.6. Summary ....................................................................................................... 197
8.7. Issues for future considerations for the nursing profession in Saudi Arabia.................................................................................................. 199
APPENDICES........................................................................................ 203
Appendix 1: A Conceptual Model (Critical Thinking) ............................................. 205
Appendix 2: Stem/guided questions ......................................................................... 221
Appendix 3: Characteristics of critical thinking instruments.................................... 223
Appendix 4: CCTST/CCTDI* .................................................................................. 225
Appendix 5: Students’ overall theoretical results ..................................................... 247
Appendix 6: 7th Development Plan Ministry of Health* ......................................... 249
Appendix 7 and 7a: MOH data on manpower, health care centres........................... 273
Appendix 8: Infant mortality rates for 2000 (World)*.............................................. 277
Appendix 9: Students enrolled in colleges of health sciences for males and females in MOH 1417H [1996G] ............................................................................. 291
Appendix 10: Achievement record for the PDP* ..................................................... 293
Appendix 11: A typical summative examination: Gerontology ............................... 295
Appendix 12: Information package and Consent form............................................. 297
Appendix 13: Sample of critical thinking questions generated by students ............ 303
Appendix 14: PDP curriculum*................................................................................ 305
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Appendix 15: Evaluation of critical thinking strategies............................................ 319
Appendix 16: Feedback of instructional techniques by researcher........................... 325
Appendix 17: Student-teacher evaluation questionnaire*......................................... 331
Appendix 18: Case study: Burn injury for focus group interview ............................ 337
REFERENCES.......................................................................................339
* Indicates appendices not present in this disc version of the thesis but can be
accessed in the printed document (available in QUT library).
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LIST OF TABLES
Table 2.1: Examples of guided or stem questions ............................................. 34
Table 2.2: Cognitive skills and sub-skills as measured by the CCTST............. 43
Table 4.1: Domain and Taxonomic Analysis of the Health Care Situation in Saudi Arabia..................................................................................... 92
Table 5.2: Comparison of health services in various health sectors in 1991... 104
Table 5.3: Number and percentage of workforce in the MOH in 1991........... 104
Table 5.4: Number of Saudi/Non-Saudi in the MOH in 1991......................... 104
Table 5.5: Infants (under 1 year) deaths and live births by month , KFNGH for 1999 ........................................................................... 109
Table 5.6 Benchmarking for (a) current world infant mortality rates - deaths per 1000 live births (1996)............................................................. 110
Table 5.7: Comparison of infant mortality rates by countries: Population Reference Bureau (PRB) 2000....................................................... 110
Table 6.8: A typical program plan for the first group of PDP students........... 136
Table 6.9: Typical breakdown/grading of a subject ........................................ 144
Table 6.10: Reflection ..................................................................................... 151
Table 6.11: Speculation ................................................................................... 152
Table 6.12: Synthesis....................................................................................... 152
Table 6.13: Metacognition............................................................................... 152
Table 6.14: Variations in Responses to Student-Teacher Evaluation.............. 157
Table 6.15: Revised theoretical and clinical components of the educational/intervention program .................................................. 159
Table 7.16: Process of Reflective Journal Documentation: Reflection........... 172
Table 7.17: Process of Reflective Journal Documentation: Speculation......... 173
Table 7.18: Process of Reflective Journal Documentation: Synthesis ............ 173
Table 7.19: Process of Reflective Journal Documentation: Metacognition .... 174
Table 7.20: The structure of a domain based on Spradley’s (1979) Tausug culture. ............................................................................... 180
Table 7.21: An overview of cultural domains identified in the three phases of the research and taxonomies leading to cultural themes................ 181
Table 7.22: The use of domains (from Table 7.21) to demonstrate the link to taxonomy to theme.............................................................. 182
Table 23: Curriculum of course schedule: 1999-2000 .................................... 215
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LIST OF FIGURES
Figure 1: Interviewing methods: the continuum model..................................... 80
Figure 2: Health Services Sectors in Saudi Arabia.......................................... 103
Figure 3: Percentage of health services provided by sectors........................... 103
Figure 4: Structure of Saudi Arabian National Guard Health Affairs (SANG-HA) ................................................................................... 107
Figure 5: Current status of Nursing in Saudi Arabia ....................................... 128
Figure 6: A conceptual framework to guide teaching and evaluation of critical thinking skills..................................................................... 210
Figure 7: Seven milestones for sample situations ........................................... 212
xxi
STATEMENT OF ORIGINAL AUTHORSHIP
The work contained in this thesis has not been previously submitted for a degree or
diploma at any other higher education institution. To the best of my knowledge and
belief, the thesis contains no material previously published or written by another
person except where due reference is made.
Signed:
Date:
xxiii
ACKNOWLEDGEMENTS
The author wishes to gratefully acknowledge the support of following individuals
and organisations:
• Queensland University of Technology for the provision of a PhD grant and
External Library Services, librarians Tony, Peter, Barbara;
• Principal supervisor, Professor Mary Courtney, for her close supervision,
prompt feedback, inspirational support and constant encouragement;
• Son, David; brother, Bert and wife Ingrid Crathan;
• Geoffrey Hudson for his assistance and constant encouragement;
• Colleagues Dr. Carol Orchard, Mollie Butler, TD Young, Dr. Suzie
Robertson-Malt, Edith Wilson and Camberwell Baptist Church;
• Supervisors Dr. James Wilmoth and his wife Helga, Dr. Deanne Mulvihill,
Dr. Hitendra Pillay, Dr. Alan Barnard, Dr. Ursula Kellett;
• Professional Development Program staff and Saudi Nurses in 1997-1999
groups;
• King Fahad National Guard Hospital in Riyadh, Saudi Arabia, research
department, preceptors (staff nurses) and health care professionals
• Tina Thornton, Director: Academic Editorial Services, for her painstaking
efforts towards the editing of this thesis.
1
CHAPTER ONE
Introduction
1.0. Preamble
The world's health care system has become increasingly complex with the
development of new technology that allows health professionals to understand
genetics, to deal with complex and chronic diseases, as well as the resulting
sophisticated procedures, surgery and increased population longevity. The concept
of critical thinking has been discussed for many years (Dewey, 1916; Schumacher &
Severenson, 1996) but became significant for nursing curriculum development in
1987 when the National League of Nursing (NLN) in the USA mandated for nursing
programs to include the development of critical thinking abilities in nursing students.
Critical thinking is imperative for nurses to comprehend the complexity of the
system and their role in protecting and promoting public health within a constantly
changing environment. Glendon and Ulrich (1997) and Jones and Sheridan (1999)
state that nurses who think critically are able to examine issues from different
perspectives or contexts; are diligent in seeking relevant information to plan,
implement and evaluate appropriate nursing interventions.
The critical thinking literature provides numerous definitions as well as a variety of
instruments to measure critical thinking (Paul, 1990; Facione, Facione & Sanchez,
1994; King, 1995; Colucciello, 1997). Commonalities in these definitions suggest
that critical thinking involves both the cognitive and affective domains of reasoning,
and focuses on processes rather than outcomes. Critical thinking also suggests the
use of purposeful, deliberate thought, with a mind open to different alternatives,
different explanations and possibilities.
In addition to the USA, countries such as Canada, United Kingdom and Australia
now require critical thinking in their respective nursing curricula (RCNA, 1997).
The health care accreditation process also requires health professionals, including
nurses, to use critical thinking when attempting to make clinical judgements about
priorities of care and patients’ responses to treatment in order to improve patient
2
outcomes (Joint Commission of Accreditation Health Organisation [JCAHO], 1993).
Another essential reason to promote critical thinking is the public's demand for
quality services within a rapidly changing health care environment, particularly
where increased knowledge is required to sort through complex situations.
Promotion of critical thinking is also significant in self-regulation and continued
development of nursing competencies.
In 1997, the researcher began working in Saudi Arabia as a nurse educator. The
hospital in which she was employed followed Western standards. During this time,
the researcher became the manager of the Professional Development Program (PDP)
with responsibility to develop critical thinking in Saudi nurses as a means of
enhancing the quality of care provision, and to integrate strategies into a nursing
curriculum. The researcher was immersed in the hospital and familiar with the staff
who were previously employed as registered nurses in the clinical units. The
researcher and associate administrator were responsible for selecting these registered
nurses as clinical instructors for the new education program. These newly employed
clinical instructors were given the assurance that the researcher would mentor and
supervise them towards the role and responsibilities of an instructor, as they had no
teaching experience or formal qualifications. The close mentoring and supervision
helped in creating effective communication skills, respect and congenial working
relationships between the researcher and clinical instructors. The researcher’s role as
manager with a teaching responsibility helped to gain trust from the Saudi students as
they revered her expertise. The researcher’s understanding of the Saudi culture was
well accepted by the Saudi students and they were not fearful of her authority,
because she adopted an open door policy, which enabled them to consult with her
confidentially. The researcher also provided counselling on issues such as the
importance of getting to work on time, giving praise to reinforce good behaviour
habits. The students respected the researcher’s role as manager and sensitivity
towards their culture, which helped to develop rapport, trust integrity, cooperation
and create a supportive learning environment. Within this thesis Saudi nurses will
also be referred to as students.
This chapter provides an overview of the significance of the study. The
methodology is introduced, and the purpose of the study and research questions are
3
presented. The limitations of the project are outlined and a perspective of Saudi
Arabia is given to highlight the context. The chapter concludes by indicating the
importance of the study.
1.1. Significance of the study
Each day in Saudi Arabia, thousands of people receive the care they need to support
their health and well-being. The health care system in Saudi Arabia includes
modern hospitals, technology and primary health care. The care delivery model is
influenced by international standards and provided by skilled health professionals
from more than fifty nations. In most hospitals the working language is English,
however a large percentage of the Saudi patients and families speak only in their
native tongue. Health care is implemented with the assistance of translators who act
as interpreters and intermediaries between patients and care providers. While
interpreters reduce the language barrier, significant cultural aspects—such as the use
of traditional medicine—are often not understood by foreign care-givers. Therefore,
the ideal candidate is a well-prepared Saudi nurse as she/he is able to communicate
effectively and interact accordingly to meet this society's health care needs.
Saudi Arabian National Guard Health Affairs (SANG-HA) recognised the value of
Saudi nurses as employees but, on review of the educational curriculum, discovered
that it would not prepare nurses to adequately meet accepted Western standards. In
1997, SANG-HA made a commitment to train Saudi nurses to adequately meet
Western standards, to improve professionalism within the country, acquire
international recognition and meet accreditation requirements. SANG-HA employs
the services of the Joint Commission of Accreditation Health Care Organization
(JCAHO) in the USA for the purpose of accreditation. JCAHO provides standards
for the hospital and the delivery of patient care together with standards for
professional education.
SANG-HA's objectives were to: (i) enhance the theoretical and clinical proficiencies
of Saudi nurses, to increase knowledge, skills and attitudes to move towards Western
standards; (ii) promote critical thinking skills to increase ability to deal with delivery
of complex healthcare services and changing needs of the Saudi population; and (iii)
support Saudiisation policy (nationalisation of the Saudi workforce). It was intended
4
that Saudi nurses would be better prepared to practice with sound clinical judgements
grounded on scientific evidence, improve their practice and to be able to defend
nursing actions. An additional goal was to encourage Saudi nurses to move forward
into leadership positions.
The purpose of the study was to examine the social and cultural experiences
associated with living and working as a registered nurse in a major teaching hospital
in Saudi Arabia, and to identify and understand how to develop critical thinking
skills in Saudi nurses during a nursing education/intervention program in Saudi
Arabia.
A conceptual framework to implement critical thinking within an educational
program for the PDP was developed and adapted from Paul (1990, 1993), Facione
(1990b), Dexter et al. (1997), Arangie (1997), and Colucciello (1997). The
conceptual framework guided teaching and evaluation of critical thinking skills and
is reflected in Appendix 1.
Research questions were drafted, revised and refined after interviews and searching
field notes to identify cultural domains, which enabled the development of
taxonomies, leading to discovery of cultural themes. Cultural themes form the basis
for the research questions in this study, which are answered in Chapter 8 and are as
follows:
1. What are the issues related to the implementation of critical thinking in a
Professional Development Program (PDP) to improve critical thinking
abilities in Saudi nurses?
2. What major elements are involved in creating and sustaining the Saudi
Arabian nursing profession?
3. How might Saudi Arabian culture be used to support the development of
professional nursing identity?
The following section will describe the context of the cultural environment where the
research was conducted. The researcher selected ethnography as the methodology
5
for this study in order to interact, seek, observe and describe behaviours, traditions
and life ways of a specific cultural group.
1.2. Overview of the methodology
This thesis provides an ethnographic analysis of a group of twelve Saudi nurses
conducted between 1999 and 2000. The original survey group comprised fifteen
nurses, but three participants left through self-attrition (see Figure 7, Appendix 1).
The researcher gained cultural access to this group's behaviour, customs and way of
life by utilising techniques such as participant observation, direct observation and
interviews. During this time, the researcher strived to understand cultural patterns of
behaviours and their cultural meanings (Depoy & Gitlin, 1998). A survey
questionnaire and focus group interviews were used to collect data about students'
feelings in using critical thinking strategies and materials (such as critical thinking
questions generated by students). A focus group interview was also conducted with
clinical instructors to ascertain their views on utilising critical thinking strategies as
an instructional strategy, and the use of critical thinking evaluation questionnaires to
assess their teaching instruction. Additional journal documentation and
observational sources of data regarding the manner in which students interacted in
the classroom and clinical field, what they said and how they learned to adapt to
critical thinking strategies as an instructional technique were also collected.
Additionally, the role of the clinical instructors in the development of students'
critical thinking skills was relevant as they stimulated interaction and participation,
shifting learning and teaching from didactic to interactive. Within the hospital,
informal interviews were conducted with relevant informants.
Ethnography is defined as the study of an intact cultural group in a natural setting
over a prolonged period, using fieldwork to gather data (Hammersley, 1990; De
Laine, 1997). “Ethnography is more than a one-day hike through the woods: it is an
ambitious journey through the complex world of social interaction” (Fetterman,
1989, p. 9). The longer the researcher remains in the community developing rapport,
the greater the probability of the researcher delving into and learning about the
“sacred subtle elements of the culture: how they pray, how they feel about each other
6
and how they reinforce their own cultural practices to maintain the integrity of their
system” (p.27).
While the students were trying to maintain the integrity of their cultural system, the
researcher was trying to adapt critical thinking strategies to fit into their culture. The
researcher fostered the development of students' critical thinking skills while
respecting their culture (for example, how to maintain a sterile field when working
with a face-veil), while concurrently maintaining the standards of care established by
the hospital. The researcher’s thesis includes information gathered from the emic
(insider perspective) and etic (outsider perspective), explained in Chapter 3, because
“success or failure of ethnography depends on the degree to which it rings true to
natives and colleagues in the field" (Fetterman, 1989, p. 21).
An ethnographic study uses a variety of techniques such as interviews, survey,
questionnaires and participant observation, to gather data (Denzin, (1989);
Minichiello et al. (1995). Minichiello et al. (1995) referred to the use of such varied
techniques as a multi-method approach. Jick (1979, p.1) stated that “the combination
of methodologies in the study of the same phenomenon” is referred to as a
triangulation. Fetterman (1989, p.89) believed that triangulation is “the heart of
ethnographic validity”. Triangulation was used in this study to highlight different
dimensions of the same phenomena and to validate the findings by investigating
them from several vantage points. Norris (1985) and Chenweth (1998) pointed out
that if a researcher desires to gather information for use in evaluating critical thinking
abilities or gain insight into the experiences of people, other methods need to be
employed to better capture all the relevant features of those realities. This study will
use Spradley’s (1979; 1980) ethnographic research cycle to ground this research, and
this is explained in Chapter 4.
1.2.1. Limitations of the study
Ethnography is a qualitative form of research. Burns and Grove (1995) stated that
one important difference between qualitative and quantitative research is the
relationship between the researcher and the participant under study. The nature of
this relationship could alter behaviour in the environment and impact on the data
gathered and their interpretations. One critical step is gaining entry into the setting
7
being studied. In this project, the researcher was a foreigner in Saudi Arabia and the
manager of the PDP (the researcher's position in the PDP is highlighted in Figure 4,
Chapter 5). The researcher's position as not 'local' to the culture had the potential to
be perceived by the students as lacking in sensitivity to the cultural beliefs and values
of this society and their cooperation may not be forthcoming. In the capacity as
manager, students could also feel threatened and forced to participate in order to
obtain good results, thereby interfering with the collection of accurate data.
Strategies to overcome such potential problems are discussed in Chapter 4. The
cultural context of this study is significant to understanding the goals of the research
and the next section will provide an overview of Saudi Arabia to highlight its
importance to this study.
1.3. Overview of Saudi Arabia
Saudi Arabia was formed in 1932 under the leadership of King AbdulAziz ibn Saud.
The Red Sea lies on the west of Saudi Arabia and the Arabian Gulf lies to the east.
The world's largest sand desert, the Rub al-Khali, stretches across the southern
border. Saudi Arabia is rapidly developing and is the largest country in the Middle
East, occupying the majority of the Arabian Peninsula.
Exploration for oil in Saudi Arabia began in 1934 and oil revenues propelled the
country from one of the poorest to one of the highest in per capita income. The
production of petroleum is the most important economic activity in Saudi Arabia.
Approximately 90% of all government revenue is derived from the oil industry,
which enabled this country to develop extensive welfare services (Mills, 1986).
King AbdulAziz ibn Saud and his successors commenced the modernisation program
that developed the country from a land of wandering Bedouins into one that has
adopted the high technology of the 21st century (Boyles & Nordhaugen, 1989). The
population has gradually shifted from being Bedouin nomadic to a stationary urban
environment over a short period.
The Population Reference Bureau (2000) estimated the current population of Saudi
Arabia at 20.8 million, with a projected increase to 44.8 million by 2025. The census
showed that children under five years of age constituted 19% of the total population
and that women in the reproductive ages between 15 and 35 years composed
8
approximately 20% of the entire population. The youth population was 50%. In
particular, individuals under 20 years of age comprised 50% of the population,
giving rise for education and integration into the workforce by 2025. The steep
increase in the population has occurred between 1970 and 1980, assisted by a
continuing high level of fertility together with the rapid decline in mortality rates.
The most common diseases are diabetes, hepatitis, tuberculosis, heart disease and
cancer. Genetic disorders relate to high rates of consanguinity and present as
metabolic disorders, or those eventually leading to expensive organ transplantation
and blood disorders, such as Thalassemia. Nutritional problems and diarrhoea are
common in children (Al Mazrou & Farid, 1991; Boyles & Nordhaugen, 1989).
Deaths and trauma from road accidents remain an increasing factor.
Traffic fatalities lead the causes of death, and are associated with the rapid
developments in the last decade in the social, economic and modern technology
leading to affluence and an increasing number of vehicles. Unfortunately, the
increase in vehicles has not been aligned with the development of policy and safety
measures. A report in 1992 revealed an average of 75 injuries per day, resulting in
considerable increases in the admissions to hospitals (Al Osimy, 1994). In 1993,
Sullivan reported that an estimated 1500 Saudis die each year in motor vehicle
accidents. A major contributing factor relates to the fact that approximately “10% to
20% of Saudis use seat belts, as compared to Canada – more that 90% use them”
(Sullivan, 1993, p.446). “The speed that cars are driven adds to the injuries. During
the past 20 years more than 8000,000 accidents have taken place in the Kingdom at
the rate of 110 accidents a day, causing the deaths of 87,000 people" (Arab News,
December 3, 2001, p.4). The government took this issue seriously and announced
penalties for failing to wear seat belts, by the imposition of fines. The government
appears to have overlooked one of the realities in that Saudi families tend to have
more than two or three children, making it challenging to accommodate all family
members into one car and comply with seat belt regulations.
Until the late 1940s, the majority of the population received traditional forms of
public welfare from religious and private charities. Since 1970, the development of
Saudi Arabia’s economy has been guided by a series of five-year development plans,
which included health policy provisions (Sebai, 1985). (These development plans
9
are further explained in Chapter 5.) The objective of these plans has been to provide
overall direction and commitment for change in terms of consolidating and
improving the physical infrastructure and available equipment. An additional goal is
to conduct research and planning for the provision of a comprehensive range of
preventative and curative health services and education on health and nutrition in all
regions. The development plans also aim for the creation of new towns and efforts to
settle the nomadic population; the introduction of electricity to urban and rural areas;
the construction of local and international airports; provision for expansion in
education; and improvements in health services, public sanitation, nutrition and food
access with resulting decrease in mortality rates (Al Osimy, 1994).
Saudis are learning how Westerners live. Well-developed roads that provide
effective infrastructure for transport are packed with vehicles impatiently beeping
their horns. These roads facilitate people to move out of the city allowing for urban
expansion. Imported consumer products from the Far East and West include
designer labels such as Christian Dior, Georgio Armani. During the day, shopping
malls/centres are crowded and at night are lit with colourful neon signs similar in
character to busy Nathan Street in Hong Kong, Piccadilly Square in London or
Collins Street in Melbourne, Australia.
In the past two decades, virtually all socio-economic indicators have progressed
towards development and modernisation. Without question social change is evident
through the influence of Western technology, health care systems, consumer
products, educational concepts, and the employment of expatriate teachers, health
care professionals, labourers, contractors, engineers and military personnel.
Other changes include the emphasis on the expansion of the education system,
resulting in increases in school enrolments and literacy levels. Literacy has increased
with free education in primary schools through to university levels. Al Osimy (1994)
and Nydell (1987) reported an increase from 3,107 schools in 1970 to 17,268 in 1991
and Saudi universities have increased from 58,000 students in 1983 to 113,000 in
1989 and are still rising. The normal primary and secondary education period is of
12 years duration beginning at six years of age. Enrolment for children in the
primary sector has increased from 32% in 1970 to 51 % in 1980 (boys 63% and girls
38%).
10
Improved public health is also influencing the quality of life. Life expectancy has
risen from 34 to 68 years of age. Other changes include the: (i) promotion of family
planning, (ii) exposure to newspapers, television, radio and computers/internet, (iii)
travel and study abroad, (iv) increase in business organisations and international
trade, and (v) increase in educational and professional opportunities for women
(Nydell, 1987).
1.4. Islam and culture
Saudis believe life is predetermined and controlled by Allah (God). Religion is
central to the people and culture and, in times of tribulation, the ritual phrase
‘inshallah’ (God willing) is frequently heard in conversations, reflecting an act of
faith in the will of God. Arabic is regarded as a sacred language, and the Koran is
the primary source book for information on appropriate Arabic grammar and style.
Islamic law, originating in the Koran and the Prophet Mohammed's teachings, forms
the basis of Saudi Arabia's constitution and its civil and penal codes. Islam
determines the calendar and guides the Saudis in their daily lives; governing morals,
dress, eating habits, and business dealings (Al Osimy, 1994). Well-known examples
are mandatory fasting during Ramadan (fasting month for Muslims), prayer five
times a day and the prohibition of alcohol.
Another important aspect of Islam is family and kinship. Arabs use kinship ties to
achieve various daily activities and personal goals throughout life. “The family is
one of the things people specifically live and work for” (Al Mazrou & Farid, 1991, p.
223) and it is the unit in which reproduction is authorised and expected and to which
responsibility for child-care is assigned. Marriage and fertility are therefore
perceived as interrelated because marriage is the primary indicator of women’s
exposure to pregnancy. Consanguinity in Saudi Arabia is common between first
cousins.
The concept of honour plays a vital role in the lives of the men and women of Saudi
Arabia. The Arab society revolves around the concept of public morality – honour is
of supreme importance. Upholding the honour of the family and protecting it from
dishonour is a paramount responsibility. Fear of scandal is a fundamental
11
consideration in the everyday lives of this society. A woman covering her face is a
sign of honour.
Spivey (1999) reported that many Saudi men perceive women as a weak link in the
chain that comprises the family’s dignity. To protect the family’s honour, the men
therefore consider it necessary to keep a watchful eye on their female relatives. It is
clear that families in Saudi Arabia tend to be patriarchal, the father being the
authoritarian figure. Loyalty to one’s family is another important aspect and it is
essential to behave in a manner which will portray a good impression in society.
Women have a prime position in the family and occupy a multifaceted role. As a
wife, a woman has a sexual responsibility to her husband and a responsibility to
maintain all household duties such as cooking and cleaning. When women marry,
they become incorporated into the household of the husband but not into his family.
Women enjoy the tradition of keeping their maiden name after marriage because
women are legally considered to belong to the family of their birth throughout their
lives and in the event of a divorce or widowhood, the woman’s closest male relative,
for example her father or brother, is obliged to support her.
Chastity and sexual modesty is highly regarded. Modesty is expected of women both
in their attire and demeanour (Mills, 1986). Applied primarily to women, these
values are not only linked to family honour but are also held to be religious
obligations. All women wear headscarves, some women veil their faces and
separation of women is considered a mechanism ensuring sexual modesty. In Saudi
Arabia, the role of women is basic to maintaining the structure of the family and
therefore the society.
Islam regards a woman’s role in society as a mother and wife as most sacred and
vital and no baby-sitter or maid can substitute for the mother’s place. Such a noble
and major standing, which primarily shapes the future of nations, cannot be taken
lightly. On the contrary, Islam does not forbid a woman to seek employment if there
is a necessity for her to be gainfully employed, particularly in a position or
profession that is suitable for her, and where society’s needs could be met. Suitable
professions include nursing, teaching (especially of children) and medicine (El-
Sanabary, 1993; Spivey, 1999). Education for women was introduced in the 1960s,
12
and has led to the changing role of women in Saudi Arabia (Al Suwaigh, 1989).
Education has provided women with options other than bearing and rearing children,
options that have led women to be employed outside of their homes.
However, educating women has presented a major problem for various reasons.
Traditionally, men have tended to carefully and strictly monitor their female
relatives’ activities. The male feels dishonoured, believing he is incapable of
supporting his family. Importantly, when his wife is employed outside the home she
is exposed to the public environment and especially to the opposite gender, where
she may be vulnerable to an attack on her honour, which is similar to an attack on the
honour of any man in her family (Spivey, 1999).
Parssinen (1980) emphasised that Islamic teaching approves the education of women.
Societal norms in this country are entwined with religious teachings, in that
education of women is seen as unimportant and could reflect on the low numbers of
women choosing nursing as a profession.
Socially there is disparity between the culture of Arabs and Westerners in regard to
acceptable behaviour with touching. It is common to see two men or two women
walking together, hand in hand. It is not uncommon to see men greet each other in
public with kisses, likewise for women. However, public intimacy between men and
women is strictly forbidden by the Arab social code (Nydell, 1987), including
holding hands (even if a couple is married) or any gesture of affection. Saudi social
attitude remains constant because this society is conservative and expects conformity
from its members.
Health care professionals therefore need to respect and understand this society's
cultural beliefs and values. All these ethical, cultural and religious differences make
living and working in Saudi Arabia an interesting and challenging experience. “It is
the understanding that members have, that provide the emic perspective (insider
view), to which ethnographers apply analysis” (De Laine, 1997, p.24). Above all, it
provides an appreciation towards a foreign culture “… to remain open to the
unexpected, even if you have previous experience in the setting ” (Jorgensen, 1989,
p. 82). The curriculum design needs to encompass culture and Islam, in order to
entice Saudis into the profession of nursing.
13
In terms of cultural tradition, the use of folk medicine is still practiced in this society
(Tabarra, 1990; Rathi, Elzubein & Srinivasan, 1993). The common and genetic
diseases, the increasing young population, and trauma from motor vehicle accidents
all have implications for healthcare policy and the manner in which educational
programs are designed for nurses being educated in Saudi Arabia. The country is
beginning to educate its own nurses, but Saudi nurses are not yet sufficiently
prepared to meet Western standards of care established by most hospitals. Currently,
demand exceeds supply and health care agencies employ expatriates, many of whom
are not Muslims who may not understand and respect the cultural sensitivities of this
society. Expatriates bring their own cultural norms and various ways of nursing
practice and are expected to meet the cultural needs of the society. The PDP at Saudi
Arabian National Guard, Health Affairs (SANG-HA) recognised the need to employ
Saudi nurses to deliver culturally sensitive care, strengthen health education and to
expand the numbers of Saudi nurses in the workforce. SANG-HA also identified the
need to educate Saudi nurses by strengthening their knowledge base, clinical skills
and English proficiency in alignment with accepted Western standards of care.
SANG-HA is further described in Chapter 5. The goals of the PDP were reflected in
the need to integrate critical thinking into the nursing curriculum to teach students to
think critically and analytically.
1.5. Summary
Nydell (1987) pointed out that the momentum of modernisation has improved the
infrastructure of roads, ports, airports, telecommunication, education and health
care—all aspects supported by the government's development plan of the 1970s (as
discussed in Chapter 5). The issue is whether Saudis can embrace this momentum
without adopting the Western influences, values and social practices that go with
them and whether they can modernise their society without losing traditional values.
Although Saudi youths fancy Western attire and entertainment (much to the anguish
of the more traditional elder Saudis), most Saudis who are well educated and
professionally employed have adapted and are able to balance the demands of
modern lifestyles with traditional values and beliefs. Likewise, Saudi women who
are nurses, teachers, physicians or scientists still acknowledge their positions and
importance in the family structure and are careful to protect their reputations.
14
Nydell (1987) reported that a regular topic for Arab journalists is the need to
scrutinise Western innovations, embracing those aspects which are beneficial to their
society, such as technical knowledge, and discarding those that threaten their society,
such as entertainment associated with alcohol. Nydell (1987, p. 6) succinctly stated
that:
We must not take an attitude to the West based on sentiment, emotion or fanaticism. We must scrutinize the elements of Western civilization carefully, and in doing so learn from its sciences and identify in its intellectual heritage those areas which we need to adopt or acquire. At the same time, we must recognize its callous traits so that we may repudiate them out of hand. Perhaps in such a balanced view there will be something that will help us to build anew in our land a new and vital Arab way of life comparable to that ancient civilization which once led the whole world.
Nydell also referred to a long article by the Saudi ambassador to the United States
that emphasised this concern in the following manner:
Foreign imports are nice as shiny or high-tech “things.” But intangible social and political institutions imported from elsewhere can be deadly. Ask the Shah of Iran. A constant problem with so much of the West is the pervasive need for short-fused solutions and instant gratification. Our pace is more for long-distance running, for durability. We Saudis want to modernize, but not necessarily Westernize. We respect your society even if we disagree on some matters and we do. (cited in Nydell, 1987, p.6)
This chapter has briefly discussed the concept of critical thinking, the ethnographical
research approach, purpose, research questions, significance and limitations of the
study. An overview of Saudi Arabia was presented and a brief description of the
Saudi woman’s position in society as it affects the family and cultural values. These
values create complexities that can impact upon a woman’s decision to embrace
nursing as a career. The significance of Islam and culture were also described to
underscore their relevance to the context of this study.
In Chapter 2, the literature review for the study is presented. Chapter 3 will outline
the methodology used in the collection of data and the research design is described in
Chapter 4. Data collection utilising Spradley’s (1979, 1980) ethnographic research
cycle is chosen for this study. Chapters 5, 6 and 7 will deal with the exploratory,
descriptive and explanatory phases of this study and domain analysis is conducted
throughout these three stages. In the exploratory phase in Chapter 5, health services
15
in Saudi Arabia featuring the evolution and current status of the health care delivery
system are discussed. An overview of nursing and the clinical site for students in the
Professional Development Program are also provided. In the descriptive phase in
Chapter 6, the development of the nursing profession in Saudi Arabia is explained.
Critical thinking in the social learning environment is discussed in Chapter 7 of the
exploratory phase. In Chapter 7 the researcher also presents an overview of the data
collection and analysis of the exploratory, descriptive and explanatory phases,
leading to the development of cultural themes. Finally, in Chapter 8, research
questions are addressed, implications and issues for future considerations for the
nursing profession in Saudi Arabia are presented.
16
CHAPTER TWO
Review of the l i terature on Critical Thinking
2.0. Introduction
This literature review will present an overview of research and the history of inquiry
into critical thinking that supports an understanding that “critical thinking is a
pervasive and self-rectifying human phenomenon” (Facione, 1990b, p.4). Central to
this interpretation of critical thinking is a realisation that critical thinking is not a
method to be learned, but rather a process, an orientation of the mind and so includes
both the cognitive and affective domains of reasoning. There has been considerable
confusion about definitions of critical thinking, with both shared terms and
conflicting meanings. This confusion led to the formation of the Delphi Group in
1990—a panel of experts representing several academic disciplines from the
American Philosophical Association. The Delphi Group provided considerable
insight and direction about what critical thinking is and is not. This research study of
Saudi nurses will clarify these perspectives.
This chapter presents a review of the nature and definitions of critical thinking. The
increasing interest in critical thinking and the need for critical thinking in nursing
will also be discussed as this has been accentuated in response to the 1987 mandate
of National League of Nursing (NLN) in North America. The various teaching
methods used to enhance students’ critical thinking abilities and the teachers’ role in
fostering and encouraging critical thinking will also be discussed. Furthermore, this
literature review will focus on five critical thinking strategies utilised to promote
critical thinking abilities in Saudi nurses. The characteristics of five measurement
instruments most frequently used in assessing critical thinking and research will be
explored.
2.1. Towards a definition of critical thinking
As a concept, critical thinking has been expressed in several ways and the work of
John Dewey (1916) has been a major influence. Dewey suggested that reflection
17
guides critical thinking and involves in-depth assessment, scrutiny and the drawing
of conclusions in relation to a situation at hand. Miller and Malcolm (1990)
concurred with Dewey and they suggested that education is a process in which
educators should capitalise on students’ interests and experiences and encourage
reflection, in order to facilitate the learning process. Mackenzie (1992, p.683)
described reflection as "recapturing experience, thinking about it, mulling it over and
evaluating it".
Ennis (1962), an early writer, suggested that to develop critical thinking, students
should be assisted in the engagement of thinking that is reflective, reasonable and
directed on what to believe or do. Ennis viewed critical thinking as “the correct
assessing of statements” (1962, p.83) and noted that an individual who is able to
think critically, according to this definition, has the skills to evaluate statements.
McPeck’s (1981) critique of Ennis’s work raised some cogent points regarding the
philosophical foundation of critical thinking theory. For example, the parallel
reasoning between traditional education, which argues and is in favour of an absolute
way of reasoning (such as the formulation of arguments) as opposed to critical
thinking theory, which advocates education as a process which is context specific
and therefore dynamic and always questioning underlying assumptions. In
consideration of this view, Miller and Malcolm (1990, p.72) stated that nursing tends
to bypass critical thinking “in favour of having students do things in a preferred way
that is too frequently assumed to be the ‘right’ way”. Such processes of education
have a tendency to demote critical thinking and reasoning and promote habitual-type
behaviours.
In recent years prominent critical thinking theorists have included Blair (1985),
Boostrum (1994), Brookfield (1987), Facione (1990a, 1990b), Kurfiss (1988);
McPeck (1981); Paul (1982, 1985); and Watson and Glaser (1980). There are subtle
differences in the way that these authors view the concept of critical thinking and it is
of value to briefly overview such variations. Watson and Glaser (1980) viewed
critical thinking as being more than a specific set of cognitive skills – critical
thinking is also a composite of skills, knowledge and attitudes. The authors
explained that critical thinking comprises an understanding of the nature of making
18
inferences and generalisations and the skills of being able to consider carefully the
logic and accuracy of evidence.
Glaser (1985) expressed the notion that having the ability to think critically is a key
element to being fully functioning in our modern complex society. Watson and
Glaser (1980) suggested that critical thinking is a fundamental requirement for active
participation in one’s social political circles. Attitude also plays a significant role,
for it influences the person’s ability to question life’s complexities and underlying
assumptions in a situation or circumstance.
To McPeck (1981, p.19), critical thinking involved both a propensity and skill and
that “one must develop the disposition to use those skills”—hence teaching someone
to be a critical thinker entails both the cognitive and the affective domains of
reasoning. McPeck’s work revolved around the two components of critical thinking:
(i) the ‘context of discovery’ and (ii) ‘the context of justification.’ In keeping with
McPeck’s second component, Kurfiss (1988) indicated that critical thinking is
associated with the justification of beliefs. Kurfiss pointed out that argumentation is
the process by which this justification is presented. Bell (1991) suggested that one
way to develop this skill of argumentation is involvement in debates, because the
steps in a debate process comprise all of the argumentation skills essential to critical
thinking, such as analysing a problem, finding evidence, constructing a case,
organising information in order to deliver a speech, planning refutation, rebuttal and
debating. A diversity of authors (Blair, 1985; Brookfield, 1987; Facione & Facione,
1994; Kurfiss, 1988; McPeck, 1981; Paul, 1985; and Watson & Glaser, 1980) stated
that critical thinking is more than a set of skills. Blair (1985) postulated that
argumentation is a focal point in critical thinking.
In extending the view of critical thinking, Brookfield (1987) proposed that critical
thinking entails more than cognitive skills, such as logical reasoning or scrutinising
arguments. Brookfield agreed that emotions are paramount to the critical thinking
process, because as one attempts to think critically and assist others to do so, one
cannot help but become conscious of the importance of one’s emotions to this
activity. Brookfield suggested that critical thinkers are typically individuals who
engage in productive and positive activity—in that they are actively involved with
life and perceive themselves as creative and being re-creative in aspects of their
19
personal, workplace and political lives. Critical thinkers also view their thinking as a
process, rather than an outcome. In this instance, Brookfield explained that being a
critical thinker involves a continual questioning of the assumptions of right and
wrong. He emphasised that this is because critical thinking is not static – it does not
bring a person to a position of finality or conclusion. An individual can therefore
never be in a mode of complete critical development—to be otherwise is
contradicting one of the major tenets of critical thinking, namely that one is sceptical
of any claims to universal truths or total certainty.
Brookfield (1987) also identified other components of critical thinking. Firstly,
identifying and challenging assumptions is considered a major tenet of critical
thinking. Secondly, promoting the importance of context as being crucial to critical
thinking—critical thinkers are always mindful of how assimilated assumptions shape
their perceptions, understandings and interpretations of themselves and the world
around them. The third component described by Brookfield (1987) is that critical
thinkers have the capacity to imagine and explore alternatives, that is, they are lateral
in thought processes. He also referred to individuals who recognise alternatives to
supposedly fixed belief systems, habitual behaviours and entrenched social structures
as having reflective scepticism. Thus, individuals who are critical thinkers become
sceptical of claims to universal truths or to ultimate explanations and do not take
things for granted or as read. They become suspicious of those who claim to have
the solutions to all of life’s problems.
Critical thinkers can provide justifications for their ideas and actions – they have the
ability to think through, project and anticipate the consequences of those actions that
support (utilising scientific evidence) these justifications (Brookfield, 1987).
Brookfield (in Garrison, 1991, p.289) expressed his views on critical thinking very
succinctly, when he stated that critical thinking is “a very constructive activity with
the ultimate purpose of gaining insight for the purposes of changing things for the
better”. Learning to think critically therefore involves expanding a person’s thought
processes.
An alternative view expressed by Paul (1985) is that critical thinking is a systematic
way of forming and shaping thinking–it is a way or orientation of thinking that
accomplishes the purpose of thinking. Paul further proposed that critical thinking is
20
based on two assumptions: (i) that the quality of one’s thinking affects the quality of
one’s life, and (ii) that individuals are capable of learning how to continually
enhance the quality of their thinking abilities. Siegel (1988) advocated Paul’s focus
on the importance of instructional methods to improve or enhance critical thinking.
By comparison, Kurfiss (1988) perceived critical thinking as an investigation in
order to explore a situation, question, problem or phenomenon. From such an
inquiry, the person is then able to arrive at a reasoned conclusion that can be
justified. As Kurfiss stated “in critical thinking all assumptions are open to
questioning, divergent views are aggressively sought and the inquiry is not biased in
favour of a particular outcome” (1988, p.2). Kurfiss appeared to imply that through
exploring and imagining alternatives, several points of view can begin to emerge and
therefore critical thinking is promoted. Kurfiss (1988) offered a range of strategies
to encourage the critical thinking process, including formal/informal writing
assignments or brief case studies, questions that involve reasoning skills and the
ability to organise and articulate knowledge, and finally dialoguing on complex
problems. Kurfiss' suggestions are typically what nurses do on a daily basis.
Dealing with questions in quality of life and death situations, nurses are forever
having to continually weigh alternatives and consider what to do, looking at reasons
for choosing one alternative over another, in an open, flexible and attentive manner.
The dimensions of critical thinking comprise both cognitive skills and affective
dispositions. Facione et al. (1998) stated that the requisite cognitive critical thinking
skills are essential to being a good critical thinker. The concept of critical thinking is
also associated with a set of personal attitudes or dispositions that can be used to
describe an individual who is inclined to use critical thinking. The cognitive critical
thinking skills as applied to nursing and the care of the patient can be understood as:
1. Interpretation: accurately interpreting problems as well as objective and
subjective data from common information sources.
2. Analysis: examining ideas/arguments in problems, objective and subjective
data and possible courses of action.
3. Inference: querying claims, assessing arguments (recognising faulty
reasoning) and reaching conclusions which are appropriate.
21
4. Explanation: clearly explaining and defending the reasoning in which an
individual arrives at specific decisions in the context of the health care of the
patient.
5. Evaluation: evaluating information to ascertain its probable trustworthiness as
well as its relevance.
6. Self-Regulation: constantly monitoring one’s own thinking using universal
criteria, for example, clarity, precision, accuracy, consistency, logicalness,
significance and correcting oneself as appropriate. (Facione et al., 1998)
Chenworth (1998), Facione et al. (1998), and Pillay and Elliott (in press) stated that
dispositions/attributes/attitudes or habits of mind could be considered as the elements
of a process of reasoning in an individual’s character that propels or stimulates an
individual towards using critical thinking. Without these dispositions the
engagement of critical thinking will not occur. These attributes can be considered as:
1. 0pen-mindedness: having an appreciation of alternate perspectives and
willingness to respect the right of others to hold different opinions. Having
the understanding of other cultural traditions in order to gain perspectives on
self and others.
2. Inquisitiveness: curious and enthusiastic in wanting to acquire knowledge,
wanting to know how things work, even when the applications are not
immediately apparent.
3. Truth-Seeking: courageous about asking questions to obtain the best
knowledge, even if such knowledge may fail to support one’s preconceptions,
beliefs or interests.
4. Analytical: thinking analytically and using verifiable information; demanding
the application of reason and evidence and the inclination towards
anticipation of consequences.
5. Systematic: valuing organisation, being focused and using diligence to
approach problems of all levels of complexity.
6. Self-confidence: trusting one’s own reasoning and inclination to utilise these
skills, rather than other strategies, in order to respond to problems. For
example, making decisions based on scientific evidence and responding to the
values and interests of individuals and society.
22
The rapid pace of changes in technology and knowledge is challenging professionals,
not only in nursing, but in every discipline (for example in journalism, education and
business), to utilise critical thinking in order to deal with a range of problems
encompassing communications, leadership, ethics, economics and design, and
making efforts for change. While varying definitions for critical thinking exist there
are constant and unique elements. Critical thinking is associated with knowledge,
action argumentation, reasoning, initiative, intuition, application, analysis of complex
meanings, identification of problems, the envisioning of alternatives and making
contingency-related value judgements. Critical thinking is substantially larger than
the sum of its parts, because it is a process that promotes attitudes to continuously
explore, redefine or understand. All these factors contribute to a process of
purposeful reasoned interaction between a person and their interaction with a
situation or surrounding circumstances. Bittner and Tobin (1998) and Pillay and
Elliott (in press), explained that the critical thinking process is multi-faceted and
Bittner and Tobin (1998, p.269) stated that “it is similar to an umbrella under which
many types of thinking flow, depending on the situation”.
Throughout the critical thinking literature the multiplicity of definitions has proved
problematic. In 1987 these varying definitions acted as a catalyst for the American
Philosophical Association to recruit Peter Facione, a prominent philosopher and
writer in the field of critical thinking, to head a systematic inquiry into the current
state of critical thinking and critical thinking assessment. Facione convened a panel
of expert theoreticians representing several academic disciplines throughout the
United States and Canada. An outcome of the panel’s activities and deliberations
was the formation of an important consensus in relation to the concept of critical
thinking intended to guide curriculum development, instruction and assessment.
This consensus was acknowledged by the American Philosophical Association in
1990, and called the Delphi Report. The final definition of critical thinking within
the report stated:
We understand critical thinking to be purposeful, self-regulatory judgement which results in interpretation, analysis, evaluation and inference as well as explanation of the evidential conceptual, methodological, criteriological or contextual considerations upon which that judgement was based. Critical thinking is essential as a tool of inquiry. Critical thinking is a pervasive and self-rectifying
23
human phenomenon. The ideal critical thinker is habitually inquisitive, well-informed, honest in facing personal biases, prudent in making judgements, willing to consider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in selection of criteria, focused in inquiry and persistent in seeking results which are as precise as the subject and the circumstances of inquiry permit. (Facione, 1990b, p.4)
Prior to the Delphi Report in 1990 there was no clear definition of critical thinking,
however, the concepts advanced by Ennis, McPeck, Blair, Paul and others were
prominent and influential in the final consensus.
2.2. Critical thinking in nursing literature
The concept of critical thinking has only been recently addressed in nursing literature
(Daly, 1998; Jones & Brown, 1991). The increasing interest in critical thinking
within education has come to the forefront in nursing following the mandate by the
National League of Nursing (1987), who stated that nursing programs must measure
critical thinking as an outcome criterion for accreditation. It is a concept currently
being used in nursing education and practice as an essential core skill in professional
development (Lenburg, 1997). However, endeavours to capture and utilise this
concept in nursing has resulted in some confusion and uncertainty. Confusion arises
when nurses, teachers and students use the term “critical thinking” interchangeably
with other terms that are components of critical thinking, but have different
meanings. To further allay confusion, it is timely to clarify the differences among
these similar terms.
2.2.1. Critical thinking versus problem solving
Until now, this literature review has emphasised an appreciation of critical thinking
as a complex process. Historically, nursing education has been dominated by terms
such as problem solving, decision-making, nursing process and creative thinking, all
of which are often paralleled with critical thinking. However, there is a crucial
difference between critical thinking and problem solving. Problem solving focuses
on a problem and finds solutions to resolve it (the outcome), for example patient
care. In contrast, Meyers (1986) stated that critical thinking goes beyond problem
solving as central to critical thinking is the ability to raise questions and critique the
solutions. Critical thinking does not seek an answer, whereas problem solving by its
24
very nature expects an answer. Perhaps a reason why confusion exists around the
differences between problem solving and critical thinking is because, as suggested
throughout this literature review, critical thinking needs to be understood as a
process.
An important step in problem solving and decision-making is the need to utilise
critical thinking abilities to reframe a problem or situation. Too often, problem
solving is used in its pure scientific term as in a recipe—follow the steps and an
outcome will be achieved. However, if critical thinking is utilised in its pure form
following the maxim that assumptions about outcomes do not exist, then problem
solving travels a different process.
Miller and Malcolm (1990) emphasised that one cannot think critically unless there
is a knowledge base on which to build arguments. It would be fair to assume that an
individual with a sound knowledge base will have more perspectives to offer, when
reframing problems and generating solutions in contrast to an individual with a
limited knowledge base. Reframing enables an individual to change the conceptual
and/or emotional meaning in order to place an event or situation in a new frame of
reference (Bittner & Tobin, 1998). Kurfiss (1988) inferred that problem solving is
one way of helping to promote critical thinking skills. One way to summarise the
perspective of these authors is that problem solving tends to be aligned with the
scientific method. By contrast, critical thinking differs in that it is purposeful
thinking, as it selectively attends to transcend the automatic thinking, which typically
surrounds everyday repetitive activities (Daly, 1998; Paul, 1990). Facione and
Facione (1993) described critical thinking as ultimately a cognitive engine that drives
problem solving and decision-making.
2.2.2. Critical thinking versus decision making
Clinical decision-making is concerned with issues of a ‘clinical’ nature, as distinct
from problems pertaining to a broader spectrum of circumstances that may or may
not be ‘clinical’ in character. It is a systematic process involving assessment of a
repertoire of actions, evaluating and making a judgement that will contribute to the
achievement of a desired outcome.
25
When using critical thinking as a process for decision-making, multiple steps are
involved. Carper’s (1978) model of knowing explained that knowing patients is
foremost in patient care. Within Carper’s framework of ‘patterns of knowing’, four
principal themes surface; these themes comprise knowledge gained from knowing
patients, peer staff, physicians and the environment. Therefore, when the decision-
maker’s knowledge of the situation is supported by cognitive knowledge and
experiential knowledge, “the outcome is a clinical decision making process that
embraces critical thinking” (Jenks, 1993 in Bittner & Tobin, 1998, p. 269). Lipman
and Deatrick (1997) concurred with Carper to affirm that a key requisite for clinical
decision-making is the use of critical thinking.
