992845

research-article2021
TCNXXX10.1177/1043659621992845Journal of Transcultural NursingHalabi et al.

Research

Journal of Transcultural Nursing

Professional Competence Among

1­–9
© The Author(s) 2021
Article reuse guidelines:
Registered Nurses Working in Hospitals [Link]/journals-permissions
DOI: 10.1177/1043659621992845
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in Saudi Arabia and Their Experiences of [Link]/home/tcn

Quality of Nursing Care and Patient Safety

Jehad O. Halabi, BSc, MSc, RN, PhD1 , Jan Nilsson, RN, RNT, PhD2,3,4,
and Margret Lepp, RN, RNT, PhD5,6,7,8

Abstract
Introduction: The Kingdom of Saudi Arabia (KSA) plans to become self-sufficient, generating a national nursing workforce.
The study’s purpose was to assess nurses’ self-reported professional competence and illuminate experiences of the quality of
nursing care and patient safety. Methodology: A cross-sectional design with 469 nurses working in different units from two
public hospitals and Regions of the KSA participated. The Nurse Professional Competence Scale short version including six
professional areas of nursing care was used. Results: There are significant relationships between self-reported professional
competence and the quality of nursing care, patient safety, nurse’s characteristics, and workplace. Discussion: Registered
nurses’ professional competence is related to the clinical areas in which they work and the nature of their involvement in
patient care. The Nurse Professional Competence Scale can identify professional competence areas for further development,
which is important for culturally congruent health care in KSA for their transformation process.

Keywords
professional competence, NPC Scale, patient safety, quality of care, nursing, Saudi Arabia

Introduction nurses with adequate knowledge, attitudes, and skills. These

programs prepare competent nurses who meet the interna-
The Kingdom of Saudi Arabia (KSA) is a multicultural coun- tional guidelines and requirements for safe practicing care
try where the health workforce consists of nurses educated in providers. They will assume significant roles in providing
different countries around the world, where their cultural quality nursing and health care to their patients, families, and
competence is necessary to assess. For several decades, the communities including people from diverse backgrounds
country depended extensively on expatriates to fill vacancies (Dunagan et al., 2014).
in different work areas, especially those related to health care Saudization refers to replacing expatriate staff with Saudi
(Ahmed, 2016). Hassan (2017) indicated that based on the Arabian citizens (Ahmed, 2016). In the past decade, there
Ministry of Health (MOH, 2014) records, the expatriate reg- has been rapid development in the country and an expansion
istered nurses (RNs) comprise around 78% of the total nurs-
ing workforce in KSA.
1
Expatriate nurses bring into the health care system a great King Saud bin Abdulaziz University for Health Sciences, Al Ahsa,
Kingdom of Saudi Arabia
diversity of educational backgrounds and competencies they 2
Karlstad University, Karlstad, Sweden
have studied and learned abroad. Halabi et al. (2021) con- 3
Sophiahemmet University, Stockholm, Sweden
ducted a study in KSA and found that RNs scored high in 4
Japanese Red Cross Institute for Humanitarian Studies, Tokyo, Japan
items of competence related to nursing care and value-based 5
University of Gothenburg, Gothenburg, Sweden
6
nursing care. On the other hand, they scored low in items Østfold University College, Fredrikstad, Norway
7
Griffith University, Gold Coast Queensland, Australia
related to care pedagogics and in development, leadership, 8
Universitas Gadjah Mada, Yogyakarta, Indonesia
and organization of nursing care. The self-reported compe-
tence was correlated to the background variables, particu- Corresponding Author:
Jehad O. Halabi, BSc, MSc, RN, PhD, Chairperson, Assessment and
larly age, work experience, level of nursing education, and
Evaluation Unit, College of Nursing, King Saud bin Abdulaziz University
nurse position. for Health Sciences, Al Ahsa, Ministry of National Guard-Health Affairs,
In preparing professional nurses by basic way of nursing Mail Code 500, P.O. Box 6664, Al Ahsa 31982, Kingdom of Saudi Arabia.
education programs, there is a great emphasis on equipping Email: halabij@[Link]
2 Journal of Transcultural Nursing 00(0)