2.2.3. Critical thinking and creative thinking
Creative thinking is a combination of knowledge and imagination. A creative thinker
typically has an attitude of interest in everything, continuously exploring new ideas,
options, alternatives and approaches and then trying to manipulate the understanding
into new knowledge or meanings. Creative thinking is ultimately stimulated through
posing Socratic questions, such as “what else?” and “why?” or “what if?” Paul
(1990) emphasised that critical and creative thinking “have an intimate relationship
to figuring things out. There is a natural marriage between them” (p.102). In order
to step outside the everyday reasoning and approaches to problem solving, a person
needs to develop an imagination of the possibilities and potential inherent in a
particular circumstance.
This often demands a creative leap of faith and a willingness to be ‘playful’ with
future possibilities. A creative thought process is a motivator, because it makes work
more interesting. Creative thinking is used in various fields of thought – from
philosophy to mechanical and technical endeavours (Facione, Facione & Sanchez,
1994). These descriptions emphasise that critical thinking is a broad umbrella under
which several forms of thinking occur. Creative thinking is of greatest value when
known solutions have failed and change has not occurred (Miller & Babcock, 1996).
26
2.2.4. Critical thinking in nursing education and evaluating critical thinking
skills
Schank (1990) pointed out that it is vital for nurses to master the skills of thinking
and reasoning in order to constructively critique the value and application of new
knowledge. Nowhere is this process of critiquing the applicability of new knowledge
more needed than in nursing education curricular design. This implies a necessity
“to re-evaluate nursing curricula in light of its structure (cohesion/depth), emphasis
placed on intellectual skills (analysis/communication) and mastery of basic principles
versus specific facts (process/how vs. content/that)” (Schank, 1990, p.86).
Therefore, when evaluating curriculum in terms of its structure, emphasis needs to be
placed on the quality of the content, how the content is organised, and how students
will be able to process and evaluate the information (Royal College of Nursing
Australia [RCNA], 1997). Techniques of instruction need to promote active modes
of learning in teaching students how to evaluate the depth of information imparted,
develop analysis, communication and application of information in new and unique
ways.
Tommie, Nelms and Lane (1999) stated that in 1965 the American Association of
Colleges of Nursing reported that the diversity and complexity of nursing practice
made it essential to prepare nurses who could think critically and creatively, and who
had substantial education in humanities, nursing and other sciences. As summarised
by Schank (1990), critical skills for nursing are the abilities to think, apply, analyse,
synthesise and evaluate situations.
Schank (1990) emphasised that critical thinking cannot be cultivated by merely
providing students with complex and copious amounts of discipline content.
Students need to actively practice the component skills, commencing with
uncomplicated operations such as identifying fundamental issues and key concepts.
Having mastered these skills, students progress to recognising assumptions and
creating and critiquing arguments. In order to do this, they need to have the essential
knowledge of the discipline.
In 1991, the National League for Nursing (1987) in the United States and the Joint
Commission of Accreditation of Healthcare Organizations (1993), announced that all
27
nursing programs must incorporate critical thinking into their curriculum for the
purpose of accreditation (Case, 1995; O’Sullivan et al., 1997). The Royal College of
Nursing Australia (RCNA) (1997) also believed that educational preparation of
nurses is essential to ensure the capacity to think critically, evaluate and modify
nursing interventions. It is therefore essential that schools of nursing develop an
investigative attitude in their graduates and evaluate critical thinking skills.
Examples of research studies to examine the development of critical thinking in
students, registered nurses and educators are reported as follows.
Within nursing programs in the USA, Gross, Takazwa and Rose (1987), examined
the relationship between age, years of previous higher education and National
League of Nursing pre-admission scores (verbal, mathematics and science), using the
Watson Glaser Critical Thinking Appraisal (WGCTA) as selection criteria for
admission. The authors also evaluated the impact of critical thinking for nursing
education on 120 nursing students’ abilities to think critically, using a pre-test and
post-test design, with no control group. The study involved 60 associate degree and
60 baccalaureate degree students. Pre and post-tests were conducted using the
WGCTA as a measurement device. Critical thinking was measured at entry into the
program and on exit.
The outcome of this study demonstrated comparable improvement in critical thinking
in these two groups of students. Once the level of critical thinking was assessed
between the two groups, the researchers were able to make a correlation between
levels of critical thinking and Grade Point Average scores. These researchers
suggested that teaching methods used accounted for the increased level of critical
thinking abilities of these students.
A later USA study by Miller (1992), evaluated registered nurses who had completed
a baccalaureate degree program, and assessed only one component of program
effectiveness—critical thinking skills. The study examined the impact of a
baccalaureate registered nurse program on the critical thinking of students as
measured by the WGCTA. Students were tested on entry and exit of the program
and a significant difference (0.05) was found. A significant relationship (0.05)
between the nursing Grade Point Average (GPA) and post-test total score existed,
accounting for a variance of 4%. No relationship was found between the post-test
28
total score and the general education GPA. The two GPA correlation coefficients
were significantly different from one another (0.05). Miller hypothesised that critical
thinking would improve if a more comprehensive curriculum was upheld.
Hartley and Aukamp (1994) reported a comparative study conducted in the USA to
measure critical thinking skills of 50 nurse educators and to compare these skills to
critical thinking values already established for nursing students using the WGCTA.
Nurse educators, with qualifications ranged from degrees to PhDs, were studied
because they were responsible for enhancing the critical thinking abilities of their
students. The authors explained that the nurse educators were involved in both
clinical and classroom activities and reported that nurse educators had a higher level
of critical thinking abilities than the nursing students as measured by the WGCTA.
The mean WGCTA score for this study was 62.46 with a deviation of 8.34.
Although an initial significance level of p < 0.05 was selected by convention, it was
found that the results were significantly higher at the p <0.005 level.
An outcome of this study reported by the authors was the appropriateness of nurse
educators continuing to examine strategies that improve nursing students’ critical
thinking skills. Case (1994) suggested that teachers with sound knowledge bases can
offer a greater range of perspectives and can therefore encourage the building of
arguments around varying perspectives—this scope of thinking is readily
acknowledged as a central tenet of critical thinking.
Colucciello (1997) examined critical thinking skills and dispositions of 328 US
baccalaureate nursing students and investigated whether or not a significant
difference existed between academic levels from junior to senior grades. This study,
also attempted to ascertain, through using the California Critical Thinking Skills Test
(CCTST) and California Critical Thinking Disposition Inventory (CCTDI), whether
a relationship existed between nursing students’ critical thinking skills (cognitive
domain) and their critical thinking dispositions (affective domain). The results
indicated that there was no significant difference among students at different
academic levels. Colucciello (1997) reported that the findings have implications for
curriculum development, clinical practice and the changing responsibilities of
registered nurses within the healthcare delivery system.
29
Building upon previous studies Chenworth (1998) not only attempted to assess
critical thinking skills in nurses and nurse educators, but also the use of different
critical thinking techniques by identifying techniques which promoted critical
thinking. Chenworth conducted an exploratory study to examine the degree to which
critical thinking was encouraged in nursing education throughout New South Wales
in Australia. The study compared ideas with regard to critical thinking of a sample
of graduate nurses and nurse educators in 12 faculties of nursing. More specifically,
the study examined the best ways to promote critical thinking processes and whether
critical thinking was a reasonable way for nurses to acquire skills necessary for
effective nursing interventions.
The outcome of this study indicated that both nursing students and nurse educators
favoured a curriculum that supported critical thinking. Reasons given refer to
improving professional standards of practice, stimulating inquiry and promoting
sound reasoning in practice, as well as contributing to personal and professional
development. Participants under study were found to favour a variety of teaching
and learning strategies for critical thinking.
The literature suggests the importance of using critical thinking strategies to develop
critical thinking skills. Miller and Malcolm (1990) advocated instructional strategies
to foster critical thinking that can be integrated into all levels of nursing curriculum.
This is in contrast to the perception of critical thinking as an independent unit to be
taught as a subject in a curriculum. The authors further suggested that how this
integration will materialise depends primarily on faculty members’ level of
discussion and participation, as they consider the necessity to increase teaching
strategies that promote critical thinking, conceptualise and revise the curriculum.
Paul (1990) stated simply that it is important for educators to “abandon methods that
make students passive recipients of information and adopt those that transform them
into active participants in their own intellectual growth” (p. 45).
Conger and Mezza (1996) also pointed out that knowledge is more than just
procuring of facts and rules, and that knowledge is an active process of deliberation
and interpretation until cognitive and affective structures are acquired. Dexter et al.
(1997) concurred and stated that “merely teaching the current state of knowledge in
the field is insufficient preparation for future nursing practice” (p.160). The variety
30
of strategies or instructional methods that can be utilised and are effective in
promoting, attaining and advancing the acquisition of critical thinking are
emphasised by Case (1995); Dobryzkowski (1994); Elliott (1996); Oermann (1997);
Schank (1990) and Schell (1998). Nursing literature abounds with strategies for
teaching critical thinking skills, particularly following the mandate by the National
League of Nursing in the United States that critical thinking be implemented as one
of the outcome criteria required for accreditation of nursing programs.
2.3. Instructional methods to develop critical thinking in nursing
Thus far, the focus has been on promoting students’ critical thinking and strategies
teachers can adopt to enhance critical thinking abilities. Teachers also have to be
supported, as they are also ‘students’ of critical thinking and are of “undeniable
importance in setting the stage for critical thinking” (Drews, 1958, p.80). Many
authors have described how the needs of educators must be met before they are able
to implement appropriate and effective teaching methods to foster critical thinking.
Miller and Malcolm (1990, p. 71) indicated that “Nursing practice requires creative,
personalized solutions to unpredictable client circumstances. This cannot be taught
by rote”. Rossignol (1997) asserted that strategies utilised by teachers when
conducting classes could greatly influence students’ thinking. Oermann (1997)
stated that “critical thinking is not developed through one lecture, nor one clinical
experience, and instead, skill in thinking develops over time through varied
experiences” (p. 25). This is also the view of Elliott (1996, p.51) who emphasised
that “critical thinking then becomes a daily experience, not an experience saved for
the clinical practice setting”.
The nursing literature reports various techniques used to develop critical thinking and
nurse educators face many challenges when teaching this concept—success requires
creative strategies. Bittner and Tobin (1998) indicated that instructional methods to
enhance critical thinking should include creative approaches to open nurses’ minds,
broaden and augment their ways of thinking and facilitate the process of problem
solving. The nurse’s problem solving demonstrated at the bedside is invaluable to
patient care.
31
Drawing on the literature, the following section will review five instructional
methods to foster critical thinking abilities. The five techniques are questioning,
small group activities, role-play and debate (which were utilised as instructional
strategies in the classroom),and journaling in the clinical field. This literature
selection explores these five strategies as innovative instructional and effective
methods for the teaching of critical thinking, and provides reasons for the selection
of these particular strategies. Nurse educators have long realised the importance of
teaching critical thinking skills to students, and the growing body of empirical
evidence supports that these skills can be developed by devising teaching methods
that stimulate higher-level thinking in theory and practice (McMillan, 1987; Weis &
Guyton-Simmons, 1998). The problem is often how to stimulate these skills or
abilities in themselves and in their students.
Many authors have explored various strategies to enhance critical thinking abilities
and support the use of questioning, small group activity, role-play, debate, use of
case studies, journaling, simulations, jigsaws, problem solving and writing
assignments (Abegglen & O’Neill Conger, 1997; Billings & Halstead, 1998; Daly,
1998; Elliott, 1996; Fowler, 1998; Jones & Sheridan, 1999; Lenburg, 1997; Lipman
& Dietrick, 1997; Morin, 1997; Oermann, 1997; Schell, 1998; Sellappah et al., 1998;
Walsh, 1997; Whiteside, 1997).
Questioning, small group activities, role-play, and journaling are well supported by
many authors. For instance, questioning as an activity to develop critical thinking
abilities is well supported by (Abegglen & O’Neill Conger, 1997; Beck et al. 1992;
Brookfield, 1987; Case, 1994 & 1995; Chenworth, 1998; Conger & Mezza, 1996;
Chubinski, 1996; Daly, 1998; Elliott, 1996; Fitzpatrick, 1994; King, 1995; Kramer,
1993; Kurfiss, 1987; Lenburg, 1997; Lipman & Dietrick, 1997; Malek, 1986; Miller
& Malcolm, 1990; Morin, 1997; Oermann, 1997; Schank, 1990; Schell, 1998;
Schumacher & Severson, 1996; Sellappah et al. 1998; Vanetzian & Corrigan, 1996;
Walsh, 1997; Whiteside, 1997; Wilkinson, 1994).
2.3.1. Questioning
Socrates first used questioning to stimulate critical thinking some 2400 years ago
when he used this technique to spur his students into deeper levels of contemplation.
32
Daly (1998) described how Socrates embraced the questioning attitude by
proclaiming “the uninquiring life is not the life for man” (p. 324). Anderson (1961 in
Daly, 1998) claimed “it is purposeful thinking about ideas and assumptions and the
weighing of logical arguments against one another which assists in clarifying those
ideas and positions” (p. 324). Flammer (1981) supported this and added that to ask a
question creates the opportunity of acquiring important information that otherwise
might have been precluded.
In considering the application of questioning to the profession Walsh (1997)
commented that, in nursing, ‘rounds’ are frequently used as a technique for
observation, inquiry and close scrutiny of decisions for nursing diagnosis or
treatment. During these rounds nurses are expected to problem solve their patients’
conditions and plan their daily care. Therefore, questioning that stimulates critical
thinking can assist students to develop their problem solving abilities during the
rounds, emphasise the need to observe, critique and ask questions to find ways of
dealing with problems confronting them. Fitzpatrick (1994) admitted that
developing questioning to stimulate critical thinking is time consuming and requires
preplanning but suggested the rewards of improved learning and motivation are
beneficial.
This value of questioning is also supported by Sellapah et al. (1998), who conducted
a study to examine clinical teachers’ use of questioning in the clinical arena. Based
on their study, the authors highlighted the importance of clinical teachers being
taught how to especially ask high-level (analysis, synthesis and evaluation) type
questions. Sellapah and associates suggested that “a limited use of high-level
questions by clinical teachers may limit the extent to which critical thinking in
students is developed” (p. 148). Findings from previous studies conducted by Craig
and Page (1981) and Malcolmson (1990) indicated that a clinical teacher’s skill in
asking high-level questions improved substantially after acquiring instructions about
the use of questioning strategies. It is important, however, to emphasise a ‘give and
take situation’ in that learning to ask questions is not only directed at students but
also to teachers, who are not all critical thinkers.
Another approach towards higher-level thinking is the filtering of information by
identifying key issues, exploring reasons, identifying ambiguous words and
33
assumptions (Browne & Keeley, 1986; Whiteside, 1997). Questioning can help
students to learn and search for alternative explanations through promoting openness
in inquiry, to evaluate reasoning, identify value preferences, and judge the
significance of various opinions to the situation at hand.
While Case (1994) and King (1995) believed that the hallmark of a critical thinker is
an inquiring mind, Whiteside (1997) advocated that “refined cognitive skills are a
hallmark of an educated person” (p. 71). These authors assert that good thinkers are
good questioners, in that they question whatever they see, read, hear or experience.
“This is a framework suitable for the examination of professional issues and
problems in nursing” (Whiteside ,1997, p. 71). Critical thinkers are challenging,
analysing, searching for explanations and alternatives and reflecting about relations
between an experience and what they already know.
Good thinkers also frame questions in a manner such as, “What is the nature of this?”
“What does this mean?” “Why is it happening?” “What if?” Chubinski (1996) and
King (1995) emphasised that formulating such questions can stimulate creative skills
to predict outcomes and create alternatives. Critical thinking could also be enhanced
if nurse educators asked effective questions that encourage students to self-question.
Nurse educators need to change their focus to consider skills as cognitive and not
merely psychomotor in nature. Kramer (1993) concurred with King and asserted that
critical thinkers enrich their awareness of differing values and meanings through
questioning. The overall impetus of King’s studies was that a model of inquiry is
focused on assisting students to develop a habit of inquiry that encourages them to
ask thoughtful questions of themselves, each other and of the content they read, hear
and encounter during classroom discussions.
Further supporting the view that the questioning technique is an essential strategy to
foster critical thinking that can be integrated into the classroom and can also provide
a means of evaluating students in the context of clinical practice are studies by Case
(1995), Oermann (1997) and Schell (1998). Acquiring the skill of questioning can be
extended into everyday living by what one sees on television, reads in a newspaper
and hears during interaction with others. King (1995) emphasised that an essential
feature of inquiry-based learning is not just looking for correct answers to the
teacher’s questions, but rather that students are thinking and formulating questions to
34
address their own lack of understanding and misconceptions and then addressing
particular gaps in their knowledge.
King further explained that critical thinking or thought-provoking questions require
students to go beyond the facts and activate high-level cognitive processes, such as
analysis of ideas, comparison and contrast, inference, application, taking other
perspectives, and drawing upon their history and experience to date. Nurses need to
“display their skills when setting priorities, interviewing, evaluating patient
responses to nursing and when critiquing plans of care” (Case, 1995, p. 274). In
order for students to grasp this concept, nurse educators must be prepared to teach
students how to question in an effective and inquiring manner. By doing so, they
will assist the promotion and development of an inquiring mind.
Elliott (1996) reported that active learning strategies are an essential element in
critical thinking that can subsequently promote information processing. The quality
of learning, as suggested by Elliott, depends to a great extent to the quality of
teaching. One way that a teacher can do this is to structure, frame and provide stem
or guided questions that can act as a model and guide for students. An example of
guided or stem questions is provided by King (1995, p. 14) and is presented in Table
2.1.
Source: King (1995) p.14
Table 2.1: Examples of guided or stem questions
(A detailed list of King's (1995) stem/guided questions used for this study is
provided in Appendix 2.)
Case (1995), Fitzpatrick (1994), Schank (1990), Schell (1998) and others also
offered similar questioning strategies. These authors supported King’s 1995 study
and reported that teaching students such questioning techniques promotes an attitude
35
of inquiry, curiosity, openness and improves critical thinking abilities. King (1995)
expressed the importance of providing students with generic stem questions as such
questions can act as cognitive prompts to induce analysis, inference, evaluation, and
other higher level cognitive processes which are effective in enhancing students’
critical thinking abilities. An essential aspect of questioning is hypothesising and
about which Whiteside (1997, p. 153) stated that “critical thinking requires
hypothesizing many possible reasons for a problem”. Nurses who make up their
minds before all facts are considered and possibilities explored are in danger of
diminishing diagnostic accuracy. Whiteside (1997, p. 156) further commented that
“generating multiple hypotheses is an indication of an advanced practitioner”.
Moreover, similar views are proposed by Fitzpatrick (1994) and King (1995) who
reported that early research found that when students are requested to generate
questions on their own, the tendency is for them to formulate factual, rather than
critical thinking questions.
The use of stem questions also prompts rapid critical inquiry. King (1995) reported
that the use of stem questions in her studies enabled students to learn the critical
thinking skill very rapidly. Versatility of the questions enabled their utilisation in
small group work and in reciprocal peer questioning.
2.3.2. Small group technique
Another commonly used technique to foster critical thinking skill development is the
use of small group activity. Small group activity encourages student interaction and
enables them to share their ideas and examine individual assumptions. Small groups
are less threatening for students and promote comfort to formulate questions for
which they may not have the answers. Small group activity promotes collaboratively
working with peer questioning in the group, and answering each other’s questions,
thereby generating an environment that promotes debate. When reconvening in a
large group, students have the opportunity to compare points of view and
interpretations and to “contrast their critical thinking styles with their peers” (Neill,
Lachat & Taylor-Panek, 1997, p. 31).
36
2.3.3. Debate
The process of debate entails analysing, critiquing and constructing arguments – all
of which are vital elements of critical thinking and the “higher level skills” required
to participate in this activity (Bell, 1991, p. 6). Doyle (1996) supported Bell and
indicated that debate is an effective teaching method that develops the skill of
argumentation. Debate is an experiential learning activity and is different from a
discussion in that debate presupposes an established situation on an issue – a ‘pro’
and ‘con’ argument of a particular assertion or proposition to solution of a problem.
In order to convince the observers to accept or reject a given position, debaters
provide reasoned arguments for and against an issue (Garrett, 1996).
The environment of open inquiry and debate provides opportunities for students to
investigate their own feelings, notions and opinions. This results in the student
becoming more involved with the topic, challenging ideas, as well as refuting and
enhancing listening and communication skills. Questioning, wondering, thinking
aloud and taking intellectual risks are encountered in a debate. Participants have the
freedom of free exchange of ideas, have their thoughts validated and enjoy the lively
discussion that takes place, without being threatened.
Fuszard (1989), Garrett (1996) and Vanetzian and Corrigan (1996) also supported
the value of debate as a teaching and learning strategy indicating that debate requires
diligent inquiry and critical thinking skills and offers students the opportunity to
learn new content in an exciting way. Preparation for a debate requires students to
thoroughly investigate and research issues in question and use reason, logic and
analysis when defining opinions about a problem. In the process of a debate,
participants need to react spontaneously, readily calling upon their reason, logic and
judgement. In order to defend their positions, participants appreciate the need to
review current literature to identify supporting facts and to procure research data so
they can anticipate opposing arguments – the basis of critical thinking. When
presenting a debate appropriately, participants can learn to differentiate between fact
and inference, which will improve their cognitive skills, especially in analysing the
problems, and will therefore gain appreciation for the complexity of issues. These
higher level learning skills will prepare students for interaction with their patients
37
and multidisciplinary health professionals, and will help them to appreciate the
elements of sound reasoning and the need to consider alternate viewpoints.
These skills are useful for nurses in their role as part of a multidisciplinary team.
Team participation requires individuals to justify their opinions in light of different
views and agendas. Experience with the skills developed through debate provides
the “mechanism for the expression of opinions through persuasive arguments and
prompt analytical rebuttals” (Garrett, 1996, p. 38). Garrett (1996) further stated that
educational debate has been recognised in the education literature as an influential or
useful instructional strategy for promoting critical thinking and verbal
communication abilities. Debate provides a comprehensive and innovative learning
mode when integrated as an essential aspect of the curriculum.
2.3.4. Role-play
Another form of participatory learning that promotes critical thinking is that of role-
play, as it involves activities that simulate scenarios of real-life situations and allows
students to place themselves into circumstances they have not previously
experienced. Students have an opportunity to become actively engaged while in a
non-threatening environment to promote critical thinking abilities (Porter Ladousse,
1988).
As stated by Chubinski (1996), through the power of role-play, people can be put
into circumstances that conflict with their ‘normal’ lifestyle and choices, hence
providing perfect opportunity to appreciate alternative views and opinions on a first
hand basis in a non-threatening environment. Fuszard (1989) described role-play as
an effective means for developing decision-making and problem-solving abilities.
The problem-solving process (identification of the problem, data collection and
evaluation of potential outcomes, exploration of alternatives and approaching
decisions to be implemented) can be analysed within the context of a role-play
situation. The post-play discussion gives an opportunity for teachers to provide
analysis and formation of new ideas and strategies in patient care.
38
2.3.5. Reflective journaling
One effective technique for instructing students to think critically is having each
student keep a clinical journal. Brown and Sorrell (1993) and Hancock (1999, p.37)
stated that “reflective practice learning journals have become a valued teaching and
learning tool in nursing education”. Journaling can prove to be a valuable medium to
assist nurse educators to teach through questioning and foster the development of an
inquiring mind. It can also help them regarding changes in students’ critical thinking
abilities at the beginning and at the end of a clinical period.
Students can reflect their practical experience through the act of writing. In writing
students can ‘think aloud’ objectively and transfer their thoughts and perceptions
onto paper, carefully documenting subjective and objective observations, scrutinising
alternatives, exploring, critiquing their ideas, analysing and evaluating experiences.
Clearly, questioning is a thread that flows throughout all the strategies discussed and
appropriate use of questioning techniques by nurse educators can facilitate students'
development in critical thinking abilities. Developing critical thinking in nurses is
vital in preparing “for the catalytic and chaotic events they are sure to face as
healthcare providers in a rapidly changing system” (Case, 1994, p. 271).
2.4. Rapidly changing healthcare environments
Health care organisations have made dramatic advances and changes over the last
few decades resulting in rapid technological advances and theory, and the associated
ethical and moral dilemmas which are part of the daily practice of nurses. Some of
the significant changes and advances facing nurses are the expansion in technology,
decreased length of stay in hospitals, an ageing population, complex disease
processes and increased patient acuity. More marked changes are predicted in the
coming decades, for example, technology prolonging an individual’s life-span—
which increasingly compounds the ageing population and increases the burdens of
the healthcare expenditure (Arangie, 1997; Bittner & Tobin, 1998; Boychuck
Duchscher, 1999; Dexter et al. 1997; Howenstein et al., 1996; Kuhar, 1998; Miller &
Malcolm, 1990; Shaughnessy, 1994; Snyder, 1993)
39
The increasing complexity of modern healthcare demands critical thinking in
response to the rapidly changing health care environment (Fowler, 1998). This has
implications for nursing because the nurse’s role needs to expand proportionately to
cope with the complexities of healthcare and nurses have to think critically to be
effective. Every day, nurses sift through an abundance of data and information to
assimilate and adapt knowledge for problem generation and solution, and in making
decisions within their practices. Colucciello (1997) proclaimed that the use of
critical thinking is vital in examining simple and complex situations in nurses’ day-
to-day responsibilities, and it is also an essential means of establishing the accuracy
of the information or assessment obtained in order to specifically and distinctly
articulate what the knowledge conveys.
Reflecting on the changes required as knowledge changes, Knowles (1980) stated
that “facts learned in youth have become insufficient and in many instances actually
untrue; skills learned in youth have become outmoded by new technologies” (p.28).
Applying this to nursing, clinicians should be prepared to function as safe,
competent, intuitive and innovative clinicians in an environment where new
information and clinical situations are constantly changing (Thornhill & Wafer,
1997). Brookfield (1987) suggested that critical thinking is a process for reasoning
that anyone has the capacity to master and that “such a reasoning process will
provide nurses with a capacity to defend their actions” (Ulsenheimer et al., 1997,
p.151). Alfaro-LeFevre (1995) emphasised that it is imperative for nurses to become
critical thinkers in order to practice sound clinical judgement, which is defined as
“critical thinking in a clinical area” (p.46). This author further asserted that critical
thinking belongs in nursing because nursing is concerned with purposeful goal-
directed thinking, with the primary aim of making judgements grounded on scientific
evidence, rather than conjecture.
Quality Improvement is one area in which critical thinking has gained particular
attention. Nurses are accountable on a daily basis for the quality of care provided to
their patients and utilise critical thinking abilities to guide Quality Improvement
initiatives effectively by coaching staff, and/or their peers in a variety of ways to
improve patient care. Case (1994) described quality initiatives as including the
identification of clinical indicators to monitor for the purpose of detecting and
40
reframing problems and implementing and evaluating actions. Enhancing patient
care is a trademark of the nursing profession and is encompassed within the Joint
Commission of Accreditation of Healthcare Organizational standards (JCAHO,
1993). In 1993 the Joint Commission of Accreditation of Healthcare Organizational
standards announced that nurses need to be proactive in identifying opportunities for
improving care, documenting that care, and recommending, implementing and
evaluating actions to bring about improvements (JCAHO, 1993).
Nurses need to act on patients’ observations in such a way that management of care
involves all facets, exemplifies reasoned consideration, constructive thinking and a
particular disposition that leads to favourable outcomes (Tanner, 1993; Chase, 1997).
Without these aspects, Chase (1997) indicated that nurses are providing less than
adequate documentation of professional nursing results. The process of critical
thinking will enhance nurses’ abilities to identify clinical indicators, assess their
significance and discuss areas for improvement.
Nurses who immerse themselves in the critical thinking process utilise reflective
learning experiences to solve complex patient problems, and are able to “explore new
understandings and appreciations” (Brookfield, 1987, p.14). “The critical thinker
begins to perceive each experience as part of an overall pattern, while a non-critical
thinker faces each experience as an isolated event” (Park Kyzer, 1996, p.67). With
advances in nurse education and its integration into higher education throughout the
world, there has been integration of critical thinking as an educational outcome.
Saudi Arabian National Guard-Health Affairs Nursing Program in Saudi Arabia is
not unlike its international counterparts in its desires to incorporate critical thinking
as a means of preparing practitioners to deal effectively with the broad scope of
situations they will encounter.
Nurses use information from nursing practice and other sciences to apply knowledge
to individual situations, and by applying the critical thinking abilities to both the
technical and interpersonal aspects of their practice they are able to promote creative,
personalised solutions to unpredictable client circumstances. Nurses need to be
prepared for lifelong learning (Meyers et al., 1991; Schank, 1990) and graduates will
need to think critically and identify complex clinical phenomena (Brock & Butts,
1996) with nursing programs also expected to evaluate critical thinking skills (Dexter
41
et al., 1997). Critical thinking instruments commonly used to measure critical
thinking abilities are described in the following section.
2.5. Critical thinking instruments used to evaluate critical thinking
There are several standardised tests used to measure critical thinking for college
students, nursing education settings, and curriculum development. In reviewing the
literature, it is clear that the evaluation of critical thinking skills is a major difficulty
due to the lack of agreement and the type of measurement that should be used in
nursing programs. Such lack of consensus has been reported by Howell et al. (1996)
and others who also describe a lack of agreement in procuring a definition for critical
thinking. This may reflect that critical thinking has been viewed as being abstract
and complex, leading to concern about defining this concept and how nursing
programs will measure critical thinking abilities.
This review will report on five instruments used in studies to measure critical
thinking. The instruments that will be reviewed are the Watson-Glaser Critical
Thinking Appraisal (WGCTA), the California Critical Thinking Skills Test (CCTST)
and California Critical Thinking Disposition Inventory (CCTDI), Ennis Weir Critical
Thinking Essay Test (EWCTET) and the Cornell Critical Thinking Test (CCTT).
The purpose of reviewing these instruments is to provide the reader with an
appreciation of content of each measure.
2.5.1. The Watson-Glaser Critical Thinking Appraisal (WGCTA)
One of the earliest definitions of critical thinking is that of Watson and Glaser
(1964), who defined critical thinking as a composite of attitudes, knowledge and
skills, and their assessment tool reflects this interpretation. Although not specific to
the discipline of nursing, this instrument has been extensively documented in nursing
literature as a method in which to measure critical thinking (Bauwens & Gerhad,
1987; Behrens, 1996; Howell et al., 1996). The WGCTA has been used to (i)
compare nursing students on entry and exit from nursing programs, (ii) make
comparisons between different levels of nursing students and practitioners, and (iii)
investigate correlations between critical thinking and variables.
42
The WGCTA involves a multiple-choice paper and pencil test format with 80 test
questions. All test items include problems and arguments based on situations
experienced in the daily workplace, classrooms, newspapers and other media. Items
consist of two types of content: neutral, for instance, topics referring to the weather
and scientific facts, or controversial, such as topics on economics, politics and social
issues. No items exceed a ninth grade reading level. The tool has five subsets
designed to evaluate different elements of critical thinking. The subsets comprise
deduction, inference, relevance of assumptions, interpretation and evaluation of
arguments, with 16 questions in each subset. Participants select the best answer to
each of the sixteen questions for the five skills. The subsets are evenly weighted to
determine the total score, the maximum score being 80. Two forms of the test are
available for the purpose of pre-test and post-test outcome measures (Forms A and
B). Items chosen for each form are balanced for difficulty, content and correlation
with the total score. According to Howell et al. (1996), Watson and Glaser
recommended that users of this tool consider the forms as equal and alternate tests
for evaluating critical thinking.
In a review of the literature, Kingten-Andrews (1991) reported on five longitudinal
studies utilising the WGCTA to assess the impact of nursing education on critical
thinking. Although these studies found no benefits in the format of nursing
education use over the periods of their studies, Kingten-Andrews reiterated that the
WGCTA was developed to provide a sample of the ability to think critically about
experiences in daily work situations.
Hickman (1993), Perciful and Nester (1996) and Pless and Clayton (1993) described
the perception of nurse educators that the WGCTA is inappropriate for use in
nursing, primarily because the items contained in the test do not accurately reflect
nursing situations. In relation to the sample cohort in this study, the WGCTA has a
section on American politics; this would not be appropriate for assessing critical
thinking skills in populations outside of America, let alone in Saudi Arabia.
2.5.2. California Critical Thinking Skills Test (CCTST)
A more recent instrument, the California Critical Thinking Skills Test (CCTST), has
been used in nursing with the cognitive aspects of critical thinking. Its companion,
43
the California Critical Thinking Disposition Inventory (CCTDI) (Facione, Facione &
Sanchez, 1994), is also used as it targets critical thinking dispositions or
characterological attributes that can be used to describe a person inclined to use
critical thinking abilities when confronted with problems to solve, ideas to evaluate
or decisions to make.
Colucciello (1997) stated that the CCTST has been available for the past six years
and is being increasingly used to assess abilities in student samples. The CCTST
measures six global reasoning skills of the Delphi model: interpretation, analysis,
inference, explanation, evaluation and self-regulation. The critical thinking cognitive
skills and sub-skills are reflected in Table 2.2.
Source: Facione et al. (1998) p.7
Table 2.2: Cognitive skills and sub-skills as measured by the CCTST
The CCTST is a paper and pencil test consisting of 34 items that takes approximately
45 minutes to complete. The CCTST was developed to evaluate critical thinking in
college-aged individuals and has undergone extensive evaluation. This is the first
instrument to derive its construct validity from the definition that evolved from a
consensus of experts on critical thinking documented in the American Philosophical
Association Delphi Report in 1990. Each of the 34 multiple-choice questions is
based on common topics, issues or situations. The CCTST is available in two forms:
Form A was developed in 1990 and Form B was developed in 1992. Howell et al.
(1996) reported that both forms are conceptually and statistically equivalent.
The CCTST addresses the areas of analysis (9 questions), evaluation (14 questions),
inference (11 questions) and inductive and deductive reasoning. Within the context
of the instruments, analysis is defined as comprehension and interpretation of
meaning related to a variety of experiences and relationships. Evaluation denotes the
44
plausibility of statements and the results of one’s reasoning, and inference means the
ability to draw conclusions. Each of the 34 items on the CCTST is assigned to
analysis, evaluation or inference. The remaining areas of inductive reasoning and
deductive reasoning can account for 30 of the 34 items through reassignment.
Inductive reasoning is defined as conclusions made from inferences, whereas
deductive reasoning means drawing conclusions based on logical reasoning.
Howell et al. (1996) stated that this instrument could assist colleges of nursing with
the development and assessment of critical thinking within their curriculum.
Although the CCTST measures the cognitive skills related to critical thinking, this
instrument does not measure the dispositions to think critically. Rane-Szostak and
Robertson (1996) reported that this highly sophisticated standardised test is the best
among the commercially available instruments. Furthermore, Rane-Szostak and
Robertson stated that significant improvement in critical thinking is more often
observed when students are exposed to critical thinking strategies – the California
Critical Thinking Skills Test purports to do this.
2.5.3. The California Critical Thinking Disposition Inventory (CCTDI)
The CCTDI uses the Delphi Report’s consensus definition of critical thinking as a
theoretical basis by which to measure critical thinking dispositions. This 75 item
instrument measures attributes, beliefs and opinions relevant to critical thinking:
open-mindedness, analyticity, cognitive maturity, truth-seeking, systematicity,
inquisitiveness and critical thinking self-confidence. Students complete the tool by
using a six-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’, as
to the degree they agree or disagree with the items; the test takes approximately 20
minutes to complete. Sanchez (1993) stated that the CCTDI is the first objective
means to measure the dispositional dimension of critical thinking.
2.5.4. The Cornell Critical Thinking Test (CCTT)
The CCTT was developed by Ennis, Millman and Tomko (1985) and the authors
defined critical thinking as the process of reasonably deciding what to believe or do.
The CCTT is based on a story format that is used to maintain the interest of the test
taker. It is a multi-choice format divided into seven components that measures
45
judgement of the reliability of statements, deductive reasoning, value judgement,
observation, credibility, assumption and evaluation.
The CCTT has two forms, Level X and Level Z, which are general critical tests and
cover many aspects of critical thinking. Level X focuses on junior and senior high
school and first year college students, while Level Z is designed for college level and
above. The tests are based on critical thinking as proposed by Ennis (1962). In a
study using the CCTT, Dungan (1985) discovered that this instrument did not
distinguish any differences in critical thinking between freshmen and senior
baccalaureate nursing students. Billings and Halstead (1998) reported a study by
Backer, Halstead and May in 1996, which examined the effect of interactive
instructional techniques conducted over one semester in order to improve critical
thinking abilities in baccalaureate nursing students. The CCTT was used as a pre-
test and post-test measure. The authors obtained mixed results, in that the two
groups who were exposed to interactive teaching strategies resulted in an
improvement in critical thinking abilities in one group, whereas the other group
declined in their critical thinking scores. The authors suggested that other factors
could have affected the use of critical thinking teaching techniques on critical
thinking.
McPeck (1981) suggested that the CCTT and WGCTA are in fact indicators of
reading comprehension, rather than critical thinking. Billings and Halstead (1998)
reported that the CCTT has not been as frequently used in nursing education as other
critical thinking instruments. In reviewing the nursing literature, the CCTT has been
primarily used to measure critical thinking among grade-level students, college-level
students and teachers.
The instruments discussed are standardised objective tests of critical thinking, which
typically use a key for the right answers; hence, the focus is on reasoning products.
Norris (1986) pointed out that an evaluation of critical thinking skills can only be
satisfactory if it supports inferences about the thinking process, rather than merely
measuring the products of students’ reasoning – a common practice in education.
Furthermore, Norris (1986) stated that objective tests tend to cover more aspects
because students do not have to spend time explaining their choice of answers.
Norris (1986) advocated the use of essay tests because they provide more
46
perceptivity into participants’ thought processes and dispositions than objective tests.
The Ennis-Weir Critical Thinking Essay Test is described below.
2.5.5. The Ennis-Weir Critical Thinking Essay Test (EWCTET)
In 1985, Ennis and Weir (1985) developed the EWCTET as one of the first tests to
measure critical thinking utilising an essay format. Participants are allowed 40
minutes to challenge the test. The test provides a fictitious letter to an editor of a
newspaper arguing in eight numbered paragraphs that overnight parking on all city
streets should be prohibited. Test takers respond by writing an evaluation of the
thinking for each paragraph and the type of thinking that is demonstrated in the entire
letter.
An example of areas of critical thinking examined in the test are: getting to the point;
stating one’s point of view; offering good reason; seeing the reasons and assumptions
and relevance, to name a few. The written justifications provided by students in their
evaluation of the reasoning of the letter gives insights into the thinking processes.
One example is good judgement and common sense that, according to Ennis, is an
element of critical thinking. According to Ennis and Weir (1985), essay-type tests
provide more in-depth information in that students are asked to give rationales for
their choice of answers, and that such explanations provide insight into the critical
thinking processes.
Evaluation of critical thinking by using such a method is time consuming and
expensive when taking into consideration the cost of the assessor’s time. This test is
scored by individual examiners with a minimum of one college level course in logic,
critical thinking or the equivalent. Rane-Szostak and Robertson (1996) therefore
cautioned that, because scorers are reliant upon the judgements established by these
examiners, inter-rater reliability is a prime concern. Werner (1991) also considered
the subjective scoring rationale of this test to be a weakness. According to Taube
(1995), the Ennis-Weir test has generally earned favourable reviews, however Taube
further reported that research utilising this test is scarce. Howell et al. (1996)
reported that the EWCTET has not been used in nursing research. Although none of
the critical thinking instruments discussed are specific to the discipline of nursing,
nursing programs are expected to measure critical thinking abilities of students and
47
“utilize these data to guide future revision and development of the programs’
curricular” (Billings & Halstead, 1998, p. 29).
This view indicates that future research on critical thinking needs to concentrate in
developing critical thinking instruments specific to nursing. One significant reason
is because nursing education in today’s environment places much emphasis on
developing techniques and designing learning experiences that foster the
development of students’ critical thinking abilities in the clinical field (Howell et al.
1996). A summary of the key characteristics of the five critical thinking instruments
is provided in Appendix 3 and Appendix 4 presents the CCTST and CCTDI).
The Professional Development Program (PDP) adopted the Delphi definition of
critical thinking and the CCTST and CCTDI test items that were constructed in
alignment with the Delphi definition of critical thinking. Colucciello (1997) made
the point that these two instruments offer mechanisms by which to assess reasoning
abilities and dispositions essential for professional nurses. Hence, this program
involved a pilot study with these two instruments, with the intent to utilise the tools
to measure the cognitive and dispositions of critical thinking. The CCTST/CCTDI
were translated into the Arabic language and back-translated into the English
language. (Back translation was the translation by bilingual Arabic/English experts
of the two instruments from English into Arabic and them from Arabic into the
English language to ensure that the meaning was not lost.) The outcome of the pilot
test showed that the Saudi nurses were not familiar with some of the concepts and
cultural inferences contained within these instruments, hence found the instrument
difficult to comprehend and inappropriate to their culture. To overcome this issue
and to measure improvement of critical thinking abilities in nursing, critical thinking
instruments need to be culturally appropriate and nursing based to “reflect client-
focused critical thinking in the clinical field” (Howell et al., 1996, p. 30).
2.6. Summary
The exponential growth in nursing and healthcare requires that nurses continuously
adapt and develop their knowledge and skills. The rapidity of changes means that it
is no longer sufficient to rely on knowledge gained in nursing school to
accommodate effectively with the changing demands. Nurse educators today are
48
confronted with the challenge to develop critical thinking skills in their nursing
courses. They are also aware of the need for teaching students the skills for analysis,
reasoning, evaluating and developing their own opinions. To enable students to
achieve these skills, nurse educators are instrumental in providing guidance,
assistance, role modelling, and instructional methods required in promoting critical
thinking skills.
In contemplating the instructional methods, it is clear that the process of questioning
is a common theme that extends throughout all the strategies. Questions that initiate
thinking urge students to make inferences and comparisons, solve problems,
construct hypotheses and evaluate information—hence developing high-level skills.
As an important element in critical thinking, questioning should be incorporated into
all teaching techniques to make learning more effective in developing students’
inquiring minds. Schank (1990) suggested that nurse educators can nurture critical
thinking abilities in their students by utilising instructional strategies effectively.
Schank (1990, p.88) proposed:
(i) creating an environment of curiosity and questioning, (ii) creating and maintaining an open environment that does not become undisciplined, (iii) involving students in dialogue to enhance an appreciation of alternate perspectives, (iv) preventing assumptions from being utilized as the cornerstone for actions without verification, (v) stimulating student-to-student dialogue, whereby students use each other as consultants, (vi) designing teaching plans with objectives that are directed on process rather than on content, and (vii) providing feedback.
In this chapter, the varied definitions of critical thinking generally and specifically in
nursing literature were examined. This chapter also focused on five critical thinking
strategies that could be used to promote critical thinking among Saudi nurses
undertaking the Professional Development Program in Saudi Arabia. The major
evaluation instruments to measure critical thinking were also examined. Information
gleaned from the literature review on critical thinking assisted in the development of
a conceptual framework to guide the teaching of critical thinking skills for this study.
The methodology for this study is explained in Chapter 3.
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CHAPTER THREE
Methodology
3.0. Introduction
Research is a purposeful activity and is conducted for a specific reason – to answer a
particular question or to solve a specific issue (Depoy & Gitlin, 1998). Research is a
systematic way of thinking and knowing and includes any type of investigation for
the purpose of revealing knowledge. There are two primary philosophical traditions
in research that can be categorised as representing either qualitative (or naturalistic
inquiry) and quantitative (or experimental-type) research. Both traditions have
strengths and limitations as both have value in investigating the depth and breadth of
research topics (Depoy & Gitlin, 1998). Research studies have multiple purposes
and can be organised into three categories based on what the investigator is
attempting to achieve. For example to explore a new topic, describe a social
phenomenon or explain why something occurs (Neuman, 1997). Exploratory,
descriptive and explanatory research concepts are explained later on in this chapter.
This study utilised naturalistic inquiry, wherein an ethnographical approach was
adopted. “Ethnography is the work of describing a culture” (Spradley, 1980, p. 3)
and is about cultural interpretation (Spradley, 1980; Wolcott, 1990). Ethnography
does not follow a linear model of research with a well-designed and explicit
procedure (Burns, 1997; Hammersley, 1990; Spradley, 1979 & 1980), because the
acquisition of ethnographic knowledge and understanding is a cyclical process,
beginning with a panoramic view and gradually narrowing to focus on detail and
extend to a broader picture again. Hence the focus broadens and narrows repeatedly
allowing the researcher or fieldworker to search “for breadth and depth of
observation” (Fetterman, 1989, p.47).
In this chapter the researcher will discuss quantitative and qualitative research and
examine two other widely used naturalistic approaches in naturalistic research, such
as phenomenology and grounded theory (Neuman, 1997; Sarantakos, 1993),
providing reasons as to why ethnography was selected over these two widely used
50
designs. The methodology literature that forms the framework for the research
methods for this study will be detailed.
3.1. Qualitative (naturalistic) and quantitative (experimental-type)
research
Qualitative research is based on multiple philosophical traditions that can be
categorised as holistic (human experience is complex and cannot be understood by
reductionism) in their perspective and focuses on an inductive form of human
reasoning. Whereas a characteristic of naturalistic design is flexibility(the
procedures and plans for conducting this type of research will change as the study
progresses), in quantitative research a blueprint for action or a predetermined
structure to the data collection and analysis is determined. Furthermore, quantitative
research is based on a single epistemologic format of logical positivism in that one
can arrive at a single reality through the process of deduction or empirical
investigations; the researcher begins with a general principle—to reduce complexity
and to test theory. In naturalistic inquiry, where inductive reasoning is employed, the
researcher moves from a specific case to making a broader generalisation about the
phenomenon under study, wherein “theories are incrementally developed to explain
and give order to observations of human experiences” (Depoy & Gitlin, 1998, p. 63).
Qualitative research structure is exploratory, providing new insights, meaning and
description as it seeks to illustrate, understand and interpret or explain about the day-
to-day life experiences and structures from the perspective of those in the field. It is
focused on naturalistic inquiry or naturalism because the research is conducted in
natural settings—wherein the natural context occurs (De Laine, 1997). Naturalism is
true to the phenomena in that the aim is to capture the character of naturally-
occurring human behaviour, the meaning of relationships, refining and expanding
theory. This can be achieved by being in the field and interacting with a small group,
not by inferences from what is conducted in artificial settings like experiments
(Hammersley, 1990; Jenks, 1993).
In contrast, the researcher in quantitative research is not part of the group under
investigation. One advantage of quantitative research is that large amounts of data
can be gathered within a short duration. In qualitative research, the study of small
51
samples and subjectivity has come under criticism in that it produces findings that
are of little value because they cannot be generalised. In terms of subjectivity,
Hammersley (1990) made the point that researchers use methods designed to
establish that their findings are not idiosyncratic – for instance, by comparing data
from different perspectives using a technique known as triangulation. (Triangulation
is explained later on in this chapter.) Yin (1994) supported this view and emphasised
that any finding or conclusion is inclined to be more convincing and accurate if it is
grounded on a variety of sources of information, “following a corroboratory mode”
(p.92).
Hammersley (1990, p. 10) also addressed the study of small samples and stated that
“the concern is not with empirical generalisation, but rather with making theoretical
inferences, and this does not require the case studied to be representative”. Sampling
techniques in qualitative and quantitative research are different and will be discussed
later. Both qualitative and quantitative research approaches are useful and the
purpose and question steers or directs the selection of appropriate methodologies,
and in turn, “the question asked and the knowledge gained must be useful to the
clinical, professional and consumer communities” (DeLaine, 1997, p.12).
Furthermore, Neuman (1994) posited that both forms of research can be used in
combination to construct a learning experience.
3.2. Exploratory, descriptive and explanatory phases of research
Exploration is the first phase of the study in which the researcher becomes familiar
with the basic facts, people, settings and the concerns involved. Exploration
provides the opportunity for the researcher to develop a well-grounded mental
picture of what is happening, to be creative and explore all sources of information,
discover new issues to generate ideas and research questions, develop strategies and
a sense for future research. Neuman (1997) stated that exploratory research is not
easy to conduct because the steps are not well defined. Hence, exploratory
researchers tend to utilise qualitative data, because qualitative research is more open
to using a variety of evidence and discovering new issues. Furthermore, exploratory
research seldom yields definite answers and addresses the “what” question, such as:
“What is this social activity really about?” (Neuman, 1997, p.19).
52
Description focuses on ‘how’ and ‘who’ questions. “How did it happen” and “who is
involved” (Neuman, 1997, p.20)—exploring new issues or explaining why
something happens. For instance, the researcher may have some insight about a
social phenomenon and wants to describe it. Hence, in the descriptive phase, a
detailed account of a situation, social environment or accurate profile of a group to
be studied is presented. “…results may indicate the percentage of people who hold a
particular view or engage in specific behaviors” (Neuman, 1997, p.20). Ethnography
is descriptive and involves interplay among empirical variables occurring naturally,
rather than manipulation by the researcher and greater control over the phenomenon
under study.
Exploration and description have many similarities and tend to overlap. The purpose
is to present background information or a context, describe a process, mechanism or
relationship and discover information to stimulate new evidence to support or refute
an explanation, whether the researcher is describing an experimental treatment or
something in the natural habitat of study participants (LeCompte & Priessle, 1993).
Explanation is the desire to know ‘why,’ “Why things are the way they are?”
(Neuman, 1997, p.20). Explanation builds on exploration and description.
Explanation and description can be used in tandem to determine and advance
knowledge about an underlying phenomenon, looking for causes and reasons and
providing evidence to support or refute an explanation (Burns, 1997; Neuman, 1997).
For example, in this study the descriptive investigator may note there are small
numbers of Saudi nationals who choose nursing as a career, whereas the explanatory
researcher is more concerned in learning why few Saudis select nursing as a
profession.
3.3. Justification for selecting ethnography
Within naturalistic research various other methods exist, and particularly within
nursing, phenomenology and grounded theory are widely used (Burns, 2000;
Sarantakos, 1993; Spradley, 1979; Streubert & Carpenter, 1999). However,
ethnography was selected for this study and the researcher will discuss some
attributes of the three methods providing rationale for ethnography as a research
method for this study.
53
3.3.1. Naturalistic Inquiry: Phenomenology
The phenomenology movement began around the first decade of the 20th century,
and Spiegelberg is best known as the historian of this movement. The
phenomenological movement has also been influenced by the works of Husserl,
Heidegger, Brentano, Stumpf, Merleau-Ponty and others (Spiegelberg, 1975).
Spiegelberg (1975, p.3) defined phenomenology’s primary objective as “the direct
investigation and description of phenomena as consciously experienced, without
theories about their causal explanations and as free as possible from unexamined
preconceptions and presuppositions”. The lived experience of the world of everyday
life is the focus of phenomenological inquiry – the lived experience presents to the
person what is true or real in his or her life (Schutz, 1970). The phenomenological
approach is inductive and descriptive in its design.
Anderson (cited in Morse, 1994, p. 26) pointed out that during the 1970s
phenomenology began to gain credence as an approach for nursing research and,
because nursing practice is enmeshed in people’s life experiences, Beck (1994)
stated that phenomenology as a research method is ideally suited to the investigation
of phenomena important to practice, education and research in nursing.
Phenomenology is different from other types of naturalistic inquiry, in that
investigators do not interpret meaning, rather they perceive that meaning can be
understood and interpreted only by those who experience it (Depoy & Gitlin, 1998).
In other forms of naturalistic inquiry, the researcher attaches meaning to experience
in the analytical phases of the inquiry. Phenomenological research is further
anchored in the principle that involvement by the researcher is limited to eliciting life
experiences, that is, “active interpretative involvement during the data collection is
not part of the investigator’s role” (Depoy & Gitlin, 1998, p. 134). Phenomenology
uses holism from an individual’s perspective, while ethnography focuses on holism
from a cultural stance.
Furthermore, in a phenomenology study the literature review follows data analysis.
The reason for suspending the literature review is related to the objective of
achieving a pure description of the phenomena under study. Thus the literature is
54
used to support the experiences that emerge from informants or to recommend a
rationale for utilising phenomenological methodology.
3.3.2. Naturalistic Inquiry: Grounded theory
In 1967, Glaser and Strauss developed grounded theory as a method of qualitative
field research to explore and describe phenomena in naturalistic environments such
as hospitals, nursing homes, and prisons. The aim of using this method is to explore
social processes with the goal of developing theory. The research question lends
focus and clarity about the phenomenon to be studied (Strauss & Corbin, 1990), and
the constant comparison method is a central tool in this form of qualitative research.
It is different from other designs because it is more structured and researcher-
directed (Sarantakos, 1993).
Grounded theory has some fundamental characteristics in that this method combines
both inductive and deductive processes (Strauss & Corbin, 1990). In terms of being
inductive, theory emanates from specific and generated data; from a deductive
perspective, theory can be tested empirically to develop prediction from general
principles. Grounded theory utilises a structured data collecting analytical process
known as the constant comparative method, which is another fundamental
characteristic where each datum is compared with others to establish similarities and
differences. Another fundamental characteristic is the development of an elaborate
and accurate scheme by Glaser and Strauss and others in which to code, analyse,
recode and produce a theory from narratives acquired from a variety of data-
gathering strategies (Depoy & Gitlin, 1998).
Grounded theory is an important research method to investigate phenomena in
nursing as the constant comparison method explores the richness in human
experiences. Nursing occurs in a natural setting rather than in a controlled
environment and the nursing process requires “constant comparison of collected and
coded data, hypothesis generation, and use of the literature as data and collection of
additional data to verify or reject hypotheses (Stern, Allen & Moxley, 1982, p.201).
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3.3.3. Naturalistic Inquiry: Ethnography
One of the primary aims of ethnography is to precisely describe what is “implicit
within a culture” (Germain cited in Streubert & Carpenter, 1999, p. 151).
Ethnography was chosen for this present study as it concerns examining the social
situation and cultural practices of a specific society. Therefore, in order to gain
cultural knowledge it is necessary for the researcher to be immersed in the culture to
understand the people within a specific society, in terms of what they do, say and
how they relate to each other, their beliefs and values and how they derive meaning
from their experiences (Goetz & Le Compte, 1984; Spradley, 1980). Furthermore,
holism (which is one of the orientations of ethnography explained later), allows the
ethnographer to explore the holistic nature of society and to ask relevant questions
about experiences of the particular setting which the ethnographer needs to know.
In addition, the natural environment in which the study is conducted provides the
ethnographer “with the view of the world as it is, not as they wish it to be” (Streubert
& Carpenter, 1999, p. 150). Streubert & Carpenter (1999) also claimed that using an
ethnographic approach allows an understanding of human behaviour.
“Human behaviour has meaning and ethnography is one way to discover that
meaning” (Streubert & Carpenter, 1999, p. 150). For example, the discoveries as to
why cultural groups such as elderly people or teenagers behave in health and illness
in certain ways can help in providing better interventions. Patton and Westby (1992)
concurred that ethnography is distinctive in interpreting and applying findings from a
cultural perspective. Spradley (1979) also pointed out that ethnography is an
excellent strategy for discovering grounded theory. For example, ethnography of
medical theories in health and disease can be informed by careful ethnographies of
folk medicine theories.
Ethnography, like other qualitative methods produces rich data. Laugharne (1995)
and Streubert and Carpenter (1999) pointed out six characteristics central to
ethnography and three of these characteristics can be shared with other qualitative
methods: (i) the researcher as instrument, (ii) fieldwork in natural settings and not in
controlled environments, and (iii) the cyclic nature of gathering data and analysis.
The other three characteristics are exclusive to ethnography and are explained as: (iv)
its unique focus on culture (v) immersion into the culture, and the only research
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method with a primary purpose to understand the lifeways of individuals connected
through group membership, and (vi) the tension between researcher as research and
researcher as cultural member, also known as reflexivity. (Reflexivity describes the
struggle between being the researcher and becoming a member of the culture.)
“These characteristics should be considered foundational to ethnographic research”
(Streubert & Carpenter, 1999, p. 148). Some factors that make ethnography different
from other naturalistic research methods are that culture is described from the
informant’s perspective and not from the investigator’s point of view. Ethnographic
research is both empirical and inductive. Ethnographers do not usually have a
hypothesis in mind before setting out into the field, because they want to develop
their ideas from observation, listening and actions employed by participants and
commence the process of theory development. Perhaps the feature that sets
ethnography apart from other methods is the role of the investigator as a participant
observer. Other qualitative methods usually depend on interview data (Laugharne,
1995).
3.3.4. Justification of methodology
Therefore, ethnography was perceived as the most appropriate methodology over
other qualitative approaches for the following reasons:
• the accessibility of the environment for the researcher owing to the length of time
(six years) the researcher has been living and working in this culture and the
rapport established. “Walking into a community could have a chilling effect on
ethnographic research” (Fetterman (1989, p. 43);
• the ability to obtain active informants;
• the ability to work in the field as a participant observer and become immersed
into the culture to obtain a description of the culture of the group under study, in
order to gain a deep understanding of the activities and ideas that comprise the
culture of the group;
• the variety of data collection techniques that could be employed and data
gathered within the field setting; and
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• the unique development of ethnography in nursing known as ‘ethnonursing’ by
theorists such as Leninger (Holloway & Wheeler, 1996) allows culture to become
part of all aspects of nursing whereby methods of examining behaviour and
perceptions in clinical settings can lead to provision of culturally sensitive care.
The concept of ethnography is detailed later on in this chapter depicting its origins,
features, orientations, reliability, validity, trust and integrity, ethical principles and
data collections methods.
3.4. Sampling
Whereas quantitative research uses probability sampling—for example simple,
systematic, stratified and cluster sampling; qualitative research adopts non-
probability sampling. Probability sampling can be explained as:
• Simple: people are selected based on a true random procedure.
• Systematic: for example, every 4th person is selected (quasi-random).
• Stratified: people are randomly selected in predetermined groups.
• Cluster: taking multistage random samples in each of several levels (Neuman,
1997, p.205).
Quantitative investigators commence their investigations with sequential strategies to
create a product and the sample that resembles the larger population. In this
instance sampling is an essential precursor to the research. Once the sample has been
determined, assuming that its population has been clearly identified, concern with
selection and sampling procedures ceases and the real study commences (Burns,
2000; Holloway & Wheeler, 1996; LeCompte & Preissle, 1993).
Qualitative research uses non-probability sampling, which can be described as
follows:
• Haphazard: select anyone who is convenient.
• Quota: select anyone in predetermined groups.
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• Purposive or judgemental: select anyone in a hard-to-find target population.
• Snowball: select individuals who are connected to one another (Neuman, 1997, p.
205).
Qualitative investigators develop parameters to specify populations and to select and
sample from these populations throughout the research. Fetterman (1989) stated that
ethnographers typically use an informal technique, namely judgemental sampling to
commence fieldwork, that is “wherever they can slip a foot in the door” (p. 43).
Judgemental sampling is also used in exploratory or field research. Neuman (1997)
emphasised that judgemental sampling is appropriate in three circumstances. First,
an investigator uses it to select unique cases that are particularly informative.
Second, an investigator may use purposive sampling to select members of a difficult-
to-reach, specialised population. Third, when a researcher desires to identify
particular types of cases for in-depth investigation (Neuman, 1997, p. 206).
Therefore, based on the unique social and cultural setting and influenced by the
reasons provided by Fetterman (1989) and Neuman (1997), judgemental sampling
was adopted for this ethnographic study. The researcher relied on her judgement to
select the most appropriate members of the unit or subculture. This judgement was
based on the researcher's previous experiences and the difficulties students
encountered with the lack of English skills and diversity in educational levels, which
enabled a limited number of students to enter the program.
3.5. Origins of ethnography
Ethnography has its roots in social anthropology and emerged in the late nineteenth
and twentieth century when famous anthropologists such as Malinowski (1922),
Boas (1928) and Mead (1928), while seeking for cultural patterns and rules, explored
several non-western cultures and the lifestyles of the people within them.
Sociologists and the Chicago School of Sociology also had an influence on
ethnographic methods, immersing themselves in the culture (LeCompte & Preissle,
1993). From the pioneering beginnings at the Chicago School of Sociology in the
1920s and 1930s a division occurred between ethnography as practiced by social
scientists and ethnographic methods used by anthropologists. Anthropology is about
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culture and anthropologists continued to study the culture of races, while social
scientists utilised the same techniques to examine culture on a social level.
Sociologists recognised that the methodology of ethnography was just as appropriate
for the description of the daily lives of Western cultures as it was for more distant
cultures. Health issues were another important area of research for sociologists and,
in using ethnography, sociologists studied various subjects, such as Whyte’s study of
gambling in 1955 and Goffman’s work on the culture in a mental hospital in 1968
(Laugharne, 1995). Morse (1994) emphasised that no matter how ethnography is
conducted or by whom, it is always informed by a concept of culture.
Anthropologists such as Mead continued to examine cultures overseas and as nursing
moved into academic settings in the 1960s in the United States of America,
Madeleine Leininger, influenced by the work of Mead, developed ‘ethnonursing’ for
using ethnography in nursing. Ethnonursing like other ethnographic methods deals
with studies of a culture, but it is about nursing care and primarily generates nursing
knowledge—such as documenting, describing and explaining nursing phenomena
(Morse, 1994). Muecke (1994) explained that nurse ethnographers differ from other
anthropologists in that they live with informants in their working day and spend their
private lives away from the setting where the research is being undertaken.
Furthermore, Muecke emphasised that nurses are familiar with the terminology and
people they study within the setting, while anthropologists are not familiar with the
environment and rarely know the language of the culture they study.
3.5.1. Ethnography
Ethnographers are descriptive, importantly “writing about people” and, in a broader
sense, studying groups of people for “the purpose of describing their socio-cultural
activities and patterns” (Burns, 1995, p. 245) and “learning from people” (Spradley
& McCurdy, 1972, p.12). The goal of ethnography as Malinowski (cited in
Spradley, 1980, p. 3) posited is “to grasp the native’s point of view, in relation to life,
to realize his vision of his world”. Ethnography entails fieldwork, which is “the
hallmark of ethnography” (Spradley, 1980, p. 3) and “fieldwork should be
theoretically driven rather than determined by technical considerations that is, what
can be measured, what can be sampled” (De Laine, 1997, p. 29). Fieldwork entails
“disciplined studies of how people see the world, how they hear, think, speak and act
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in ways that are different” (Spradley, 1980, p. 3), by learning from people rather than
by studying them.
The important element of ethnography is applying “meaning of actions and events to
the people we seek to understand (Spradley, 1980, p. 5), while some of these
meanings are directly expressed in language, others are demonstrated indirectly
through action and taken for granted. Spradley (1980) stated that people in all
societies frequently use these complex systems to organise their behaviours and
“these systems of meaning constitute their culture; ethnography always implies a
theory of culture” (p. 5). People are creatures of meaning as they order their lives in
relation to what things mean and Spradley (1979, p. 95) explained: “A bell rings and
we know its meaning—to end a class. Meaning in one form or another permeates the
experience of most human beings in all societies”. Hence, it is important at this stage
to comprehend the concept of meaning in ethnography, which is explained as
follows.
Spradley (1979) claimed that cultural meaning is created by utilising symbols and a
symbol is any object or event one can perceive or experience. Symbols comprise
three elements, that is the symbol itself, one or more referents and the relationship
between the symbol and referent—and these three elements are fundamental for all
symbolic meaning. Cultural meanings are encoded in symbols, and the task of the
researcher is to decode the rich meaning of the cultural symbols by seeking and
describing what was observed, said and heard within the constructs of the social
group’s perspective of reality. Hence, domain analysis is conducted in the
exploratory, descriptive and explanatory phases of this research. Domains “are the
first and most important units of analysis in ethnographic research” (Spradley, 1979,
p. 100). (The concept of domain analysis is explained in Chapter 7.) Folk terms and
sounds used by informants are examples of symbols and Spradley (1979) provided
the following explanation: When a shiver runs down one’s spine, this event can be
perceived and can also become a symbol of fear, excitement or anything else. As
people can experience colours, sounds, objects, actions, group activities and complex
social situations, these events can become symbols.
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A referent is the thing a symbol represents and it can be anything contrived in human
experience. For instance, a tree can be referred to as a symbol; similarly dreams,
people who will live in future times or the day-to-day things that surrounds people
and so forth. The relationship between a symbol and a referent is the third element in
meaning—“at a minimum, meaning involves symbols and referent” (Spradley, 1979,
p. 96). To facilitate the reader’s understanding of referent, Spradley (1979) offered
an example of “a mouse – a symbol of our own culture” (p. 96). Referentially, a
mouse denotes a small mammal, a rodent with four legs and a pink nose. However,
Spradley explained that this referential definition does not describe children’s desire
for pet mice or fear and repulsion from some adults.
Furthermore, it does not even begin to inform people about how corporations create
mouse traps, poisons or animated mouse films (as displayed in Mickey Mouse shirts
and hats) or hint at the fact that mice are used in laboratories for experimental
purposes. “A full cultural definition of this symbol would include all these things
and more” (Spradley, 1979, p. 96). One way in which scholars have attempted this
broader sphere of meaning is by differentiating ‘denotation’ from ‘connotation’.
Denotation entails the things words refer to (what is known as a referential meaning),
as in a mouse denotes a small rodent. By contrast, connotative meaning involves all
the suggestive significance of symbols, over and above their referential meaning, that
is a mouse connotes a large number of suggestive ideas. Ethnographers utilise what
people say, do and act in order to describe meaning in a specific culture, and an
essential principle of ethnographic research is:
Don’t ask for meaning, ask for use, as this principle leads directly to decoding full meaning of symbols in any culture. It also applies to participant observation and the study of non-verbal symbols. It is by the use of symbols that relationships are revealed. (Spradley, 1979, p. 97-98)
Spradley (1980) explained three major aspects of human experience that
ethnographers need to consider when studying other cultures: “What people do, what
people know and the things people make and use” (p. 5). When each of these aspects
are learned and shared by members of the group, these elements are known as
cultural behaviour, cultural knowledge and cultural artefacts respectively. In doing
fieldwork ethnographers will frequently make cultural inferences from what people
do and how they act and researchers go beyond what is seen and heard to examine
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what people know. Making inferences, according to Spradley (1980), entails
reasoning from evidence (what one perceives) or from premises (what one assumes).
During fieldwork an ethnographer frequently makes inferences from what people
say, their actions and from artefacts they use. “None of these sources for making
inferences—behaviour, speech and artefacts—are foolproof, but together they can
lead to an adequate cultural description” (Spradley, 1980, p.10).
While anthropologists may differ in their opinions regarding a definition of culture,
“all would agree that culture should be treated as something that is ‘unique’ and that
its’ meaning should be discovered” (De Laine, 1997, p. 104). Although there are
several definitions of culture (Depoy & Gitlin, 1998), for this study culture is
described as the behaviour, customs and way of life of a specific group of people
(Fetterman, 1989). Fetterman (1989) stated that the advantage of living and working
in a foreign culture for any length of time allows a researcher working in the field to
view the strengths of dominant ideas, values and behaviour patterns in the manner in
which individuals talk, walk, dress and sleep.
A useful way in which to utilise ethnography in nursing might be to embrace a view
of culture as a system of knowledge “used by human beings to interpret experience
and generate behaviour (Fetterman, 1989, p. 104). Ethnography has the potential to
offer an understanding of the meaning of health, and insights into some of the
unexpected behaviours observed in hospital settings. This can enhance the prospects
of delivering culturally sensitive care.
Ethnography can also be useful within nursing practice to enhance clinical and
education outcomes. As an example, an ethnographic study by Mackenzie (1992)
provided relevance to nursing practice by exploring district nursing students’
experiences during community rotation. This project had significance for the
development of initiatives in the United Kingdom and community-based health care
in general. Mackenzie’s study also had implications for nurse educators in
environments that were not equipped for direct supervision of students.
Ethnographic research of this nature is relevant where health care initiatives tend to
lead to more community-based nursing practice, because such studies promote
understanding of the impact of learning and practicing in community environments.
Using an ethnographical approach within this study gave the researcher an
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opportunity to comprehend the learning and cultural experiences of Saudi students in
the classroom and clinical settings.
In this study the researcher worked in the field, wherein she was able to observe,
detail, describe, analyse and document this social group's (Saudi nurses/students)
interactions with their facilitators and peers—what they said, how they performed
and acted in order to gain a deep comprehension of the culture and to discover
meaning of this group of individuals’ (or emic) perspective of reality. By contrast,
those who are external to the group under study but select to participate can be
understood as the etic perspective. The researcher also interacted with individuals
outside the field (in the hospital setting) to provide an analytical “lens through which
to examine information” (Depoy & Gitlin, 1998, p.103). Emic and etic perspectives
are explained later on in this chapter.
3.5.2. Ethnography as science
Thomas (1993) stated that there is no reason to question ethnography’s scientific
credentials, because ethnographers such as Agar, Denzin, Hammersley, Lincoln and
Guba and others have sharpened the scientific basis of their data collection and
analysis techniques. Hammersley (1990) supported this view, by stating that
ethnographers utilise methods to ascertain that their “findings are not idiosyncratic –
for example, by comparing data from different sources, a technique sometimes
referred to as triangulation” (p. 9). Furthermore, Thomas (1993) made the point that
ethnography is as scientific and rigorous as quantitative social science or even the
natural sciences because ethnography respects the basic rules of logic (for example,
laws of identity, contradiction), validity, reliability and theory building. Hammersley
(1990) also stated that more and more the scientific nature of ethnography is being
justified, because it is better suited than experimental research to the nature of human
behaviour, specifically to its meaning-laden character.
3.5.3. Features of ethnography
Hammersley (1990, p.1) pointed out that the term ethnography typically relates to
social research, which comprises most of the following characteristics, in that:
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• people’s behaviours are studied in everyday context, rather than under
experimental situations developed by the investigator;
• data are collected from various sources, with observation and interviews being
the primary aspects;
• data are gathered in an ‘unstructured’ manner in that it does not follow a plan.
This does not imply that the research is unsystematic, rather “data is collected in
as raw a form, and on as wide a front, as feasible;”
• the focus is commonly a single setting or group and on a small scale; and
• data analysis entails interpretation of the meanings and functions of human
actions and is primarily conducted in the form of verbal descriptions and
explanations.
Furthermore, Burns (2000) and Spradley (1979) stated that, in an ethnographic study,
there is “no single ideal to which all such research can be expected to conform”.
However, ethnography does provide a set of general orientations to research, which
is different from those of the experimental type research. These orientations can be
identified as: naturalism, understanding and interpretation, holism, emic and etic
perspectives, selecting key informants, multiple perspectives, multiple methods and
process and sequence. All were utilised in this study and are described as follows.
3.5.4. Orientations of ethnography
Naturalism: Ethnographers conduct their study by being in ‘natural’ settings for the
purpose of capturing the character of naturally-occurring human behaviour or social
life, which can only be achieved by “first-hand contact with people and not by
inferences from what people do in artificial settings as in experiments or from what
they say in interviews about what they do elsewhere” (Hammersley, 1990, p. 7).
Ethnographers cannot depend on laboratory settings for purity of design because the
researcher is reliant upon participants for friendships, services or access to additional
participants (LeCompte & Preissle, 1993). Ethnographers recognise that what people
say and do must be explained in terms of the relationship to the social context in
65
which they occur (Burns, 2000; Hammersley, 1990). In this study, naturalism was
the principal technique utilised, wherein the researcher was “pre-eminently
concerned with observation and recording of real-world phenomena” (LeCompte &
Preissle, 1993, p. 30), with key informants in their natural work environment.
Understanding and interpretation: Ethnographers acknowledge that human actions
are different from physical objects or other animals in that, human actions “involve
interpretations of stimuli and the construction of responses” (Hammersley, 1990, p.
7). Therefore, in order to understand and explain human actions, the researcher
needs to interact and acquire an understanding of the cultural perspectives on which
they are based. In this study, it was important for the researcher to gain an
understanding of the Saudi people’s beliefs and values, because the researcher was
examining a society that was alien to her culture and Hammersley (1990, p. 8) stated
that “we shall find what we see and hear puzzling”.
LeCompte and Preissle (1993) asserted that ethnography is usually equated with
hermeneutic or interpretive research. Hermeneutics involve meaning, in other words,
ways to explain, translate and interpret perceived reality. (In contemporary research
hermeneutics is concerned with interpreting and recounting accurately the meanings,
which research participants provide to the world around them.) In ethnographic
studies, investigators are concerned with interpreting cultures accurately, however
because they can only see segments of a cultural reality, “they also struggle with the
issue of portrayal” (LeCompte & Preissle, 1993, p. 31). Most ethnographers,
according to LeCompte and Preissle (1993, p. 30), assume that “the ‘reality’ of a
cultural scene is the product of multiple perceptions, including that of the researcher
and that produced by the interaction between researcher and the people they study”.
Gadamer (1998) supports this view and states that the product of multi perceptions
are the result of understanding which takes place through language and tradition, and
which represents the present and past horizons of an individual’s understanding of
reality (or the emic perspective which is explained later on). Gadamer explains
‘horizon’ as not being limited to what is nearby, rather having a range of vision.
Therefore, understanding can be perceived as the fusion of these horizons, which is
established by “the verbal aspect of interpretation” (Gadamer, 1998, p. 397).
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Meaning is often given to the data through visual presentations (such as photographs,
diagrams demonstrating how ideas are related), and verbal descriptions, including
quotes of specific events (Neuman, 1997). Fetterman (1989, p. 22) pointed out that
“verbatim quotations are extremely useful in presenting a credible report of the
research.”
Holism: A study that assumes a holistic outlook or complete picture of a social group
is considered to have a holistic perspective (Fetterman, 1989). The researcher needs
to be aware of the social group and setting within a wider context that is, “the
surrounding vicinity, the milieu of the values and beliefs and the larger social
environment” (Burns, 2000, p. 397).
Emic and etic perspectives: The reasons for the use of these two modes of
perspectives will now be explained. De Laine (1997) explained that since both the
participant's and observer's points of view can be reflected as subjective and
objective data in an ethnographic study, the words ‘subjective’ and ‘objective’ could
cause confusion among anthropologists. To allay this confusion, many
anthropologists commenced the use of the terms emic and etic to refer to
‘informants’ or ‘observers’ perspectives. The emic approach, according to Barrett
(1991), is the insider’s perspective and this emic position encourages the
ethnographer to bring forth and report voices of individuals through the use of the
informant’s own words and interpret their unique understandings of their reality. In
contrast, the observer-oriented view is known as the etic approach, which might
pertain to issues of social, political, economic organisation and social control, or
provide speculation on how individuals of a particular group conduct their daily life
routines, and/or communicate their cultural beliefs and values with each other.
Selecting key informants: According to Barrett (1991), informants are members who
actively collaborate with the fieldworker. The reasons for the use of informants are
primarily to gain ‘rich’ information from people who have been socialised and who
have been accustomed to the rules and behavioural norms of their culture. These
informants can provide an abundance of knowledge, which is invaluable for the
fieldworker. Barrett illustrated the value of such informants when describing women
as more knowledgeable than men when discussing childbearing issues. Goetz and
LeCompte (1984) asserted that nurse ethnographers usually use purposive sampling
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which is criterion-based and non-probabilistic, which implies that researchers adopt
certain criteria to select a specific group and setting to be studied. For example, the
researcher selects key informants within a culture who can provide specific detailed
information about the culture—their own special knowledge about the origins and
subculture of a group, their interactive processes and cultural rules, rituals and
language. Key informants also assist the ethnographer to become accepted in the
culture.
Leininger (1985) claimed that a small sample of informants can be more beneficial to
the ethnographer than a large sample of general participants without precise
knowledge of a topic, and the bond between the ethnographer and informants
becomes stronger as the two parties spend time with each other. However, Fetterman
(1989) cautions against prior assumptions held by key informants in that, if they are
very knowledgeable, they may tend to thrust their own ideas on the study and
researcher—hence the ethnographer needs to compare informants’ news or materials
with observed reality. Furthermore, Fetterman (1989) pointed out that informants
may want to please and only relate what the researcher wishes to know. However,
the long-term contact between the two parties helps to overcome this situation.
Multiple perspectives: Ethnographers recognise that individuals interpret their world
based on their own unique experiences, and these interpretations include their
perceptions, intentions, expectations and pertinent concerns through which each
individual makes sense of things. Therefore ethnographers immerse themselves in a
particular situation in order to uncover and describe how different people interpret
their actions and beliefs.
Multiple methods: Fieldwork is a major characteristic in ethnography. Ethnographic
fieldwork is not a homogenous method, hence field workers utilise a variety of data
collection techniques, also known as triangulation. The most common strategy is
participant observation in which the researcher is immersed in the everyday life of
people in a selected setting, gathering information, such as audio recording, direct
observation, interviews, questionnaires and collecting materials (Bailey, 1995;
Burns, 1997).
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Process and sequence: In quantitative research the focus is on the testing of theory.
This contrasts with the ethnographic researcher who is involved in fieldwork, dealing
with process rather than outcomes (Cresswell, 1994), and with the primary concern
to generate and develop theory for the purpose of making “a contribution to
knowledge that is relevant to some public concern” (Hammersley, 1990, p.7).
Ethnographers strive to grasp the social reality of a group in order to generate the
appropriate research questions, which become the most important characteristic of
the research. As a consequence, research design in ethnography follows a non-linear
cyclical pattern, depending on various decisions that have to be anticipated during
the course of fieldwork and, according to Spradley (1979), ethnographic design
consists of five tasks in ethnographic research requiring regular feedback to give the
study direction. These tasks can be explained as: selecting a problem, collecting
cultural data, analysing cultural data, formulating research questions and writing the
ethnography. In other words, the technique adopted is determined based on the
nature of the social environment in the study, such as “How is it done?” “What
cultural resources, stocks of knowledge, routines and strategies do they bring to
bear?” (Burns, 1997, p. 301). The five ethnographical tasks are briefly outlined as
follows.
• Selecting a problem: Ethnography begins with a problem or topic of interest
(Fetterman, 1989; Spradley, 1979).
• Collecting cultural data: This phase commences before any research questions
are developed. The ethnographer starts by asking descriptive questions,
observing and recording field notes.
• Analysing cultural data: The analysis of information is continuous and begins as
soon as the ethnographer enters the field, exploring, collecting data and travels
from description to explanation. The researcher reviews field notes seeking for
cultural symbols and relationships among symbols during the period of
participant observation. (Depoy & Gitlin, 1998; Spradley, 1979).
• Formulating research questions: Research questions arise from the culture under
study.
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• Writing the ethnography: Writing is part of the analysis process as well as a
means of communication, which can lead to new questions and observations and
occurs towards the end of the research cycle.
Spradley’s (1979), five ethnographical tasks will influence the design for this study
and will be discussed in the research design chapter. As a participant observer the
researcher was involved in exploring the field to describe and explain the social
situation and cultural perspectives of the group, hence the design will also
incorporate the explorative, descriptive an explanative phases of research and
explained in Chapters 5, 6, and 7 of this study.
3.6. Triangulation
The integration of a multi-method approach is termed triangulation. Triangulation is
basic in ethnography and “is the heart of ethnographic validity” and “…improves the
quality of data and the accuracy of ethnographic findings” (Fetterman, 1989, p. 89).
A multi-method approach could include the use of survey questionnaires, interviews,
participation observation and analysis of documents (Denzin cited in Minichiello et
al., 1995, p.14). Triangulation is a commonly used strategy in social sciences for the
purpose of acquiring or explaining “more fully, the richness and complexity of
human behaviour by studying it from more than one standpoint and/or using a variety
of methods (Burns, 1997, p. 325).
Burns (1997) postulated that triangulation leads to verification and validation of
qualitative analysis in two ways. Firstly, by examining the consistency of
information generated by different data collection techniques. Secondly, by
examining the consistency of different information within the same technique. In
other words, conforming to one method could have the tendency to bias the
researcher’s perspective of a “particular slice of reality being investigated” (Burns
1997, p. 325), but could be “neutralized when used in conjunction with other data
sources, investigators and methods” (Jick cited in Cresswell, 1994, p.174). Denzin
and Lincoln (1998, p. 46) identifed four basic types of triangulation and are
explained as:
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• Data triangulation: The use of different types of data sources in a study, for
example time, space and person (Denzin, 1989, p. 237), and each occurrence or
social interaction is unique (Denzin, 1989, p. 244).
• Investigator triangulation: The use of different researchers or evaluators. The
main purpose is to eliminate any bias inherent in using a single observer.
• Theory triangulation: The use of multiple perspectives to interpret a single set of
data.
• Methodological triangulation: Involves the use of multiple techniques to study a
single problem.
In this study, various triangulation methods were used. In the descriptive phase of
this project the researcher used data triangulation by interviewing various people
within the setting. Peer review evaluation was employed to establish inter-rater
reliability and ensure investigator triangulation when evaluating clinical instructors’
teaching techniques. Theory and methodological triangulation were applied through
multiple methods using interviews, observations and questionnaires to acquire
multiple sources of evidence.
3.7. Validity in ethnography
Data collection and analysis strategies used by ethnographers in ethnographic studies
maintain high internal validity (Burns, 1997) for various reasons. Firstly, the long-
term living relationship with participants in the setting allows continual data analysis
and comparison to “refine constructs and to ensure the match between scientific
categories and participant realities” (Burns, 1997, p. 324). Secondly, interviews with
informants, which constitute a primary ethnographic data source, must be solely
derived from experience or observation and “are less abstract than many instruments
used in other research designs” (p. 324). Thirdly, the researcher’s role as participant
observer, in order to acquire the reality of life experiences of participants, is found in
the natural settings. Fourthly, ethnographic analysis embodies a process of
ethnographer self-monitoring—known as disciplined activity, in which the researcher
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continually questions and re-evaluates information and challenges his/her own
opinions or biases.
Finally, Hammersley (1990, p. 10) advocated that although replication is not always
possible in natural sciences and may not be feasible in ethnography, it does not
therefore “detract from the validity of ethnographic findings”. Furthermore,
ethnographers utilise methods designed to secure that their findings are not
idiosyncratic – for instance by comparing information from other sources, a term
known as triangulation. Triangulation is employed to enhance validity (Burns, 1997;
Hammersley, 1990).
3.8. Reliability in ethnography
The degree of reliability in ethnographic research is based on replication of the study,
and that two or more individuals can have comparable explanations by conforming to
categories and procedures in the study (Burns, 1997). Although replication in natural
sciences is not always achievable (due to changes in the setting or behaviours of
members), the possibility to replicate ethnographic findings does not undermine
assessments of their validity, though it may make the task more difficult. Burns,
(2000, p. 417) stated that qualitative research does not pretend to be replicable. The
researcher “purposely avoids controlling the research conditions and concentrates on
recording the complexity of changing situational contexts.”
The threat to reliability in ethnographic studies can be overcome in the following
ways. Ethnographers can: (i) provide a profile for the research together with major
question(s) they wish to address, (ii) describe their views on the question(s) and
explain the research assumptions and biases, and (iii) explain the data collecting
process in view of timing and parameters of the study, interviews, relationships with
members and categories to be developed for analysis (Burns, 1997). The quality of
data is also improved when the participant observer establishes and sustains trusting
and cooperative relationships with people in the field (Johnson, 1975).
In a sense, validity and reliability are closely associated issues that “acquire a distinct
character for the methodology of participant observation” (Burns, 1995, p. 325).
Dependable and trustworthy results are major concerns and participant observation
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facilitates a number of techniques for checking for valid and reliable findings (Burns,
1995). Furthermore, in this study the researcher and peer review evaluations of
clinical instructors’ teaching techniques were conducted to increase reliability
because “critical also to reliability is inter-rater or inter-observer reliability” (Burns,
2000, p. 417).
3.9. Trust and integrity in ethnographic research
There are no definite guidelines for researchers in order to gain trust and integrity in
ethnographic research and, according to Neuman (1994, p. 342), “a genuine concern
for and interest in others, being honest, and sharing feelings are good strategies”.
The researcher’s long-term period in this study interacting with members, listening
and understanding their concerns, their verbal and non-verbal language and
acknowledging their cultural rules helped to develop rapport, trust, integrity and co-
operation. This degree of relationship between the researcher and members is very
helpful in obtaining “accurate and dependable information” (Jorgensen, 1989, p. 70)
and checking of data was undertaken with informants.
3.10. Ethical principles
Informants are human beings who have interests, concerns and problems and
researchers’ values are not necessarily similar to informants. As fieldwork is an
essential component of ethnography, researchers in the field frequently confront
conflicting values and a broad range of possible choices. For example: “How will I
use the data collected and will I tell the informants how it will be used” (Spradley,
1979, p. 79). Therefore, ethnographers need to protect the physical, social and
psychological welfare and to honour the dignity and privacy of their informants.
Ethnography also entails interaction with other people such as sponsors and
gatekeepers, who may have the power to grant or withhold permission to conduct
interviews. The researcher must also safeguard the artefacts that are collected,
because:
No matter how unobstrusive, ethnographic research always pries into the lives of informants. Ethnographic interviewing represents a powerful tool for invading people’s way of life. It reveals information that can be used to affirm their rights, interests and sensitivities or to violate them. All informants must have the
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protection of saying ‘off the record’ which never find their way into the ethnographer’s field notes. (Spradley, 1979, p. 36)
Therefore, informants have the right to be made aware of the ethnographer’s aims for
the study, which must be clearly explained. Informants also have the right to have
their privacy protected by remaining anonymous, which must be respected, as well as
other data, such as materials or any interview equipment. For this research, a
proposal and consent for the study was approved by the appropriate ethics
committees within the two organisations involved, and consent was gained from
informants.
3.11. Data collection methods
There are several different information-gathering techniques that are used in
ethnography—watching, listening, asking and examining materials—which are
conducted during fieldwork in order to survey the setting, which includes the nature
of the language, kinship ties, historical data and function of the culture (Fetterman,
1989). The key to fieldwork “is being there” (Fetterman, 1989, p. 19) for the
purpose of observation, asking “seemingly stupid yet insightful questions” (p. 19),
taking notes and recognising that cultural influences are created from what
individuals say, do and act (Fetterman, 1989; Neuman, 1994; Spradley, 1979).
Minichiello et al. (1995) posited that the goals of qualitative research are to capture
an individual’s meanings and definitions of events and to comprehend the meaning
of phenomena in context. This enables the provision of an in-depth account of
phenomena under study. The collection methods deemed most suitable to meet this
goal within this research group were those of fieldwork and participant observation,
which are now described.
3.11.1. Fieldwork
Fieldwork is the hallmark of ethnography and involves the researcher working for
long periods of time in a natural setting. This natural approach steers clear from the
controlled or laboratory situations used typically in experimental-type research
(Fetterman, 1989; LeCompte & Preissle, 1993). Depoy and Gitlin (1998) suggested
that ‘observation’, ‘asking’, ‘examining materials’ and ‘recording information’ are
essential elements in fieldwork. The process of “watching and listening is referred to
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observation” (Depoy & Gitlin, 1998, p. 219). In ethnographic studies, researchers
work in the field and embrace the role of participant observer in order to observe
people and their behaviours, and comprehend and interpret social and cultural
meanings within real life settings where individuals interact with each other.
Spradley (1980) asserted that observation is a fundamental component of all
ethnographic inquiry, because ethnographic fieldwork commences when one begins
to ask questions. For example, “What are people doing here?” “What is the physical
setting of this social setting?” (p. 32). In fieldwork, researchers also make use of
various data collection strategies to ensure the integrity of the data. Participant
observation is a primary data collection technique (De Laine, 1997) and the most
complete immersion in a culture (Spradley, 1980).
The watching and listening phase moves from broad descriptive observations to
acquiring a more precise understanding of the meanings of what has been observed.
The researcher proceeds to asking questions in the form of interviewing as a method
of data collection. Unlike observation, asking entails direct contact with individuals
who are able and willing to provide information and are known as informants. (The
aspect of informants was explained earlier on in this chapter.)
There are several styles of asking questions, from informal unstructured interviews to
structured or long in-depth conversations. (Questioning and interviewing are
explained later on in this chapter). Depoy and Gitlin (1998) stated that, in
naturalistic research, unstructured interviewing is the most common type of asking
and this form of interviewing is essential in the early phases of fieldwork as the
researcher is beginning to gain rapport with the group, their language and behaviours
within the setting. In the ethnographic interview the researcher attempts to
understand culture by communicating with insiders in the culture. The unstructured
interviews comprise informal dialogue or face-to-face twosomes in small groups
wherein the researcher “sets the context and the informants offer their knowledge”
(Depoy & Gitlin, 1989, p. 222). Throughout fieldwork, interviewing occurs in one
or more sessions and is generally combined with other strategies of observation and
review of existing materials.
Examining materials consists of journals, diaries and so forth—which are rich
sources of data and the researcher needs to secure permission for these documents.
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Initially, the investigator examines a broad array of documents and as the researcher
moves closer into the study, becomes more focused to exploring “recurring themes
and events” (Depoy & Gitlin, 1998, p. 224) and uncovering patterns and
irregularities (Spradley, 1980).
There are several techniques that a researcher can use when recording information.
For example field notes, audiotapes and videotapes; with field notes the most
common form of recording information. Typically researchers record events,
observations, occurrences and notes of the researcher’s own experiences and
feelings. Field notes are used in conjunction with observations, interviews and other
data collection materials. Audiotapes are also important when conducting interviews
and especially in open-ended interviews when informants provide lengthy detailed
descriptions of their situations. Researchers should also take notes as a back-up in
case of equipment failure, despite pre-testing the equipment.
Fieldwork was utilised in this study. In the field the researcher was involved in
observing behaviours and listening to hear what and why people or informants said
what they said, what they did, and how they acted. The researcher was involved in
interviews to compare information between informants in order to secure findings,
sustain cooperative relationships with people in the field and to enhance validity.
The researcher utilised a questionnaire to determine students’ feelings and engaged
in communication with them. In addition, the researcher collected written
documents/materials, for the purpose of checking the information for validity and
reliability.
3.11.2. Participant observation
Spradley (1980) asserted that participant observation has two objectives when
entering a social situation: (i) to be involved in activities appropriate to the setting,
and (ii) to observe the activities, people and physical elements of the setting.
Hammersley and Atkinson (1995) and De Laine (1997) stated that ethnographers use
participant observation as a principal technique for data collection, while Jorgensen
(1989) indicated that participant observation can be used with other methods for
collecting information in the field. Jorgensen made the point that the methodology
of participant observation is inappropriate where questions relate to fairly large
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populations – this is better addressed via surveys or experiments. In other words,
participant observation is most suitable when minimal conditions exist such as:
• the observation pertains to human meanings and interactions as seen from the
standpoint of insiders;
• the phenomenon of investigation can be surveyed in the here and now of an
everyday life setting;
• the researcher is able to obtain access into the setting;
• the research problem can be addressed by qualitative information collected by
participant observation pertinent to the field setting;
• the process of inquiry is open-ended and flexible providing direct experiential
and observational access based on facts about human life grounded in the
realities of daily existence; and
• the researcher is able to use direct observation together with other techniques for
collecting information.
Chenitz and Swanson (cited in Jorgenson, 1989, p. 12) supported participant
observation for developing theories “grounded in practice that are useful to nursing”
and about “applying knowledge” (p. 30). In view of conditions outlined by
Jorgensen in the previous paragraph, similar circumstances in this study were
amenable for the researcher who took the opportunity to utilise this “very special
strategy and method for gaining access to the interior seemingly subjective aspects of
human existence” (Jorgensen, 1989, p. 21). “Direct observation is the primary
method of gathering information, but the participant observer usually employs other
strategies” (Jorgensen, 1989, p. 22). Documents (such as newspapers, diaries,
memoranda) together with various forms of communication (audio recordings,
photography, video-tapes, television) and artefacts (art, tools, clothing, buildings and
so forth) are easily obtainable in many field settings (Jorgensen, 1989). In the
process of accumulating data, the researcher may collect information from
knowledgeable informants regarding issues of interest, life histories and/or from
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casual communication, in-depth, formal or informal, structured or unstructured
interviews and questionnaires (De Laine, 1999; Jorgensen, 1989).
Participant observation involves immersion in a culture, learning the language and
observing patterns of behaviour to obtain meaning (Fetterman, 1989; Spradley, 1979
&1980). LeCompte and Preissle (1993) asserted that familiarity with the language of
participants is an essential dimension, in order to gain an understanding needed for
unravelling behaviours and belief patterns under study, which cannot be effectively
achieved with the use of translators. Radin (cited in LeCompte & Preissle,1993, p.
94) suggested acquiring some fluency in the language as well as extensive and
intensive participant observation. Fetterman (1989) supported this view and stated
that the long-term interaction with participants helps researchers to internalise
beliefs, expectations and hopes of the individuals under study. In this study, the
researcher attended language classes and had spent a long time in the country
socialising and working in the culture. For instance, the researcher recognised the
importance of a simple ritualistic behaviour, and the incorporation of essential prayer
time within the curriculum, informing or teaching how individuals use their time and
space and how they decide what is “precious, sacred and profane” (Fetterman, 1989,
p. 45).
The role of the researcher in participant observation involves variations in overt or
covert dimensions. In terms of the overt, participants in the field are fully aware who
the observer is and that observations are being conducted together with a complete
explanation of the study. By contrast, in a covert position, participants are not
informed or aware of anything occurring. The duration of observations could range
from a limited one hour to long-term (months or years) (De Laine, 1997).
Participant observation technique is dissimilar to the positivistic approach in that the
latter involves experiments and surveys. Experiments demand control and
manipulation of the research setting and can be highly obstructive and involve
human subjects (Hammersley, 1990). Surveys are best suited for collecting large
amounts of data. Participant observation, by contrast is flexible, open-ended and an
opportunistic and creative process to gain access to otherwise inaccessible dimension
of human life and experiences (Jorgensen, 1989).
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In desiring to be part of the information, the researcher in this study immersed in the
everyday social interactions of the participants for the purpose of entering the
“everyday world of the other in order to gather accurate, truthful information” (De
Laine, 1997, p. 142). Hence, participant observation was used in this study for the
purpose of observing social and cultural processes and, as De Laine (1997)
described, trying to reveal meanings of reality that individuals exercise to make sense
of their everyday lives. Participants were made fully aware of the researcher’s
intentions in the field setting. As it is important that findings of participant
observational studies be documented (Jorgensen, 1989), the researcher kept tape
recordings of interviews while in the field and collected documents, such as various
types of written material.
3.11.3. Questioning and interviewing
In ethnographic interviewing “the very structure of the interaction forces participants
to be aware of the ethnographer as audience” (DeLaine, 1997, p. 146). Interviewing
involves questioning and questioning is a useful method to gain data and is described
by Minichiello et al. (1995, p. 62) as “a means of gaining access to information of
different kinds” and “questions always imply answers” (Spradley, 1979, p. 84).
Descriptive questions form the backbone of ethnographic interviews and take
“advantage of the power of language to construe settings” (Frake cited in Spradley,
1979, p. 85). Descriptive questions encourage dialogue in an informant’s native
tongue about an experience or a specific cultural setting about which the
ethnographer needs to know. One major principle in asking descriptive questions is
that “expanding the length of the questions tends to expand the length of the
response” (Spradley, 1979, p. 85). Most descriptive questions are asked in the first
interview and these questions continue throughout other interviews. Descriptive
questions have many advantages and Spradley (1979) provided five essential types of
descriptive questions. The precise form of questioning depends on the cultural
scenario chosen for the study. The five forms of descriptive questioning are
explained as follows.
Grand Tour Questions: Grand tour questions stimulate an experience ethnographers
have when they embark on a cultural scene. This form of questioning is conducted
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in a particular locale, for example a hospital, home or college. A typical example of
a grand tour question is: “Could I have a grand tour of the place?” From the
response, the ethnographer can expand the experience by asking “could you describe
the main events of this place in a typical year?” In this answer an informant can
provide the ethnographer with a grand tour through certain groups of people. Hence
grand tour questions enable an informant to “ramble on and on” (Spradley, 1979, p.
87), giving information on space, time, people, activities, events or objects.
Mini Tour questions: This type of questioning is similar to grand tour, except that it
focuses on a much smaller unit of experience. For instance: “Could you describe
what you do during a break?” (Spradley, 1979, p. 88).
Example questions: Example questions are still more specific as they deal with a
single act in terms of: “Can you give me an example of someone giving you a hard
time?” (Spradley, 1979, p. 88). Clearly, this type of questioning leads to interesting
stories of occurrences, which the researcher will discover.
Experience questions: These questions deal with an informant’s prior experience in
some particular setting. For example the researcher may pose a question such as,
“You probably had some interesting experiences in jail; can you recall any of them?”
(Spradley, 1979, p. 88). These types of questions are open-ended and sometimes
informants encounter difficulty responding, as they tend to elicit a typical situation
rather than recurrent routine ones. Spradley (1979) suggested that these questions
should be posed after grand tour questions and mini tour questions.
Native-Language questions: Native language questions encourage informants to
utilise terms and phrases commonly used in a cultural setting. For example “Could
you describe a jail?” (Spradley, 1979, p. 89). Such questions “serve to remind
informants that the ethnographer wants to learn their language” (p. 89). Therefore,
as the familiarity between the researcher and informant develop, native-language
questions become more important.