of higher education scholarship programs to prepare quali- patients of different backgrounds. These nurses originate
fied specialized nurses and educators. In addition, many pub- from over 30 countries around the world; therefore, have to
lic and private universities have been established in a short respect different beliefs of patients and to provide culturally
amount of time. With these developments, the number of sensitive care that appreciates their patients’ values and cul-
graduates in all specialties including nursing has markedly tural traditions (Gashash, 2015).
increased. It has created a demand among its young popula- The multicultural work environment might cause some
tion for employment and entering the workforce. With these conflict because of different cultural norms and beliefs and
developments, it is expected that the newly graduated cohort languages, it might influence patient care and cultural safety
of Saudi nurses will replace the current expatriates and (Almutairi, 2015). Al-Yateem et al. (2015) indicated that for
slowly implement the Ministry of Labor’s Saudization laws the delivery of safe health care it is important to assure trans-
aiming at workforce localization. The purpose of this study cultural health care service competently. They emphasized
was to assess self-reported professional competence among that preemployment education should be given to nurses
RNs related to working in different clinical areas, and further who deal with patients from a Muslim–Arabic background.
to illuminate their experiences of the quality of nursing care They include culturally and religiously specific topics that
and patient safety at two hospitals in KSA. concern appropriate practice for the nurse involving basic
Islamic principles and basic language skills.
Background
The Saudization. Saudization is known as the process of
Nursing and Regulation in KSA. There is a paucity of informa- replacing Saudi nationals with expatriate workers in differ-
tion, lack of published articles and official sources that docu- ent jobs in Saudi Arabia. The process started early in the
ments the historical background of nursing in general, and 1970s to increase the percentage of Saudi employees in the
the development of the profession and education of nursing Saudi labor market in all sectors (“Steady Rise in Saudiza-
in KSA. Nursing started in 1948 and since then has under- tion in Private Sector,” 2020).
gone significant changes and development on many levels. The SCFHS (2015) established the guidelines of profes-
The need for recruiting around 186,000 expatriate nurses to sional classification and registration for all health workers,
achieve the recommended nurse-citizen ratio of 1:200 was including nurses. The employment of the nurses goes through
highlighted by Alomran et al. (2017). However, this recruit- a complex process. Expatriate nurses must register with the
ment poses numerous challenges and concerns, particularly SCFHS before arrival in Saudi Arabia under a special system
concerning patient safety, competitive labor markets, high (the Mumaris system, online portal for nurse registration;
employee turnover, and job instability (Aljohani & Alomari, SCFHS, 2015). The SCFHS will assess and determine if the
2018). The need for increasing and promoting local pro- applicant meets the criteria to be a RN in the country.
grams in nursing is essential to meet the need for local nurses The KSA launched the Saudi Vision 2030, which focused
who can achieve the Saudi government’s strategic require- on the necessity of enhancing the education system and all
ments and goals. regulations and policies, including nursing education and
Alomran et al. (2017) point out that the Saudi Commission service (“KSA Saudi Vision 2030,” 2016). However, this
for Health Specialties (SCFHS, 2017) classified nurses into vision is reported as a potential challenge to the nursing pro-
several categories according to the Regulations of Nurses fession, education, and practice, since it necessitates the
Classification Article 17, including bachelor’s degrees where escalation of the Saudization process in nursing by 60%
currently there are around 14,000 Saudi RNs employed in (SCFHS, 2018).
KSA. The Ministry of Education (MoE) was established in
1975 and established university level programs (MoE, 2019), Patient Safety and Rights. Patient safety is expressed as “the
which included a Bachelor of Science in Nursing (BSN) and prevention of errors and adverse effects to patients associ-
regular and bridging programs. In the 1980s, the first Master ated with health care” (World Health Organization [WHO],
of Science in Nursing (MSN) program was established. In 2015). Protecting patients from harm is recognized as a com-
2004 and under the MoE authority, the establishment of the plex matter (National Patient Safety Foundation, 2015). The
National Commission for Academic Accreditation and harm is related to an extended length of stay in hospital and
Assessment (NCAAA) took place to follow up on nursing larger hospitalization costs (Al-Hazmi, 2015; Dreyfus et al.,
education and practice programs. 2018), besides unnecessary suffering and higher risk for
mortality (Jones et al., 2016; Pirmohamed et al., 2004).
Expatriate Nurses. The Kingdom of Saudi Arabia has a short- Worldwide, a rate of 10% of the patients is reported as being
age of Saudi nurses, and the government recruits many inter- harmed in the hospital (National Patient Safety Foundation,
national nurses. To cover this shortage, expatriate nurses of 2015). For example, in Sweden, around 8% of the patients
different cultural values, religious beliefs, and backgrounds are reported as being harmed during their hospital stay
are hired (Gashash, 2015). The expatriates, as all nurses (Swedish Associations of Local Authorities and Regions,
globally, need to deliver competent and quality care to 2018).
Halabi et al. 3