Questions and can be structured or unstructured and used in surveys, or performed
face-to-face, in groups or as telephone interviews. Minichiello et al. (1995, p. 62)
offered the traditional image of interviewing as displayed in Figure 1.
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Figure 1: Interviewing methods: the continuum model
(Minichiello et al.1995).
In standardised interviews the role of an interviewer is to promote responses to
primarily ‘closed’ or ‘fixed’ questions, which are ordered in the area of inquiry.
Interviewers control the flow of communication, record the responses of informants
in order to elicit information about what they are investigating. Each informant is
asked the same question in an attempt to control bias between interviews.
Furthermore, to enhance reliability Minichiello et al. (1995) stated that the social
interaction between informants is structured and formalised.
Unstructured interviews, by contrast, lean on social interaction between members
and the interviewer to acquire information. Members are permitted to allow their
thoughts to wander and, although structuring and ordering of questions are not
utilised, there is an element of controlled communication relating to the interests of
the interviewer.
Semi-structured or focused interviews are patterned on the unstandardised, rather
than on the standardised pattern of interviewing. In a semi-structured interview an
interview schedule is formulated to address the topic and to guide the interview, yet
“without fixed wording or fixed ordering of questions” (Minichiello et al., 1995, p.
65). The content of the interview is directed on matters that are foremost to the topic
of the research. The manner in which questioning takes place allows room for
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flexibility, social interaction, exploration of ideas and “provides opportunities to
observe participants in the face-to-face ongoing interaction of the focus group” (De
Laine, 1997, p. 294).
Morgan (1997) elaborated on the significance of focus group interviews in terms of
the importance of social context to the construction of meaning (and on which the
analyst must focus) and the need to treat the group as the unit of analysis and not the
individual. Morgan (1997) also stated that it is imperative to pay particular attention
to the amount of consensus and interest that topics generate within and across
groups, and how the dynamics of the group influences what is said thus creating a
greater diversity of communication than the more conventional methods of data
collection (De Laine, 1997). A diversity of authors have advocated that focus group
interviews promote critical thinking abilities because group interaction triggers other
ideas and argumentation, which involves the essential component of critical thinking
(Bell, 1991; Burrows & Kendall, 1997; Clarke, 1999; Glendon & Ulrich, 1997;
Kingry, Tiedje & Friedman, 1990; McDaniel & Bach, 1994; Morgan, 1997;
Morrison & Peoples, 1999).
For this study, descriptive questioning was utilised because it forms the “basis of all
ethnographic interviewing” and it leads “to a large sample of utterances that are
expressed in the language used by informants in the cultural scene under
investigation” (Spradley, 1979, p. 90). The researcher used semi-structured or focus
group interviews of members in order to engage groups of individuals in
conversation. A semi-structured type of interview format was employed because: (i)
“Ethnographic interview is one strategy for getting people to talk about what they
know” (Spradley, 1979, p. 9) (ii) the context of focus groups in particular “permits
the expression of divergent opinions, audience interpretation and audience reaction”
(De Laine (1997, p. 191), and (iii) to observe the “face-to-face interactions of the
focus groups” (p. 204).
3.11.4. Questionnaire
Neuman (1997) provided two key principles for good survey questions, which are to
avoid confusion and maintain the focus of the respondent’s perspective, so that
respondents can comprehend the questions and their responses are meaningful. The
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main use of questionnaires in research is based on the assumption that respondents
are willing and amenable to providing truthful responses. Burns (2000) pointed out
that the nature of questionnaires may be explanatory or descriptive and that the aim
of explanatory questionnaires is to seek to “establish cause and effect relationships
but without experimental manipulation, for example the effects of social climate on
adolescent values” (p. 566). Descriptive questionnaires assess as precisely as
possible the state of existing situations in terms of the characteristics of a
population—such as its demographic composition, attitudes, expectations that people
hold and the manner in which they express their expectations. Questionnaires can be
one way in which to gather such information. Fetterman (1989) stated that while a
questionnaire is similar to an interview in that questions can be pre-planned, the
difference is that a questionnaire falls short of the interactive spirit of interviews.
There are advantages and disadvantages in using questionnaires. The advantages are
that the researcher can either mail or give questionnaires directly to respondents,
hence this activity is cost effective because it can be conducted by a single
researcher. Mail questionnaires provide anonymity, avoid interviewer bias and can
be beneficial for a target population that is well educated or has a keen sense of
interest in the topic. Questionnaires are useful in quantitative studies because large
amounts of data can be easily collected, coded, analysed and outcomes obtained
relatively quickly. Conversely, the disadvantages are that people do not always
complete and return mailed questionnaires. Mail questionnaires are inappropriate for
the illiterate or near illiterate in English and these individuals are not likely to return
the questionnaires. Besides a low response rate, other disadvantages are: (i) the
researcher is not present to clarify or probe questions when respondents provide
incomplete answers, (ii) the possibility of misinterpretation of questions, (iii)
complex questions are impossible to include, and (iv) spontaneous questions cannot
be recorded (Burns, 1997; Neuman, 1994).
Various strategies can be implemented to deal with some of the disadvantages in
using questionnaires. Pilot testing the questionnaire is one technique to identify
ambiguous and confusing questions or inconsistencies in the questionnaire, so that
modifications can be made prior to administrating the questionnaire. Another
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strategy to ensure control over completion especially when it is a work-related, is to
arrange a place and time in the workplace.
A questionnaire was used in this study to obtain participants’ feelings about the use
of critical thinking strategies. This questionnaire was piloted and, to ensure
attendance, participants were notified two weeks prior to the date for completion of
this questionnaire and a follow-up memo was also circulated to remind participants.
Completion of the questionnaire was conducted in the workplace. Sudman and
Bradburn (1989) stated that when questionnaires are appropriately implemented, they
can yield effective results and prove to be just as effective as the more costly data
gathering techniques.
3.12. Summary
In this chapter the differences between qualitative and quantitative research are
explained. The distinctions between exploratory, descriptive and explanatory
research were discussed because “ethnography is the work of describing a culture
and learning from people (Spradley, 1980, p. 3). The researcher also discussed two
other qualitative methods (phenomenology and grounded theory) and provided
rationale for selecting ethnography as a method for this study. Ethnography, the
research method for this study was examined. Sampling, reliability and validity were
also discussed and the rationale for the various data collection methods utilised in
this research was highlighted. The researcher identified the design for this study,
which is influenced by Spradley’s (1979) cyclical patterns and consists of five tasks
in ethnographic research. The following chapter will deal with the research design
for this study.
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CHAPTER FOUR
Research Design
4.0. Introduction
In quantitative research design the investigator uses control to limit the effects of the
extraneous variables, the data collection is discussed followed by data analysis, data
presentation and interpretation (Cresswell, 1994). By contrast, ethnographical design
concerns the gathering of an in-depth, rich description and explanation of
phenomena. Data analysis begins as soon as the researcher enters the field to see and
understand phenomena. This analysis continues throughout the researcher’s
involvement in the setting. Depoy and Gitlin (1998, p. 274) indicated that “it is the
basis from which all decisions are made” and questions emerge, such as what to
observe, who to interview, and form the initial step that leads to the next data
collection phase. Hence, the process is a continuous cyclical pattern of data
collection and analysis requiring constant feedback in which each cycle is dependent
upon interpretation of data from a previous cycle (Spradley, 1979), and the
researcher is immersed in the field and culture of the study group. Spradley (1979)
offers five tasks in ethnographical research design and although these tasks may
appear to be sequential, “they must all go on at the same time” (p.93). The tasks
involved in an ethnographic design were briefly outlined in Chapter 3 and will be
described as follows.
4.1 Five tasks in ethnographical research design
The five tasks in ethnographic research design, although appearing sequential are
actually cyclical in design (Spradley, 1979).
4.1.1. Selecting a problem
The cycle begins with selecting a problem or topic of interest (Fetterman, 1989;
Spradley, 1980), or developed through practical experience or suggested by
colleagues, researchers and advisors (Cresswell, 1994). The problem is the driving
force and what the researcher wants to do (Fetterman, 1989). Spradley, (1979, p. 94)
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advocated that “all ethnography begins with the same general problem: What are the
cultural meanings people are using to organize their behavior and interpret their
experience?” Such a general aim encourages the researcher to study whatever
informants feel is essential in a particular cultural setting, including critically
examining literature, official reports, journal articles and questioning to define the
problem (Spradley, 1980). Hammersley and Atkinson (1995) pointed out that,
although there are no hard and fast rules to guide how far the initial research problem
can be clarified, the problem needs to be elaborated before the collection of data
commences. However, Jorgensen (1989) cautions that while it is useful to revisit and
explore existing literature and theories (related to the problem), as various issues
emerge from the analysis and “you should not be constrained by what other people
have done” (p. 110).
4.1.2. Collecting cultural data
The next major task in the ethnographical cycle is gathering cultural data through
participant observation and becoming familiar with the setting. On entering a new
situation the ethnographer surveys the general features of the setting in terms of its
space: “What kind of space, is it unusual or typical of other buildings?” “How is the
space organised?” “What kind of things are in the space?” By answering such
questions the researcher is able to describe the physical environment and form an
impression about it (Jorgenson, 1989). A similar strategy is applied when observing
and collecting information about the people and events within the setting. “How
many people are there?” “What are the people doing?” “What feelings do I get about
this setting?” Aside from asking questions, the main purpose is to get a “feel for the
setting and then to attempt to fit in” (Jorgenson, 1989, p. 83). More focused
observations take place once the researcher is familiar with the setting and the
people. The researcher concentrates on matters of particular interest, derived from
the emerging problem and issues of the research, starting with the widest range of
phenomena and gradually narrowing the attention to specific phenomena. Jorgenson
(1989) stated that listening is the main feature of gathering data, questioning or
interviewing are most appropriate for getting acquainted with people and “to open up
the data” (DeLaine, 1997, p. 219).
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Collecting data is conducted in the field and the researcher utilises different data
collection strategies (discussed in Chapter 3). The data gathered are recorded as field
notes (Spradley, 1979). However, prior to entering the field, the researcher must
contact informants because ethnography is conducted in the context of the situation
under study, and ethnographers acknowledge the importance of being in the natural
setting and spending time with key informants. Hence, caution must be undertaken
in preparing entry into the setting as the entire study “depends in large part on the
group’s acceptance of the researcher” (Burns, 2000, p. 401). Gaining entry is best
obtained through mutual contact or through recommendation to the gatekeeper.
Gatekeepers are protective of the environment and are often guarded by lengthy
periods spent in the setting by researchers and of the investigators relationships of
people in the environment. Therefore, trust and confidence are useful strategies
(Hammersley, 1990). Furthermore, most gatekeepers are unfamiliar with
ethnographic inquiry and the ethnographer may be requested to produce a draft
proposal, questionnaires or interview schedules and time-lines for the study. In this
study permission was sought from the appropriate authorities prior to submitting the
formal proposal. These aspects were established between the researcher and
authorities in the field setting, which were invaluable and needless to say, these
authorities were powerful advocates for this project. Fetterman (1989, p. 44) stated,
“the closer the go-between’s ties to the group, the better”. Furthermore, the
researcher’s long-term employment with the organisation was also acknowledged as
being a member, friend and associate.
4.1.3. Analysing cultural data
Analysing data is a continuous process in ethnographic inquiry because the
researcher does not come into the field with specific questions, rather the
ethnographer analyses the field data gathered from participant observation to
discover questions. The ethnographer also looks for patterns of thought and actions.
“Patterns are a form of analysis” (Fetterman, 1989, p.92). Taking field notes, key or
focal events, photographs, various documents, as well as human artefacts and other
means to record observations help to “build a bridge between observation and
analysis” as they can capture a wealth of information or a “lens through which to
view a culture” (Fetterman, 1989, p. 93). Field notes are analysed after each
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fieldwork session in order to inform the researcher what to examine for the period of
participant observation.
In order to understand cultural meaning, ethnographers must analyse social
situations they observe. A social situation is different from the concept of culture in
that social situations refer to the stream of behaviours (activities) carried out by
people (actors) in a specific location (place), and analysis of a social situation leads
to discovery of the cultural scene. By contrast, culture pertains to patterns of
behaviour, artefacts and knowledge that individuals have learned or discovered.
“Culture is an organization of things, the meaning given by people to objects, places,
and activities” (Spradley, 1980, p. 86). Therefore, analysis of field notes goes
beyond descriptions of behaviour and things in order to uncover the cultural meaning
of behaviours observed and perceived by the ethnographer. Spradley (1979) posited
that four levels of ethnographic analysis exist in ethnography with a primary aim “to
uncover the system of cultural meaning that people use” (p.96). The four levels of
analysis are: domain analysis, taxonomic analysis, componential analysis and theme
analysis and are explained as follows.
Domain analysis: The first step in analysis is to do a domain analysis, which involves
a category of cultural meaning in search of smaller categories. These categories or
cultural domains are categories of meaning (which involve the use of language) and
consist of a cover term, included term and semantic relationship (Spradley, 1980).
The aspect of cover term, included terms and semantic relationship are described in
Chapter 7. In doing this type of analysis, ethnographers will uncover cultural
symbols which are included in larger categories (domains), and which could provide
important insight into the culture of the situation, leading to the making of a
taxonomic analysis.
Taxonomic analysis: This kind of analysis is more in-depth in that ethnographers are
seeking larger categories to which the domain may belong (Spradley, 1979). For
example, in this study ‘culture’ is identified as a domain of category of meaning.
Culture also relates to religion, constraints, culturally appropriate attire and so forth.
The researcher examines for relationships to the whole, makes more observations
and asks more questions. For example: “What is the meaning of culture in Saudi
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Arabia and how does it play an important role in the lifestyles of the people in this
country.” “Does culture impact on the profession of nursing in Saudi Arabia?” The
ethnographer continues to search for the “internal structure of domains and leads to
contrasts sets” (Spradley, 1979, p. 94).
Componential analysis: A component is another term for ‘unit.’ Componential
analysis entails the entire process of searching for contrasts, sifting them out,
grouping some together as dimension of contrasts and entering all this information
into a matrix or worksheet. The worksheet acts as a check sheet that will guide the
ethnographer in preparing questions for further research. The information can be
verified through participant observation or interviews as a way of triangulating data.
Theme analysis: This kind of analysis involves seeking relationships among domains
and how they are inter-related to the culture as a whole. One way for the
ethnographer to discover cultural themes is to be completely immersed into the
culture (Spradley, 1980), examining the data gathered and identifying recurrent
patterns. Cultural themes may be either tacit or explicit level of knowledge, with a
“large part of any culture being tacit knowledge” (Spradley, 1980, p.11). All this
type of “ethnographic analysis leads to the discovery of cultural meaning” (Spradley,
1979, p. 94). Tacit knowledge is knowledge outside one’s awareness, that is “we all
know things that we cannot talk about” (Spradley, 1979, p. 9) and the researcher has
to make inferences about what people know by listening, observing behaviour and
studying artefacts and their use. By contrast, explicit knowledge is part of what
people know, a level of knowledge that individuals can communicate easily. For
example, cultural rules for appropriate behaviour among kinsmen (Spradley, 1980).
Both explicit and tacit knowledge are imparted through speech, in casual comments
and in lengthy interviews—these will be highlighted in the explorative, descriptive
and explanatory phases of the study. This research will use certain aspects of
Spradley’s (1979) analysis, namely identifying cultural domains, taxonomies and
cultural themes, in order to unfold meaning and to answer the three research
questions in Chapter 8. The researcher found that using these aspects was adequate
for this study.
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4.1.4. Formulating research questions/hypothesis
In this phase, the researcher collects initial data through communication and
questioning, enhancing observations—which are brought clearer into focus leading
to more involvement with individuals in the setting. A “hypothesis (will) arise from
the culture studied” (Spradley, 1979, p. 94). In this stage the researcher refrains from
formalising the problems into defined research hypothesis(es) until all avenues have
been explored – this is known as progressive focusing. Burns (1997) stated that
ethnographers use progressive focusing in an “attempt to avoid commitment to
existing theoretical and /or commonsense categories or sources of data” (p. 309).
4.1.5. Writing the ethnography
Writing is part of the analysis process as well as a means of communication, which
can lead to new questions and observations and occurs towards the end of the
research cycle. Burns (2000) stated that the most distinctive element is the emphasis
on reflexivity: description and analysis of the research process itself, reporting
extracts from the data—which gives the reader an opportunity to assess the study,
especially when quotations from the data are utilised to support arguments. Burns
(2000, p. 420) offered sevens stages in ethnographic reporting, and are explained as:
1. The focus and purpose of the study and the questions it addresses; 2. The research model or design used and justification for its choice; 3. The participants or subjects of the study and the setting(s) and context(s)
investigated; 4. Researcher experience and roles assumed in the study; 5. Data collection strategies used in the study; 6. Techniques used to analyse the data collected during the study; and 7. Findings of the study and their interpretations and applications.
The researcher explained the five cyclical tasks associated with ethnographic
research design. This study utilised three well-defined phases, namely, the
exploratory, descriptive and explanatory phases. In the next section the researcher
deals with these tasks involved in each of the phases of this study. For example, in
the exploratory phase the researcher selected a problem or topic; gathered cultural
data; analysed cultural data utilising domain, taxonomic analysis in order to generate
research questions. In the descriptive phase the researcher gathered and analysed
more cultural data. In the explanatory phase the researcher collected the entire data
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together, analysed and interpreted the data to reveal cultural themes, which formed
the basis for the research questions and which are answered in Chapter 8. Finally the
researcher writes the ethnography.
4.2. Explorative phase of the research design
Ethnographic research usually involves fieldwork and data collected through a
variety of methods, primarily participant observation and interviews with individuals
who are amenable to providing information to the researcher about behavioural
norms, and examination of the meaning of cultural objects or materials (Bailey,
1995; Depoy & Gitlin, 1998; Neuman, 1994). Hence, this study entailed the
researcher communicating with and observing “an intact cultural group in a natural
setting during a prolonged period of time” (Fraenkel & Wallen, 1990, p. 11). The
researcher utilised non-probability (judgemental) sampling technique. The aspect of
sampling was described in Chapter 3.
In this phase the researcher is guided by broad research interests–gathering data with
a view to explore a variety of possible ideas and lines of inquiry. The researcher
scrutinises the general characteristics of the particular human landscape, in order to
gain some impression about the setting in terms of: “What kind of space (or building)
is this?” “Is it typical of other buildings of this sort?" “How is it organised?”
(Jorgensen, 1989, p. 83). In addition, in the initial observations the researcher
approaches the situation with no specific question in mind, except a general inquiry
in terms of “who to interview, what to observe, which piece of information to
explore further, such as: “What is going on here”? (Spradley, 1980, p. 80), are people
arranged in “some recognizable patterns (such as gender)?” (Jorgensen, 1989, p.83).
“What is the culture of this group of people?” (Patton & Westby, 1992, p. 2). The
purpose of asking questions in this phase is to become familiar with the setting and to
‘fit’ in unobtrusively to get a ‘feel’ of the place.
For a period of six years commencing in 1995, the researcher was employed in the
organisation of King Fahad National Guard Hospital (KFNGH). In order to get a
broad mental picture of what is happening, the researcher adopted a naturalistic
approach and immersed into the environment to become familiar with the setting, the
people within the setting and concerns involved. For the first two years, the
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researcher worked as a nurse educator in the Nursing Education Department within
Nursing Services. In this role, the researcher was involved in staff development and
interaction with approximately 1400 expatriate nurses from many countries (56
nations). The researcher also observed that there were only a small number of Saudi
nurses and most of them received nursing education via hospital training programs,
graduating with associate degrees in nursing.
When the researcher was invited to develop critical thinking for an education
program known as the Professional Development Program for Saudi nurses, the
researcher undertook the role of participant observer. In order to gain an
understanding of health care, the researcher examined the health care situation in
Saudi Arabia. The researcher also investigated the status of nursing in Saudi Arabia
to gain an understanding of the system and to investigate why few Saudis selected
nursing as a career.
Multiple data collection techniques were conducted to ensure internal validity and
reliability through triangulation. For example direct observation, unstructured
interviews with nurses, nurse managers, doctors and so forth in the natural setting, in
order to get a feel of the social situation—focusing on holism from a cultural
perspective, because incoming data raises more questions (Burns, 2000, p. 421). The
researcher was also able to take an active part in observing, immersing and
interacting with Saudi nurses as an “outsider” to the cultural scene, seeking to obtain
an “insider’s” perspective (Depoy & Gitlin, 1998). Insiders, according to Depoy and
Gitlin (1998), are also known as informants–individuals who are willing to engage
with the investigator. “Informants are the ‘finger on the pulse of the culture’ without
which the investigator will not be able to achieve full understanding” (p.136).
Therefore the insider’s, or emic, perspective “is at the heart of most ethnographic
research” (Fetterman, 1989, p.30). This is because the insider’s view of reality is
conducive to understanding and precisely describing situations and behaviours—for
example, why members of the social group do what they do.
Review of the literature followed with examination of relevant documents and
government reports and journals pertaining to health care in Saudi Arabia—this
provided a rich understanding of the social situation. As the researcher reviewed
literature pertaining to the topic or problem a literature review was formulated, as
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described in Chapter 2. From the review of the literature, a conceptual model was
formulated (Appendix 1) and the three research questions for the study were
generated (Chapter 1).
Throughout data collection, the researcher analysed data in order to structure later
encounters with the social group while in the field. As the researcher focused on the
specific situation, domain analysis was conducted in order to formulate lists of
categories. Domain analysis allowed for further exploration, leading the researcher
to ask more questions and make observations. Taxonomic analysis followed to
identify the internal structures relating to the domain, generating more questions in
order to establish relationships to the whole. For instance, the researcher explored
health care in Saudi Arabia, which was identified as a domain or category of
meaning. Internal structures relating to this domain (health care) were identified
under the term taxonomy and are reflected in Table 4.1. The explorative phase of the
study is explained in Chapter 5.
Domain Taxonomy
Nurses Doctors Modern medicine Health care Traditional medicine Culturally sensitive care Accreditation Language barriers Sectors of health care
Table 4.1: Domain and Taxonomic Analysis of the Health Care Situation in Saudi Arabia
4.3. Descriptive phase of the research design
In this phase the researcher employed a naturalistic approach to capture the features
of naturally occurring human behaviour, as people’s interpretations are grounded in
their life experiences, values, beliefs, or cultural perceptions and thus operate from a
different frame of reference. The researcher investigated and described the social
situation, the development of nursing in Saudi Arabia, the educational program (the
Professional Development Program), and critical thinking in the social learning
setting to give a deeper understanding of the social environment. Within this phase
the researcher adopted the role of participant observer and collected relevant data
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specific to aspects of the field of study. For example, unstructured interviews with
distinguished nurse consultants, Saudi nurses, staff nurses, managers, a
questionnaire, written documents and tape recordings of interviews. These data
added scope and breadth to the study and validated findings of a specific cultural
group, to triangulate data. Fetterman (1989, p. 91) stated that triangulation “always
improves the quality of data and accuracy of ethnographic findings,” as it has the
“classic sense of seeking convergence of results” (Cresswell, 1994, p. 175).
The data are scanned for categories of phenomena and relationships among such
categories, segmenting and chunking the data, which then can be assigned into
particular groups. Each particular group would relate to a specific element, for
example, particular individuals and sites (Burns, 1997). The ethnographer provides
the big picture of the social group—and this includes the groups’ perspectives,
religion and so forth (Fetterman, 1989). The holistic perspective or holism compels
the researcher to examine beyond the cultural scene, for example in this study events
in the classroom, the clinical field and interviews. Consequently, holism entails a
great deal of time in the field to collect information that will ultimately produce a
picture of the group, because “what people do and what they ought to do are often
very different” (Burns, 1997, p. 302). Hammersley (1990, p. 9) suggested “the same
questions asked by an interviewer at the same point in an interview may mean
different things to different people”.
In this study the researcher became absorbed and concentrated on the new experience
the group was encountering in order to “describe and interpret people's actions”
(Burns, 1997, p. 302) towards a specific strategy. For example: “How they reacted
to a new teaching technique?” “Were they amenable to this method?” “Did they
actively participate?” “What are other informants saying about Saudi nurses?” In
this project the researcher also collected samples of items generated by students, tape
recordings of interviews by informants, and records of assessments through direct
observation.
As Keats (1988) would argue, the affective relationships between researcher and
participants influence the accuracy of data collected. Burns and Grove (1995) postulated
that in ethnographic research, the researcher needs to become familiar with the culture
being studied through active interaction and participation. Therefore, it was important to
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maintain a supportive relationship, trust and confidence with these individuals in view to
complete the study. There was no coercion given and the researcher ensured that she
maintained a collegial relationship with the students. Within this environment not only
would the students answer questions, "they may also help formulate the questions because
they understand the culture better than the researcher does" (Burns & Grove, 1995, p.
427), thus, the following strategies were implemented to collect data: (i) provision of
information, (ii) maintenance of confidentiality, and (iii) invitation for open discussions.
Provision of information: The purpose of the study was explained to the students on
the first day of the program to elicit their support and cooperation for implementing
critical thinking strategies. The data to be collected—which involved direct
observation, survey, interviews, critical thinking questions to be generated by
students and journal documentation—were explained. The students were informed
that their participation was on a voluntary basis, with no penalties attached if they
chose to withdraw from the study. Based on the researcher's experience in Saudi
Arabia, as far as the nursing profession is concerned, Saudis revere the knowledge
and expertise of the Western expatriate. In fact, the researcher’s role as the manager
of the program with a teaching responsibility helped to gain trust and confidence of
the students. The researcher became closely involved in the students' experiences and
attempts were made to create an environment to support their learning.
While the researcher wanted to implement critical thinking strategies, students were
also desirous for a change in learning style. This meant above all, the introduction of
critical thinking strategies was effectively implemented. The gathering of data was
easily executed because students participated willingly with the researcher and other
facilitators.
Maintenance of confidentiality: Students were assured absolute confidentiality and
informed that numbers would be used in place of names, if necessary. Furthermore,
the researcher reinforced that all information collected would be securely locked in
the researcher's filing cabinet and that the research team would be the only people
with access to these data. Their permission to use a tape recorder was sought
initially, and reinforced each time a focus group interview was conducted. As the
researcher was sensitive to cultural values and beliefs, the use of videos was not
considered.
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Invitations to open discussions about critical thinking strategies: During weekly
program meetings students were encouraged to speak candidly about the
implementation of critical thinking strategies, or any aspect of the program. These
meetings provided an avenue to open and free discussions of their experiences and
feelings about critical thinking strategies. The students were not reluctant to lodge
complaints if they were dissatisfied, and demonstrated their appreciation by
rewarding the program with gifts such as books. It was sufficient for them that they
were informed about the study, the critical thinking strategies and given an
opportunity to view their feelings openly. The fact that their final results reflected
high grades is a reflection of their acceptance of critical thinking strategies as a new
learning technique, which could be perceived to have yielded such results. (See
Appendix 5 for students’ grades.) Furthermore, students were also reminded that
they could make an appointment to speak confidentially with the researcher and/or
associate administrator about any aspect of the study with no adverse effects to their
credibility or integrity.
Analysis in the descriptive phase entailed searching for domains or categories and
taxonomies to uncover cultural themes. The descriptive phase will be explained in
Chapter 6.
4.4. Explanatory phase of the research design
In this phase the researcher begins to answer the research questions, building on
exploration and description, searching for causes and reasons, and providing
rationale to support or refute an explanation. Data collection involved interviews
with Saudi nurses, staff nurses, nurse managers, clinical instructors and consultants;
it also involved examining government documents, collecting materials and
reviewing the literature again. Data analysis from domains and taxonomies led to
uncovering cultural themes, which are explained within the research questions. The
explanatory phase will be reflected as Chapter 7.
4.5. Summary
In this chapter the research design for the study was explained together with the
ethnographic tasks, typical of ethnography (Spradley, 1979). The researcher
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explained the four levels of analysis. The three defined phases for the study, namely
exploratory, descriptive and explanatory were described. Chapter 5 deals with the
explorative phase of the research.
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CHAPTER FIVE
Health Services in Saudi Arabia: Explorative
Phase
5.0. Introduction
The researcher initially scrutinises the characteristics of the landscape, investigating
the depth and breadth of the setting to get a wide-angle view and become familiar
with the research environment. Furthermore, the researcher makes observations of
what health care means to this society, the structure of health care, who to
interview—searching for patterns within the study setting and taking field notes in
order to refine research questions. During the explorative phase of this study, the
researcher was a participant observer and conducted fieldwork. The field wherein
the researcher worked, lived and undertook this research was the setting in which
critical thinking strategies were implemented into the education program of a
Professional Development Program (PDP). As a participant observer the researcher
employed various research techniques such as direct observation, literature review,
document analysis and unstructured interviews. The researcher also utilised
Spradley’s (1979) ethnographic cyclical research tasks to collect and analyse cultural
data, throughout the explorative, descriptive and explanatory phases of the study.
When selecting a problem or topic the researcher scanned the literature and
examined government reports and journals pertaining to the health care system for
the people of Saudi Arabia. In this chapter a brief description of cultural practices as
they pertain to the Saudi population and the need for culturally-sensitive care to meet
the needs of this society is provided. Evolution of the health care system and its
current status are described in order to give the reader insight to how oil revenues
helped to build and resource the health care system from the 1950s to the present
time. As the researcher progressed through this initial scanning, other issues that
facilitated in defining the research questions emerged. Hence, an overview of Saudi
Arabian National Guard-Health Affairs (SANG-HA) and the clinical field
placements for students enrolled in the PDP at King Fahad National Guard Hospital
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are described. This provides an understanding of the structure of a typical large
health care facility, and the variety of clinical experiences available for nursing
students from the hospital’s clinical speciality units.
5.1. The general problem
In 1995, the researcher arrived in Saudi Arabia and noticed a variety of issues: (i)
large numbers of skilled expatriate health care professionals, particularly nurses were
providing care in the health care delivery system; (ii) language barriers, because most
Saudis speak Arabic and the working language in hospitals is English; (iii) the
complexity of disease processes; (iv) the rapid rise in population; (v) the curriculum
of nurse training programs for Saudi nationals did not contain the knowledge base to
deal with the complex diseases prevalent in the culture, nor meet Western standards
adopted by many of the hospitals; (vi) although hospitals utilised modern technology,
a large number of Saudis still favoured traditional medicine, which is not well
understood by the people in this society, especially when used in combination with
modern medicine, hence, the need for health education; (vii) the need for culturally-
sensitive care (viii) the constraints placed on women in this society, and (ix) the lack
of a National Nursing Registration Board. Having identified the general problem,
the researcher began an exploratory research by gathering data relating to the history
and general status of the research setting. The researcher examined literature,
government documents, journals and conducted interviews to provide the reader with
a deeper understanding of the natural environment. In the following section the
researcher presents examples of traditional medicine practices to illustrate the strong
ties with traditional medicine in today’s Saudi culture.
Tabbarra (1990) and Rathi, Elzubein and Srinivasan (1993) reported that traditional
medicine continues to be practiced widely in Saudi Arabia (for example, herbal
remedies for a variety of illnesses, including the setting of broken bones).
Cauterisation is one of the most commonly used techniques to cure ailments ranging
from simple abdominal colic in newborns to severe infections in older children.
One instance cited by these authors describes an eight-month-old Saudi male who
was admitted with bronchopneumonia and pyogenic meningitis. On the second day
of admission, the parents removed the child against medical advice and took him to a
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local healer who treated him with 'massae'. Massae is a sticky plaster, placed tightly
over the entire chest, that is left on for several weeks. When patients present to local
healers with suspected trauma to the chest accompanied by pain, local healers
manage such patients by applying massae and holding them by the wrist, hanging
them in the air for a few minutes. The local healer also strictly advised the parents to
maintain the child in a specific position.
In another case, a four-year old Saudi female was admitted to hospital with viral
hepatitis. The child was febrile, deeply jaundiced and dehydrated. Liver function
tests were markedly deranged. The child was managed as a case of impending
hepatic failure. On the third day following admission, a slight improvement in the
child’s condition was apparent. However, against medical advice, the parents took
the child to a local healer who promised an instant cure. Traditionally, hepatitis is
treated with multiple cauterisations specifically located over the limbs and liver areas
in conjunction with herbal medications (Rathi et al., 1993). The outcome of the
treatment is unknown as this child was lost to follow-up. Many children are exposed
to unscientific, sometimes dangerous practices and, at times, it is impossible to
convince parents not to follow these practices. There is an attempted fusion of
traditional and modern medicine, but this can create difficulties in the management
of patients, resulting in complications and poor outcomes.
In pursuit of high-quality medical care, SANG-HA based their system on United
States standards. King Fahad National Guard Hospital (under the auspices of
SANG-HA) is one of the few hospitals in Saudi Arabia to obtain certification from
the Joint Commission on Accreditation of Healthcare Organizations (JACHO). Most
patients attending hospitals speak only Arabic, yet the official language in all
hospitals in Saudi Arabia is English. Interpreters and other Arabic-speaking staff are
readily available to assist the mostly expatriate nurses and doctors communicate with
their patients. The use of standards borrowed from the United States, together with
the availability of interpreters to assist with language barriers (language barriers are
addressed in Chapter 7), does not mean that care provided necessarily meets the
culture-specific needs of the patients. “True access to care is impeded by language
and cultural barriers that prevent adequate history taking and limit discussions of
health maintenance and prevention measures" (Brown, 2001, p. 191). A lack of trust
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results on the part of the patient if nurses are limited in their ability to provide
holistic (including psychosocial) care, and are unlikely to facilitate health education.
Nurses embarking on a nursing career in this country need to provide culturally-
sensitive care to meet the needs of the people in their social situation. One
significant example is that when a Muslim dies, the body is only handled by a fellow
Muslim. Being culturally-sensitive requires a health professional to view a culture as
viable and valid even though it differs from one’s own cultural perspective.
"Cultural competence requires knowledge of the values, beliefs and practices of
various cultures, along with attitudes of awareness, openness and sensitivity"
(Wilkinson, 1996, p.71). These attributes are often difficult for foreigners to
comprehend and accept, particularly if they are in conflict with their own values and
belief system.
Saudi nurses are ideally suited to deal with the language, cultural norms, health
problems and traditional medicine practices of this society. "Knowing that providers
may understand the language and culture of the community may improve use of
facilities" (Brown, 2001, p. 191). Saudi Arabia has attempted to bridge the gap
between nursing practice and the public in terms of employing expatriate nurses,
using translators and adopting accepted Western standards. However, to date this
country has not yet effectively expanded its nursing workforce to meet the health
care demands of the people. It is estimated that it will take at least 25 years to
prepare sufficient Saudi nurses to meet 30% of the Kingdom’s nursing workforce
requirements based on the current number of educational places available. Few
places are at Bachelor's level, with the majority of places at Associate Degree level in
programs that do not prepare graduates to meet accepted Western standards of care
as established by most hospitals in the Kingdom. Furthermore, in the researcher’s
experience, the continuing high numbers of technical nurses does not contribute to
raising the image of nursing in Saudi Arabia.
Nursing programs in Saudi Arabia also have to address the specific health care needs
of the population. With approximately 50% of the population under 20 years of age,
programs need to focus on diseases and hereditary conditions of significant
importance in the community; preventive and therapeutic approaches towards health
care, and their effects on national health status. Patient education is another aspect
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that needs to be included in order to address traditional medicine practices as part of
the Saudi culture, poor eating habits and other negative behaviours such as smoking,
and the non-wearing of seat belts.
The quality of content in nursing curricula needs to be evaluated in relation to
upgrading knowledge and skills, and integrating critical thinking to meet accepted
Western standards of care so that students can cope and deal with the complex health
care needs of this society. Schank (1990) and RCNA (1997) proposed that the
educational preparation of nurses is essential to ensure the capacity to think critically
and evaluate complex situations. One can surmise that the emerging population
trends previously described have helped to influence the following policy and
development plans.
5.2. Evolution of the Saudi health care delivery system and current
trends
The Directorate of Public Health was among the first changes implemented by King
AbdulAziz when he initially began the organisation of the government system. In
1951, there were 16 government hospitals with 1,169 beds. In 1954, Public Health
was allocated a ministry of its own called the Ministry of Health (MOH), which
subsequently implemented a plan for the construction of public health hospitals and
health care centres (Al Osimy, 1994). Nursing schools were also founded in the
1960s to meet the workforce needs and to train Saudi nurses. The policy for free
medical treatment was reinforced for all citizens at the ministry’s health centres.
In 1960, an increase of funds was allocated to health sectors from a budget allocation
of 60 million Saudi Riyals (SR) (A$16 million) in 1959 to SR 140 million (A$37.5
million) between 1968 and 1969. During the 1970s, the budget increases were
substantial, from SR166 million in 1970 to SR 499 million in 1973 and 1974 and
between 1979 and 1985 the budget increased again (Al Osimy, 1994).
In 1970, a series of five-year development plans began (the current one is entitled the
Seventh Development Plan 1999-2004) and within these plans the following health
actions were identified: (i) to consolidate and improve the physical infrastructure and
available equipment, (ii) to master the English language, (iii) to develop nursing
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education, and (iv) to expand and extend the delivery of health services to the entire
Saudi population (Berhie, 1991). Between 1975 and 1980, the socio-economic
progress of the country associated with the sale of oil allowed a second development
to be implemented, to provide a comprehensive range of preventive and curative
health services in all regions, thereby improving the heath status of the population.
From 1980 to 1985, guidelines to translate primary health care policy into strategies
were implemented. The Fourth Development plan (1985 to 1990) defined more
specific objectives, strategies, and methods through which to implement Primary
Health Care (PHC). Hospitals and approximately 250 dispensaries offered curative
services while an estimated 30 health centres and 12 Mother and Child Health
centres provided preventive care (Al Osimy, 1994).
The current government plan is entitled the Seventh Development Plan (1999-2004).
This Plan places emphasis on human resources and the provision of job opportunities
focusing on the provision of education, social and health sciences as well as training
of Saudi workers. This plan also concentrated on 'Saudiisation' (nationalisation of
the Saudi workforce). The purpose is to increase the share of national workforce in
total employment from 44.2% in 1999 to 53.2% by the year 2004, by providing
approximately 8000 job opportunities for new entrants to the labour markets. As
such, more than 4000 jobs will be available by replacing non-Saudis with Saudis.
Another emphasis of this plan is to increase job opportunities for Saudi women and
promote their share in the labour force in conformity with Islamic Saharia law, the
judicial system of Saudi Arabia. The seventh Development Plan is reflected as
Appendix 6.
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The health care system infrastructure in Saudi Arabia provides health care services in
three main sectors. The government provides free services, which are available to
both Saudi and non-Saudis with minimal restrictions, as reflected in Figure 2.
Figure 2: Health Services Sectors in Saudi Arabia
(Al Osimy, 1994 p.9).
The Ministry of Health (MOH) provides 61.2% of all health care. Other government
agencies provide 20.3% (that is, Ministry of Defence 8%, teaching hospitals 6%,
National Guard 6%) and the private sector provides the remaining 18.5%. The
itemisation is reflected in Figure 3.
Figure 3: Percentage of health services provided by sectors
(MOH 1997, p. 371).
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Major hospitals exist in different cities with advanced technology helping to provide
open-heart surgery, cancer therapy, kidney and liver transplantation. The numbers of
hospitals, clinics and health centres have increased, and nursing schools have been
established to meet the workforce needs. Table 5.2 reflects the comparison of health
services in different health sectors, while Tables 5.3 and 5.4 display the number and
percentage of workforce and the number of Saudis and non-Saudis in 1991
respectively.
Table 5.2: Comparison of health services in various health sectors in 1991
(Al Osimy, 1994, p .9).
Table 5.3: Number and percentage of workforce in the MOH in 1991
(Al Osimy, 1994).
In 1991, MOH sector included 166 hospitals with 2.1 beds per 1,000 population; and
1,692 PHC centres (one PHC is expected to service 7,678 persons).
Table 5.4: Number of Saudi/Non-Saudi in the MOH in 1991
(Al Osimy, 1994).
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Further detail is provided in Appendices 7 and 7a, and reflects MOH (1997) data of
healthcare centres by region between 1993–1997 and physicians, nurses and allied
personnel (Saudis and non-Saudis) in health centres.
Saudi Arabia is a rapidly developing country with promising economic and human
resources, with numerous developments in many aspects of life. As a result of the
planning and access to resources, the Kingdom has experienced a rapid expansion in
health services (Al Osimy, 1994). However, despite increased physical resources,
there remains a delay and deficit in health professional resource development.
With the consistent rise in population the Saudi Government realised the need for
health services and the implementation of nursing programs. Hence, in 1997 Saudi
Arabian National Guard Health Affairs (SANG-HA) established nursing programs
to: (i) address Saudi nursing workforce needs, and (ii) comply with the government's
Development Plans. Nursing programs are under the direction of the Deputy Chief
Executive Officer, spearheaded by the Associate Administrator. The Professional
Development Program (PDP) is one of the programs under the umbrella of Nursing
Programs. Other programs include the establishment of a School of Nursing and
formation of a Nursing Board for SANG-HA. At the time of writing this thesis, the
School of Nursing is yet to commence.
5.3. Status of nursing within Saudi Arabian National Guard-Health
Affairs (SANG-HA)
5.3.1. Overview of SANG-HA
SANG-HA is the health administrative body of the National Guard. SANG-HA is
the organisational body that manages the operations of the King Fahad National
Guard Hospital in Riyadh—which has 537 beds and 20,792 admissions each year—
and King Khalid National Guard Hospital in Jeddah (Jeddah is in the west, by the
Red Sea). King Khalid is a 330-bed, teaching hospital with 12,624 admissions per
annum. SANG-HA’s goal notes: “delivering the best care is the way to do what we
are so proud of doing: caring for the community and acting as a resource to achieve a
physical, mental, emotional and social well being” (Quality Management, Annual
Report, SANG-HA, 1999).
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Primary Health Clinics in several locations throughout the Kingdom are attached to
these two hospitals and have more than 903,851 patient visits annually. These clinics
are part of the overall National Guard Health Care System and require nursing
services under Saudiisation to be at least 80% supplied by National Guard Health
Affairs. Other departments, for instance the academic and training components of
both King Fahad and King Khalid Hospitals and Nursing Services, come under the
jurisdiction of SANG-HA. Figure 4 presents a dependent series of flow charts
schematically illustrating the organisational relationships of the Saudi Arabian
National Guard Health Affairs organisational structure. Nursing programs are under
the administrative (governance) direction of SANG-HA. The Associate
Administrator for nursing programs reports to the Deputy Chief Executive Officer
and the Manager of the PDP (the researcher) reported to the Associate Administrator,
who provided support in developing the nursing educational programs.
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Figure 4: Structure of Saudi Arabian National Guard Health Affairs (SANG-HA)
.
(Structure of Professional Development Program (PDP) within Nursing Programs).
In Saudi Arabia, there is no national regulatory mechanism for determining standards
(knowledge, skills, experience and application) of nursing practice, or for obtaining
minimum competencies which graduating nurses should have achieved. When
English Instructor
Chief Executive Officer (SANG-HA)
Hospital Medical
Director
Hospital Director
Hospital Director
Hospital Medical
Director
Deputy Chief Executive Officer
Associate Administrator, Nursing Programs
Associate Professor School of Nursing
Preceptors (RN) Saudi Graduate Nurse
NURSING PROGRAMS
ORGANISATIONAL RELATIONSHIPS.
Clinical Instructors
Manager (PDP) (Researcher)
King Fahad National Guard Hospital Riyadh
Primary Health Care (PHC)
Academic Affairs
King Khalid National Guard Hospital
Deputy Chief Executive Officer
Allied Health Training & Educational Services
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nurses complete basic nursing they become registered nurses simply by having
completed the course of study (Al Osimy, 1994). Saudi Arabian hospitals depend on
other countries' regulatory system when they import foreign nurses into the
Kingdom's health care system and the recruiting agent is responsible for ensuring
practice is current. As there is no National Nursing Registration Board, Saudi nurses
have not been able to become members of the International Council of Nurses (ICN),
thereby limiting Saudi nurses' participation in the international nursing arena. The
ICN is an international forum operated by nurses for nurses, drawn from
approximately 120 nations to ensure quality care and sound health policies globally
(ICN, http://www.icn.ch/psscope.htm, 13 Dec.2001). Saudi Arabia has no voice
within the ICN, only observer status. To date, Western expatriates and a few senior
Saudi nurses are still attempting to establish a model of the National Nursing
Registration Board. In the next section an overview of King Fahad National Guard
Hospital in Riyadh, under SANG-HA and the clinical site for the PDP students will
be presented.
5.3.2. Overview of King Fahad National Guard Hospital (KFNGH)
KFNGH was the clinical setting for students in the PDP, under the auspices of
SANG-HA. This hospital is dedicated to, and named after, King Fahad—the
country’s present King. It is a large modern, acute-care and tertiary facility
providing care for National Guardsmen (similar to Australia’s armed forces), their
families and dependents. Similar to other health care facilities in Saudi Arabia, it has
a multinational staff. Doctors and nurses come from the United States, Canada,
Great Britain, Australia, New Zealand, Netherlands, South Africa, Philippines, and
other Middle Eastern and Far Eastern countries. Approximately 1500 nurses from a
variety of countries around the world are employed in the Nursing Services
department. This hospital served as the clinical site for students completing the PDP.
Students were able to obtain different clinical experiences from the hospital’s clinical
specialties—Surgical/Critical; Intensive Care Unit; Maternal and Child and
Medical/Ambulatory care.
5.3.2.1. Surgical/Critical Care
Critical and Surgical Care consisted of an Intensive Care Unit (ICU), Burns,
Operating Room, Emergency Room, Short Stay Ward, Female Surgery Endoscopy,
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Pre-Anaesthetic Clinic and the Hepatobiliary Clinic. The critical and surgical care
wards are dynamically busy with emergency and trauma cases. Organ
transplantation involving the kidney and liver, are also performed due to the high
prevalence of diabetes and hepatitis.
5.3.2.2. Maternal and Child Health
The Maternal and Child Health department comprises three distinct patient
population groups: Obstetrics, Neonatal and Paediatric services. The patients are
wives and dependents of National Guardsmen employed by the organisation. There
are approximately 600 live births per month at KFNGH. The infant mortality rate
under one year of age remains at one infant death per 100 live-births or 10 infant
deaths per 1000 live births during 1999. The main reasons contributing to infant
mortality at KFNGH and the population at large are typically due to poor patient
education (Matasif cited in Al Osimy, 1994; Quality Management Report, 1999).
Data in Saudi Arabia are difficult to procure, however a summary of infants (under 1
year) deaths and live births by month at KFNGH for 1999 was available and is
characteristic of other hospitals throughout the country (Matasif cited in Al Osimy,
1994). The data are presented in Table 5.5.
Table 5.5: Infants (under 1 year) deaths and live births by month , KFNGH for 1999
(Quality Management Annual Report, 1999).
Saudi Arabia has made some positive impact on health care but, as a developing and
wealthy country, in terms of infant mortality rate they have not yet made much of a
reduction in the infant mortality rate. Table 5.6 illustrates benchmarking of infant
mortality rates around the world for 1996 and 2000.
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Table 5.6 Benchmarking for (a) current world infant mortality rates - deaths per 1000 live births (1996)
Source: WebResource:http://www.overpopulation.com/infant_mortality.html in Quality Management Annual Report (1999).
When compared to Australia (5.3), Canada (5.50) or even Bahrain (8.07), Saudi
Arabia's infant mortality rate is between six to eight times higher (see Table 5.7).
Table 5.7: Comparison of infant mortality rates by countries: Population Reference Bureau (PRB) 2000
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(Appendix 8 presents more detailed information for Current World Infant Mortality
rates from Population Reference Bureau (PRB) 2000).
Although improvements in community health structures have been established—
including sewage, nutrition, transportation and necessary numbers of healthcare
professionals—more needs to be accomplished to improve health outcomes in public
health. One significant example is health education, a tool used in developed
countries to educate and teach prevention of diseases, trauma from road accidents
and therapeutic modalities towards care. The mortality rate at KFNGH in 1999
remains at two deaths per hundred inpatient discharges (Quality Management Annual
Report, 1999).
5.3.2.3. Intensive Care Unit (ICU) and Emergency Room (ER)
New state-of-the-art units for ICU (21 beds) and Burns (8 beds) have recently been
completed. Construction within the Emergency Room has commenced and will be
ready in approximately 12 months. The Emergency Room served 135,000 patients
in 1998. Admissions in the ER are primarily road trauma accidents and consequently
these cases utilise a high percentage of ICU beds (Nurse Manager, Emergency
Room, 2000, pers. comm. Sept.).
5.4. Data collection and analysis
Throughout the exploratory phase of this study the researcher as participant observer
utilised the following participant observation strategies:
• Direct observation; • Unstructured interviews; and • Literature, journaling, field notes, a questionnaire and document analysis.
5.4.1. Direct observation
Direct observation in the field as a participant observer allowed the researcher to
gather data by observing and listening to what was occurring in the natural setting.
The researcher was also able to interact and develop rapport with informants.
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5.4.2. Unstructured interviews
The researcher as field worker and participant observer spoke to various people who
were well informed and willing to communicate—for example, staff nurses and
nurse managers. Aware of the large numbers of foreign nurses in the health care
system, the researcher wanted to investigate why expatriates chose to work in Saudi
Arabia and their feelings about the social environment. Unstructured interviews
were conducted with staff nurses from the Philippines and Western countries. The
researcher used descriptive questioning and made general observations, attempting to
discover meaning in what they were trying to say within the context of the social
situation. The researcher recorded these responses as field notes, which were
typically:
Philippines:
Researcher: “Why are you here?”
Nurse: “In the Philippines the salary is very low and it is hard to survive, so most of us come here to support our families. For me, I have three kids and two younger brothers in college who are dependent on me. There are always many newspaper advertisements for nursing positions in Saudi Arabia because Saudis don’t want to join nursing as it is a low status profession here, so this was an opportunity for me”
Researcher: “Are you here on your own?”
Nurse: “Yes, my husband is back home so I return every six months. I can’t afford to travel anywhere else and I miss my family.”
Researcher: “How do you manage with speaking Arabic and what is it like working here?”
Nurse: “It was not easy at first, but we Filipinos pick up foreign languages easily. It is in our breeding. But I also depend on translators and this is not easy too, because they don’t interpret exactly what you want them to ask. If there is a Saudi nurse, I always ask her to help me out, because they also understand the language of nursing and know what to ask so that an appropriate assessment can be obtained. Interpreters don’t know this. It’s better working here than back home – working conditions are poor in the Philippines.”
Researcher: “How do you cope with the cultural difficulties?”
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Nurse: “The culture is different but speaking some Arabic makes it a little easier to understand the patients. No doubt, it takes a long time to get used to their culture. I have to make sure that I don’t let my values and beliefs get in the way. Especially the word ‘inshalla’ – it took me a long time to understand and accept the meaning of this word and why the Saudis use it for everything they say and do.”
Researcher: “Do you think there should be more Saudi nurses in the health care system, if so, why?”
Nurse: “Yes, because they can speak the native language, know the culture, can be sensitive towards their culture and assess the patient’s needs more effectively.”
Researcher: “How long do you intend to stay here?”
Nurse: “For as long as I can. There are more Saudi nurses being trained now, so hopefully I won’t lose my job.”
Western:
Researcher: “Why are you here?”
Nurse: “Travel, travel, travel. Can’t travel so easily at home, the vacations here are great – 54 days a year. The salary is about the same at home but the tax-free incentive makes it worthwhile to work here.”
Researcher: “Are you here on your own?”
Nurse: “Yes, but every three to four months I leave the Kingdom and meet my family somewhere in the world and we have a great time and an opportunity see different places and also to keep in touch.”
Researcher: “How do you manage with speaking Arabic and what is it like working here?”
Nurse: “I have attended Arabic classes, but I am not so confident. My Philippino counterparts do better at speaking Arabic. It is not so easy working here. A lot of the patients are illiterate, so I usually get the help from a translator. Sometimes the translators don’t interpret what you ask them to say, this makes it frustrating and time consuming, because you are going around in circles. Importantly, it makes assessing the patient very difficult. Of course it makes working much easier if you can speak the language fluently.
Researcher: “How do you cope with the cultural difficulties?”
Nurse: “I had a lot of trouble with the word ‘inshalla’ as it frustrated me initially. I am now beginning to be more tolerant and understanding and to respect other people’s values. For me, conditions are better at home because
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there are more resources and I don’t have to struggle with the language barriers I encounter or with translators, so once I meet my objective to travel, I will return, say, in 2 years max. Working here is very different. There is so much diversity in the cultural workforce as standards vary and giving care is difficult as we are not familiar with the culture. It is an experience, so two years is enough! The diseases here are different too. Really, Saudi Arabia must seriously promote their own nurses to care for their people. We can read and learn all about being culturally sensitive, but the Saudis have it on their finger-tips and this is a very complex society. We sometimes have Saudi nurses, they are training and I always get their help - they are great! They helped me come to terms with the meaning of inshalla.”
Having interviewed several nurses, the researcher reviewed field notes to search for
cultural symbols through what people were saying and what they were using to
organise their “behaviour and interpret this aspect of their experience” (Spradley,
1980, p. 94). These interviews suggested that nurses from both parts of the world
had different objectives. Clearly, for nurses from the Philippines, working in Saudi
Arabia was a means to an end, while the Western nurses utilised the tax-free
incentives and disposable income for personal gain. However, both parties expressed
difficulties when encountering translators, cultural differences and advocated the
need for Saudi nurses in this complex health care system. Similarly, interviews with
nurse managers provided insight about Saudi nurses in the clinical areas, reinforced
the need for more Saudi nurses and their comments are as follows.
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Nurse Managers’ typical comments:
“Saudi nurses understand the culture and language of their people – there should be more of them, but unfortunately the image of nursing is not good in this country and this is an issue that must be addressed soon. The construction of a National Nursing Registration Board will be invaluable to this cause.”
5.4.3. Literature, journaling, field notes, a questionnaire and document
analysis
The researcher scanned various nursing curriculum, identifying areas for
development. The researcher also examined government documents, annual reports,
books and magazines, which provided a wide perspective of the cultural setting and
social situation. Scanning the literature and documents, conducting unstructured
interviews, listening, asking questions, examining journal documentation, utilising a
survey questionnaire and searching through field notes, allowed the researcher to
uncover cultural domains. Cultural domains are categories of meaning and are “the
first and most important unit of analysis in ethnographic research” (Spradley, 1979,
p.100). The aim was to identify cultural categories and gain an overview of the
cultural scene under study, and each week the researcher sifted through the field
notes in search of new domains.
5.5. Cultural domains in the explorative phase
The domains or categories related to what people do (cultural behaviour), what they
know (cultural knowledge) and what people make and use (cultural artefacts); they
are fundamental aspects of human experiences (Spradley, 1980). Spradley (1980, p.
6) pointed out that although it is easier to identify behaviour and artefacts, they
represent the “surface of a deep lake. Beneath the source, hidden from view, lies a
vast reservoir of cultural knowledge”. Spradley (1980) also advocated that when
ethnographers identify cultural knowledge as fundamental, the emphasis is shifted
from behaviour and artefacts to their meaning. Cultural knowledge exists at two
levels of consciousness – explicit and tacit knowledge (this aspect was explained in
Chapter 3). Large parts of cultural knowledge remain tacit, which are symbols with
special meaning and people do not “act towards the things themselves, but to their
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meanings (Spradley, 1980, p. 9). In fieldwork, ethnographers therefore make
inferences by looking beyond tacit culture to discover meaning (Spradley, 1980) and
the researcher will look beyond tacit culture to obtain meaning. The domains
identified in the explorative phase of the study are identified as follows.
• ‘Inshalla’ • Interpreter • Illiteracy • Expatriate nurse • Recruitment • Language • Traditional medicine • Prayer • Fasting • Religion • Attire • Covering the face • Role of men • Role of women • Family • Sex segregation • Culturally sensitive care • Punctuality
In the first wave of analysis in the explorative phase, the researcher used cultural
behaviour, cultural artefacts and cultural knowledge to make inferences about what
people say, the way they act and from the artefacts they use in order to provide
cultural meaning in the context of the social situation. The researcher noted the
following domains, which are now described.
‘Inshalla’ (or God willing):
The researcher noted that the term inshalla was always verbalised by Saudis when
they were asked to do anything or go any place. For example, if one asked a Saudi:
“Could you be at work at 0730 hours?” Instead of replying “yes or no”, she or he
would say, “inshalla.”
Within their religion, Saudis leave their fate in the hands of God, that is, everything
is determined by the ‘Maker,’ hence, the term inshalla. Initially this was very
frustrating for the researcher who had very little understanding of the culture.
Having worked and lived in the cultural environment, the researcher recognised that:
(i) the word inshalla came naturally to their lips, (ii) they were unable to explain the
context in which it is used as it is outside of their awareness (tacit cultural
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knowledge). It is not that the Saudi wants to avoid making commitments. More to
the point, it is their culture and to criticise this behaviour is demonstrating a lack of
sensitivity and understanding towards their values and beliefs.
Interpreter, illiteracy, language, recruitment and expatriate nurse:
The researcher noted with interest that, within the health care delivery system,
recruitment consisted of large numbers of nurses from overseas countries. The
researcher asked several expatriate nurses in the hospital their reasons for living and
working in Saudi Arabia. A typical response was: “Nursing is a low profession in
Saudi Arabia, that’s why there are small numbers of Saudi nurses.” The researcher
also observed that English was the language spoken in hospitals, hence there were
several interpreters because most of the patients were illiterate and many nurses were
not bilingual. A typical interview with expatriate nurses relating to this situation
would be: “We have translators to help us, but they don’t always get the responses
we are seeking. It is frustrating”.
Clearly, the image of nursing needs to be raised so that more Saudis will enter the
nursing profession in order to give culturally sensitive care. Translators are only a
‘band-aid’ to alleviating the language problem. Previous interviews with expatriate
nurses (reported earlier) also confirmed difficulties encountered with language
problems and translators.
Traditional medicine:
Traditional medicine is a widespread cultural practice, and especially children are
exposed to such unscientific regimens (tacit culture). As a result, hospital beds are
used to manage problems associated with complications from poor traditional
medicine practices. The researcher asked her Saudi colleagues about traditional
medicine and why it was widely practiced. They confirmed its use by typically
stating:
“it is hard to explain, when someone in the family is sick we all know traditional medicine is available and we turn to it and use it. We are brought up with this and this is our culture, (explicit and tacit cultural knowledge). But not all traditional medical practitioners are good and this is another problem. Also some Saudis mix traditional medicine with modern medicine which is dangerous practice, but they don’t know it is unsafe to do this. Nobody tells them, they need education for this.”
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Health education is lacking in this country and this aspect needs to be addressed and
promoted, because when people are informed, they can make decisions. Saudi
nurses would be ideally suited to provide patient education and their input would
improve health outcomes in public health.
Prayer, fasting and religion:
Fasting and prayer are explicit as well as tacit cultural behaviours. Explicit in that,
when Saudis hear the prayer call, they know it is time to pray and they submit to this
activity. Prayer call is heard five times a day throughout the country. Prayer is also
tacit behaviour because when one asks a Saudi why they have to pray five times a
day, rather than once or twice a day, they are unable to explain in a direct manner
why they follow this pattern of frequent daily prayers. When interviewed, the
response was typically: “it is our religion or it is our culture and we just do it.”
Fasting is a very religious part of Saudi culture and they get prepared for the holy
month of fasting. Even hospitals are organised to accommodate the fasting month.
In terms of religion, only mosques are evident in Saudi Arabia, no other religion is
practiced. Everything a Saudi does or says revolves around religion, as it guides
their daily lifestyles. Clearly, Saudis react to the meaning of prayer and fasting and
not solely to the activities. Fasting and prayer can be explained as explicit and tacit
cultural knowledge.
Given that religion is a very important aspect of Saudi culture, it was essential to
consider prayer time when constructing a nursing curriculum, in order to entice
Saudis into the nursing profession. Hence, the Professional Development Program
allocated prayer into every lesson plan of the curriculum. Similarly, provision was
also made to accommodate the month of fasting.
Attire, covering the face, role of men, role of women, family and sex segregation:
All of these domains relate to the culture of Saudi Arabia, which are intertwined with
Islam and are very important in the everyday life of a Saudi. Women are expected to
be appropriately dressed, which also means covering the face. Women know that
they must cover themselves when they leave their homes (explicit cultural
knowledge), but the reason why they cover themselves is something they are unable
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to explain (tacit cultural knowledge). A typical response would be: “We do it”.
Similarly, the role of men and women and the allegiance towards their families is a
cultural norm and a religious obligation because the Holy Koran depicts looking after
one’s family as a duty, especially for their aged parents. Sex segregation is a very
important part of Saudi culture and men and women are fully aware and respect this
aspect of their culture (explicit cultural knowledge). The culture of Saudi Arabia is
not going to change rapidly, hence it must be respected and acknowledged by
foreigners. For the researcher and faculty, it meant recognising Saudi culture and
formulating policies and practices to incorporate into the structure of a nursing
program, to entice Saudis into the nursing profession. For example, designing attire
that was cultural appropriate for the clinical field that would not compromise patient
care.
Culturally-sensitive care:
In the natural hospital environment the researcher noticed basins of sand beside
patients’ beds. The patients know that the sand is for washing the body (explicit
knowledge). By contrast, the researcher assumed that they were used for butting out
cigarettes, because a large number of Saudis engage in smoking. On interviewing a
nurse, the researcher confirmed that the sand basins were used for washing the face
and hands, just as we use water to perform a similar activity. Such practices are
common to this society but foreign to the expatriate health care professional. A
Saudi nurse would be ideally suited to the sensitive cultural norms of the people,
hence Saudi nurses should be encouraged to enter the nursing profession.
Punctuality:
Saudis are known to be late, whether it is for work or other engagements. When one
becomes acquainted, the meaning of late relates to the culture wherein family issues
are given first priority, hence, ‘inshalla.’ For example, the researcher asked several
Saudis and a typical response was: “This is our culture, we have to attend to our
family needs. Similarly when students were late attending class, faculty met with
them to investigate this issue. Typically the comments were: “We have to care for
our families first, especially when one of our children are sick. It is our duty.”
Others stated: “My father or brother was sick and no one to drive me to work, so I
had to miss class.”
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One must bear in mind that women are not permitted to drive, but one could also
argue as to why women cannot use taxis or the bus service. It is not that women
cannot use taxis or ride in buses, but clearly husbands are protective of their women
folk and women know that using public transport means interacting with the opposite
sex, which is not permitted (explicit knowledge). Hence, women are dependent on
their menfolk for transportation needs. The researcher also noted that students were
not deliberately coming late or missing class. They were torn between their cultural
values of being primarily responsible for their families and trying to fulfil the needs
of the program. Therefore, in order to entice students to remain in the program,
structures were established in terms of recognising the role of women in this society.
For example, students with young children were permitted to leave an hour early to
spend quality time with their families and certificates-of-attendance was created (this
aspect is explained in Chapter 6).
Having identified these domains in the explorative phase, the researcher returned to
the study and field notes to uncover other domains in the descriptive and explanatory
stages of the study.
5.6. Summary
Revenue from oil sales has helped to fund the Saudi health care system between
1950 to the present time via Development Plans designed to provide direction to
increase and improve health and health care facilities for the people. However, the
current system needs more emphasis in the following areas:
First, primary health care needs to be developed to help address issues such as infant
mortality, which is still relatively high (10:1000). Greater health
promotion/prevention is required in relation to pregnancy, given that approximately
50% of the population is under 20 years of age. Tertiary care is not the answer to
prevention. Second, there is a need to increase nurse training in order to provide
culturally-sensitive care because the health care system largely depends on foreign
health care professionals, particularly nurses who are unable to speak the Arabic
language or understand the culture. Given that it would take approximately 25 years
to prepare sufficient nurses to meet 30% of the country’s nursing workforce (based
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on the current educational places available) this country has not yet adequately
increased nursing education.
Third, nursing curricula have to be reviewed to meet the complex health care needs
of the society. The majority of nurses currently graduating are prepared at a
technical level (pre baccalaureate). There needs to be a balance of technical and
professional nurses (for example, baccalaureate and masters’ levels), who could
assume leadership and nurse specialist roles, in all aspects of nursing and especially
within the community. This would help to bring about change, particularly in
traditional practices, to help the population understand some of their dangerous
practices. The increasing complexity of care and advancement in technological
procedures being performed has created a demand for nurses with critical thinking
abilities in the health care environment. Optimal benefits can be provided for Saudis
if those who deliver the hands-on care are familiar with the culture specific needs of
Saudi Arabia’s rapidly growing population.
Fourth, Saudi nurses need support from the government in terms of legislation to
establish a National Nursing Registration Board and a process of credentialing and
registration for the whole country. The government also needs to support public
awareness campaigns to raise the social status of nursing in order to encourage more
Saudis to enter the nursing profession and to meet the Saudiisation policy. However,
Saudiisation as an increasing underpinning principle has motivated hospitals such as
SANG-HA to upgrade the skills and aptitude of Saudi nurses.
Chapter 6 will address the descriptive phase of the research, which includes an
examination of the development of the nursing profession, nursing education and the
history and implementation of a National Nursing Registration Board in Saudi
Arabia. Nursing education at SANG-HA will also be described, together with the
early beginnings of the Professional Development Program and a conceptual model,
which guided the implementation of critical thinking into an education/intervention
program.
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CHAPTER SIX
The development of the nursing profession in
Saudi Arabia: Descriptive Phase
6.0 Introduction
In the descriptive phase, the researcher provides an account of the social environment
and the people in the study, in order to reveal the nature of existing conditions and
obtain a detailed perspective of the group (Neuman, 1997; Sarantakos, 1993). The
researcher continued in the role of participant observer, working in the field to
collect more data from an emic perspective.
In this chapter a brief history of nursing in Saudi Arabia, society's image of nursing
and the reasons underpinning the need for formal nursing training and the status of
nursing education are described. The lack of standards for nursing practice and
rationale for a National Nursing Registration Board are also discussed. The
development of a Professional Development Program (PDP) for Saudi nurses is
presented, highlighting the implementation of critical thinking into an educational
program. The researcher continued with Spradley’s (1979) ethnographical cyclical
research tasks.
6.1 Nursing in the Prophet Mohammed’s period (579 AD)
The history of nursing in Saudi Arabia commenced during the Prophet Mohammed's
period (579AD). There are no records of nursing in the pre-Islamic era (569 AD) (Al
Osimy, 1994). The earliest descriptions of nursing activity were recorded during the
time of the Prophet Mohammed, whereby Muslim women cared for the wounded and
dying men in the holy wars. Nursing was not restricted to care during war, as
women also practiced nursing during times of peace. The Prophet encouraged
nursing and allowed Rufaidah bint Sa’ad Al Aslamiyyah to cure wounded soldiers in
a tent she constructed in the Prophet’s mosque. Rufaidah is decorated as the first
nurse in Islamic nursing history. There were several other women who nursed
concurrently with Rufaidah: such as Fatima, the Prophet’s daughter; and Salma, the
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Prophet’s maid, who was a midwife and nurse. These women were recognised by
the prophet and mentioned in the literature (Al Osimy, 1994). Al Osimy (1994)
stated that nursing is held in high regard by Islamic teachings and culture, just as
Islam advocates and supports its followers to help and provide services to fellow
Muslims in sickness and in health. The prestige of these nurses who participated in
the Holy wars achieved recognition in the eyes of the Prophet, in that he considered
their actions as a cause of Allah (God). The Prophet rewarded their efforts by giving
“them their share of war loots just as he was giving men theirs” (Al Osimy, 1994, p.
18).
Nursing was the principal duty delegated to women in the Muslim army. They
provided water for the thirsty, attended to the fallen and transported the fatally
injured to Madinah, the holy city of Islam in Saudi Arabia. The nurses armed
themselves with medicines, bandages and the like to attend to the injured soldiers.
Even after the demise of the Prophet in 590 AD, these nurses continued to go to war
with Muslim armies (Al Osimy, 1994).
6.2. Nursing in the post-Prophet Mohammed period (590 AD) to the
present
Islamic hospitals expanded throughout the vast network of the Islamic civilisation
and included male and female wards. Nurses worked alongside physicians and
pharmacists. The nurse’s role was to care for the patients’ needs by ensuring
adequate food and fluids were consumed and giving prescribed medications on time.
Unlike the teaching profession, nursing started with volunteers who performed
simple procedures for patients to provide them physical comfort, emotional support,
and relief from pain and discomfort (Husain, 1995; Mansour, 1992; Al Osimy,
1994). Following the death of Prophet Mohammed, there was a decline in the public
image of the nursing profession. With no formal training establishments, women
who were interested in nursing were given on-the-job training to work in
dispensaries and clinics, carrying out simple procedures and care. They were
classified as assistants and had no formal educational backgrounds. However, after
the discovery of oil in the 1930s, there was recognition of the health care needs of the
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citizens, a few hospitals were built, and nursing education was introduced in the
1960s (Al Osimy, 1994).
6.3. Image of nursing in Saudi Arabia
Despite many developmental improvements, Saudi Arabia’s health care system
continues to experience a nursing shortage, as evidenced by the low number of
enrolments in the baccalaureate nursing programs (Al Osimy, 1994). Mansour
(1992), in a survey of university students and their parents, reported that both
students and parents felt a need for Saudi nurses for ease of communication, loyalty
to Islamic principles and a better understanding of the Saudi culture and psychology.
Al Osimy (1994) and Husain (1995), reported that parents did not approve of nursing
as a profession for their sons or daughters. This lack of approval was due to its low
social image, long working hours, and mixing with the opposite sex. The social
stigma associated with nursing is primarily related to nursing in the post-Prophet era
being principally the role of those from the lower socio-economic classes and
academically poor individuals.
Nursing education for Saudis is available in the Kingdom. However, the Kingdom’s
nursing needs exceed the supply of Saudi nurses. Jackson and Gary (1991)
conducted a health workforce study and indicated that approximately 25,000 nurses
were employed in the Kingdom. Of this number, only 8.5% were Saudi nationals,
while 91.5% were expatriates. Culture has a significant influence on Saudi Arabia’s
nursing profession and, for women, many social and cultural factors contribute to
this phenomenon. Women are still heavily influenced by their families and Al Rabea
(1994) reported that women leave nursing because of family circumstances and
control of their male counterparts.
In Saudi culture, men and women do not generally mix in public and separate
facilities are provided in banks, restaurants and the like. Women are not permitted to
drive cars, and females therefore have to rely on male members of the family or hired
help for transportation needs. If a woman decides to marry, she is required to obtain
permission from her husband to continue her nursing career (Boyles & Nordhaugen,
1989). Traditionally women do not have identity cards and are usually listed as
dependents on the identity card of their father or husband. Although women are
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issued with passports, they are not permitted to travel unless accompanied by a male
legal guardian or with written permission from a male relative.
A significant problem exists for the government and society in Saudi Arabia to be
able to work within the culture, and to try to increase the likelihood of women
coming into nursing, when women are given limited freedom and have to depend on
their men. Both the government and society at large have many issues to deal with,
in particular to include Islam and culture when designing nursing curricula. Saudi
Arabia needs more nurses, particularly to provide culturally competent care to the
people. However, as most women are still under the control of men, it remains an
issue for women to deal with shift work and travel to and from the workplace,
especially when they are not permitted to travel on public transport or
unaccompanied. It may be difficult given that many men may not allow their
daughters or wives to do shift work, without being under their (men’s) watchful eye.
The aspect of women working after marriage also needs consideration. Hence, the
cultural traditions of Saudi society and role of women have a major impact on the
nursing profession and health care system, as it directs the limitations and
expectation of women.
Al Tuwaijri (1994) and Al Osimy (1994) suggested that the low status of nursing was
fostered by Dr. Al Hussein, Deputy President for Intermediate colleges in Saudi
Arabia, who advised women with low grades to enrol in nursing colleges (Arab
News, July 30, 1996, p. 3). In Bahrain, one of the Middle East countries, the low
image and difficulties encountered in recruiting students into nursing was reported by
Kronful and Affara (1982). These authors attributed the poor image of the
profession to family disapproval, shift work, hard work and perceived low
educational requirements. The authors further stated that high school students rated
nursing below that of a secretary, while medicine was highly rated.
In 1992, Mansour reported that many study respondents did not know that nurses
could work in administration, education, or research, or be critical to a family’s
health status. Husain (1995) stated that Saudi nurses felt hostility towards their
profession and had developed a mentality of retaliation against a society that does not
respect them. Husain further stated that this unfavourable climate could be improved
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by launching public awareness campaigns about the nursing profession and its
importance to society.
Nurses and the nursing profession need to work with their partners—such as the
Ministries of Health and Education, physicians, and health care organisations to
create its own professional identity. A professional nursing identity includes
characteristics that contribute to professionalism, and Muller (1998, p. 17) stated that
professionalism implies that practitioners comply with the norms, traditions and
expectations of the profession, and proposed the following:
• Preparation for nursing requires a number of years of integrated education and
clinical training at a university or a recognised school of nursing;
• Testing of professional competence before admission to the profession;
• Registration or licensure is required to practice professionally and that a nurse
should be registered with the professional board or council for the specific
country;
• Self-organisation, leading to the formation of a professional association and a
self-governing body to control professional standards;
• Ethical control of professional conduct by the members of a profession.
Professional conduct is controlled by the ethical rules set down by the regulatory
board;
• Accountability for professional services towards the community;
• The nursing profession sets the boundaries of its exclusiveness by setting specific
training requirements, practice standards and registration;
• A sustained critical analysis of activities and changes of practice, keeping the
profession abreast of development and change;
• Nurses are obliged to provide the best practice in order to meet the needs of the
client;
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• A sustained striving towards service excellence, because competence alone is not
enough; and
• Legislation, in which no nurse is allowed to practice without the necessary
registration and certificate of good standing from the regulatory board.
If nursing in this country develops the foregoing characteristics the profession will
have an identity and establish a place in society to voice and be held accountable for
what nurses do as a professional responsibility. Creating a more positive image
could attract individuals in power to value nurses, and this demand would encourage
more entries into the profession to eventually meet the supply required, ultimately
satisfying the Saudiisation policy and the health care needs of the society. Mansour
(1992) supported continuing nursing education as an important strategy for ongoing
development and to uphold the nursing profession in Saudi Arabia. Phillips (1989,
p.197) succinctly stated the following.
There is no doubt that the present psychosociologic conditions militate against the entry of young Saudi women to nursing. This unfavourable climate can be improved only by increasing the information available about the nursing profession and its importance to society.
6.4. Nursing education in Saudi Arabia
Nursing education in Saudi Arabia is the responsibility of two ministries: the
Ministry of Health (MOH) and the Ministry for Higher Education (MHE). Since
1960, the MOH has conducted general nursing in Health Institutes and Intermediate
Colleges and courses are available to females and males who have completed nine
years of secondary school level education. The MHE offers a four-year university,
plus one-year internship baccalaureate nursing program, currently limited to females
only. This program commenced in 1976 (Phillips, 1989). There are no hospital-
based nursing programs in Saudi Arabia. The current status of nursing education in
Saudi Arabia is presented in Figure 5.
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Figure 5: Current status of Nursing in Saudi Arabia
Adapted from Al Osimy (1994 p.23). [Nurses wishing to gain PhD have to study overseas]
6.4.1. Evolution of nursing education under the MOH
As health services expanded rapidly in the 1950s, so did the MOH’s response to the
acute demand for trained health care personnel, in particular the training of technical
nurses. Health Institutes were established to cope with this need and the evolution of
nursing education is described as follows.
Health Institutes Education (Nursing Assistants Program):
In 1958, the first Health Institute for male nursing assistants was established in
Riyadh, the capital of Saudi Arabia, based on a five-year agreement between MOH
and the World Health Organisation (WHO). In this agreement, WHO provided the
training expertise and the MOH contributed to finance, building, employees and
Current Status of Nursing Education in Saudi Arabia
Ministry of Higher Education (MHE) Ministry of Health (MOH)
Health Institute – 1 yr. (Diploma)
Bachelor of Science: Nursing (BSN) – 5 years (Degree)
Master of Science: Nursing (MSN) – 2 years
Intermediate College – 3 yrs + 4 months. (Associate Degree)
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administrative factors. In 1958, 15 students with elementary certificates (indicating
completion of ten years of schooling) were admitted into a one-year institute
program in a health inspector specialty (Al Osimy, 1994). Health Institutes were also
established in other parts of the Kingdom including Jeddah (Western region), in
1961, and in Houfoff in 1964 (Eastern region). Currently there are approximately 17
Health Institutes for male nursing assistants.
In 1960, nursing education for females commenced with two nursing schools in
Riyadh and Jeddah. Females with elementary level school certificates after ten years
of education gained entry into the program. Between 1966 and 1979, four Health
Institutes opened in various regions of the Kingdom. Male and female students were
paid SR 600 (A$250.00) per month and provided with living, transportation and
health care allowances and students graduated as nursing assistants (Al Osimy, 1994,
p.54).
Intermediate College (Health Science College):
In the 1970s, as the need arose for nurses with technical specialisation, Intermediate
Colleges were established. On completion of a three-year academic program and
twelve weeks internship, an associate degree is awarded, which is equivalent to a
technical nurse—one who is equal to that of a practical nurse in the United States
(Phillips, 1989). “The diploma nurse is not to be confused with a nurse’s aide,
because the nursing content in the diploma program is more comprehensive”
(Phillips, 1989, p.195). Although the MOH is continually upgrading the curriculum,
it still does not meet accepted Western standards (Al Osimy, 1994). Subjects are
taught in Arabic and supplemented in English, but when graduates arrive at the
workplace, they encounter difficulty understanding and communicating in English.
The MOH programs are popular routes for entry into nursing. In 1996, the MOH
released statistics of the number of male and female graduates in Health Institutes
from various regions in Saudi Arabia, which is reflected in Appendix 9 (Students
enrolled in colleges of health sciences for males and females in MOH 1417H
[1996G]). Nurses who graduate from health institutes and colleges are employed in
MOH hospitals, primary health care clinics and medical companies. They are in
great demand because they speak the native language and are able to deliver
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culturally competent care. Currently there are approximately 25 colleges across the
Kingdom.
6.4.2. Nursing education under the Ministry of Higher Education
Baccalaureate Education: Bachelor of Science in Nursing (BSN)
In 1976, the university baccalaureate-nursing programs were offered by the MHE at
King Saud University in Riyadh in 1977 and at King AbdulAziz University in Jeddah
with six students in each university. In 1987, fifteen students commenced at King
Faisal University in the Eastern region. These programs are open to high school
graduates following the completion of 12 years of study. The initial recruitment of
students was a problem with high withdrawal rates, which were attributed to several
factors:
i. loss of interest in the nursing program; ii. inability to cope with certain scientific components within the curriculum; iii. family obligations and constraints of a cultural nature; iv. inclination to transfer into Medicine, especially after the first year when the
core subjects for Medicine have been successfully attained; v. public image of the nursing profession; and vi. the nature of the work, in particular shift rotation with night duty being a
problem (Al Osimy, 1994).
The BSN program consists of nursing studies for four academic years with a one-
year internship. The nursing curriculum is designed to provide students with a
knowledge base from the physical and behavioural sciences, the humanities and
nursing theory and is based on a USA nursing curriculum developed in 1976
(Phillips, 1989). Clinical practice is offered throughout the course at selected
hospitals. On graduation the baccalaureate degree is awarded, enabling the graduate
to practice as a professional nurse in a variety of health care facilities, and meets the
prerequisite for further education in nursing. All subjects are taught in English, and
therefore students must pass English proficiency examinations before admission.
However, some of these nurses encounter difficulties with the English language
when they enter the workplace. The researcher observed a Saudi teacher
(baccalaureate graduate) conducting her teaching session. The teacher’s behaviour
demonstrated tacit cultural knowledge, in that the teacher was frequently slipping
into the Arabic language (unaware of her actions) to facilitate her instruction. This
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behaviour (teaching in Arabic) provides meaning as to why difficulties with English
are experienced by Saudi nurses when they enter the workplace. During the course
of participation observation, the researcher informally interviewed the teacher, which
is presented as follows.
Researcher: I noticed that you were teaching in English and Arabic.
Saudi teacher: Did I really. I can’t explain why, but sometimes I use an Arabic term here and there when I cannot find an equivalent English word to express myself appropriately. I did not realise the extent of Arabic that I used. This is not good for the students, I need to watch myself.
Researcher: In your experience as a student in nursing college, was this behaviour commonly practiced?
Saudi teacher: Oh yes, especially when the teachers are trying to keep up with the curriculum. It is so easy to slip into our native tongue unconsciously.
In 1991, 120 baccalaureate nurses graduated from the MHE (Al Osimy, 1994).
Although there is no current documentation of graduated nurses from the MHE, it is
estimated that approximately 500 baccalaureate nurses have graduated since 1991
and less than 100 graduates have successfully completed their master’s degrees (Al
Osimy, 2001, pers. comm., 10 April). Currently there are no baccalaureate or
master’s programs for men in Saudi Arabia. Nursing for males is only available in
Health Institute and Health Colleges. However, in 1996 a leading tertiary hospital in
Riyadh arranged for ten Saudi men to study nursing in George Mason University
(USA) and in 2001 another ten males were sent to this same university.
Master of Science Nursing (MSN):
The critical need for nurses with post-graduate nursing education to fulfill roles such
as clinical nurse specialists and administrators gave rise to the development of a
MSN program. In 1987, the MSN program was established in King Saud University
in Riyadh with six enrolled students who graduated in 1990. The admission
requirements included a BSN degree, with at least one year in clinical practice and
English language proficiency requirements established by the university. The MSN
course requires completion of four semesters of study, with a specialisation in
nursing administration, maternal and child health or psychiatric mental health.
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“Nurses who graduate from any nurse training program are not registered because
there are no national registration licensure process or examinations for nurses in
Saudi Arabia (Dr. Gail Tumulty, 1997, pers. comm. Aug.). Al Osimy (1994) stated,
“currently when Saudi nurses obtain their graduation certification they are
considered to be registered” (p.23). “Newly graduated nurses have to fulfil the
internship requirements; otherwise, they are not permitted to practice” (Saudi senior
nurse, Task Force, National Nursing Registration Board (NNRB), pers. comm.,
August 2000). However, Saudi nurses are unable to practice internationally or have
a seat in the International Council of Nurses because they are not formally registered
or licensed in the jurisdiction in which they were educated. Discussions for a NNRB
commenced in 1991 and the post of Regional Nursing Officer within each of the 18
regions of Saudi Arabia was established to set professional nursing standards,
develop a conceptual framework, and engage in nursing research (Al Osimy, 1994).
In 1992, the Saudi Board for Health Professionals began discussing nursing
registration. The establishment of a Nursing Department in the MOH was in the
planning stage and the accreditation of nursing schools by the Civil Service Bureau
was being considered. The history of the NNRB follows.
6.5. History and current status of the National Nursing Registration
Board in Saudi Arabia
In 1995, Dr. Gail Tumulty was appointed as Nurse Consultant by the MOH to form a
Central Body of Nursing and develop nursing standards leading to regulation and
licensure. An NNRB for Saudi Arabia is essential to enhance the image of nursing
and to provide public assurance that nurses meet a standard of educational
preparation and that there is a mechanism to monitor and ensure that they are
accountable for their practice.
In September 1998, efforts were made by a small group of senior Saudi and
expatriate nurses to form a national regulatory body for nursing practice in Saudi
Arabia. Their purpose was to establish a Nursing Registration framework for the
Kingdom. Many meetings were conducted and the following statements were
developed: (i) scope of practice, (ii) standards of professional practice, (iii) standards
of nursing education, and (iv) a code of ethics according to Shariah Law, the law of
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Saudi Arabia, which is derived from the holy Koran. “As of December 2001, the
process of this Board of development is still ongoing and the framework has not yet
been released to the public” (Senior Saudi nurse, National Nursing Registration
Board, 2000, pers. comm., Sept.).
In an effort to upgrade the standard of nursing education of Saudi nurses the Saudi
Arabian National Guard-Health Affairs (SANG-HA) commenced Nursing Programs.
This was to assure that National Guard personnel and their eligible dependents are
receiving nursing care from personnel who are duly qualified, committed to high
quality care with the ability to think critically and able to meet the complex needs of
the Saudi population. SANG-HA also commenced the Professional Development
Program (PDP), which comes under Nursing Programs, and a detailed account of the
PDP follows.
6.6. The Professional Development Program at Saudi Arabian
National Guard-Health Affairs
When the concept of Saudiisation was introduced, SANG-HA established a
department known as ‘Nursing Programs’ to train Saudi nurses and that offers the
Professional Development Program. Nursing Programs under SANG-HA is
independent of the Education Department within Nursing Services under KFNGH
(the clinical site for Professional Development Program students). [Refer to the
organisation chart in Chapter 5, Figure 4.] The Nursing Education Department
facilitates the needs of registered nurses in the clinical units, the majority of whom
are expatriate. Essentially the role of the Nursing Education department is to ensure
the continuing professional development of nurses and their competence to practice.
Nursing Programs and Nursing Education departments collaborate with regard to
organising clinical placements and preceptors for students from the PDP.
SANG-HA developed nursing education based upon sound theoretical knowledge,
clinical practice, English competency and the capacity to think critically and practice
critically. The Associate Administrator and Manager of the PDP were tasked with
the responsibility to develop Saudi nurses who could practice competently and
demonstrate critical thinking abilities. An intervention/education program consisting
of critical thinking strategies was developed and integrated into the PDP curriculum.
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These critical thinking techniques (questioning, small group activities, debate, role-
play in the classroom and journaling in the clinical field), were utilised to promote
critical thinking abilities in Saudi nurses.
Meyers (1986) stated that critical thinking does not develop unaided during a course
of study, nor will critical thinking arise primarily from students listening to lectures,
reading texts and sitting for examinations because it is a complex concept. Teachers
need to know explicitly what they mean by critical thinking and provide
opportunities and appropriate teaching methods to promote and practice critical
thinking skills.
6.6.1. Early beginnings
The purpose of the PDP is to develop Saudi nurses to meet accepted Western
standards, develop critical thinking skills, to prepare them to satisfy all nursing
registration requirements, to meet Saudiisation policy and the complex health care
needs of this society. From the inception of the PDP in 1997, the researcher worked
as the manager for this program, taking an active role in talking, listening, mentoring,
counselling, teaching, administrating, observing and collecting data on socio-cultural
activities and patterns of this group.
The first group of Saudi nurses or students was admitted into the PDP with diplomas
and/or degrees in nursing from Saudi Arabian nursing colleges/universities in
September 1997. Many arrived from different regions within the country and
accommodation was provided in villas. Local students resided with their families
and were provided with a monthly transportation allowance. The first group of 18
students comprised two who were enrolled in a master’s program at King Saudi
University, five who had graduated with degrees and, eleven who held associate
degrees. Their ages ranged between 20 to 30+ years.
Following admission into the program, the students were examined for their English
proficiency, in which they completed the Oxford English examination. Their scores
ranged between 90 and 140, and were divided into various levels based on their
English proficiency and educational standards. The diversity of their educational
status and English competency skills highlighted many difficulties. Hence, in the
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next program, criteria for admission in terms of educational and English competency
levels were established.
When the PDP commenced, there was no established building to house this program,
except for a large conference room and a four-bed unit in an unused ward. The
conference room was utilised for meetings (program meetings being conducted every
Wednesday afternoon), and the four-bed ward was the classroom. Resources were
scarce, but the program managed to secure tables, chairs, blackboards and so forth, to
equip this ‘new classroom.’
Students met in the large conference room on the first day of the program, arriving at
nine o’clock. The Associate Administrator and her staff (manager and two clinical
instructors) welcomed them and they were invited to coffee and an informal, yet
informative introduction and expectations of the program. The discussion related to
the general concepts of punctuality, dress code, importance of fulfilling homework
assignments, utilising the library and critical thinking strategies.
Aware of the unusual physical circumstances, the staff made every effort to gain
rapport with the students by showing concern for their comfort, making friends with
them, and engaging in conversation to discover mutual interests. All of these
behaviours helped to “build common experiences and rapport” (Jorgensen, 1989, p.
76) and recognised that “age, ethnicity and gender are grounds for much social
distance” (Jorgensen, 1989, p.76). In Saudi Arabia, social distance includes culture
and language. The main objective for the staff on these early encounters was to
acquire some degree of acceptance from the students, carefully watching and
listening to what transpired, in order to become acquainted with the scene and the
students’ way of life.
Jorgensen (1989) stated that it is essential in the early stages of trying to gain
acceptance to be as unobtrusive as possible in the setting. Gaining acceptance is
similar to learning a different culture or subculture. This phase, according to
Jorgensen (1989) is known as “learning the ropes” (p.74). Researchers in this
naturalistic setting are able to have face-to-face interaction with students—listening,
observing, questioning—at the same time participating in the mind of another human
being “in sociological terms, take the role of the other” (Lofland & Lofland, 1995
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p.16). The purpose was to acquire cultural knowledge over a prolonged period of
time.
Following a two-week orientation period the students were exposed to seven weeks
of an intensive classroom theoretical program (study block), consisting of subjects
such as Anatomy and Physiology, Nutrition, Growth and Development. These
subjects were mandatory for the diploma/associate diploma students to upgrade their
theoretical knowledge base. By contrast, the BSN and MSN had the option to either
participate in the theoretical component or develop their English competencies
and/or clinical practice (as some of them had minimal clinical practice experience).
On completion of the study block students worked in the clinical field with
preceptors to further develop their clinical skills and fulfil clinical requirements of
1100 hours, under the supervision and mentor-ship of preceptors and clinical
instructors. Program staff developed clinical competencies or Achievements
Records for the clinical area. (Appendix 10 reflects a sample of an Achievement
Record.) In the clinical field, students were ‘buddied’ with preceptors and were
supervised by clinical instructors—and before they could practice independently,
they had to fulfil all achievement records. Students were also involved in reflective
journal documentation, which is discussed later. A typical program for this group of
students is reflected in Table 6.8.
Time Sat Sun Mon Tue Wed
0800-1500 Study Block ( 3 days a week) English (2 days a week) After a 7-week Study Block period 0700-1500 Clinical Practice (3 days a week) Journals;
Competencies English (2 days a week)
1500-1700 Study Time (3 days a week) English (2 days a week) NB: On Wednesday - formal Program Meetings between 1330-1430
Table 6.8: A typical program plan for the first group of PDP students
In the early days of the program, some students faced difficulty in arriving at class on
time and they were informed about the importance of being punctual. To avoid
hostility, conflict situations and unfriendly relationships that would “create serious
barriers to gathering accurate and dependable information” (Jorgensen, 1989, p.78),
they were allowed to express their feelings, which provided insight to some of their
difficulties. The students usually related their difficulties to family commitments, as
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most of them were married with very young children. Al Osimy (1994) made the
point that, in this society, a mother is primarily responsible for the wellbeing of her
family. Typically, this responsibility is a reflection of the cultural values attached to
women in this society, which inevitably affects the Saudi Arabian nursing profession.
This information from the students was valuable for “gaining insight into their
world” (Jorgensen, 1989, p. 76). A staff meeting was conducted to discuss
punctuality and new plans were implemented. The Associate Administrator
suggested that one hour be allowed at the end of each day for bonding time for
students with children under two years of age and awarding a ‘certificate-of-perfect-
attendance’. To win a certificate for perfect attendance, students had to be on time
with no record of absence including sick leave each month. Attendance was
documented. Just as honour is paramount in Saudi society, recognition for efforts
and human needs are also important and it is not uncommon to discover a variety of
certificates, for example for ‘good behaviour,’ ‘general proficiency,’ ‘good
attendance’ and so forth, in a curriculum vitae. Often, the potential candidate at an
employment interview would purposefully and proudly inform the interviewing
panel about the various certificates acquired. Students were elated with this new
development and efforts to develop cooperative relations were successful.
Discovering, acknowledging and compromising “are effective in generating
sympathetic understanding” (Jorgensen, 1989, p.77). At monthly program meetings,
certificates of perfect attendance were awarded to the students who were consistently
punctual during a particular month.
Approximately three months after the PDP commenced, a building was allocated for
the program, a converted villa in the housing complex of the hospital. This
environment was more conducive for learning and socialising. There were
appropriate classrooms, recreational areas, cooking facilities and an essential prayer
areas. “People are defined socially by where they are located in relationships to and
in association with other people” (Jorgensen 1989, p.53). Therefore, Jorgensen
(1989) emphasised from a researcher’s standpoint that observation is influenced by
an individual’s physical location, furthermore, for human studies, the social location
is also critically important.
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The students were able to remove their ‘abayas’ (voluminous cloaks, primarily black
in colour, worn over a woman's attire for modesty). Before acquiring this new
building, the students had to don the abayas throughout the day, as they were in a
hospital environment – this change was a welcome relief for them, which also
provided additional freedom and comfort.
Having satisfied the theoretical component (75% score in all subjects), clinical
component (1200 hours) of the curriculum and attained a score of 130 in the Oxford
English test, students attempted the Registered Nurse’s examination. The first group
of students are now functioning effectively within King Fahad National Guard
Hospital’s (KFNGH) system in the clinical areas, such as medical and surgical,
paediatrics, operating rooms, post-partum units and diabetic clinics.
The first group of Saudi nurses did not experience the education/intervention
program in which critical thinking strategies were integrated into the curriculum,
because the researcher was still in the process of developing a curriculum that
integrated these concepts into lesson plans.
6.6.2. The second group - Study group
As stated previously, difficulties with the diversity in levels of education and English
competency within the first group of students in 1997 were realised, hence criteria
were established for the next intake. Potential candidates had to satisfy the following
criteria: (i) pass the Oxford English test at a level of 120, and (ii) possess an associate
degree qualification from a nursing college or institute in Saudi Arabia.
Before this second group of students commenced, the researcher was immersed in
developing a program to enhance critical thinking abilities by integrating these
critical thinking strategies into the PDP curriculum. Furthermore, the researcher
ensured that the physical environment was adequately equipped, and clinical
instructors, students, and health care professionals in the hospital were provided
opportunities to promote and practice critical thinking skills, which are explained as
follows.
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6.6.2.1. Physical environment
The physical environment included space and resources to support critical thinking
instructional techniques. For example, a classroom large enough to accommodate
chairs arranged in a ‘U’ shape manner (the reasons for which are explained later) and
three white/blackboards, organising three to four workrooms for small group activity
and video and television facilities.
6.6.2.2. Clinical Instructors
Clinical instructors had a wealth of clinical experience, but did not possess formal
teaching skills and were not familiar with using critical thinking strategies. It was
the role of the researcher to inform and guide the clinical instructors through the
concept of critical thinking and advise them of the supportive strategies to be
utilised. These strategies included questioning, small group activities, role-play and
debate in the classroom and journal documentation in the clinical field. Furthermore,
they also needed assistance with the construction and integration of critical thinking
strategies into lesson-to-lesson plans for all subjects within the curriculum.
Prior to the commencement of the program, clinical instructors attended several in-
service sessions, conducted by the researcher and Associate Administrator and which
discussed critical thinking strategies, provided the opportunity to raise questions or
seek clarification as required. Clinical instructors were given articles to read related
to critical thinking and encouraged to familiarise themselves with this concept. At
the in-service sessions the issues discussed were:
• creating a classroom environment to acknowledge listening, respect for the
comments and questions of others and openness to new views;
• providing praise for students' participation;
• allowing quiet time for reflection during the course and at the end of a lecture;
• avoiding information overload, as this would inhibit critical thinking; and
• teaching critical thinking strategies together with tools or devices such as stem or
guided questions, videos and homework to enhance and develop cognitive skills
(for example analysis, inference, explanation, interpretation, self-regulation and
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evaluation) and dispositions (inquisitive, truth seeking, open-minded, analytical,
systematic, confident in reasoning and judicious)
Structure or guidelines for reflective journal documentation were developed, based
on the work of Brown and Sorrell (1993), Hancock (1999), Holmes (1997), Patton et
al. (1997) and Schell (1998) and these were used in clinical practice to reflect on
lived experiences and how these influenced students’ practice and thinking abilities.
These journals were also the conduit whereby clinical instructors and preceptors
could dialogue with students, share experiences and concerns, and involve them in
analysis and evaluation of their clinical experiences.
Faculty staff agreed that two journal entries from each student would be submitted
each week, and journals would not be graded. Timely, constructive feedback and
guidance would be provided, and praise for superior quality work given.
In another session, formative and summative assessments were addressed.
Formative evaluation related to utilising pre and post-tests at daily lectures to assess
students’ comprehension of the content. Summative evaluation assessed students’
understanding of the core content, instead of their ability to recall memorised
material. These evaluations focused on observable behavioural manifestations of the
kinds of thinking demonstrated by students in the classroom, for example, analysis,
prediction, explanation, comparing and contrasting and so forth. (Appendix 11
reflects a sample of a typical summative examination.) Finally, clinical instructors
were encouraged to verbalise any difficulties they experienced with the
implementation of critical thinking strategies.
6.6.2.3. Students
During the student interviews, the researcher participated as a member of the
interviewing panel. Each potential student was informed about the concept and
implementation of critical thinking strategies in the program to ascertain their
feelings and to obtain feedback. Students appeared to be interested and stated as
follows.
We are used to listening to the teacher and writing a lot of notes and the teacher expects us to write what they say - it makes the
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hands very tired. That’s how they teach in Saudi Arabia. We are looking forward to this new technique. How can we prepare for it?
Students were informed that homework was an important part of their learning and
an expectation to come prepared with homework assignments completed. A two-
week orientation period was organised for the new PDP students. The researcher
interacted with students informing them about the study, dealing with their questions
openly and directly. Students had queries such as: “What happens if we wish to
withdraw from the research, can you guarantee that there will be no harm towards
our study?” “We know that research is valuable and want to be involved, but will
you make sure that you do not use our names in publications?” “We are not allowed
to be in videos, is this ok?” Students were assured that the object of the research was
not to harm them or their interests in any way. The researcher emphasised that their
participation was voluntary, their identity would be anonymous and any information
provided would be kept confidential. Furthermore, the researcher discussed the
research plan, providing an overview of the study with the group, informing them
that the researcher would be interacting closely with them, in order to “dispel
possible misconceptions and gain their acceptance” (Jorgensen, 1989, p.75). The
group was accepting and enthusiastic and asked “When do we start this new way of
learning, because we want to know about it and also, we want to be the first group to
experience and learn this.”
The reason for the 'U' shape format of the classroom was explained to students,
because they were accustomed to a military style arrangement. Other devices, for
instance the use of a question stem-guide were also discussed. During the orientation
phase, students were also exposed to a session on journaling in the clinical area,
which is explained later. The orientation process was important for socialisation.
Students also gave their official consent, and this is explained later in this chapter.
6.6.2.4. Health care professionals in the hospital’s clinical field
Before the students worked with staff nurse preceptors in the clinical area, the PDP
staff conducted several hospital-wide forums to discuss and share the critical
thinking concept with multidisciplinary health care staff. Some wards specifically
scheduled PDP staff in their in-service education agendas and invited PDP to provide
more information about critical thinking skills. As a result, staff and especially
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preceptors were aware of the students’ clinical objectives, journal documentation and
critical thinking skills that were taught in the classroom.
When students were active in the wards the researcher and clinical instructors
reinforced critical thinking in the clinical field with the preceptors. Journal
documentation and use of the structure/guidelines were also explained and students
were expected to document. Preceptors were encouraged to question the students
about their clinical practice. As part of the students’ clinical learning objectives, they
were encouraged to present case studies of their experiences and document lived
experiences in their journals.
6.6.2.5. Consent for the study and ethical considerations
Consent and ethical approval/considerations were granted from Saudi Arabian
National Guard-Health Affairs and Queensland University of Technology. During
orientation, the researcher conducted a seminar and provided detailed explanation of
the study to fifteen Saudi nurses. The researcher also emphasised that their
involvement was voluntary and students informed that the:
• Researcher was part of the data collection and would be an observer;
• Students would be involved in focus group interviews during the program;
• Students would be required to complete a student-teacher evaluation
questionnaire at the end of the program;
• Students’ responses would remain anonymous at all times in terms of collected
data and they could withdraw from the study without repercussions.
Students were encouraged to ask questions about the study. Before written consent
from students was obtained the researcher gained verbal confirmation of their
understanding and the extent of their involvement in the study. Copies of the
‘Subject Information Package’ and ‘Consent forms’ were distributed to them and are
presented in Appendix 12. They were given an opportunity to peruse these
documents and then the researcher again discussed the contents of the documents.
Permission to conduct this study was obtained from the Ethics Committees of both
SANG-HA (the employing agency) and the Queensland University of Technology,
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and the support to undertake the study within the PDP were given by the Deputy
Chief Executive Officer and Associate Administrator of SANG-HA. Participation in
the study was on a voluntary basis, following a detailed explanation of the rationale
for the study. Students were also informed that they were free to withdraw from the
study at any time without influencing their standing, or involvement with SANG-
HA. A signed consent form was required from each participant and this was counter-
signed by the principal researcher. Confidentiality was maintained by allocating a
number to each study participant in the study. Once the questionnaires were
completed, they were collected by the researcher and locked in a filing cabinet in the
locked office of the researcher. The research did not materially influence subject-
matter content or reveal private information concerning participants in the program.
In the published results to QUT or to journals for professional publication, absolute
anonymity of participants was and will be maintained.
6.6.3. Implementation of critical thinking strategies in the classroom and
clinical field
The students experienced an educational/intervention program in which critical
thinking strategies were utilised on a daily basis in the classroom and in the clinical
field to improve critical thinking skills. Critical thinking strategies comprised
questioning, small group activities, debate and role-play in the classroom; and
journal documentation in the clinical arena. The intervention or education program
commenced in September 1999 and concluded in April 2000.
The students were diligent and extremely interactive, reiterating their view of the
critical thinking concept as a “good idea.” During the educational program, their
classes started at 0800 and finished at 1700 three days per week (Saturday, Sunday
and Monday) and on Tuesday and Wednesday they attended English classes. In the
initial stages of the program, punctuality was a problem also experienced by this
group. The same strategy successfully used with the first group (that is, awarding
certificates of attendance) was implemented and in a short period, it was no longer an
issue. Tools or devices such as homework, stem-questions, videos, were used in
conjunction with critical thinking strategies to stimulate critical thinking skills.
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Students were provided with handbooks containing the content for the entire
curriculum (404 theoretical hours, reflected in Appendix 1), homework assignments
and reading material for all subjects. They were also informed that they had to
complete 1100 clinical hours. The items of evaluation for all subjects were
explained to students and a representative subject illustrated in Table 6.9.
Subject Exam Content
Homework (Pre/Post-
Tests)
Participation &
Interaction
Critical Thinking Questions
(CTQs) generated
Total
Example: Anatomy & Physiology
75%
10%
5%
10%
100%
Table 6.9: Typical breakdown/grading of a subject
These students had previously graduated from nursing colleges wherein basic
nursing subjects were taught, but critical thinking was not included in the curriculum
and the nursing content did not meet accepted Western standards. In constructing the
curriculum, consideration was given to upgrading the theoretical content, English
competency, and enhancing critical thinking skills to transform students into active
participants in order to enhance intellectual growth and development (Paul 1990).
An additional goal was to integrate critical thinking strategies into the curriculum as
a process of effective teaching so that critical thinking became a daily experience
rather than a subject to be taught within a curriculum (Case, 1994; McPeck, 1981;
Miller & Malcolm, 1990; Schank, 1990).
6.6.4. Setting the scene to improve critical thinking
The classroom was arranged in a ‘U’ shape, which allowed students to have eye
contact and the ability to question and interact with each other. It also permitted
clinical instructors the opportunity to interact openly with the participants. This was
a new experience for both students and clinical instructors, as they were accustomed
to a traditional classroom layout style in which students sit in rows behind each other
(military style). During the implementation of critical thinking, the researcher
observed, listened and noted students’ behaviours. The researcher was also involved
in interviews with informants which allowed data collection for the study and which
is now presented.
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6.7. Data collection
6.7.1. Direct observation: Questioning
As a participant observer the researcher observed the manner in which clinical
instructors utilised critical thinking skills in their teaching sessions. Clinical
instructors utilised stem or guided questions (King, 1995) as a tool or device to
induce critical thought in order to help students generate their own critical thinking
questions based on the content material. (The concept of stem/guided questions is
discussed in Chapter 2 and examples presented in Appendix 13.) Students were
provided with copies of stem-questions and encouraged to utilise them. Furthermore,
clinical instructors kept students alert by randomly calling upon them to respond to
questions, pausing for brief moments in order to provide thinking time for quality
answers.
The guided critical thinking questions were also used in homework assignments as a
device to stimulate students to formulate questions, based on their reading material.
At the beginning of each session, these questions were submitted to the clinical
instructor, who selected some for immediate discussion, other questions were used in
small group discussions. Students were requested to submit their homework
assignments, which were shuffled and redistributed amongst the students, hence each
student had the opportunity to correct each other’s work. At the end of each session,
clinical instructors collected the tests and recorded the scores. A ‘round-robin’
technique (a systematic technique where each student is given a turn to provide an
answer) was conducted, in which students were encouraged to participate. Following
this, the clinical instructors asked questions about pre-reading content in order to
confirm students’ comprehension of the material. For example, ‘What do we already
know about……….” (activation of prior knowledge); “What does….mean?’
(analysis). Such questions energised the students to participate and interact
actively—it was also a way to allow another voice in the classroom, other than that
of the teacher. Students also had the opportunity to monitor their comprehension of
the topic.
King (1995) had similar findings in her study with psychology students and reported
that teachers can enhance their (students') use of critical thinking questions by using
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critical thinking type questions in their teaching. Clinical instructors always extended
praise for each student’s questions and responded to them promptly.
Homework and pre-reading materials were used as teaching devices/tools to identify
gaps in knowledge and to remedy these gaps openly. In the first two weeks of the
program, some students came unprepared and they were directed to one of the
workrooms to complete the pre-assigned reading and written exercises. They were
also reminded that homework was part of the grading system (see Table 6.9).
Homework was therefore also a teaching strategy to achieve changes in behaviour, in
terms of acknowledging the value of coming prepared with pre-reading and written
homework completed. Pre and post-tests were derived from homework reading
materials and assigned each day. The duration of a subject within the curriculum
varied between two to four days, for example, Anatomy and Physiology was
reviewed over a four-day period. A sample of a typical curriculum for the PDP is
attached as Appendix 14.
Clinical instructors used overhead materials or slides to demonstrate and engage in
thought-provoking or critical thinking questions. For example, ‘explain
why…….explain how……?”; “What will happen if….?”. Such critical thinking
questions induced higher-level cognitive processes such as problem solving, analysis
of ideas, comparison and contrast, inference, prediction and evaluation. Students
were forced to go beyond the facts to think of each focal situation in a variety of
ways. Clinical instructors provided ‘wait time’ for students to respond in order to
improve the quantity and quality of their answers. At the end of each session, five to
ten minutes was set aside for students to formulate critical thinking questions
(CTQs), using stem questions to guide their thinking processes.
Generally, the CTQs generated by students were collected, shuffled and redistributed
to the class. This method allowed them to answer each other’s questions, as well as
their own and were active listeners, alert and motivated. They were particularly
elated when the clinical instructors read out well-constructed CTQs, providing praise
for questions generated. The clinical instructors’ role was both active and passive.
Active in that the facilitator would spring surprises on any student to answer and
passive in terms of facilitating and clarifying answers only when necessary.
Students were constantly reminded that participation was worth 5% of the total
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examination grade and this stimulated participation. When students experienced
difficulty answering a question, the clinical instructor paused for a few seconds to
give students the opportunity to consider the question. Silence was effective,
because when some students were hesitant to respond, perhaps for fear of providing
an incorrect response, the clinical instructor did not volunteer the answer.
In her study King (1995) found that when students experienced difficulties, they
were not necessarily seeking correct answers, but they were making mental
connections between concepts that were already familiar to them. The researcher
observed the rapid progress in the students' development of CTQs using guided
questions. Additionally the researcher noticed a change in behaviour, in that,
students who acquired the technique in formulating CTQs subsequently assisted
others who were still learning this technique. Other critical thinking activities were
also employed to stimulate their thinking, encourage questioning, participation and
interaction, for example:
Videotape presentations of case studies were also utilised as a device to support the
questioning technique. At different intervals of these sessions the clinical instructor
would stop the videotape and question participants about certain aspects of the case
study. For instance, “what is happening here?”(analysis); “what if……had happened
instead?” (prediction). The videotape sessions also allowed for group discussions to
convene as students shared their thoughts and asked more questions. This generated
further discussion and participation by all members.
Frequently, before closing a session, facilitators formulated several questions with
corresponding answers, which were typed onto flash-cards. The class was divided
into either three or four teams. One student from a team was randomly selected to
start with a question. All other students were required to think and analyse the
question. An opposing team member was selected to give the correct response. If the
student in an opposing team was unable to answer a question, the members within
the team were given the opportunity to collaborate in order to produce the correct
response. In the event that an incorrect response was verbalised, the team lost a point
and the other team(s) was allowed to retrieve the correct answer. This activity forced
students to think before they answered a question. A score was awarded for a correct
answer(s).
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The researcher observed that this playful approach created a relaxed atmosphere and
it also challenged students to engage actively and think prior to providing an answer.
At the end of a lecture the clinical instructors provided closure by concluding five
minutes early to allow students time to process the information presented. The
students were invited to write down on a piece of paper, two to three important
things they learned and one to two questions about what traditional information they
needed to know on the subject content. This information provided feedback for the
clinical instructors on area(s) which needed clarification or modification.
6.7.2. Direct observation: Small groups
Small group activities were conducted in almost all of the sessions with three to four
students in a group. Students were randomly selected for group work so that they
had the opportunity to interact with different individuals. To provide a quiet working
environment, each group was allocated a room set up for this purpose (known as
work-rooms) where they sat around a small conference table and interacted with each
other.
During the group process students utilised the whiteboard/chalkboard in each
workroom to write, create diagrams, and flowcharts to express their thinking and
present their findings to other group members. The students in each group
formulated critical thinking questions, which they posed to their peers and
discussions ensued. The presenter in each group was randomly selected in order to
prevent weaker students avoiding participation.
When the students were working in their groups, the clinical instructors and
researcher circulated between the groups, listening and observing students
interactions. The clinical instructors also commented that circulating around groups
provided constructive feedback about the instructional process because it informed
the facilitator which concepts needed clarification or modification. Students
generated critical thinking questions to challenge each other, and discussion between
students was productive. Clinical instructors praised the students for their
enthusiasm and active participation. Students often commented that group work
activity “keeps us active, thinking and we can’t afford to fall asleep.”
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6.7.3. Direct observation: Debate
The first debate was introduced on a topic of “Growth and Development” in October
1999. The students had not experienced this exercise before, therefore the debate
process was explained in detail and they were encouraged to ask questions about this
activity. The topic for discussion was provided before the scheduled debate. The
students were then randomly selected into two teams. Journal articles were given for
background knowledge and lists of references were made available in order for the
students to conduct additional research in the library. Student judges and
timekeepers were randomly selected. The clinical instructor explained the judging
process.
The classroom was rearranged, so that the teams faced each other and the judge and
timekeeper sat at the head of the two teams. During a debate process, the clinical
instructor was a passive facilitator, assisting only when required. When all members
had the opportunity to respond and argue their views, the student judge pronounced
her verdict with support from the clinical instructor as required. Following the
debate, students were given the opportunity to raise any issue(s). The clinical
instructor asked students about their feelings regarding the debate process. Students
formulated critical thinking questions, which were collected and the facilitator
randomly picked questions and encouraged students’ responses to the questions.
Following this experience, several debates were conducted during the educational
program.
6.7.4. Direct observation: Role-play
This strategy was also a new experience and the first role-play was introduced in a
topic within “Fundamentals of Nursing” in October 1999. The clinical instructor
described the characters and provided brief but sufficient information to elicit
responses to meet the learning objectives. The students’ simulated roles were
assigned by the clinical instructor and the classroom was rearranged to facilitate the
activity. The actors sat face-to-face in the middle of the room and improvised their
behaviours appropriately to illustrate the expected actions involved in the particular
scenario, while the other students or audience sat in a semi-circle. The clinical
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instructor as facilitator explained the role of the audience as active and interactive
participants.
The audience participated and contributed to the discussion and analysis. Students
had the opportunity to be creative and actively involved in a learning experience, in a
non-threatening situation. Clinical instructors were always passive observers, who
interceded as required. At the end of each role-play, the facilitator debriefed the
class by asking questions, such as “how did this experience make you feel?” “Would
you like to do this exercise again, if so, why? if not, why not? The participants were
encouraged to ask questions. The participants also used stem guides and generated
their own critical thinking questions based on the scenario. These questions were
collected and addressed. The first experience paved the way for other role-play
scenarios. Clearly, not all of these strategies could be utilised within the framework
of a single lecture.
Critical thinking strategies used in the educational program reinforced to students
that thinking critically was a daily experience, and an important element of learning.
The emphasis of classroom learning was transposed from memorisation to
interaction and active participation. In practice, critical thinking strategies and
devices are nested within each other. For instance, using a videotape (device) to
encourage questioning of the content adds depth, richness and creativity to an
instruction.
6.7.5. Direct observation: Preparation for the clinical field
Clinical skill workshops were conducted to reinforce students’ psychomotor skills,
assess competencies and facilitate the transition from theory to practice. Skill
laboratories were set up to strengthen skills such as tracheotomy suctioning,
medication and so forth. These skills laboratory workshops were intended to guide
students and provide the opportunity for familiarisation with procedures in the
clinical field, seek clarification and develop confidence. Clinical instructors manned
the various stations and laboratories, questioned the students without intimidation,
sought a rationale for their answers, and provided feedback on their responses.
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The first theoretical phase of the educational program (12 weeks) concluded at the
end of November and students worked in the clinical field. Students were involved
in reflective journal documentation to develop critical thinking abilities by making
fundamental links between classroom theory and clinical practice and to “use
reflection in developing an effective practitioner” (Cameron & Mitchell,1993, p.
293). Reflective journaling is also discussed in Chapter 2 and again in Chapter 7.
6.7.6. Materials: Reflective journal documentation
Besides listening and observing, the researcher noted how students utilised materials.
For example, a Saudi clinical instructor in the PDP (Ahlam Sheikhoon), took the
initiative to develop structure or guidelines for journaling, building on the literature
by Brown and Sorrell (1993), Hancock (1999), Holmes (1997), Patton et al. (1997)
and Schell (1998). Students utilised these guidelines for their journal documentation.
These authors stressed the importance of structure and process as a guide for
students, so that growth and development can be achieved. Guidelines or structure
for reflective journals are presented in Tables 6.10, 6.11, 6.12 and 6.13. Sheikhoon's
efforts inspired students with reflective journal documentation in the clinical field.
Students in the PDP had not previously documented in journals and they found the
structures/guidelines useful to document, ask questions and share thoughts that they
had not verbalised about their lived experiences. The guidelines also facilitated
clinical instructors and preceptors, by giving them the opportunity to provide
constructive and timely feedback, and teach through questioning to develop inquiring
minds. An example of a student’s journal documentation is presented in Chapter 7.
The following Tables outline the structure and process to guide journal
documentation.
Reflection
What Happened? How Do I Feel About It? What did I Learn?
Table 6.10: Reflection
Adapted from Brown and Sorrell (1993), Hancock (1999), Holmes (1997), Patton et
al. (1997) and Schell (1998) and developed by Ahlam Sheikhoon (1999).
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In the reflection phase, students identified the activity, then reflected on the lived
experience, mulling over to discover and explore assumptions, searching for meaning
and increasing self-awareness and sensitivity of the situation, thus leading to
speculation.
Speculation
What Happened? What Could Happen Because Of This?
Table 6.11: Speculation
Adapted from Brown and Sorrell (1993), Hancock (1999), Holmes (1997), Patton et
al. (1997) and Schell (1998) and developed by Ahlam Sheikhoon (1999).
The speculation phase required students to examine events, looking at
inconsistencies, reflecting deeply on lived experiences, reasoning and making
predictions and connections within the situation.
Synthesis
What I Did? What I Learned? How I Can Use It?
Table 6.12: Synthesis
Adapted from Brown and Sorrell (1993), Hancock (1999), Holmes (1997), Patton et
al. (1997) and Schell (1998) and developed by Ahlam Sheikhoon (1999).
When addressing the synthesis component in their journal, students reflected on the
cumulative activities. The activity encouraged review of lived experiences, provided
opportunity for discovery and exploration, evaluation and plans for future
applications. The act of writing reinforced what was learned.
Metacognition
What I Learned How I Learned
Table 6.13: Metacognition
Adapted from Brown and Sorrell (1993), Hancock (1999), Holmes (1997), Patton et
al. (1997) and Schell (1998) and developed by Ahlam Sheikhoon (1999).
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The final stage of this journal documentation activity involved metacognition. King
(1995, p. 16) defined this aspect as “the awareness, monitoring and control of one's
cognitive processes". In metacognition, higher level of critical thinking occurs when
one is aware of one’s thought processes. Students become aware of the purpose of
the task, monitoring, questioning their actions and progress towards a decision,
identifying mistakes and continually analysing thought processes. For example,
when giving a drug, various kinds of questions need to be considered, in terms of
“What must I teach my patient to look out for in case of side effects and why? What
will happen if I do not inform my patient?” Hence, more in-depth reflection occurs
to obtain meaning for actions or interventions considered.
Key questions at this stage were: “What enabled you to gain the most from this
experience? What would you do differently if you had more time?”
Clearly, students accepted this new method of instruction because it offered a variety
of techniques, which challenged them.
6.7.7. Direct observation: Evaluation of Clinical Instructors’ teaching
The researcher developed critical thinking strategies evaluation instruments using
criteria influenced by Paul (1990, 1993). The criteria used were clarity, precision,
specificity, accuracy, relevance, logicalness, depth, completeness and fairness.
(Details of the evaluation of instructional strategies instruments are presented in
Appendix 15). The criteria for the evaluation instruments are discussed in the
literature review in Chapter 2.
During the educational program, the researcher audited the clinical instructors’
teaching sessions for instructional effectiveness using these criteria-based evaluation
instruments. After each teaching session, the researcher provided immediate
constructive feedback on the clinical instructors’ performances. The evaluations
were presented so that they could peruse the comments, ask questions and make
modifications to their instructions accordingly. The researcher provided relevant
research-based literature to reinforce their teaching and to enhance growth and
development. The researcher also compared past and present instructional
evaluations and met with the clinical instructors on a frequent basis to inform them
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of their improvements in their teaching skills. An example of feedback provided by
the researcher is provided as follows.
Your random assignment of students was well carried out by ensuring the cliques were divided. You also rotated from group to group to ensure that the weaker students were participating. In doing so, you listened to students answering and engaged in discussion. Furthermore, you ensured that students worked collaboratively with each other in peer questioning (whilst within the groups assigned) and answered each others’ questions. Vanetzian & Corrigan (1996) state that this process stimulates critical thinking abilities.
During direct observations of clinical instructors’ instructional sessions, the
researcher noted the confidence exhibited by instructors towards using critical
thinking strategies. Students were also responsive and interactive, participating with
the instructors and using the tools to facilitate critical thinking. (Appendix 16
provides a detailed account by the researcher on the clinical instructors’ teaching
techniques.) Clinical instructors were also encouraged to conduct peer appraisals,
using the same criteria-based evaluation instruments and they provided feedback to
peers and made improvements as necessary. The researcher wanted to obtain clinical
instructors’ feelings towards the use of critical thinking strategies as a means of
triangulating the data and organised a focus group interview, which follows.
6.7.8. Focus group interview with Clinical Instructors
A focus group interview was held with clinical instructors to give them an
opportunity to air their views about the critical thinking strategies and make
comments or offer modifications about the evaluation instruments. Clinical
instructors were provided with the following questions for the focus group interview
prior to attending the interview to facilitate reflection and participations.
1. Do you have any suggestions for improvement in the structure or content of these evaluation tools?
2. What are your feelings about using critical thinking strategies as a method of instruction?
3. Was the evaluation tool helpful and clear in terms of meeting the expectation of how to teach critical thinking?
4. Was the evaluator helpful? 5. Did you perceive a difference between being evaluated by your boss and
peer? 6. What was most beneficial about these tools? 7. What in particular helped each one of you?
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8. Did you receive sufficient feedback from the evaluator? Was the feedback constructive?
9. Can you explain if the use of critical thinking strategies shaped your teaching in any way? (Would you use it in future)?
10. Do you believe that critical thinking can be developed? 11. What other comments do you have?
Clinical instructors were forthcoming and their comments are presented as follows.
Interviewer: “What are your comments to question 1?”
Clinical Instructors (CI) collectively: “It is very clear.” Especially the part following each criterion, there is a comment - we like that part, it’s simple and easy to follow. It is very in-depth. The criteria helped a lot. It helps to focus, to note the kinds of things that you need to stress on.”
Interviewer: “Do you think critical thinking can be developed?”
CI: “Yes, especially when we were given the direction, preparation and the tools to use.”
Interviewer: “Did the feedback help you at all.”
CI: “Yes, you read the comments and reflected upon them and discussed it with the manager (researcher). It’s like, what I fall short of now, I can pick up and I can better myself.”
Interviewer: “Because you dealt with the feedback in a serious nature, you revised it and therefore made improvements. How do you think this experience compares with the statement ‘great teachers are born’?”
CI: “I disagree. I was not born a teacher (laughter). Perhaps give them the tools and they can become better teachers. Like I did, developed myself. I embraced critical thinking and used the tools to help me. Also I believe that when you help to develop critical thinking, you are also developing your own skills. For example, when we taught pharmacology, at first we gave them big chunks and they struggled. Then we questioned them in a non-threatening manner. We broke the topic into small sections and put them into groups to discuss each section. They were focused, they asked questions on the small sections, and every group shared their components and they got the whole picture - we had more people passing. I strongly believe other ways that helped them develop their critical thinking was the compulsory pre-requisite homework they had to do. When they came prepared they were able to interact and participate. Other effective methods were the use of stem questions and group work activity, as these techniques provided participation and interaction. Critical thinking strategies is an effective way to teach as it keeps everyone interactive and awake.”
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The previous interview demonstrated the positive attitudes of clinical instructors
towards the use of critical thinking strategies. Besides investigating critical
instructors’ feelings about critical thinking strategies, the researcher also wanted to
explore how students felt about the use of these strategies, given that it was a new
concept for them, and developed a questionnaire as well as engaged in focus group
interviews with them, which are presented below.
6.7.9. Use of questionnaire: Evaluation of students' responses towards critical
thinking strategies
The content for this questionnaire was adapted from Queensland University of
Technology’s Program Evaluation and Development Services (1999-2000): Student
Evaluation Units. (Appendix 17 reflects the Student-Teacher Evaluation.) Students
were encouraged to evaluate the clinical instructors’ critical thinking techniques and
a student-teacher evaluation questionnaire was administered at the end of the
intervention program (approximately seven-and-a-half months). Before distributing
the questionnaire, the researcher consulted with a student representative and
explained the purpose for this evaluation. The researcher chose to be absent for this
evaluation so that a non-threatening environment was maintained. The student
representative was responsible for explaining the purpose of the survey,
administering and collecting completed checklists and submitting them to the
researcher. The researcher instructed the student representative to explain the
following to the participants:
Thank you for your participation. Since September 1999, the clinical instructors used critical thinking techniques when they presented their lectures. These strategies were questioning, small group activities, role-plays, debates and journaling. As students we participated with the clinical instructors by questioning, answering questions and writing critical thinking question, using a critical thinking stem-guide. We also worked in groups, gave presentations, argued in debates and interviewed each other in role-play situations.
The purpose of this checklist is to evaluate the clinical instructors’ teaching techniques, as to whether we liked this way of teaching and whether it was helpful to meet our learning and understanding of the subjects. In addition, whether the clinical instructors used these techniques effectively in order to enhance our critical thinking skills.
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The student representative was also instructed to explain the following:
• No names were necessary, instead a number was given which was to be reflected on the top right-hand side of the page;
• On completion of the checklist, they were to submit them to the student representative;
• They were free to leave the room, as soon as they completed the checklist; and • Checklists would be locked in the researcher’s secured filing cabinet.
Eleven students completed the questionnaire (one student was on sick leave). There
were 89 questions and 100% positive feedback was received for all but 12 questions.
Students provided positive feedback and the responses for the 12 questions are
displayed in Table 6.14. The Student-Teacher Evaluation questionnaire is reflected
in Appendix 17.
Variations in Responses to Student-Teacher Evaluation Questions Responses
Positive Negative 2.2. The teacher presents the unit content clearly 90.9% 9.1% 2.7 The teacher allows sufficient time for note taking 81.8 18.2 2.11 The teacher teaches at a level understood by students 90.9 9.1 2.13 The teacher manages the situations in a way that helped me
to learn 90.9 9.1
3.4 The teacher helps me to feel that I am an important member of the class
90.9 9.1
3.8 The teacher demands high standards 90.9 9.1 3.12 The teacher helps me to feel that my participation and
learning are important 90.9 9.1
4.1 The teacher is aware when students have difficulty understanding topics
90.9 9.1
5.7 Assignments are marked promptly 90.9 9.1 5.8 Assignment questions are worded clearly 90.9 9.1 6.19 The teacher encourages students to read widely in the unit
area 81.8 18.2
7.1 The teacher provides a variety of interesting resources for study
90.9 9.1
Total Number of Responses: 11
Table 6.14: Variations in Responses to Student-Teacher Evaluation.
6.7.10. Focus group interviews with students
The researcher also wanted to investigate how students were coping with the new
theoretical content and integration of critical thinking strategies. Typical comments
were taken from the two focus group interviews and presented as follows.
Interviewer: “What do you think of the content of the course?”
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Student: “It’s good, it covers the things that we need to know, but the time period is very short and sometimes we feel stressed.”
Interviewer: “You are saying that the content in the material is adequate. What about the method of teaching?”
Student: “It’s really a good way of teaching. Actually you’re not just giving us a lecture, you are giving us information, by questioning us - it’s very nice. We have to do homework to be able to answer and participate, but we have not got enough time to do this because the content is so much and we need more time, because you have an expectation of us to cover the subjects.”
Interviewer: “Are you saying that you don’t have sufficient time to complete homework because there is too much content?”
Student: “No, the content is not too much, it is the time factor that we need to cover the content. The content is good and we need this especially to upgrade our theoretical knowledge so that we can practice proficiently in the clinical area, but we need more time to do reading…. time, time, time, that’s what we need.”
Interviewer: “Ok, we’ve heard you. What about the critical thinking questions that the instructors ask you to generate in class, can you explain how you felt about doing this and this method of teaching?”
Student: “This is a very good idea and the stem guide questions are helpful, very helpful. Also when you don’t know the answer and you hear other students’ answers, you learn from them. For me, critical thinking is always there. I have to have critical thinking skills with the patient and the doctor when he gives orders and when we discuss the patient’s condition.”
Various members in the group: “Critical thinking is good, it’s a good idea.”
Interviewer: “What about the debate you had, did you like this idea?”
Student: “Yes, because we had to research the subject, then prepare for it and discuss it with everyone……very nice. We never did this before.”
Interviewer: “What about role-play, did you like this and how did you feel?”
Student: “Yes, a good experience. We never did this before too.”
(Interviewer writes the four critical thinking strategies on the board and asks students to rate in order of preference).
Interviewer: “Which strategy did you learn best from?”
Students in the group: “Group work and questioning, then debate and role-play. It is not that we don’t like the last two, but because we are not familiar with them and need more practice. They are good too.”
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Interviewer: “Why group work?” Student: “Because when I have an idea we can all discuss it together, write on paper or on the blackboard and we share our ideas and then present our work to the group – it sticks in my head. Also it is not so threatening.”
Students unanimously: “Yes, yes. Questioning happens in all the strategies that the instructors use too – this is good and it keeps us thinking.”
The outcomes of the student-teacher questionnaire, focus group interviews with
students and clinical instructors, evaluation of facilitators’ instructional effectiveness
indicated that critical thinking strategies were accepted. Hence, critical thinking
strategies continued following the comments. Faculty heard the difficulties that
students verbalised regarding having insufficient time at night to fulfil homework
requirements as well as pre-reading material in order to be able to participate and
interact in the classroom. Their comments were acknowledged and the original
curriculum was immediately reviewed and revised to meet their needs and these
changes extended the program into early April 2000 (instead of February, 2000).
Changes were made in the curriculum, which is reflected in Table 6.15.
Activity of Educational/Intervention Program: September 1999 – April 2000
Month Number of Weeks Activity 1999 September 3 Weeks Orientation Oct. – Late Nov. 7 Weeks First Study Block: Theoretical
Component Nov. – Mid December 3 weeks First Clinical Practice December 2 Weeks Holidays: Ramadan (fasting month
celebration) 2000 January - March 8 Weeks Second Study Block: Completion of
Theoretical Component April 3 Weeks Second Clinical Practice TOTAL: 26 Weeks
Table 6.15: Revised theoretical and clinical components of the educational/intervention program
In Chapter 5, the researcher provided two case studies of traditional medicine
practices commonly used in this society. The researcher wanted to investigate this
issue from the students’ perspective. Hence, a case study relating to burn injury
(Appendix 18) was formulated in another focus group interview. Their responses
were typically:
Interviewer: “You have read the case study, what do you think of traditional medicine as a remedy for healing?”
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Students: “We use it all the time. This is our culture. Our mothers’ used it on us and we use it for your families. We have faith in it. For example, honey is effective for everything, even for healing burns. But modern medicine is good too. The advantage we have is that we understand modern medicine as well as traditional medicine, so we know not to mix the two healing methods together. Unfortunately most of the people have no idea, and that’s why complications happen. In this country we need more patient teaching programs. It is hard to change our cultural beliefs, but we as educated Saudi nurses can try to make a change through educating our people.”
Although this group acknowledged the importance of modern medicine, they
vehemently reinforced their cultural practices “to maintain the integrity of their
system (Fetterman, 1989, p. 27). This experience with the students in the focus
group enabled the researcher to ponder, think, suspend judgement and refrain from
making inappropriate and or unnecessary value judgements about a given cultural
practice. It also helped to verify how traditional medicine influenced the cultural
practices of the society. It is interesting how working and living in a foreign culture
enabled the researcher to be objective about the behaviours and beliefs of the culture.
Essentially, the emphasis during ethnographical research is to view another culture
impartially and acquire an “understanding of the cultural perspectives in which they
are based” (Hammersley 1990, p.8), the “social group’s view of reality (Fetterman,
1989, p.28) and why social groups “do what they do” (p. 30).
In June 2000, students passed the registered nurses examination. (The students’
overall theoretical efforts are presented in Appendix 5.) These Saudi graduates are
currently working in various wards in the hospital and have adapted effectively into
their roles following a three-month orientation period in the unit.
6.8 Data analysis
In the second wave of analysis of the descriptive phase, the researcher continued to
listen and observe people’s actions, searching through field notes and previous
interviews to obtain more in-depth cultural meaning in the context of the social
situation. Domains for this phase were identified and are explained as follows.
• Criteria for entry
• Curriculum with critical thinking
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• Low theoretical knowledge and skills
• Conceptual framework
• Policies
• Physical environment
• Image/status of nursing
• Technical nurse
• English language
• Segregation of sexes
• Nursing Board
• Nursing identity
• Nursing Practice Act and policies
• Higher nursing education for males.
Criteria for entry:
The researcher learned from the previous program the difficulties students
encountered with the lack of English skills and diversity in educational levels.
Hence, criteria for entry relating to academic qualifications and English competency
levels were established. At the established levels students would also be able to
participate in critical thinking. Criteria for entry are discussed in Chapter 8.
Curriculum with critical thinking and low educational levels:
Critical thinking strategies were integrated into the curriculum to meet Western
standards and accreditation adopted by most hospitals in Saudi Arabia. Aware of the
cultural norms of the society, prayer time was slotted into each lesson plan.
Upgrading the theoretical and clinical skill levels facilitated students’ comprehension
of the theoretical content. Students commented that: “Critical thinking strategies is a
good idea, because it makes us read our subjects before coming to class so that we
can interact and participate with the facilitator and also it makes learning easier – we
learn from each other”.
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Clinical instructors also supported the use of critical thinking strategies because “it is
creative and it makes learning come alive. It is a good idea to integrate critical
thinking strategies into every lesson plan. This way, we could plan our topics using
the appropriate strategies to increase interaction and participation. It was effective
for us. It made the implementation of critical thinking easier.”
Conceptual framework:
A critical thinking conceptual framework provided structure and guidance for
implementing critical thinking. This model prompted the researcher to develop
evaluation instruments to assess critical thinking to ascertain students’ and clinical
instructors’ feelings about the use of critical thinking strategies. The students made
typical comments such as “critical thinking strategies made us think, especially when
the teachers asked us questions. We like this way of learning.” Similarly, clinical
instructors also stated: “Using critical thinking strategies is a very creative way of
teaching. It makes instruction interesting, instead of the didactic method”. When the
researcher evaluated the facilitators’ instructional effectiveness, she found that
instructors were effectively using critical thinking strategies to encourage interaction
and participation and students were equally attentive.
Policies and physical environment:
When the PDP commenced, structures such as policies and procedures, clinical
competences and the physical environment had to be established. These structures
were immediately constructed to obtain compliance from students, in particular their
punctuality and dress code, which had the potential to compromise patient care. The
physical environment to support the implementation of critical thinking strategies
was also constructed.
Image/status of nursing, technical nurse, segregation of sexes, low English language skills:
The researcher noted that only a few Saudi men and women chose nursing as a career
and decided to interview Saudi nurses. Typically they stated: “In our country
nursing is not recognised as a profession. It is a menial job. Most people when they
graduate prefer to become doctors especially, because it is a prestigious profession.
Many become teachers or secretaries as it is considered better than nursing.” Others
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pointed out that “our parents, especially our fathers and brothers (if the father is
deceased) are not happy for us as women to join nursing because they don’t know
much about nursing. They think it is only shift work, mixing of the opposite sex and
low pay. Also when we marry we have to get permission from our husbands to
continue nursing. Some of us write it in our marriage contract before marriage, so
that when we marry, our husbands cannot change their minds and stop us from
practicing as nurses.” Many also stated that “Saudi Arabia needs to look at nursing
curricula, because it is different everywhere. If you are from the university it is
better, you graduate as a professional nurse and get more respect. But for us, we
graduate as technical nurses and we are not really well respected. Look at us in this
program (meaning the PDP), you have to upgrade our theoretical knowledge, clinical
skills and English abilities. You see the difference?”(Explicit cultural knowledge).
As stated in Chapter 5, large numbers of nurses are trained at a technical level. At
this level the curriculum (knowledge and skills) and English language skills do not
address the complex health care needs of the population, nor do they meet Western
standards adopted by most hospitals in Saudi Arabia. Therefore, when technical
nurses graduate they ‘struggle’ within the hospital system, become frustrated and
eventually leave the nursing profession.
National Registration Nursing Board, nursing identity, higher education for males,
and Nursing Practice Act and Policies:
There is no formal registration for Saudi nurses and Saudi Arabia wants to be
recognised in the international arena of nursing and the International Council for
Nurses. Saudi nurses are only permitted observation status. When speaking to an
executive Saudi nurse, she stated: “This is very frustrating for Saudi nurses. We
need our own nursing identity as professionals so that we can interact and participate
and share knowledge and expertise, not just listen. A National Nursing Registration
Board (NNRB) must be constructed soon, not only for international status, but also
defined standards of practice and policies are required. Saudi Arabia also needs
more highly skilled males in nursing and they are being under-privileged right now.
Their voices for nursing would be invaluable to raise our status.”
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What Saudi nurses are trying to say is that the government needs to play a major role
in legislating for a NNRB and public awareness campaigns to raise the image of
nursing, and support nurses as important to caring for the cultural and sensitive
health care needs of the society and for Saudiisation.
6.9. Summary
Nursing in Saudi Arabia has had a long history rooted in the Prophet and post-
Prophet Mohammed periods. Effectively formal nursing education only began in the
1960s, utilising a Western curriculum from the USA. While the West has continued
to upgrade their curricula, Saudi Arabia has not kept pace with these changes.
Ministries have not adequately prepared Saudi nurses to deal with greater acuity of
inpatients, advanced technology and the complex health care needs of the Saudi
society, as the majority of nurses are trained at a technical level.
The PDP was able to take graduate nurses (trained a technical level) into a secondary
program to increase their theoretical knowledge, clinical practice skills and English
language competencies by upgrading and integrating critical thinking strategies into
the curriculum. Saudi nurses can be trained to meet Western standards but need
more preparation in terms of upgrading the curricula by increasing theoretical
knowledge, clinical practice skills, English competency skills and promoting critical
thinking abilities. Furthermore, Saudi Arabia urgently needs a National Nursing
Registration Board.
Nursing education, highlighting the processes undertaken by the researcher to
implement critical thinking strategies in an educational/intervention program was
also described. The conceptual framework used within the critical thinking
component for the PDP and the implementation of the PDP is reflected in Appendix
1, Figure 6. Data collection was explained. Cultural domains were identified and
analysed. Chapter 7 deals with the explanatory phase of the research.
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CHAPTER SEVEN
Critical Thinking in the social learning
environment: Explanatory Phase
7.0. Introduction
For the past three years the researcher’s major responsibilities included managing a
Professional Development Program (PDP) for Saudi nurses, classroom teaching and
supervising students in the clinical field. Consequently, the researcher was able to
interact and participate in the daily lives of the people in the hospital setting, to
become informed and to provide an informed account of what people said, what they
did and how they acted. Fieldwork, according to Fetterman (1989), is an important
part of ethnographical design. The researcher engaged in interviews with nurses,
nurse managers, senior administrators and physicians, socially interacting with
knowledgeable well-informed individuals and engaging in questioning. Although
the researcher did not rely on structured questions, there was an element of
controlled communication relating to the interest of the researcher. The questions
asked were: “What is it like to function as a nurse in Saudi Arabia?” “How do you
cope with the culture and language in the workplace?” “Do you think there should
be more Saudi nurses in the health care system, if so, why?”
In the explanatory phase of this study the researcher continues the ethnographical
tasks of data collection and analysis. The researcher builds on the domains identified
in the explorative and descriptive phases such as language difficulties, cultural
sensitivity, the role of men and women in this culture, to explain why these domains
are important in this culture in order to provide culturally congruent care for the
people of Saudi Arabia. In particular, how fluency in the native language and
understanding the cultural needs of patients facilitates in the provision of culture care
congruence and the enhancement of critical thinking skills. The researcher provides
evidence to support these domains by firstly describing the functions of nurses in a
typical health care setting in Saudi Arabia, explaining how nurses coped, adapted and
developed ways of working within this complex culture and how critical thinking can
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be hindered in this setting. Secondly, by describing how Saudi nurses’ familiarity
with their culture and skills to communicate in the native tongue facilitated in
providing culture sensitive care and promoted critical thinking in order to acquire
better patient outcomes. Difficulties encountered by Saudi nurses in trying to
practice nursing in their daily lives are also reported. Interviews with health care
professionals and Saudi nurses are reported to support the benefits of Saudi nurses in
the health care system in Saudi Arabia.
7.1. Data collection and analysis
The researcher was involved in direct observation, interviews and collecting
materials or artefacts as data collection techniques and examples of these are
provided in this chapter.
7.1.1. Direct observation: Functioning as a nurse in Saudi Arabia
Expatriate nurses speak different languages, have dissimilar socio-cultural
backgrounds and bring a broad range of educational expertise and a range of
standards of practice to the workplace. This makes them vulnerable to varying
degrees of culture shock and adjustment difficulties (Dalayon, 1990). New nurses
are offered an orientation program to familiarise them with the culture, work
environment and standards of practice established by the hospital. Each health care
facility in the Kingdom has its own individual standards of practice as there is no
National Nursing Registration Board to determine common practice standards or an
official system of registration established for nursing in Saudi Arabia. Expatriate
nurses cope with language difficulties by either attending Arabic language classes or
making use of translators, or both. Nadler and Nadler (1987) suggested that most
people who capitalise on the services of translators have little knowledge of what is
expected from a translator, and have little or no way of knowing whether the
translator has performed effectively. Hence, communication can break down and
goals may not be met because of the ineffective use of translators.
To provide culturally sensitive care, expatriate nurses must familiarise themselves
with the religious beliefs and learn new cultural norms. For example, getting
accustomed to some patients using sand instead of water to wash themselves, the
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ritual of prayer which begins with the process of ablution or washing five times a
day, refraining from washing the body of a deceased “because ritual washing is
performed by another Muslim” (McKennis, 1999, p. 1194) and so forth. Socially
too, there are cultural constraints which are very different and which must be
respected and acknowledged. For example, observing modesty by wearing an
‘abaya’ (voluminous long black cape) when leaving the home and covering the head
when asked to do so by the ‘Muttawa’ or religious police. Environmental factors,
such as language and cultural difficulties, have implications for the development of
critical thinking in this setting and a case scenario is reported later in this chapter to
indicate the difficulties encountered by expatriate nurses.
The hospital complies with cultural requirements such as an appropriate dress code
for nurses and delegation of nursing assignments. Nurses have to comply with
wearing a uniform that does not reveal the shape of the body. Uniforms are white
with three-quarter length sleeves, a high neck line and long enough to loosely cover
the hips. Nurse managers typically assign male nurses to male patients and female
nurses to female patients, except in specialty units such as Intensive Care. In the
specialty units, the wishes of patients or relatives who request the services of female
nurses only are acknowledged and respected. Strong perfumes are not permitted.
(This aspect is illustrated later in this chapter.) Nurses' schedules reflect 12-hour day
and night shifts and English is the medium of communication.
Expatriate nurses must always preserve a female patient’s modesty. Therefore, if a
male physician wants to examine a female patient, he first consults with a female
nurse. The nurse ensures that all other female patients in the room are culturally
appropriate and that all bed curtains are fully drawn. The nurse remains with the
female patient during the physician’s visit. Culturally appropriate, in this culture, is
interpreted in two ways for the Saudi and female expatriate. The Saudi female is
expected to wear headgear that also covers the face. Clothes should have sleeves that
are long enough to cover the wrists and ankles. For the expatriate, the attire should
cover the shoulders, upper arms and be mid-thigh in length. Covering the hair is not
usually necessary, unless requested by a ‘Muttawa’ or religious leader.
One of the cultural traditions that expatriate nurses have to cope with is dealing with
Saudi women, whereupon most of them are veiled. Veils can influence the accuracy
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in arriving at an appropriate diagnosis because the inability to see the face makes it
difficult, not only to ascertain facial colour or expression, for example if she is
cyanosed or anxious, but also to initiate the appropriate critical thinking questions.
Not only is the Saudi woman’s face concealed, she may not be able to speak English
in order to give her own history. Consequently, the nurse’s assessment is impaired
because of the inability to observe the patient and speak the local language. These
difficulties result in the inability to provide culturally sensitive care and promote the
growth of critical thinking abilities. A scenario follows to highlight these aspects.
Scenario:
A newly hired nurse had been caring for the same group of female patients in a four-bed ward for two days. The nurse sought the assistance of a translator to explain the purpose for pre-medication prior to preparing a patient named Fatima for ‘C Section' surgery. The translator also informed Fatima that this same nurse was scheduled to care for her again the next morning following her surgery. Fatima smiled, nodded and acknowledged, saying ‘queis’ meaning ‘good’.
The next morning this same nurse strolled into the ward wearing a sweet perfume and she made a point to greet Fatima. As the nurse approached, Fatima screamed, asking the nurse to go away. The nurse was perplexed and upset at the patient’s change in attitude, knowing of her good relationship with Fatima, at the same time felt helpless, frustrated and unable to communicate in Arabic to question the patient’s behaviour. Although Saudis delight in wearing perfume, they are equally cautious of it, because in their culture they believe that fresh perfume has the tendency to cause a surgical wound to burst open or manifest an infection. The nurse manager intervened, calmed the patient and explained the cultural beliefs to the nurse. The nurse manager also advised that, given that the majority of patients only speak the native tongue, coupled with the difficulties encountered with translators, there was a need for nurses to speak Arabic.
Many similar scenarios relating to environmental factors such as cultural, language
barriers and problems with translation could be cited, and these elements can also
impede the growth of critical thinking. This case study typically illustrates what
expatriate nurses can experience when working in this society. Therefore, it is
essential that expatriate nurses speak the local language and have knowledge of the
complex social structure and cultural context in promoting a sense of care for these
patients. For instance, Luna (1989) pointed out that although Western models
encourage terminal patients to discuss approaching death, it is inappropriate practice
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in this culture to do so, because the Arab Muslim believes in hope and that Allah is
in charge of one’s destiny and “do not wish or plan for death” (McKennis, 1999, p.
1191). Therefore, nurses need to be culturally sensitive when counselling patients’
with terminal illnesses. Confronting the patient with a grave diagnosis could shatter
their hopes and create mistrust. Nurses must also be aware that the dying patient
may wish to face Mecca – this request must be respected and acknowledged. Luna
(1989) and Lawrence and Rozmus (2001) also emphasised that, in this culture,
visiting during birth and illness are important roles for men and women. Islam
teaches that visiting and bearing good deeds is an act through which a believer
obtains closeness to Allah (God). An inspiring aspect of Saudi culture is the
commitment made to care for their members when in poor or ill health, especially for
the elderly. Islam demands that children care for their ageing parents. Al Muzaini,
Salek and Nicholls (1998, p. 371) stated that in the Holy Koran (17:23-24) "Allah
said: your Lord had decreed that you worship none but Him, and that you be kind to
parents."
Leininger (cited in Bartz, Bowles & Underwood, 1993) stated that transcultural
nursing offers opportunities to appreciate culture and to develop ways in working
with patients. Leininger advocated that “a captive client in a hospital bed is another
matter” (p. 233), a view supported by Powell (1997, p. 6) who stated that
“functioning and working harmoniously with each other requires that we all have
some degree of cultural sensitivity”.
Spradley and McCurdy (1972, p. 87) stated that “…a society’s culture consists of
whatever it is one has to know or believe in order to operate in a manner acceptable
to its members, and do so in any role that they accept for any one of themselves.”
Nursing is not just the task of performing skills and Parse (1992) reinforced that
nursing is understanding, respecting, illuminating meaning, supporting, as well as
teaching. All of these functions require effective communication, sensitivity and
rapport between nurses and their patients and patients are entitled to this right.
Clearly, the integration of Saudi nurses into the health care system will be effective
in bridging the language barrier, understanding the religious beliefs, utilising critical
thinking skills and providing care that is culturally appropriate, so that “the country
can blossom on its own terms” (Mansour, 1994, p. 92).
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7.1.2. Direct observation and interviews: Importance of Saudi nurses
in the workplace
To be employed and practice nursing, Saudi nurses have to compromise some
important traditional cultural norms. These norms particularly refer to honour and
modesty, due to their exposure to the opposite sex, and their roles as women in
family dynamics, owing to irregular working hours. They are also required to learn
English both orally and written because this language is the medium of
communication in the hospital setting. However, it is important to encourage and
retain more Saudi nurses into the nursing profession because “Saudi nurses cope
better as they have an understanding of the culture and skilled in the native language.
These aspects are invaluable in providing cultural sensitive care to this society”
(Saudi Nurse Manager, 2000, pers. communication, September).
The researcher provides examples of interviews from health care professionals
concerning the value of Saudis in nursing. The researcher also presents interviews,
journaling and observations from Saudi nurses illustrating their relevance in nursing
practice.
In a community program in Saudi Arabia, male Saudi translators have dual roles in
that they drive expatriate nurses to home visits as well as interpret for them, as nurses
are Western expatriates. In some situations, female patients are uncomfortable with
male translators being in the same room, even when the woman’s husband has
granted permission. Consequently, nurses are translating behind a semi-closed door
“this makes providing assessments, clinical judgements and quality care difficult”
(Home Health Care Nurse Manager, 2000, pers. communication, September). The
researcher interviewed the Nurse Manager from a community program who reported
the following:
The Saudi nurse that we had from the PDP was able to communicate in Arabic and interact with the patients. She was familiar with the cultural needs of her people. She did not need a translator. She knew how to care for them - where and how to touch or feel the patient without offending them, and asked thought-provoking questions to obtain factual information to make informed clinical decisions, evaluate care and provide appropriate teaching for her patients. It is not as easy for expatriate nurses because they don’t speak the native language fluently, nor fully comprehend family dynamics
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and Saudi culture. Saudi nurses should definitely be encouraged to work at the bedside as they are assets to the nursing profession and to the patients at large (Nurse Manager, 2000, pers. communication, September).
Similarly, interviews with expatriate nurses, senior nursing staff, executive
administrators and physicians indicated a high level of satisfaction from Saudi nurses
who had completed the PDP. Typically they stated that:
Saudi nurses understand the culture of this society. They are able to communicate with patients and significant others in the native tongue, which reduces translation problems and miscommunication. This ability to use the local language coupled with their acquired critical thinking skills enhances their efficacy in patient care.
A Saudi nurse who was involved in patient teaching made the following comment:
It is very important in this society to speak Arabic and to understand our culture, because most of our patients are illiterate. Being a Saudi nurse I was able to ask a patient’s mother questions when I was teaching her how to catheterise her daughter, because I wanted to make sure that she understood what I taught her to reduce her daughter’s infection rate. She did a perfect return-demonstration for me. Now she does not have to come into the outpatient clinic as often, because the infection rate should be less. It is hard for her to come to the hospital because she must depend on her husband who is not home most of the time and she also has to be responsible for a large family. She said that she felt comfortable with the procedure now and she was able to understand what I said. She speaks and understands very little English. She asked me lots of questions, which she could not ask my expatriate colleague, which is a big problem in our health care system. I was able to provide guidance and clarification. This was a learning experience for me and I am going to write in my journal for future reference.
This Saudi nurse reflected on the lived experience and documented in her clinical
journal, which is presented in Tables 7.16 to 7.19. Fulwiler (1980) and Holly (1989)
(cited in Patton et al., 1997) concluded that reflection helps in learning to release
feelings and search for the meaning of a situation.
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Reflection
What Happened? How Do I Feel About It? What Did I Learn?
6 year old with diagnosis of frequent urinary tract infection. Mother catheterises her child. Poor aseptic technique and the mother’s poor English language skills to understand what my expatriate colleague was trying to say and teach could be the problem.
I felt sorry for the child, having frequent infections and hospitalisations. I also felt for the mother who thought she was doing it right and could not understand why her child always had infections. She had other children at home and was worrying about them. It was important for me to find out more and teach the correct technique and explain the procedure in my native tongue.
How important to ask questions to get all and the right information, so I can help this patient. So I asked the nurse first, then the mum. The nurse told me that the mother was taught the procedure before discharge. When I asked the mum, she said that she watched the nurse, but did not under- stand and embarrassed to ask because she could not speak English well. She said she did the care the best she can. I recognise there was a language problem and my job was to explain the procedure carefully and ask the mum questions. I also identified it was important for the mum to do a return demonstration, which I believe the nurse did not do.
Table 7.16: Process of Reflective Journal Documentation: Reflection
The nurse reflected on the practical experience, transferring thoughts, and carefully
documenting observations. This nurse was making inferences about the patient’s
situation, querying, being inquisitive, open-minded, truth-seeking, analysing and
evaluating information to obtain the best information relevant to this patient’s
particular care situation. The nurse was interactively applying the core critical
thinking skills, described in Chapter 2, in the reflective reasoning process to make
judgements about what to believe or do.
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Speculation
What Happened? What Could Happen Because Of This?
Identified poor aseptic technique by mother and talked to mother about the procedure and the reasons why it must be done correctly. I asked her questions to see if she under stood. When I demonstrated, I stopped from time to time to ask her questions and explained to her why I did certain things, just like we did in the video sessions in the classroom with the clinical instructors. When she did her return demonstration, she also asked me questions for clarification. When I was satisfied with her technique, I praised her and told her she can call me anytime. She was happy about this.
When the mother performs the procedure effectively, will result in a reduction in infections, less hospitalisations and she can have more time with her family, which is her primary role in this culture.
Table 7.17: Process of Reflective Journal Documentation: Speculation
In this example, events and speculation about the possible long-term effects are
examined, increasing sensitivity to the environment and contributing to growth and
development in self-awareness, analysis and prediction of situations.
Synthesis
What I Did What I Learned How I Can Use It?
I wrote this experience in my journal to reflect what and how I approached care for this patient so I won’t forget. Also, I can use it for reference at a later date. I referred to hospital’s Policy and Procedure manual to make sure my practice is current.
Questioning to get the right information and facts is important, so I can make decisions and come up with a nursing diagnosis. To check Policy and Procedures. Also to share this experience at ‘report’ with my colleagues. I also identified that poor knowledge/techniques was responsible for poor management for this patient and importance of speaking the same language & being sensitive to our culture.
I can use this experience to teach other patients and my colleagues in the future.
Table 7.18: Process of Reflective Journal Documentation: Synthesis
In the synthesis journal, the nurse reflected on cumulative activities, mental
connections between learning and evaluating practice were made. This nurse was
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also applying one of the core critical thinking skills of self-regulation, by referring to
standards of care to ensure that she was practicing competently and acting in the best
interest of the public.
Metacognition
What I Learned How I Learned
I learned to do problem solving by observing, recognising, questioning my own thoughts and feelings about what is happening so I can take actions and find solutions. Again, I learned the importance of effective communication and knowing the cultural needs of the patient.
By asking the mother and nurse probing questions; by observing the mother’s technique before my intervention to teach her, I was able to identify the problem. After this, I was able to teach and reinforce the mother’s knowledge. I also learned to do it properly by checking my Procedure Manual, to make sure I was maintaining Standards of Care.
Table 7.19: Process of Reflective Journal Documentation: Metacognition
In this form of journal documentation, analysis of one's thinking occurs following a
lived experience. The nurse monitored and judged her own thinking, analysed,
applied, synthesised and evaluated the situation, ultimately “gaining insight for the
purpose of changing things for the better” (Brookfield cited in Garrison, 1991, p.
289).
This journal documentation illustrates the importance of a sound knowledge base, the
ability to communicate in the patient’s native tongue and understand the patient’s
cultural values to provide cultural congruent care. The journal documentation also
demonstrates how Saudi nurses had to learn the English language to be able to
comprehend the theoretical content and document effectively, which is a new
learning experience for them.
Another scenario is presented wherein the researcher observed how a Saudi nurse’s
familiarity with the culture, and the ability to communicate in the native language
was effective in gaining rapport between the patient and the nurse. The nurse
enhanced her critical thinking abilities because she was able to question the patient
appropriately, to obtain information when documenting in the nursing care plan
using the Data, Action and Response (DAR) system. This scenario is presented in
the following section.
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Data refers to information. A patient complained of post-surgical pain.
Immediately the nurse used critical thinking skills to obtain clarification of the
situation through inquiry, such as: “What type of pain? Where is the pain? When
did the pain occur? How long have you had the pain? Describe the pain – what does
it feel like?” At the same time, the nurse was sensitive to the patient's cultural
beliefs and values, by asking the patient to cover her face, while the nurse cautiously
examined her by touch and feel. Nurses with no depth of the Arabic language
negotiate these situations by making use of pain assessment charts to evaluate and, if
unsuccessful, use translators or both. A pain chart is only one measure of assessment
and places a numerical value on one’s feelings, which does not necessarily define
sensations exactly or examine the psychosocial aspect of pain perception. Parse
(1992) advocated that nursing is not just the task of performing skills. To be able to
function competently, it is essential to communicate in the patient's native tongue
and to understand the meaning behind the words they are using, to obtain
information and make sense of the patient's situation in order to make an accurate
diagnosis. Saudi nurses have the advantage over their Western counterparts and this
nurse, for instance, was able to communicate with the patient fluently in the native
language and touch the patient where she knew was culturally appropriate and would
not offend the patient, in order to obtain relevant and factual information to make
clinical decisions and take appropriate action(s).
Action is the intervention undertaken by the nurse. The nurse assessed the pain by
communicating and clarifying with the patient, touching and feeling. Following the
assessment the nurse referred to the patient’s records and medication chart. Drawing
upon her knowledge the nurse examined all information, considered other
interventions, and made a decision based on evidence and facts obtained. In this
instance analgesia was given.
Response is the outcome of the intervention. The nurse documented a positive
outcome to the patient’s condition because she was able to accurately assess what
was happening, in order to intervene appropriately.
The researcher conducted interviews with several of the Saudi nurses to capture their
feelings about nursing and their experiences and how they coped given the cultural
constraints placed upon women in this society. The researcher employed the use of a
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semi-structured interview format with guided questions, but initially engaged in
conversation to lighten the atmosphere and casually explained that: “I’m interested in
your job, your work and your life as a staff nurse since your graduation from the
PDP.” They said, surprisingly, “just ask.” The researcher’s longstanding and
trusting relationship with the Saudi nurses helped break barriers and enabled them to
speak comfortably.
These nurses engaged in dialogue, expressing their daily work experiences and
uncovering a wealth of information and how they their knowledge of the culture and
ability to communicate in the patients’ language facilitated the use of critical
thinking skills in their practice. Students’ comments following the interviews were
typically:
Examples of interviews:
Researcher: “Why are you here?”
Saudi nurses: “To give the best care for my patients and to get the best experience and knowledge so that I can give them education about their diseases and how to cope and deal with it. Being a Saudi, I know our culture and I can speak the language, which is very important to the people in this society, respecting their values and beliefs and questioning them appropriately to help make them understand. In our culture there are a lot of traditional and cultural norms that expatriates are not used to. Besides being able to speak in my own language, I had to study hard to upgrade my English competency, because I have to communicate with the multidisciplinary team in English and it was not so good when I first joined the PDP. I also had to document in English. Those Saudi nurses who cannot speak or write effectively are not able to join big hospitals like this one. Sadly many leave nursing.
The PDP gave me confidence, to speak English and upgrade my knowledge, also the critical thinking skills you taught us. I get a lot of appreciation from the nurses and nurse manager and doctors too, because they can see that I do my job well. I have no problem questioning the doctors and they don’t mind. In fact the physicians not only answer my questions, they ask me questions and we engage in analysis and making clinical decisions for the best outcome for the patients. Before the PDP, I did not have the courage or confidence to question a physician’s decision. I am trying to work as a team by the way I behave, to be a role model and others can learn from me and feel comfortable around me. I like nursing because it’s a humanistic job. Also in the Kingdom, we have lots of teachers but few nurses and nursing is an important
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job as well as teaching. Our country is developing and I want to increase the professional people in this job.”
Researcher: “What about shift work, especially night shift.”
Saudi nurses: “No problems for me with shift work. Other Saudi nurses are not as fortunate as I am, usually their husbands or fathers are very traditional and especially object to night duty and caring for male patients. Fortunately the PDP helped the hospital understand the cultural difficulties faced by some Saudi nurses, now these nurses have alternative places to work within this hospital. Night duty is not too bad, because I can sleep while the children are at school in the morning and spend the afternoon with them, which is important for me. Although I have a maid, I am still the homemaker.”
Researcher: “What about your family. Do they support you working shifts?”
Saudi nurses: “Yes, of course. They encourage me to be a nurse, but many Saudis still believe that nursing has a low social image and won’t allow their children, especially women to join this profession because of exposure to the opposite sex.”
Researcher: “Did the PDP help you, and if so, how?”
Saudi nurses: “A lot of things. The PDP helped develop my knowledge and skills and English competency too. Exposed me to the policies, procedures and standards of care before I went into the clinical field. Importantly the PDP gave me confidence to be able to communicate in English in the workplace, otherwise I or we would not be able to survive in this hospital setting. I am able to make decisions and I’m using my critical thinking skills all of the time – I question all the time.”
Researcher: “How do you use your critical thinking abilities?”
Saudi nurses: “If a patient has pulmonary oedema, I ask myself questions like: “What contributes to this condition and how I can help to relieve his symptoms? Why should I watch his intake and output? What sort of medication is he taking? I try to analyse situations and make appropriate decisions, which I was unable to do before I joined the PDP.”
Researcher: “How do you feel about nursing male patients?”
Saudi nurses: “Male and female patients, they are all people who need care, some cooperative and others are not. My mother (father is dead) accepts me a nurse and my duties too, even night shifts. My mother tells me to take care of the male patients as if they are my father, but I am always aware of our culture, where men and women should not mix, so I am professional with the men and I keep my distance.”
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Researcher: “You are fortunate to have a supportive family in terms of working on shifts, night duty and nursing males. What about those who have cultural constraints placed on them?”
Saudi nurses: “They work in outpatient clinics on day shifts only and have weekends off with their families and others are only assigned to female patients.”
Researcher: “What do you do when patients don’t listen to you?”
Saudi nurses: “I try to teach them to listen and accept. I use the religion. I tell them that Muslims should be kind to each other and that I’m their nurse who is trying to help them, yet they use bad words. I let them know they are upsetting me. I educate them by telling them that the Prophet Mohamed supported nursing. When I say all these things they keep quiet and begin to be cooperative.”
Researcher: “What are your goals?”
Saudi nurses: “To practice as a professional nurse right now. Use my communication skills to give cultural sensitive care to the patients and help other nurses who cannot speak Arabic language, because most of our patients don’t speak English. I believe that if I work hard, someday I will become a nurse manager or higher. Everyday I’m learning something new and I have to critically ask myself how I can apply it.”
Conclusion of interviews:
The inferences made from the interviews are concluded as:
• The importance of understanding the cultural needs of the patients and being able
to communicate in the native language, facilitated in the provision of culturally-
sensitive care;
• The cultural norms given up by Saudi nurses in order to practice nursing. For
example, doing shift work and/or working with the opposite sex;
• The need to learn English in order to practice nursing effectively in the hospital
setting;
• The paving of the way by the PDP for the hospital to be flexible to students’
cultural needs. For example, those who were not permitted to work with males
were given alternatives;
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• The enabling by the PDP for Saudi nurses to approach their professional
activities with greater confidence, utilising critical thinking skills to provide
better patient care.
7.3. Overview of data analysis
In Chapter 3, the researcher explained cultural meaning as being encoded in symbols
and that the task of the ethnographer is to decode cultural symbols and identify
underlying meaning. In Chapter 4, the researcher described the four levels of
analysis. In the following section, the process for uncovering cultural meaning will
be presented by conducting domain analysis. According to Spradley (1979; 1980),
cultural meaning can be accomplished by discovering the relationships among
cultural symbols. One way is to conduct domain analysis. A cultural domain is a
category of cultural meaning that encompasses other smaller categories. A category
is an “array of different objects that are treated as if they were equivalent” (Spradley,
1980, p. 88). Spradley (1980) also pointed out that “every culture creates hundreds
of thousands of categories by taking unique things and classifying them together” (p.
88). For example, eye blinks, dreams and so forth can be used to create cultural
categories. The researcher commenced in-depth investigations selecting several
cultural domains throughout the three phases for careful study.
A domain consists of three basic components: a cover term, an included term and a
semantic relationship (Spradley, 1980). A cover term is the name of a cultural
domain. Included terms are the names of all smaller categories inside the domain. A
single semantic relationship links together the two categories (cover term and
included term). To provide the reader with a perspective of a domain, Spradley
(1979, p. 101; 1980, p. 88) illustrated the following example:
The Tausug culture in the Philippines: This Philippine group organises people into the following types of friends: ritual friend, close friend, casual friend, opponent, follower, ally and personal friend.
In using the above scenario: ‘friend’ is a cover term for the Tausug domain. The
included terms are the names of all the smaller categories inside the domain, such as,
ritual friend, close friend, casual friend and so forth. A single semantic relationship
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links the two categories by using the term ‘a kind of.’ Spradley (1980 p. 89) stated
that “semantic relationships are extremely important for discovering cultural
domains.” Clearly, the semantic relationship operates on the principle of ‘inclusion’
and its primary function is to define included terms by placing them inside the
cultural domain. Cover terms, included terms and semantic relationships are words
and phrases that provide meaning to objects, activities and events that the
ethnographer observes. Therefore, by listening to what people say, observing what
they do and use and how they act, the researcher can record numerous examples of
folk terms to construct cultural domains. Table 7.20 reflects the three elements of a
cultural domain as illustrated in the scenario of the Tausug culture.
Domain
Friend (cover term) Is a kind of (semantic relationship) Personal enemy
Ritual friend (included term)
Table 7.20: The structure of a domain based on Spradley’s (1979) Tausug culture.
(An overview of the data analysis in the explorative, descriptive and explanatory phases of the research is captured in Table 7.21.)
On reviewing previous interviews and field notes for clues given by people to the
meaning(s) attached to domains (throughout the explorative, descriptive and
explanatory phases), included terms were uncovered and linked to cover terms
through semantic relationships, to achieve a perspective of the social situation. The
researcher investigated the domains and conducted taxonomic analysis to reveal all
included terms and “their relationships among domains (Spradley, 1980, p. 149), and
“the way they were related to the whole” (p. 113) to discover cultural themes.
Cultural themes involved a single idea occurring repeatedly, suggesting a possibility
of a cultural theme. In this study, the structure of the program, culture of nursing,
language difficulties, culture of Saudi Arabia, recruitment of nurses and National
Nursing Registration Board are cultural themes identified and explained within the
research questions in Chapter 8.
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Exploratory Phase Domains
Descriptive Phase Domains
Explanatory Phase
Domains Language difficulty; Attire; Role of men and women; Family support; Culturally sensitive care; Low educational level. Linking semantic relationships between cover terms and included terms as identified in the exploratory and descriptive phases.
Taxonomies Criteria for entry; Policy; punctuality; Physical environment; Nursing curriculum; Conceptual framework; Language difficulty; Nursing Practice Act.
Themes Structure
Low educational skills; Nursing curriculum; Technical nurse; English competency; Low education level; Nursing identity.
Culture of nursing
Role of men; Role of women; Prayer; fasting; Religion; Attire; Face cover; Family support; Cultural sensitive care: Image of nursing; Sex segregation;
Culture of S Arabia
Nursing Practice Act; Nursing identity; licensure; Higher nursing education for males.
NNRB
Low numbers of Saudis in nursing; Expatriate nurse.
Recruitment
Interpreter, illiteracy, language difficulty, expatriate nurse; Prayer, fasting, religion; Attire; Covering the face, Role of men and women, Family; Culturally sensitive care; Punctuality; Sex segregation; Recruitment. Linking semantic relationships between cover terms and included terms 1. Interpreter and illiteracy is a kind of language difficulty; 2. Language difficulty is a kind of problem within the structure; 3. Expatriate nurse is kind of recruitment; 4. Prayer is a kind of culture of Saudi Arabia (SA); 5. Fasting is a kind of culture of Saudi Arabia; 6. Religion is kind of culture of Saudi Arabia; 7. Attire is a kind of culture of Saudi Arabia; 8. Covering the face is a kind of culture of Saudi Arabia; 9. Role of men/women is a kind of culture of Saudi Arabia; 10. Culturally sensitive care is a kind of culture of Saudi Arabia; 11. Punctuality is a kind of structure; 12. Culture is a kind of behaviour pattern typical of a specific society; 13. Sex segregation is a kind of culture of Saudi Arabia; 14. Family support is a kind of culture of Saudi Arabia; 15. Recruitment is a kind of nursing culture; 16. Low numbers of Saudi nurses is a kind of recruitment.
Criteria for entry; Curriculum with critical thinking; Policy, Physical environment; Image/status of nursing; English language; Nursing Board; Nursing identity; Technical nurse; Low theoretical knowledge and skills; Licensure; Conceptual framework; Nursing Practice Act. Linking semantic relationships between cover terms and included terms 1. Criteria for entry is a kind of structure; 2. Nursing curriculum is a kind of structure; 3. Policy is a kind of structure; 4. Physical environment is a kind of structure; 5. Conceptual framework is a kind of structure; 6. Image of nursing is a kind of culture of S. Arabia; 7. Low English language is a kind language difficulty; 8. Nursing Board is a kind of culture of Saudi Arabia; 9. Technical nurse is a kind of person related to the culture of nursing; 10. Low educational level is a kind of culture of nursing; 11. Nursing identity is a kind of structure within the NNRB; 12. Licensure is a kind of structure in NNRB; 13. Nursing Practice Act is a kind of structure within NNRB; 14. Higher education for males is a kind of structure within NNRB
Interpreter; Illiteracy Low English language
Language difficulty
Table 7.21: An overview of cultural domains identified in the three phases of the research and taxonomies leading to cultural themes.
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Domain
A category of meaning to include other smaller categories
Taxonomy
Revealing the subsets and how they are related to the domain
Theme
Connecting different subsystems of a subculture
Interpreter
Arabic/English interpreter;
Men; women;
Patients; doctors; nurses;
Communication; illiteracy;
Culture of Saudi Arabia
Language Difficulty
Technical Nurse
Women; men;
Attire: face cover;
Sex segregation;
Low English level;
Low education level;
Low image of nursing;
No NNRB
Culture of Nursing
Table 7.22: The use of domains (from Table 7.21) to demonstrate the link to taxonomy to theme.
7.4. Summary
When providing health care to Saudis in this society it is necessary to speak the
language, otherwise incomplete or inaccurate communication results. It is equally
important to comprehend Islamic religious beliefs and culture that underpin the
lifestyle of this society to effectively meet the cultural and sensitive needs of the
patients and their families. Saudi and expatriate nurses face different issues when
nursing patients in this society.
Saudi nurses are compelled to learn and communicate in English if they want to
practice nursing effectively in the hospital, because English is the medium of
communication with the multidisciplinary health care team. They also have to give
up some of their cultural traditions. For example, mixing with the opposite sex is
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considered socially inappropriate because this interaction could compromise their
chastity and modesty and men are protective of their womenfolk. Other issues relate
to working irregular shifts, which keep her away from the family and a woman’s role
is important in the moral teachings of the children, because “the mother remains a
symbol of comfort and compassion throughout a child’s life” (Mc Kennis, 1999,
p.1189).
Expatriate nurses also confront difficulties, such as having to cope with cultural,
religious and translation barriers which are foreign to them. Hence, they have to
adopt new cultural norms into their daily nursing practice and social lifestyles. All of
these elements make working and living in Saudi Arabia a challenging experience.
Although each group has to cope with different types of issues, Saudi nurses have an
advantage over their expatriate counterparts because Saudi nurses speak the language
and understand the cultural traditions of the people, and are better able to provide
culturally sensitive care in this complex society.
This chapter reinforced the importance of domains identified in the explorative and
descriptive phases of this study. Difficulties experienced by expatriate nurses in not
being able to communicate in the native tongue and comprehend the sensitive
cultural requirements were reported. The researcher also provided evidence about
the ability of Saudi nurses to function harmoniously and effectively because they
were familiar with the Arabic language and culture of this society. Difficulties
encountered by Saudi nurses in pursuing nursing as a profession were also
highlighted. Interviews with students and health care professionals are reported to
support the benefits of having Saudi nurses/students in the health care field. An
overview of data analysis for the three phases of research, highlighting domain
analysis was provided. The conclusion for this project is presented in Chapter 8
wherein the research questions for this study are answered based on the cultural
themes identified. Implications of the research and recommendations for the nursing
profession in Saudi Arabia are also presented.
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CHAPTER EIGHT
Conclusion
8.0. Introduction
The purpose of the study was to examine the social and cultural experiences
associated with living and working as a Registered Nurse in Saudi Arabia. It also
aimed to identify and understand how to develop critical thinking skills in Saudi
nurses during a nursing educational program in Saudi Arabia. In this chapter, the
researcher presents a summary of the ethnographic research, and research questions
are answered based on cultural themes following domain analysis. Implications for
this research and recommendations for Saudi Arabia are also reported.
8.1. Methodological approach
An ethnographical approach was adopted for this study. The researcher observed
and listened in order to comprehend the meaning of phenomena in context, recording
naturally-occurring human behaviour, with key informants in their natural work
setting. Hence, naturalism—one of the orientations of ethnography—was the
principal technique utilised, as the researcher did not control the research conditions.
Key informants were beneficial in that: (i) they provided ‘rich’ information about the
rules and behaviour norms of their culture; (ii) their verbal descriptions, quotations
and artefacts helped in presenting a credible report of the study; and (iii) the
researcher’s long term contact with them, acknowledging their cultural rules helped
to gain acceptance in the culture. In the initial phase of this project the literature on
critical thinking was examined. Based on the literature review the California Critical
Thinking Skills Test (CCTST) and California Critical Thinking Disposition
Inventory (CCTDI) were selected and a pilot study undertaken to establish their
suitability for evaluating critical thinking for the PDP Saudi nurses. However, these
instruments were judged to be inappropriate for use in the study to measure the
development of critical thinking because several words and phrases were difficult to
comprehend or translate accurately, in that the meaning was inconsistently
understood in the translation. The tools were also culturally inappropriate because
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the contents contained questions on labour law and alcohol. Labour law does not
reflect the reality within Saudi Arabia and alcohol is forbidden, and these aspects
offended the students.
Multi-methods were employed in the exploratory, descriptive and explanatory phases
of this study. These methods included participant observation, direct observation of
students and clinical instructors, interviews with relevant informants, evaluation of
clinical instructors’ teaching technique in utilising critical thinking strategies,
evaluation of students’ responses in the use of critical thinking strategies, focus
group interviews of students and clinical instructors, fieldwork and examining
artefacts. Multi-methods provided the opportunity to examine more fully the
richness and complexities of the culture by gathering data from various sources to
validate the consistency of information to reflect the multiple realities of this cultural
group. Review of the literature on critical thinking allowed the construction of a
conceptual model to guide teaching and evaluation of critical thinking skills. It also
maintained the focus on dialogue to stimulate interaction and participation in order to
promote critical thinking abilities in Saudi nurses. The conceptual model is
explained in Appendix 1.
Before the implementation of critical thinking strategies in September 1999, the
researcher was deeply involved in preparing an environment to support critical
thinking. Results from focus group interviews conducted with students and a survey
questionnaire established their approval of critical thinking strategies in the
classroom and clinical field. Furthermore, interviews with nurses and nurse
managers reinforced that students were actually using critical thinking in the clinical
field. A focus group interview with clinical instructors confirmed improvement in
critical thinking instruction and approval of the critical thinking evaluation
instruments (Appendix 15), which are reported in Chapter 6.
Fieldwork allowed data to be gathered through participant observation. Interviews
were conducted with health care professionals to acquire a wide perspective and
comprehension of the behaviours and culture of this social group in this setting. The
researcher identified cultural domains throughout the three phases of this study.
Domain analysis to search for the larger units of cultural knowledge (called domains)
was conducted. Taxonomic analysis followed and cultural themes were uncovered,
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and the researcher communicates the cultural themes within the research questions.
Recommendations are presented and reported in light of the cultural themes.
8.2. Research questions for this study
The research questions for this study were as follows:
1. What are the issues related to the implementation of critical thinking in a
Professional Development Program to improve critical thinking in Saudi
nurses?
2. What major elements are involved in creating and sustaining the Saudi
Arabian nursing profession?
3. How might Saudi culture be used to support the development of professional
nursing identity?
8.2.1. Question 1: What are the issues related to the implementation of critical
thinking in a Professional Development Program (PDP) to improve
critical thinking in Saudi nurses?
In Chapter 5 (section 5.1—The general problem), the researcher highlighted several
issues pertaining to the health care system and nursing training in Saudi Arabia.
Many of these issues, which are related to the social fabric of religion and culture,
influenced the program. The researcher, having lived and worked in this
environment, has learned that this fabric guides the everyday lifestyle and maintains
cohesiveness of local society. As such, it must be acknowledged and respected at all
times. These issues can be broadly listed within the following categories:
• Culture of nursing; and
• Structure for the program.
8.2.1.1. Culture of nursing
In Saudi Arabia many hospitals adopt Western standards. A large number of nurses
graduate from Saudi nursing colleges and institutes and their theoretical, clinical and
English levels do not meet the Western standards expected in the hospital setting.
These Saudi nurses are only able to practice at a technical level, because the
curriculum in these colleges and institutes do not meet Western standards.
Therefore, when Saudi nurses enter the workplace (which is designed and maintained
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on Western standards), they not only have an inadequate knowledge base, they are
also forced to communicate and practice in English. While English has helped to
transmit scientific and best practice knowledge to the health care system from West
to East, it has also robbed Saudi nurses of the use of their native language during the
course of their clinical practice. This causes a barrier to potentially good Saudi
nurses who cannot communicate effectively in this language, thus potentially losing
those who would otherwise like to stay in nursing. This may be a contributing factor
for the low numbers of Saudis in the nursing workforce.
Given that most Saudis speak Arabic, these Saudi nurses are invaluable to health care
because they speak the native language, understand the culture and are able to
provide culturally-sensitive care. One way to entice and retain these nurses in the
nursing profession is to enhance their educational levels (both theoretical and
clinical ) while simultaneously improving their English levels. The Professional
Development Program aimed for the establishment of a curriculum with content
based on Western standards and to retain Saudis in nursing, hence a structure for the
program was formulated.
8.2.1.2. Structure for the program
Structure relates to the elements used to construct the program and comprise the
following: (i) criteria for entry, (ii) formulation of policy, (iii) nursing curriculum re-
design, and (iv) preparation of staff.
(i) Criteria for entry
Having experienced the problems with the first group of students wherein their
varying educational levels and low English language competencies were insufficient
to meet the upgraded curriculum established by the Professional Development
Program, criteria for entry were established. The academic qualifications required
for selection were determined at Associate Degree level in nursing, which is
composed of three years of academic studies, plus 12 weeks internship in the clinical
field. This qualification is equivalent to a practical nurse in the USA (Phillips, 1989)
or a State Enrolled Nurse in Australia. The English competency required for entry
was established at an Oxford English Test score of 120. Students admitted below
this score in the previous program experienced difficulties in communicating,
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documenting fluently and comprehending the theoretical nursing components. Low
English levels also limited their ability to interact and participate in the classroom
and clinical field. Selective entry requirements were key elements for a successful
program as students functioned more effectively and all students passed the
Registered Nurse examination and completed the program in 2000.
(ii) Formulation of policies
Policies provided adherence to protocols within the program. For instance, poor
time-keeping and absenteeism are not uncommon practices in this society. This
behaviour is primarily related to the cultural traditional roles for men and women and
the cultural responsibilities that could detain them from their appointments. Men are
not only responsible for the welfare of their immediate families, but also for the
extended family. For example, if his mother needs transportation to a particular
destination at a time when he has to go to work, his priority is to attend to her needs,
because the culture in this society does not permit a woman to drive or travel by
public transport. Likewise for a woman, her role is paramount in maintaining family
dynamics, especially when children are very young or ill. Clearly, absenteeism and
poor time-keeping are not deliberately practiced by the Saudi people. The problem is
that they are not accustomed to informing their supervisors if they could not be
present. Students were expected to be punctual, therefore they were informed about
its importance and to contact a faculty member if they were intending to be absent.
A policy enacted to address the reporting of non-attendance made it easier to
discipline and to remind students of their responsibilities.
The program respected and acknowledged a woman’s role in this society and the
cultural constraints placed upon them, especially for students who were married,
those with very young children, and the significance of modesty, as these elements
could contribute to either the success or failure of the program. The program wanted
to retain married women. Traditionally, women tend to discontinue nursing once
they are married because men are protective of their wives’ exposure to the opposite
sex and prefer that they stay home with the children. Therefore, students with very
young children were permitted bonding time and left the program an hour earlier
each day, making up their required clinical time later. Students who requested to
nurse female patients only (in compliance with their husbands’ or fathers’ wishes)
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were acknowledged and scheduled accordingly. In terms of modesty, a dress code
policy was enacted which ensured sexual modesty expected of women in this society.
Under the policy directive, a Saudi nurse’s uniform was to cover the arms, legs and
hair and for those who wished, the face could be covered with a veil. Having some
flexibility in the program helped maintain retention of students within the program.
Appropriate policies were necessary for the smooth running of the program. Overall,
these structures provided certainty for both faculty and students, beginning with
efficient recruitment.
(iii) Nursing curriculum re-design
The curriculum was redesigned in order to upgrade the theoretical content, clinical
practice hours and English language so that students could practice in hospitals based
on Western standards and to promote the image of nursing. (See Appendix 1:
Curriculum of Course Schedule 1999-2000.) The PDP included the design of a 14-
hour per week English language program, to enable students to comprehend the
theoretical components effectively. Witkins (cited in Farquharson, 1989, p. 3)
suggested “there is some evidence that specially designed educational efforts may
influence some component of cognitive styles”. Importantly, for a curriculum to be
effective within an Islamic culture, aspects such as prayer times and reduced working
hours during the fasting month must be incorporated. For example, twenty-minute
periods were allocated within the lesson plans for noon and mid-afternoon prayers
and six-hour days were scheduled during the fasting month. To support worship the
physical environment had to be considered in terms of creating a separate area for
prayer. Given that the nursing profession has a low image in Saudi Arabia,
upgrading the curriculum enhanced their educational standards and confidence.
Upgrading the curriculum also helped them gain respect with patients as these
students graduated and held staff nurse one positions (SN1), instead of staff nurse
two status (SN2). (Western nurses are categorised as SN1 because their Western
educational standards are considered to be higher than far Eastern nurses, who
occupy SN2 positions and receive lower salaries. Furthermore, a SN1 nurse has
more accountability and responsibility, in that the SN1 assumes and rotates in the
role of a Charge-Nurse, whereas the SN2 is primarily a bedside nurse.)
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The curriculum was also re-designed to incorporate critical thinking skills to enhance
critical thinking abilities in Saudi nurses. Prior to being invited to develop critical
thinking into an educational program, the researcher had not experienced
implementing this concept in this culture. Hence, the researcher developed a
conceptual framework for guiding, teaching and evaluating critical thinking. The
model provided a framework to develop a curriculum that supported critical thinking
strategies. The model also maintained the focus on dialogue, allowing students to
interact and participate and to function at a higher cognitive level, ultimately
providing better care as bedside nurses. Practicing and learning critical thinking also
requires appropriate space, equipment and resources. Classrooms and workrooms
for small group activity were organised and resources included audio-visual aids,
blackboards and so forth.
Once students gained more knowledge, their level of communication and practice
improved. There was a noticeable change in their dispositions, from being silent
listeners to becoming open and interactive. They also began to question their own
practice and that of others, including physicians. Their increased understanding
ultimately reflected their successful passes in their exams.
(iv) Preparation of staff
Critical thinking is not only new to nursing education in Saudi Arabia. Clinical
instructors and health care professionals in the hospital setting were unfamiliar with
this concept. Given that critical thinking skills require a high level of interaction and
a feeling of safety and support, clinical instructors were provided with in-service
programs to assist them with instruction and the integration of critical thinking skills
into the curriculum. Likewise, health care professionals were exposed to short
educational programs and were invited to question and seek clarification.
Overall, clinical instructors improved their teaching techniques because they adopted
different tactics and strategies, and those that were more conducive to developing
critical thinking abilities and making critical thinking come alive. Clinical
instructors were the researcher’s ambassadors for critical thinking.
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Orientation of the hospital staff about critical thinking was essential, in particular
among preceptors because it decreased their anxiety about how critical thinking
could be used in practice and they were not threatened when students constantly
questioned their practices. It also increased acceptance, making it easier for the
students in the clinical field because they had support during their clinical practice
rotations.
8.3.2. Question 2: What major elements are involved in creating and sustaining
the Saudi Arabian nursing profession?
The major elements involved in creating and sustaining the nursing profession in
Saudi Arabia related to the following issues:
• Culture of Saudi Arabia;
• Recruitment of nurses into Saudi Arabia; and
• National Nursing Registration Board.
8.3.2.1. Culture of Saudi Arabia
A number of cultural constraints impede the implementation of the Saudiisation
policy. These constraints include the low image of nursing, lack of family support
for nursing as a career, the social pressure placed on women and men being educated
or working together, the subservient role of women, and limited leadership to support
this career choice. As these constraints are deeply rooted, it will take effective
leadership to increase the number of Saudi nurses and to prepare them adequately to
take over the health care system.
There is a high value placed on childbearing and family relationships in this society.
Full-time nurses are scheduled to work 44 to 48 hours a week, with one or two days
off. Saudi nurses and their families prefer they work only in the morning and
afternoons. In hospitals where patients need 24-hour care, some compromise will
have to be reached.
Saudis also place importance on having degrees and increasing the number of degree
programs may increase the image of nurses. Currently, Saudi nurses are prepared at
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technical, bachelor and master’s levels—with the majority at technical level. More
recently, a few doctoral Saudi nurses (trained overseas) have begun to emerge.
Higher levels of nursing education are available at the master’s level for females, but
are still limited at the associate degree level for males. Higher education for Saudi
nurses would help to prepare more Saudis for senior leadership positions. With
Saudi nurses in key leadership positions, they would be better placed to form new
coalitions and give voice to nursing issues throughout the health care system and
within the wider society. Clearly, in terms of leadership, male Saudi nurses are
compromised and their voice in a male-dominated, bureaucratic and hierarchical
system could strengthen the image of nursing.
The 5th Health Care Development Plan (1970-1990s) and the 7th Development Plan
(1999-2004) continue to address the educational needs of this society, with emphasis
on increasing the number of nursing programs and the academic standard, in order to
elevate the status of the nursing profession in Saudi Arabia.
Changes towards enhancing the image of nursing are already occurring, for example
the formation of a task force to establish a National Nursing Registration Board;
inclusion of Islamic nursing history into the university nursing curriculum in 1987;
and integration of critical thinking into the curriculum for the PDP in 1999. Changes
will continue to take place and Saudi nurses need to be instrumental in these changes.
This can be achieved by informing their people through advertisements and the
media with positive and accurate information of nursing in a variety of up-to-date
nursing roles. Such efforts will help to eliminate the outdated stereotyping which has
been harmful to nursing.
8.3.2.2. Recruitment of nurses into Saudi Arabia
The low numbers of Saudi nurses is grounded in the culture and peoples’ attitudes
towards nursing, as it is perceived as a low social status career. There is also the
tendency for Saudi nurses to discontinue nursing once they get married. Hence, the
continuing expansion in health care in Saudi Arabia is likely to depend on expatriates
from Arab countries, Europe, North America, India and the Far East. The
recruitment of expatriates is the backbone of the health care system and is an
essential factor in sustaining the nursing workforce, and a variety of forces contribute
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to this phenomenon (Al Osimy, 1994; Al Rabea, 1994). By contrast, Saudi females
face a variety of social problems in their work lives that are not normally
experienced by the foreign nurse. For example, pressure from family who restrict
her shift duties or long working hours away from the family.
8.3.2.3. National Nursing Registration Board
Currently there is no National Nursing Registration Board (NNRB) in Saudi Arabia.
A NNRB would improve the professional status of nursing in Saudi Arabia and be
the cornerstone in changing this society’s perception of nursing. The diversity in
standards of practice, educational and cultural backgrounds, presents major problems
because there is no NNRB to maintain standards of practice. The absence of policies
to uphold the agreed standards of the profession, education, employment and
training, code of professional conduct, registration and licensure of both Saudi and
non-Saudi nurses contribute to fragmentation, variable standards of nursing practice
and complex relations with employers—especially when there are issues with
nursing practice. Therefore, it is vital that a professional structure (such as the
NNRB) be completed as soon as possible to support the development of a
professional identity for nursing in Saudi Arabia. The implementation of a NNRB
could provide some leadership with nursing institutes and universities to design the
curriculum so that nurses are prepared to meet public needs.
The NNRB would have responsibility to shape nursing and nursing practice to adapt
to the health needs of the population of Saudi Arabia. The NNRB would also
provide the public with the important facts about nursing, encourage media
discussion and bring the profession to the forefront in Saudi Arabia. Abu Zinadah
firmly stated, “nursing practice needs to have a clearly defined Nurse Practice Act
that accurately reflects the realities of current practice, rather than a lagging behind
practice (cited in Al Osimy, 1994, p. 81). The NNRB could be instrumental in
instigating a Bachelor of Science–Nursing program for males within the Kingdom.
In the long term the cultural needs for male nurses to care for males and female
nurses to care for females would be realised, which could lead to an increase of
Saudi nurses within the workforce.
Currently some structures are in place that could influence and propel the progress of
the NNRB. These structures include a chief nursing position, which was created
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within the Ministry, and a Central Nursing Committee to monitor the nursing
workforce, communicate with nurses and offer training programs. Working with its
regional counterparts, the committee has begun to formulate guidelines for nursing
practice within the Ministry of Health (Tumulty, 2001). Furthermore, on 31
September 2001, a World Health Organisational Regional meeting was conducted in
Riyadh, Saudi Arabia consisting of members of the Mediterranean regions. The
agenda included nursing and midwifery curricula. The Ministry of Health (MOH)
for Saudi Arabia participated at this meeting and could be a voice for the NNRB in
similar future meetings. The question remains why the formation of the NNRB is
taking such a long time to be established, since the early lobbying by Tumulty in
1995 (Chapter 6).
A personal interview with Dr. Willingham, Consultant for NNRB (September 2001),
proposed several reasons for the delay in the formation of a NNRB. The key issue
suggested that the MOH is intertwined with the status of nursing and culture. The
MOH is struggling to allow nursing to be an entity of its own because the MOH
perceives nursing as subservient to medicine. Therefore, the MOH would prefer that
nursing comes under the auspices of medicine. The cultural aspect relates to the type
of conservative gender ideology promoted in this country and Duomato (1999) made
the point that the government of Saudi Arabia still keeps women economically
marginalised and under the legal control of men. The inequality of sex segregation is
evident in education programs and facilities, especially in universities and colleges
and in public waiting rooms.
With nursing in its infancy in Saudi Arabia, there is only a handful of leading female
Saudi nurses available to lobby for nursing’s right to stand-alone. However,
Daumato (1999) reported that Crown Prince Abdullah (who has been deputising for
his ailing brother King Faisal since 1995) made statements suggesting royal support
for women’s empowerment—for example, granting permission for women to drive
cars. Daumato also emphasised that, in one of his statements, Prince Abdullah
alleged the government would leave no door closed to women, as long as there was
no violation to Islam and ethics of Saudi Arabia. For the foreseeable future, change
might be on the horizon and perhaps one avenue could be for senior Saudi female
nurses to use the Prince as their advocate to establish a precedent for the NNRB’s
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independent status from medicine, thus giving the nursing profession in Saudi Arabia
its own entity.
8.4.3. Question 3: How might Saudi culture be used to support the
development of professional nursing identity?
An important strategy in the development of the professional nursing identity would
be to change the perception of nursing from that of being of low social image to an
honourable profession. In Saudi Arabia, nursing is still in a developmental phase and
struggling to establish itself as a profession. The roots of nursing emerged during the
Prophet Mohammed’s era and he held nurses and their work in high esteem, and this
is a powerful basis from which to shape the modern professional Islamic identity of
nursing. One Saudi nursing leader, Al Osimy (1994) is promoting nursing as a
honourable profession. She reminds her people that Prophet Mohammed considered
the work of nurses as a calling from Allah. Husain (1995) also advocated for public
campaigns and support from media to raise the image of nursing. It could be argued
that defining nursing within the religious context could be a way in which to change
society’s perceptions, as Islam also determines cultural behaviour. The university
Schools of Nursing in Saudi Arabia have included Islamic studies in their nursing
curricula since 1987, providing another link with Islam. Inclusion of the Islamic
nursing studies is another step towards the nursing identity.
Saudis remain a minority group in health care and expatriate nurses continue to
dominate positions in hospital clinical, specialty and Primary Health Care areas. The
government has two policy options for staffing its health care facilities. First, the
choice to ignore nursing training as high priority and to continue employing and
depending on expatriate nurses. Second, the option is to reduce foreign workforce
within a realistic timeframe. The intent is to give nursing training high priority
backed-up with attractive salaries, continuing education within Saudi Arabia and
overseas—particularly in specialty areas—and promotion opportunities. This move
should not only attract high school science graduates with high grade point averages
and substantial English language skills, but also give nursing recognition as a
prestigious profession as Islam advocates.
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The formation of a NNRB would establish a system for registration of nurses and
common practice standards, paving the way towards nursing identity in Saudi Arabia
and international recognition of Saudi nursing qualification as a consequence of their
affiliations to Western nursing councils.
8.5. Implications of the research for nursing in Saudi Arabia and
internationally
Ethnography was useful in providing a description of what really happened in the
classroom and clinical field. These descriptions helped faculty develop a program
that was grounded in the actual situation, rather than to an ideal situation. For
example, students within the context of the study provided particular meaning to
social-cultural factors and behaviours in terms of punctuality, coming prepared to
class with homework completed, dress code, religious and traditional beliefs,
verbalising the importance of family obligations and so forth. Having an
understanding of these contextual factors helped to shape and implement the
development of critical thinking in Saudi nurses.
This study has the potential to make a significant contribution to nursing education in
Saudi Arabia in promoting critical thinking in nurses and in curriculum development
for the following reasons. First, didactic instruction was replaced with an interactive
approach by utilising critical thinking strategies and devices to facilitate the
development of critical thinking abilities. Second, working with a conceptual
framework or model made it easier to manage complex multifaceted concepts, such
as critical thinking. The model maintained the focus on dialogue and experiential
learning thereby assisting students and staff to integrate theory and practice. This
model was effective for the program and, if duplicated by other programs, could
create a learning environment that would allow the effective development and
evaluation of critical thinking.
Ultimately, critical thinking utilised in nursing practice where nurses are required to
know, comprehend, apply, analyse, synthesise and evaluate can lead to safe,
competent and quality patient care as well as promote professionalism in nursing.
Hence, the challenge for nursing is to provide structure, resources and curriculum
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that support critical thinking. This study and the resulting curriculum is a first step
towards meeting this challenge.
8.6. Summary
An ethnographical approach was adopted for this study. This approach allowed the
following: (i) the researcher to be a participant observer and become immersed
within the culture wherein the researcher was able to explore, describe and explain
the culture of a social situation (ii) a higher level of participation of all people
involved (for example, students, hospital staff including physicians, clinical
instructors), (iii) the researcher had greater interaction between the subjects and
others who supported the study, and the opportunity to understand the learning
experiences of Saudi students, and (iv) data collection from a variety of sources to
obtain meaning about this society’s cultural and social situation.
One of the factors leading to the enhancement of critical thinking in the PDP’s
educational program depended upon the students’ Oxford English scores at a level of
120. At this level students were comfortable in comprehending and interacting.
The development of faculty and students was essential in order to make a change
from a passive to an interactive process. Critical thinking strategies needed to be
incorporated into all lesson plans. Resources and devices such as workrooms,
videotapes, critical thinking stem questions and so forth, should be readily available
for learning to take place.
Clinical instructors need to be supported to “set the stage for critical thinking”
(Drews, 1958, p.80). Furthermore, instructors should have a sound knowledge of
their curriculum content and adopt an interactive teaching style, utilising critical
thinking techniques to encourage participation and interaction from the students to
influence their thinking. Thus, critical thinking “becomes a daily experience”
(Elliott, 1996, p. 51) and not an isolated subject.
Similarly, sessions about the program’s desire to implement the use of critical
thinking to enhance critical thinking abilities that were conducted for healthcare
professionals in the hospital (where students performed their clinical practice) were
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informative. They provided an avenue for discussion and clarification, and hospital
staff accepted the students favourably.
Saudi Arabian National Guard-Health Affairs took a step forward by implementing
the PDP. The PDP curriculum was introduced to students in the 1999 and 2000
programs with positive outcomes. Critical thinking abilities enable Saudi nurses to
examine simple and even complex situations, provide better patient care and cope
more effectively with the ever-increasing demands and responsibilities required of
nurses in the health care profession.
On completion of this study, the researcher understands that the educational program
has developed individuals who have transformed from being passive or rote learners
to having inquiring minds. They have socialised into critical thinking and have
started on a path that could lead them to be life long learners. Therefore, not only
will patient’s outcomes improve but also the actual healthcare environment should
improve.
Curriculum cannot exist in isolation of ministries, governments, the needs of the
population and the workplace. The decision to import expatriates is evolving into
one that favours Saudis, and this has an impact on the population and overall health
of the population. Therefore, a curriculum must reflect all of the changes.
Curriculum developers must also consider the increasing evidence-based research
that is occurring, for example the elements responsible in keeping the population
healthy in terms of health promotion, prevention and rehabilitation. It will be
interesting to see how nursing in Saudi Arabia will look in twenty years time.
The researcher identified cultural domains within the exploratory, descriptive and
explanatory phases of this research, which were analysed for taxonomies leading to
cultural themes. Cultural themes formed the basis for the research question, which
were addressed in this chapter.
It is difficult to raise the image of nursing as a profession, particularly when leaders
such as Dr. Al Tuwaijri (1994), advised women with low grades to enrol in nursing
colleges. In contrast to their western counterparts, Saudi nurses face a variety of
social and cultural problems in their work life, which are not normally experienced
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by foreign nurses. Furthermore, the restrictions Saudi society places on the role of
women and the manner of their appearance outside of their homes, provides greater
challenges for the longevity of the nursing profession.
In considering these issues and their meaning for nursing, it is evident that the
challenge for nursing and society is to provide support and opportunities for the
enhancement and practice of critical thinking skills. Critical thinking utilised in
nursing practice can lead to safe, competent and quality patient care, as well as
promote professionalism in nursing. This study and the resultant curriculum are first
steps towards meeting this challenge.
The PDP is only one program in Saudi Arabia that integrated critical thinking into
the curriculum. One program cannot function independently to train all Saudi nurses
to be critical thinkers to meet the needs of this society. Other programs have to be
involved to integrate critical thinking into the curricula nationwide. Furthermore, the
achievement of a nursing profession in Saudi Arabia requires integration of some
cultural traditions and change in the norms that prevent women being professionals.
8.7. Issues for future considerations for the nursing profession in
Saudi Arabia
The following section will provide items for consideration, but should not be
generalized as the study was conducted in one hospital.
4. To establish the Nursing Practice Act which subsequently leads to the formation
of a National Nursing Registration Board to guide the development of nursing.
Self-regulation based on competence to practice also needs to be established for
annual renewal of registration, in order to enhance patient confidence in the
quality of care that they receive. (Self-regulation involves nurses regulating
nursing in the interest of the public. For example, referring to standards of care
and code of ethics to guide daily practice in the interest of the public).
5. To re-design curricula: Presently curricula are multi-tiered without consistent
standards. The Ministries of Health and Higher Education, universities, hospitals
and other nursing programs need to collaborate to redesign curricula and include:
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• Sufficient theories and practice in health promotion,
prevention and treatment modalities from a cultural
perspective;
• Support for the expectations of the hospital system in terms
of language, knowledge, cultural needs, clinical practice and
to meet Western standards;
• Integration of critical thinking into nursing curriculum, so
that nurses are better prepared to make clinical judgements
grounded in factual evidence about priorities of care to meet
the complex health care needs of this society, and
• Construction of evaluation instruments for critical thinking
skills, not only to reflect the discipline of nursing, but
include cultural norms of this country.
6. To transfer nursing into the higher education sectors, on par with their Western
counterparts. To establish a Bachelor of Science Nursing, fostering a career
incentive for men to meet the cultural needs of the people, increase Saudi nurses
in the workforce and to raise the image of nursing. With the image of nursing
elevated, more Saudis will enter nursing and eventually Saudiisation policy will
be realised, and particular, open job opportunities for women and men.
7. To enact Saudiisation policy. Saudiisation is slow to develop because the cadre
of individuals entering nursing are being prepared as technical nurses, with a
minority at the degree level. It is not a question of the critical mass not being
able to take over from the expatriate cohort, but more that they are inadequately
prepared to do so. Islam can be used to support the development of professional
nursing identity if all involved—the government, hospitals and other nursing
educational programs—work in unison to establish curricula to meet the complex
health care of this society using a culturally sensitive approach.
8. To incorporate Islamic nursing history into diploma nursing and other nursing
educational programs and to implement it into the workplace, government policy
and the media, so that this society’s cultural beliefs and values can be realised
through the delivery of culturally congruent care. These strategies could entice
Saudis into the nursing profession.
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9. To construct separate male and female hospitals to exclusively accommodate the
respective sexes, to solve the gender issue. For example, women and children
could be accommodated in one hospital - this approach could be beneficial in
organising the system for delivery of better patient outcomes.
10. To systematically collect, collate and analyse nursing data. Currently all
statistics of the overall number of Saudi nurses employed are generic (no specific
level of training is recorded). Accurate information regarding the numbers and
qualifications of nurses is important to facilitate future training targets.
11. To develop continuing education programs to meet educational needs of nurses.
In this chapter research questions were answered, implications of the research for
nursing and issues for future consideration for the nursing profession in Saudi Arabia
were presented.
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APPENDICES
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APPENDIX 1: A CONCEPTUAL MODEL
(CRITICAL THINKING)
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Appendix 1: A Conceptual Model (Critical Thinking) Introduction
Critical thinking is an essential element for nurses who function in today’s complex
health domain. In this environment, they are required to deal with issues such as
advanced technology, greater acuity of clients in hospital settings, the ageing
population and complex disease processes. Nursing organisations worldwide have
recognised the need to develop and stimulate higher-order critical thinking in both
theory and practice situations by utilising innovative strategies to stimulate critical
thinking abilities. In 1987, the National League of Nursing revised its criteria for re-
accreditation and now requires nursing programs to measure critical thinking skills
(Rane-Szostak & Robertson, 1996). Saudi nurses desiring to be as successful as
nurses trained at a Western standard need to develop critical thinking skills.
A conceptual framework was constructed to guide teaching and evaluation of critical
thinking skills in this research context. The setting for the participants, inclusion and
exclusion criteria, inducement to participate and the implementation of critical
thinking in an intervention/education program is presented.
The conceptual model
The conceptual framework for this study is adapted from the work of Arangie,
(1997); Colucciello (1997); Dexter et al. (1997); Facione et al. (1998); Facione and
Facione (1993); King (1995); Paul (1990, 1993); and Whiteside (1997) and
comprises the dimensions, variables and evaluation of critical thinking, which form
the basis for this project. This conceptual framework facilitated and guided the
development of critical thinking in nursing students, and appears as Figure 6.
“A conceptual framework explains either graphically or in a narrative form, the main
dimensions to be studied – the key factors, or variables – and the presumed
relationships among them” (Cresswell, 1994, p.97). “In this sense frameworks guide
research and coordinate researchers’ activities” (Sarantakos, 1993, p. 93). The
conceptual framework for this study was developed based on the relevant literature
and was intended to guide the teaching and evaluation of critical thinking skills in
order to enhance these abilities in Saudi nurses. The model is divided into three
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components consisting of the dimensions, variables and evaluation of critical
thinking.
Dimensions and variables of critical thinking
The dimensions and variables of critical thinking will be explained simultaneously as
they are closely inter-related. Details pertaining to the evaluation follow. The term
‘dimensions’ relates to the cognitive and affective dispositions developed by a panel
of experts within the Delphi project. The panel’s work yielded a list of core critical
thinking skills and dispositions crucial to becoming an effective critical thinker
(Colucciello, 1997), and their definition of critical thinking was discussed in Chapter
2. The conceptual model illustrated in Figure 6 also consists of interacting elements
such as critical thinking strategies to promote critical thinking skills as well as
intellectual criteria required to assess the use of these elements as proposed by Paul
(1993). The variables associated with each of the dimensions as used in this study
are explained as follows:
Critical thinking cognitive skills: encompass analysis, interpretation, inference,
explanation, evaluation and self-regulation, as proposed by Facione and
Facione (1993), Facione et al. (1998).
Critical thinking disposition skills: open-mindedness, inquisitive, truth-seeking,
being analytical, systematic and self-confident in reasoning (Facione &
Facione, 1993; Facione et al., 1998);
Critical thinking strategies: questioning, small group activity, role-play and
debate in the classroom and journal documentation in the clinical area.
Critical thinking criteria: clarity, precision, specificity, relevance, depth,
fairness, accuracy, logicalness and completeness (Paul, 1990, 1993).
In reviewing Paul’s work on critical thinking criteria, no explanations were provided
by the author to describe each of the criteria. Appropriate explanations for critical
thinking strategies were extrapolated from the literature to ‘fit’ each of Paul’s (1990,
1993) criteria, in order to formulate four evaluation instruments to assess
instructional effectiveness in the classroom (Appendix 15).
Pillay and Elliot (in press) stressed the importance of developing and changing
dispositions or attitudes—such as being inquisitive, open-minded, truth-seeking and
the like. These authors also advocated that, while content knowledge and cognitive
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skills (for example, analysis, evaluation) are necessary, they emphasise that without
stimulation of dispositions engagement of critical thinking will not occur. Hence,
facilitators should be willing to expand their teaching repertoires to include those
classroom techniques that aid the growth in cognitive skills, development and change
in dispositions or attitudes, and work alongside students and colleagues to promote
critical thinking abilities.
Tools or devices were utilised to support critical thinking strategies, such as guided
questions, videotapes, pre-reading homework/assignments, presentations, white
boards as teaching aids, to increase effectiveness of techniques (Robinson, 1994).
Robinson (1994) made the distinction between techniques and devices or tools, in
that techniques are also known as methods or strategies. Techniques are the ways in
which a facilitator establishes relationships between the learner and the learning task,
and they may be designed to assist the learner obtain information, acquire a skill,
apply knowledge, develop creativity or achieve a change in attitude.
By contrast, devices are the instructional materials or teaching aids that increase
effectiveness of techniques or strategies “but which cannot themselves instruct.
They range from books to simulations, from films to working models, from chalk-
boards to video tapes” (Robinson, 1994, p.101). Robinson stressed that there are a
variety of devices available, hence it is important to select the appropriate
devices/tools to achieve the desired results. The tools utilised for this project were
homework which entailed pre-reading assignments, videotapes, guided critical
thinking questions and activities such as presentations, puzzles and so forth.
Evaluation: Evaluation for this model consists of interviews with students, clinical
instructors, nurses and health care personnel, students-teacher evaluation
questionnaire; generating critical thinking questions, reflective journal
documentation; participation and interaction of students with their clinical instructors
and critical thinking evaluation instruments (questioning, small group activity, debate
and role-play to assess instructional effectiveness).
Structure for the critical thinking evaluation instruments were developed from
criteria influenced by Paul (1990, 1993). The criteria are clarity, precision,
specificity, relevance, depth, fairness, accuracy, logicalness. In the first three months
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of the study the researcher utilised critical thinking evaluation instruments to observe
clinical instructors critical thinking teaching techniques. For example, “What critical
thinking strategies were selected for a particular session and how was it delivered?”
“Were adequate devices used to assist and increase effectiveness of critical thinking
strategies?” “Were the instructors clear, relevant, accurate or logical in their
presentations?” “Did students interact and participate?” The clinical instructors
were provided with prompt constructive feedback, advice and guided towards
literature on the use of critical thinking strategies if necessary. In the latter part of
the program peer review evaluations were conducted. Clinical instructors were also
invited to participate in a focus group interview where they were encouraged to
provide comments about the evaluation instruments and voice their feelings towards
the direct observation method used by the researcher and peers to assess their
teaching abilities.
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Figure 6: A conceptual framework to guide teaching and evaluation of critical thinking skills
The conceptual model is adapted from Arangie, (1997); Colucciello (1997); Dexter
et al. (1997); Facione et al. (1998); Facione and Facione (1993); King (1995); Paul
(1990, 1993); and Whiteside (1997). This model reflects the dimensions, variables
and evaluation of critical thinking.
Dimensions
Variables
Evaluation
Analysis Interpretation Inference Explanation Evaluation Self-regulation
Open-minded Inquisitive Truth-seeking Analytical Systematic Self-confident in Reasoning
Questioning Small Group Role-play Debate Journaling
Clarity Precision Specificity Relevance Depth Fairness Accuracy Logicalness Completeness
Cognitive Skills
Disposition
Skills
Strategies Criteria
Clinical • Questioning
Instructors • Small groups • Role-play • Debate • Focus Group Interviews
Students • Focus Group Interviews
• Interaction with Instructors utilising CT Strategies and Devices • Students' Evaluation of Teaching Strategies Questionnaire
• Skills: - generating CT Questions - cooperative learning/class interaction & participation
- presentations - journaling
CRITICAL THINKING (CT)
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Study participants
Study participants were female Saudi nurses who had graduated from a nursing
program in a Nursing College and who were accredited with an Associate Degree or
Diploma. The participants also needed to have scored at least 120 on the Oxford
English test administered just prior to the interview.
Saudi Arabian National Guard Health Affairs (SANG-HA) placed an advertisement
in several Arab newspapers in Saudi Arabia, inviting Saudi nurses with Associate
Degrees to join the PDP in Riyadh. Those who responded and were subsequently
interviewed became study participants.
Population and sampling
There were seven critical milestones in the process defining the population, selecting
the sample and sample attrition. A flowchart detailing these events is presented as
Figure 7. All Saudi nurses who could be described with the selection criteria
constituted the potential population. In number, the size of the potential population
was estimated at 150, twenty Saudi nurses self-selected as the potential sample.
They were interviewed at SANG-HA between February and August 1999. The
interview panel consisted of five people: the Associate Administrator, Manager and
Saudi Nurse Educator came from Nursing Programs; while the Director of Nursing
Education (Nursing Services) and the local female Saudi Recruitment Officer were
associated with the King Fahad National Guard Hospital, Riyadh. (See
Organisational Relationships in Chapter 5 Figure 4.)
Fifteen of the potential candidates met the criteria for entry into the program. The
remaining five had an English language deficit and were encouraged to attend further
English courses. They were invited to reapply for the next program in September
2000, when they had gained an Oxford English score of 120.
212
Figure 7: Seven milestones for sample situations
During the interview process, candidates were requested to provide an overview of
their theoretical and clinical experiences and their desires to be involved in the PDP.
The questioning by the panel members and subsequent answers supplied by the
interviewees provided insight for the interviewers regarding the candidates’ abilities
to comprehend and express themselves in the English language.
The panel also asked candidates if they were familiar with critical thinking.
Candidates appeared to be enthusiastic and asked for more explanation about this
concept, which was new to them. The panel paid attention to the candidates’
interactive and participatory abilities. On completion of all interviews, the Associate
Administrator of the program notified the successful sample of fifteen candidates.
POPULATION: Saudi females with Associate Degrees/Diplomas from Nursing colleges in Saudi Arabia.
The responding twenty for the program were administered the Oxford English test
Fifteen successful applicants were selected
Fifteen arrived on the first day of the program (orientation)
Fourteen continued after orientation
Two left after Ramadan
Twelve completed the program
213
Inclusion and exclusion criteria
To be included in the study the following inclusion criteria were applied. Saudi
Associate Degree nurses who had:
• Completed a nursing program in a nursing institute/college in Saudi Arabia;
• Attained an Oxford English score of at least 120; and
• Attended an interview with a view to demonstrate competence in English and
comprehension abilities.
Those excluded from the program are described as follows:
• Saudi degree nurses from a university were excluded through the wording of the
newspaper advertisement; and
• Five of the applicants were excluded because their Oxford English test scores did
not meet the criterion.
Inducement to participate
Students were offered and paid a monthly stipend of 4500 Saudi Riyals (A$2000) for
the duration of the program. The only out-of-pocket expense was the purchase of
two English language text workbooks. Housing was provided at no cost for out-of-
town candidates and local students lived at home with their families.
During the program the students were recognised with personal acknowledgements
for quality work and perfect attendance and awarded a certificate of graduation.
They received the promise that they would upgrade their theoretical and clinical
knowledge and gain Staff Nurse One/Level One (SN1) positions, and would become
eligible to gain SANG-HA direct hire status when they graduated. In other words,
they would be permanent employees and enjoy benefits provided by SANG-HA.
Furthermore, PDP staff were interested in increasing the students’ critical thinking
abilities. At the SANG-HA, a registered nurse with Western qualifications is
classified as an SN1 nurse. Registered Nurses from other countries (such as the
Philippines and India) are categorised as Staff Nurse Two/Level Two (SN2), because
the nursing curricula from these countries are not at the same standard as that of
214
Western nursing curricula. Hence, there are differentials between the two categories
of Registered Nurses in terms of salary and status. The SN1 nurse has more
accountability and responsibility, in that the SN1 assumes and rotates in the role of a
Charge-Nurse, whereas the SN2 is primarily a bedside nurse. The remuneration for a
SN1 is higher than that of an SN2. Twenty students were interviewed, of which
fifteen were selected. Of these fifteen students, three left the program through self-
attrition.
Education/intervention program
The PDP's curriculum consists of 404 theoretical and educational hours and 1100
clinical hours conducted over a period of approximately 18 months. Critical thinking
strategies were incorporated into the curriculum of the structured educational
program of the PDP. The critical thinking techniques included, questioning, small
group activities, role-play, debate in the classroom and journaling in the clinical
field. Devices were also selected to increase the effectiveness of critical thinking
strategies. Lesson-to-lesson plans for each subject in the curriculum were designed
to contain critical thinking strategies in order to enhance the development of critical
thinking abilities in Saudi nurses. The PDP was structured to acknowledge previous
learning experiences and comprised theoretical and clinical components. The goals
of the program encompassed a review of the nursing curriculum for the purpose of
increasing the theoretical content and establishing minimum clinical practice hours,
as well as to shift teaching and learning from didactic to interactive processes to
enhance critical thinking skills. A curriculum was developed and is reflected in
Table 23.
215
Subjects Hours
Anatomy and Physiology 21 Pathophysiology 21
Growth and Development 12
Nutrition 14 Nursing Fundamentals 21
Pharmacology 21 Normal Pregnancy 14
Complications of Pregnancy 14 Care of the Child with Common Illnesses 21
Care of the Critically Ill Child 21
Family Concepts 14
Medication Administration 14
Community Health Nursing 21
Evidenced-Based Practice 21
Advanced Nursing Practice 21 Health Assessment 21
Care of the Patient having Surgical Intervention 07 Pain Management 07
Care of the Patient with Chronic Illness 14
Care of the Elderly Patient 21
Care of the Critically Ill Adult 21
Issues in Professional Nursing 07 Nursing Ethics/Leadership 14
Family Mental Health Concepts 21 Total: 404
Table 23: Curriculum of course schedule: 1999-2000
Critical thinking strategies
In the nursing literature various strategies were discussed that could be employed to
enhance critical thinking skills. For example, Schank (1990) recommended pre-
assigned reading materials (homework), to give the learner time for thought and
reflection and to facilitate discussion in class. Stringfield (1995) suggested videotape
presentations, while Whiteside (1997) advised the use of debate, case studies to
enhance core critical thinking skills of analysis, inference, judgement, explanation,
216
interpretation and evaluation. Pond, Bradshaw and Turner (1991) suggested
incorporation of written assignments to encourage abstract thinking, analysis,
interpretation, inference and evaluation. During the initial interview, candidates
stated that they were familiar only with instructional practice based on a didactic
theory of learning, in which teachers talked and students listened.
Therefore, in the process of selecting the five critical thinking strategies used, the
researcher collaborated with clinical instructors and the Associate Administrator of
the program. This facilitated the planning and implementation of the development of
critical thinking strategies as teaching methods within the curriculum of the nursing
program. Program staff were acutely aware that, for the program to have maximum
success, it was essential to “consider individual differences in learners, including
differences in learning styles” (Case, 1994, p. 106). The educational/intervention
program concentrated on questioning, small group activity, debate and role-play and
journaling. These teaching approaches are validated by a variety of authors
(Arangie, 1997; Bell, 1991; Blair, 1985; Brown & Sorrell, 1993; Case, 1994 & 1995;
Chubinski, 1996; Elliot, 1996; Fitzpatrick, 1994; Fuszard, 1989; King, 1995;
Sellapah et al. 1998; Stringfield, 1995; Venetzian and Corrigan, 1996; and
Whiteside, 1997).
These authors stressed the importance of active participation for effective learning to
occur. The authors also suggested questioning technique, small group activity,
debate, role-play and journaling were valuable to improve critical thinking abilities.
Case (1994) stated that using a variety of teaching strategies would help learners
incorporate different approaches to learning, and that active learning from a critical
thinking viewpoint drives learners to broaden their repertoires by developing greater
proficiency with more ways of learning.
Since the intent was to stimulate and develop an inquiring mind, Fitzpatrick (1994)
suggested the importance of asking, as this stimulates higher order thinking and helps
to create the opportunity of acquiring essential information that otherwise might have
been precluded. Bonnstetter (1988) supports this view and stated that the
development of critical thinking in nursing students is related to effective
questioning. Clearly, questioning is a thread that runs throughout the other five
techniques that were selected. It was important to remember that students were still
217
developing their English writing and speaking skills, therefore techniques such as
note-taking could prove to be too challenging for them in the early stages. “Note-
taking from oral presentations can be a problem for Arab students due to slow and
inaccurate handwriting and difficulty with listening for the main ideas and supporting
points” (Farquharson, 1988, p.12).
As the educational program was going to be conducted over a duration of
approximately six months, it was important to select teaching strategies that could be
utilised in participative, non-threatening, yet effective ways in which to enhance
critical thinking abilities. The Associate Administrator and the Manager in the PDP
had previous experience with these five teaching methods and could readily assist the
clinical instructors. Following the decision to employ these five teaching strategies,
a set of complete lesson plans were devised incorporating critical thinking teaching
strategies and put to use in the classroom. The four critical thinking strategies that
were embodied into lesson plans were questioning, small group activities, debate and
role-play. Criteria for reflective journal documentation was determined for the
clinical area and clinical instructors used this structure to assess the students’ journal
writing skills. (Refer to Chapters 2, 6 and 7.) In order for students to participate
with the clinical instructors when implementing critical thinking strategies in the
classroom, resources such as slide and overhead projectors, videos, whiteboards and
blackboards, stem-guided questions, flash-cards, mannequins, syringes and so forth,
were utilised. In addition, there was one large classroom and three smaller work
rooms for group work activities.
The researcher devised critical thinking strategies evaluation instruments for
questioning, small group activity, debate and role-play to assess instructional
effectiveness (Appendix 15), and a student-teacher evaluation questionnaire to assess
students’ responses to critical thinking strategies (Appendix 17). (The critical
thinking strategies evaluation instruments are discussed in Chapters 2 and 6 and the
student-teacher evaluation questionnaire is explained in Chapter 6.) It was important
for students to come prepared to the class so that they could participate and interact.
Critical thinking was also integrated into the grading system to entice them this
preparation, as they were not accustomed to homework assignments during previous
studies. The grading system is reflected in Chapter 6, Table 6.9.
218
Prior to the commencement of the PDP's educational program, several components
had to be organised and established. The components were the preparation of
clinical instructors, selection of commercial critical thinking instruments, preparation
of the environment, consent required for the study and ethical considerations and the
construction of evaluation instruments.
1. The preparation of the clinical instructors:
Preparation of clinical instructors entailed several in-service sessions, conducted by
the researcher. The purpose was to (i) familiarise them with the concept of critical
thinking, (ii) discuss the critical thinking strategies to be adopted, and (iii) prepare
them to use critical thinking strategies and devices to develop students’ critical
thinking abilities. The researcher also guided clinical instructors in formulating
lesson plans, incorporating critical thinking strategies into the PDP’s curriculum and
developed critical thinking-type examination questions and criteria for journal
documentation.
2. Selection of commercially-available critical thinking instruments:
The California Critical Thinking Skills Test and California Critical Thinking
Dispositions Inventory were initially selected and piloted, but were not applied in the
research study because instruments were culturally inappropriate. For several words
on the form there were no direct Arabic translation, thus leading to difficulty in
comprehension among respondents.
3. Preparation of the environment:
The environment was constructed to encourage and promote critical thinking by
arranging the classroom in a ‘U’ shape to encourage interaction and participation.
This layout also assisted the placement of audio-visual resources and erection of
sufficient white/blackboards in the classrooms and workrooms for group activities
and presentations. Recreation and prayer areas were also determined.
4. Consent required for the study and ethical considerations are discussed in
Chapter 6.
219
5. Construction of evaluation instruments:
Evaluation tools were constructed to assess instructional effectiveness. In addition, a
student teacher evaluation questionnaire was formulated to evaluate students’
responses to critical thinking strategies.
Evaluation of students and Clinical Instructors
Evaluation involved the researcher observing the students’ interaction and
participation with their instructors, in particular how they learned to generate critical
thinking questions using the stem guide provided. Students were exposed to focus
group interviews and were requested to complete a paper-and-pencil questionnaire to
comment on the instructors’ teaching techniques. Outcomes of focus group
interviews and evaluation questionnaires for students are reported in Chapter 6.
Focus group interviews allowed the researcher to explore participants’ individual
views and concerns. Clarke (1999) stated that data obtained by a defined group of
individuals could help in identifying common experiences and shared concerns.
Evaluation also involved students generating critical thinking questions and their
cooperative learning abilities in group work, participation in debates, role-play,
presentations and so forth. In the clinical field journal documentation was utilised
and criteria established that related to reflection, speculation, synthesis and
metacognition; and structures/guidelines for each dimension were developed to guide
the process for journal entries (Chapter 6) and outcomes are reported in Chapter 7.
When incorporating critical thinking strategies into the curriculum, the emphasis was
not to encourage students to copy information from textbook care plans onto a plan
for their patient(s) or memorise notes from lectures. Rather, the aim was for students
to be accountable for identifying and clarifying problems, deciding what they needed
to know, sifting out relevant information, weighing evidence and making discerning
judgements. Students were encouraged to think critically and to decide with their
patients on the best course of action to take to provide better patient care at the
bedside – “the goal of nursing education” (Whiteside, 1997 p.161).
A focus group interview with clinical instructors was conducted to establish their
feelings about the use of critical thinking strategies. The researcher also assessed
220
clinical instructors’ teaching effectiveness. These two evaluations are reported in
Chapter 6.
Summary
The development of a conceptual framework was discussed together with the
development, implementation and evaluation of the use of critical thinking strategies
in an education/intervention program.
221
APPENDIX 2: STEM/GUIDED QUESTIONS
222
Appendix 2
King, A. (1995). Designing the instructional process to enhance critical thinking
across the curriculum. Teaching Psychology, Feb. 22, (1), 13-17.
223
APPENDIX 3: CHARACTERISTICS OF
CRITICAL THINKING INSTRUMENTS
224
Appendix 3: Characteristics of Five Critical Thinking Instruments
Instrument Theoretical Definition of
Critical Thinking
Subscales Format Target Audience
WGCTA Composite of attitudes, knowledge and skills
Inference Recognition of assumptions Deduction Interpretation Evaluation of arguments
Forms A and B 80 items 40 min to complete
9th grade and above
CCTST (1980)
Process of purposeful, self-regulatory judgment
Analysis Evaluation Inference Inductive Deductive
Forms A and B 34 items 45 min to complete
College-aged individuals
EWCTET (1990)
No definition given Getting the point Seeing the reasons and assumptions Stating one's point Offering good reasons Seeing other possibilities Equivocation Irrelevance Circularity Reversal of conditional relationships Straw person fallacy Overgeneralization Excessive skepticism Credibility problems Using emotive language to persuade
Essay format 40 min to complete
High school and college-aged individuals
CCTDI (1992)
Open-mindedness Analyticity Cognitive maturity Truth-seeking Systematicity Inquisitiveness Self-confidence
One form 75 items 20 min to complete
College-aged individuals
CCTT (1985)
Process of reasonably deciding what to believe and do
Induction Deduction Value judgment Observation Credibility Assumptions Meaning
Level X and Z Level X - 71 items Level Z - 52 items 50 min to complete
Level X: 4th grade to 2nd year college-aged -individuals Level Z: gifted high school and college-aged adults
WGCTA = Watson-Glaser Critical Thinking Appraisal; CCTST = California Critical Thinking Skills Test; EWCTET = Ennis-Weir Critical Thinking Essay Test; CCTT = Cornell Critical Thinking Test
225
APPENDIX 4: CCTST/CCTDI
247
APPENDIX 5: STUDENTS’ OVERALL
THEORETICAL RESULTS
248
������������� ���������������Nursing Program, Health Affairs Appendix 5
Students Grades Report - 1999 - 2000 Subjects ������ ����� �� ����� �� ����� �� ����� � ����� � ����� � � ����� � � ����� � � ����� � ����� � � ���� �
Advance Practice I Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed Anatomy & Physiology 75 90 92 86 95 76 75 78 75 91 77 91.5 Care of Child w/Common Illness 83.5 92 89 85 78 75 80 75 79 88 85 96 Care of Critically Ill Adult 78 98 89 89 75 77 Passed 75 94 89 75 86 Care of Critically Ill Child 76.5 91.5 93 96 79 81 Passed 85 75 97.5 78.5 99
Community Health Nursing Passed 99 95.4 86 76 88 75 76 N/A 94 78 Complication - Pregnancy 86 96 93 93.4 94 75 87 85 91 85 86 96
Evidence-Based Practice 80 85 97 90 79 83 82 87 N/A 90 82 95 Fundamentals in Nursing 95 96 95 94 90 98 98 89 88 85 98 100 Growth & Development 84 96 92 90 84 92 88 88 90 92 92 86 Health Assessment Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed Issues in Professional Nursing Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed I. V. Exam (Hospital) 84 87 90 90 82 87 83 Passed 78 88 83 89 Medication Exam (Hospital) Passed 95 95 95.5 93.5 90 Passed 80.5 93 90 89.5 92.5 Normal Pregnancy 82 95 93 88 90 76 75 89 91 90 88 92 Nutrition 79 95 94 97 100 96 90 91 91 87 91 100 Older Adult 79 96 98 96 78 96 Passed 88 91 95 92 94 Pain Management 83 90 90 92 75 75 75 84 75 88 75 81 Pathophysiology 75 86 89 82 89 75 75 77 75 85 82 86 Pharmacology Passed 92 97 94 88 Passed 75 Passed 79 96 76 86 Surgery 75 95 95 95 92 78 78 82 80 97 80 94 Advance Practice II Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed Passed
Updated 25Nov2Th/hbv SNTGradesWksht22Mar2Th/hbv
249
APPENDIX 6: 7TH DEVELOPMENT PLAN
MINISTRY OF HEALTH
273
APPENDIX 7 AND 7A: MOH DATA ON
MANPOWER, HEALTH CARE CENTRES
274
Appendix 7
Source: Annual Health Report (1418H: 1997G). Ministry of Health. Kingdom of
Saudi Arabia, p.93
275
Appendix 7a
Source: Annual Health Report(1418H: 1997G). Ministry of Health. Kingdom of
Saudi Arabia, p.108.
276
277
APPENDIX 8: INFANT MORTALITY RATES
FOR 2000 (WORLD)
291
APPENDIX 9: STUDENTS ENROLLED IN
COLLEGES OF HEALTH SCIENCES FOR
MALES AND FEMALES IN MOH 1417H [1996G]
292
293
APPENDIX 10: ACHIEVEMENT RECORD FOR
THE PDP
294
295
APPENDIX 11: A TYPICAL SUMMATIVE
EXAMINATION: GERONTOLOGY
296
Appendix 11
GERONTOLOGY Examination (sample)
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297
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APPENDIX 12: INFORMATION PACKAGE AND
CONSENT FORM
298
Appendix 12
CONSENT FORM
Title:
Evaluation of an Instructional Program to Improve Critical Thinking Skills in Saudi Associate Degree Nurses.
As part of my dissertation in the School of Nursing at Queensland University of Technology, it is necessary to obtain a consent form from Saudi nurses in the Professional Development Program at Saudi Arabian National Guard Health Affairs prior to the research being undertaken. Participant’s name: (Please Print) 1. The tests and education/intervention program involved in this study have been explained
to me and I have been given the opportunity to ask questions regarding the critical thinking instrument/test and the program involved.
2. 1 acknowledge that:
• The possible effects of the education/intervention and critical thinking test have been explained to me.
• My participation is voluntary and that I may withdraw from the study at any time without comment or penalty.
• I have been informed that the confidentiality of the information I will provide will be safeguarded.
3. I consent to participate in this project. Signature:……………………….. ……………… Participant Date
Signature:……………………….. ……………… Researcher/Investigator Date
299
Appendix 12
INFORMATION PACKAGE
Project Title: Evaluation of an Instructional Program to Improve Critical Thinking Skills in Saudi Associate Degree Nurses. This study is the basis of a dissertation in the degree of Doctor of Philosophy at QUT and will be performed by Elaine Simpson under the guidance of an academic staff member Professor Mary Courtney. AIM OF THE STUDY. The purpose of this study is to assess/measure critical thinking in Saudi Associate nurses, before and after, a structured educational/intervention program. Specifically, it is a study to investigate changes in critical thinking skills of Saudi nurses as measured by a critical thinking instrument. PROJECT SUMMARY. The aim of this study is to examine changes in critical thinking skills of Saudi nurses between the beginning and end of an intervention/education program. Critical thinking (CT) is an expectation of the Saudi Arabian National Guard Health Affairs (SANG-HA) who have established a program for Saudi nurses, called Professional Development Program (PDP). IN order for Saudi female graduate nurses to be successful in North American nursing registration examinations they need to develop critical thinking skills. These skills are essential to nurses who function in today’s complex health arena while dealing with issues such as advanced technology, greater acuity of clients in hospital settings, the aging population and complex disease processes. Writing clinical assignments may assist in developing critical thinking skills, but additional efforts are needed to develop and stimulate higher-order CT in both theory and practice situations. Success in teaching clinical thinking requires innovative strategies such as, questioning, analysis, synthesis, application, problem solving. Hence, during the education/intervention program between September 1999 to February 2000, nursing educators in the PDDP will be utilizing teaching approaches, such as, role play, debate, group activity etc., in order to stimulate and enhance CT skills.
TEST PROCEDURES.
At the commencement of the program, on or about 12 September 1999, you will be asked to complete a critical thinking test. As well, you will be invited to complete several case studies. At the completion of this program in February 2000, you will again be asked to complete the test and case studies. Prior to taking these tests the researcher will explain the process of the tests and case studies fully. These tests will take approximately one hour to complete. The case studies will take about 20 minutes to complete.
300
FREEDOM OF CONSENT. Participation in this project is voluntary. Under no circumstances will you be prejudiced as a result of your participation. You are free to withdraw your participation from the study at any time. If you decide that you do not wish to participate or if you decide to withdraw from the study at a later stage for any reason, it will not influence your present standing in the program nor your future involvement with SANG-HA. QUESTIONS OR CONCERNS. As a participant in this research study, you may contact the researcher, Elaine Simpson with any questions regarding the study. Ms. Simpson’s telephone number in 2520252 extension 3537, or my supervisor, Professor Mary Courtney 00617 3864 3887 or email: [email protected]. if you have questions about the ethics of this study, you may also contact/telephone the Queensland University of Technology Human Research Ethics Committee Secretary at: 0061 738642902 or email:gx.aIlen@qut,edu.au CONFIDENTIALITY. Your results will be known only to the investigator, the research team and yourself. When the results of the study are published the researcher will ensure that you remain anonymous. Any test results, evaluations or interview data, will be kept in a locked filing cabinet and only the research team will have access to the information/data. The research team is identified as the researcher, the supervisors (principal and two associates) and a statistician, who is also an associate supervisor. No identifying information about the participants will be used in any paper that may result from this research. BENEFITS THAT RESULT FROM THE RESEARCH.
1.SANG-HA nursing education in which recommendations will be made for further curriculum development. 2.Nursing programs in Saudi Arabia in terms of: • Allowing them to meet graduation requirements of Western universities. • Preparing Saudi nurses for their expanded roles under Saudization. • Producing more qualified with improved critical thinking skills. 3.The researcher will publish papers on the outcome of the study that will contribute to the international nursing literature on critical thinking skills.
POSSIBLE RISKS TO PARTICIPANTS. Although the researcher is a staff member of SANG-HA and the manger for the PDP, you are assured that despite the researcher’s association with the program, no information provided by yourself will be forwarded to SANG-HA. The intent of the study is to evaluate the program you are presently undertaking which has been designed to help students/trainees think critically. The psychological stress that you may experience during pre-and post-tests will be similar to the normal stress students experience in ordinary cycles of tests and evaluations when undertaking education at your level. However, if you experience any adverse effects from this study then access to hospital counseling services are freely available to you if required. FEEDBACK TO PARTICIPANTS. A summary of research findings will be provided to you when all data have been collected, collated and analyzed. ACKNOWLEDGEMENT. Thank you for your consideration of participation in this study. Your assistance is appreciated in the completion of my Doctorate in Philosophy. Please ensure that you have read and understood the information herein, before you sign the consent form attached.
301
CONSENT. By completing the section overleaf you indicate that you:
1. acknowledge the nature of this research and your involvement in the project has been explained to you;
2. understand that confidentiality will be maintained and no identifying information will be released;
3. understand that you may withdraw from this study at anytime, without comment or penalty;
4. understand that your participation in the study is voluntary; 5. understand that this study is for the purpose of research and not for treatment
and 6. have had every one of your questions answered to your satisfaction.
NAME (PLEASE PRINT):________________ SIGNATURE:_______________
DATE:__________
302
303
APPENDIX 13: SAMPLE OF CRITICAL
THINKING QUESTIONS GENERATED BY
STUDENTS
304
305
APPENDIX 14: PDP CURRICULUM
318
319
APPENDIX 15: EVALUATION OF CRITICAL
THINKING STRATEGIES
320
Appendix 15:
Evaluation of Critical Thinking Strategies: Questioning to Improve Critical Thinking Skills:
Criteria
Did not happen (0)
Less than adequate performance (1)
Adequate performance (2)
More than adequate performance (3)
Total Score
Clarity
*Communication: Clear, not muffled *Explanation: makes clear what is obscure; gets to the point
Comments
Precision
*Definite/thorough with explanations *Particular in following teaching plan/ is disciplined *Asks critical thinking-type questions
Comments
Specificity
*Effectively presents lesson, not easily distracted *Breaks information into components and probes students to question *Gives realistic clinical examples
Comments
Accuracy *Free from error/thorough
Comments
Relevance
*Pertains to the topic *Asks pertinent questions on the content
Comments
Logicalness
*Information developed and presented in a logical format and teaching is sequenced *Recognises logical answers and gives feedback
Comments
Depth
*Encourages students to generate their own critical thinking questions by using stem-guide
Comments
Completeness
*Provides closure by asking if students have further questions
Comments
Fairness
*Ensures no students dominate *Using tone of voice suggesting openness *Gives positive feedback
Comments
(King, 1995; Paul, 1990, 1993; Arangie, 1997) Grand Score:
321
Appendix 15
Evaluation of Critical Thinking Strategies: Debate to Improve Critical Thinking Skills:
Criteria
Did not happen (0)
Less than adequate performance (1)
Adequate performance (2)
More than adequate performance (3)
Total Score
Clarity
*Communication: Clear, not muffled *Explanation: makes clear what is obscure; gets to the point
Comments
Precision
*Thoroughly explains topic and activity/process *Particular in following teaching plan/ is disciplined *Ensures classroom atmosphere is conducive to an open debate
Comments
Specificity
*Facilitator sets up the expectation that free expression will take place and encourages critical thinking questions
Comments
Accuracy *Free from error/thorough
Comments
Relevance *Pertains to the topic * All ideas honoured
Comments
Logicalness
*Recognises logical answers and gives feedback *Ensures debate process is sequenced
Comments
Depth
*Ensures climate of open inquiry *Allows students to examine own views and become involved with topic and exchange of ideas
Comments
Completeness
*Facilitator intervenes if topic tends to stray *Encourages discussion and ensures topic is summarised at the end of the session
Comments
Fairness
*Ensures all students have a chance to speak *Gives reinforcement for participation
Comments
(Whiteside, 1997; Paul, 1990, 1993) Grand Score:
322
Appendix 15
Evaluation of Critical Thinking Strategies: Role-Play to Improve Critical Thinking Skills:
Criteria
Did not happen (0)
Less than adequate performance (1)
Adequate performance (2)
More than adequate performance (3)
Total Score
Clarity
*Communication: Clear, not muffled *Explanation: makes clear what is obscure; gets to the point
Comments
Precision
*Thoroughly explains topic and activity/process *Particular in following teaching plan/ is disciplined *Scenario is outlined and character roles randomly assigned
Comments
Specificity
*Defines important characteristics of the major players in order to establish and provide a framework for behaviours and actions to be elicited *Facilitator adopts a passive role
Comments
Accuracy *Free from error/thorough
Comments
Relevance
*Pertains to the topic * Students allowed to practice behaviours without risk.
Comments
Logicalness
*Recognises logical answers and gives feedback *Role-play method is sequenced into 3 sections: briefing, running and debriefing
Comments
Depth
*Facilitator gives feedback, for example: interpersonal, interactive, problem- solving skills
Comments
Completeness
*Allows post-play discussion to occur *Gives positive feedback
Comments
Fairness *Ensures all students have a chance to speak
Comments
(Fuzard, 1989; Paul, 1990, 1993; Arangie, 1997) Grand Score:
323
Appendix 15
Evaluation of Critical Thinking Strategies: Small Group Activity to Improve Critical
Thinking Skills:
Criteria
Did not happen (0)
Less than adequate performance (1)
Adequate performance (2)
More than adequate performance (3)
Total Score
Clarity
*Communication: Clear, not muffled *Explanation: makes clear what is obscure; gets to the point
Comments
Precision
*Thoroughly explains topic and activity/process *Particular in following teaching plan/ is disciplined *Randomly assigns students into groups/splits cliques
Comments
Specificity
Each groups given a topic- each group share findings with other groups *Facilitates group discussion from ideas identified in this exchange Facilitator monitors group discussion, ensuring equal participation by rotating between groups
Comments
Accuracy *Free from error/thorough
Comments
Relevance
*Content and direction of class is determined by students’ needs *Questions/issues are addressed, clarified by students and facilitator prompts as needed
Comments
Logicalness *Recognises logical answers and gives feedback
Comments
Depth
*Ensures climate of open questioning *Encourages students to use devices, such as flip-charts etc. to serve as organising framework for dialogue *Offers clues to stimulate discussion
Comments
Completeness
*Encourages periods of silence for reflection *Facilitator intervenes only when topic or discussion goes astray
Comments
Fairness
*Ensures all students have a chance to speak *Gives reinforcement for participation
Comments
(Whiteside, 1997; Paul, 1990, 1993) Grand Score:
324
325
APPENDIX 16: FEEDBACK OF
INSTRUCTIONAL TECHNIQUES BY
RESEARCHER
326
Appendix 16
Feedback of instructional techniques from Evaluator (Researcher)
Clinical Instructor 1: Instructional Feedback:
There was an opportunity at the end at the session to further explore a topic raised by
a student such as: "Is the hospital a cleaner place than the home?" At the time the
student raised this issue, you were keeping in time with the lesson plan – great! Now
try to adjust the lesson plan to accommodate questions, such as the one mentioned
above at the completion of your lesson. As it turned out, you finished before the
time allocated – this would have been a perfect opportunity to hone in on this issue.
You could have used the ‘Plus; Minus; Interesting’ (PMI) method suggested by
Elliott (1997). The outcome of this discussion would have provided the preparation
required in debating this issue at a later date.
It was a good idea to have students generate critical thinking questions and the idea
of randomly distributing the questions is effective in that, students’ answer each
other’s questions and sometimes even their own – it allows another voice, other than
the instructor’s. There were some excellent critical thinking questions formulated.
For example, question 1: :"What is the difference between an open wound and a
closed wound?" The students provided adequate answers, however, the answers
provided could have been explored more intensely by getting them to:
compare and contrast, look for similarities etc.
Question 2: "What would happen if the patient ignored what he was taught?"
(hypothesis/prediction –type question). Nursing is fraught with predictions – here
the students could have implemented a teaching plan for this patient. Do not miss
the opportunity to use these questions and others to stimulate critical thinking – these
questions are actually an extension of your teaching session which could have been
explored further, utilizing the additional time left over at the end of the session.
At the end of six months this clinical instructor improved significantly and the
comment for a teaching session was: ‘A very active and participative session.’
327
Clinical Instructor 2: Instructional Feedback:
You generate a lot of participation within the class. One thing you must try to
develop is to give them time within the session(s) to ‘ponder’ say 2 – 3 minutes (to
reflect, to generate questions etc.). The students in your class are really learning how
to think – challenge them a little further. Another creative strategy that you can
implement, other than just group work is to construct a case-scenario based on the
group work topics. Then divide the class into three – everyone explores the same
case study.
Divide the whiteboard into three, namely groups 1, 2 and 3. Write all the
information provided by each group under groups 1, 2, and 3 respectively. When all
information has been written on the board:
Compare, contrast and critique information
To ‘kick-off’ generate questions, for example:
1.Why did this group include this?
2. Why is….important?
3. What is another way to look at….?
Probe further
Allow 2 –3 minutes for reflection
Get them to generate 1 – 3 critical thinking questions – collect the questions and
randomly select students’ to question and respond – instructor facilitates as
necessary.
This way you will get a discussion on the way! Remember that you will have to
learn to ‘think on your feet’ in order to identify an appropriate topic for a case study.
The use of case studies is a classic method to analyse data by identifying problems
and planning appropriate care. Case studies provoke students’ interaction as they
328
discuss the case. “Classroom activities cause students to reflect on their ideas and
discuss their decisions” (Vanetzian and Corrigan, 1996, p. 47). Try it – you can do
it!!
With feedback and guidance, this instructor developed her instructional techniques
rapidly. She was effective in being able to steer students into addressing their own
lack of understanding, identifying specific gaps of knowledge and some
misconceptions they had had – a feature of inquiry-base learning (King, 1995). This
type of activity was meaningful for the students, hence they were making the kinds
of mental connections between concepts that were more memorable to them.
329
Clinical Instructor 3: Instructional Feedback.
Your random assignment of students’ was well carried out, by ensuring the cliques
were divided. You also rotated from group to group to ensure that the weaker
students were participating. In doing so, you listened to students answering and
engaged in discussion. Furthermore, you ensured that students worked
collaboratively with each other in peer questioning (whilst within the groups
assigned) and answered each others’ questions. Vanetzian and Corrigan (1996) state
that this process stimulates critical thinking abilities. When students recovered into
the class, they had the opportunity to compare points of view, interpretations, reflect
on their ideas and their decisions. Neill, Lachat and Taylor-Panek (1997) report that
these activities aid in developing critical thinking skills.
This instructor was very innovative in her teaching techniques and frequently utilized
devices such as, crossword puzzles, flash cards etc. to enhance her instructional
techniques and to make the lesson more interesting, which allowed communication,
discussion and augmentation to take place. Within a brief period of time the three
clinical instructors developed their own style of instruction, hence complimenting
each other and adding energy and innovations in all the topics within their teaching
sessions.
Clinical instructors were aware of the need for teaching students the skills of
analyses, reasoning, evaluating and developing their own opinions, hence they were
instrumental in providing the guidance, assistance and instructional methods and
devices required in promoting critical thinking abilities in their students.
330
331
APPENDIX 17: STUDENT-TEACHER
EVALUATION QUESTIONNAIRE
328
337
APPENDIX 18: CASE STUDY: BURN INJURY
FOR FOCUS GROUP INTERVIEW
338
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