One of the top priorities of health for the Saudi MOH is to patients and their families, and to nurses, to be sure the care
patient safety, as manifested in the projects and initiatives is implemented safely within the accepted standards.
implemented for this purpose throughout various MOH insti-
tutions. The establishment of several national bodies con- Research Significance. The competent nurse uses the right
cerned with health care, such as the SCFHS, focused on all knowledge, judgment, skills, and motivation in responding
attributes of providing safe care to all patients (Alhawsawi to the patient’s care needs according to Berman et al. (2016).
et al., 2017). All these authorities adopted the Patient Safety Therefore, it is necessary to have professional competence to
Guideline published by the WHO (2008a, 2008b). Patient enhance the patients’ quality of care and patient safety. It is
safety was set as a priority by the WHO and other concerned important to assess how nurses estimate the quality of care
institutions in relation to patient care (WHO, 2008b). given besides the safety assurance of all patients. This study
Patient safety is an international phenomenon facing will add to the limited information about the level of profes-
issues in high-, middle-, and low-income countries. Elmontsri sional competence among RNs and its influence on the qual-
et al. (2017) conducted a systematic review regarding patient ity of provided nursing care and patient safety.
safety in the Middle East. They concluded that the need
exists for strategies to promote a positive culture regarding
patient safety, which would consequently improve patient
Aim
safety in the region. The search did not reveal enough pub- The overall aim was to assess self-reported professional
lished research studies that handled patient safety and competence among RNs related to working in different
adverse events in a health institution. The limited literature clinical areas, and further to illuminate their experiences of
on the status of patient safety shows that adverse events are the quality of nursing care and patient safety at two hospi-
not uncommon in KSA health care institutions. Elmontsri tals in KSA. The research questions of the study were as
et al. (2017) indicated that the reported statistics emphasize follows:
that patient safety is a major concern for the health policy
agenda in Arab countries. This necessitates identifying the 1. What are the nurses’ characteristics related to experi-
causes of harm and developing strategies for improvement. ences of the quality of nursing care and patient
The Saudi Central Board for Accreditation of Healthcare safety?
Institutions (2016) reported difficulty in estimating the exact 2. Does nurses’ professional competence relate to work-
number of medical errors in the KSA and acknowledged that ing in different clinical areas? If yes, how does it
these errors present a problem and need to be addressed. relate?
Therefore, they published the Central Board’s policy for seri- 3. What are the nurses’ experiences of the quality of
ous medical errors in order to enforce the reporting of such nursing care and patient safety?
errors. In addition, the SCFHS (2019) published a safety
handbook and guidelines for patient safety to overcome
Method
medical errors.
A few studies examined medical errors, the exact magni- Study Design and Setting
tude of the problem has yet to be determined. In a study con-
ducted in KSA, Sadat-Ali et al. (2010) showed the occurrence The study incorporated a cross-sectional design using a
of a 0.15% medication errors incidence among inpatients; questionnaire with RNs at two governmental health care
that is, an error of 1.58 is taking place for every 1,000 admis- institutions within two medical cities in the Eastern and
sions. Shaheen (2011) indicated that there is an increasing Western regions of KSA. The hospitals are equipped with
frequency of medical error claims in KSA. However, studies state-of-the-art technology and employ highly qualified
showed that health care providers have positive knowledge nurses from KSA and other nations around the globe. In
and attitudes toward the safety of their patients. There is addition to domestic nurses, the hospitals employ nurses
underreporting of medical errors in health institutions and from India, Jordan, Malaysia, Philippines, Singapore, South
hospitals (Alsafi et al., 2015). Africa, the United Kingdom, and the United States. This
All the hospitals and health care institutions in KSA makes up around 80% of the nurses; of whom nurses from
emphasize patient rights. These rights ensure patient safety Philippines, are about 56%. Their preparation took place in
and inform the patients of their legitimate rights, and the the countries from which they came. Only 9.8% of nurses
health care providers of what to consider when working with were educated in the KSA. The hospitals are considered uni-
their patients and their families (Ministry of National Guard versity hospitals with a 300- and 700-bed capacity and offer
for Health Affairs, 2014). The bill of rights is displayed on a variety of services to all groups of eligible patients’ popula-
every unit as well as in the main halls of the hospitals. Nurses tion. These hospitals adopt international professional values
receive orientation and in-service courses to ensure full and goals of patient-centered care, characterized by high
understanding of patient rights and to observe, follow up, and quality of safe care and excellence. Great emphasis is placed
monitor these rights. Patients’ responsibilities are also given on patient safety as part of a competent workforce.
4 Journal of Transcultural Nursing 00(0)

Participants Data Collection

The study used a convenience sample and 541 RNs partici- Data collection was done by one researcher after securing the
pated in the study by returning a completed questionnaire, university’s institutional review board and Hospital manage-
resulting in a response rate of 36%. Nurses who did not spec- ment permission and approval for data collection. The study
ify the working area and nurses working in areas with few took place from December 2018 to October 2019. The ques-
responses were excluded from the analysis. Eligible for par- tionnaires were handed to each clinical unit manager, accord-
ticipation in the current study were RNs (n = 469) working ing to hospital recommendations, with clear information
in different units such as Medical; Surgical; Special Care about the study and its purpose. Voluntary participation was
Units (ICU, NICU, Hemodialysis, Burn Unit, and others); emphasized and anonymity was assured for all participants.
Pediatric; Maternity; Obstetric; Gynecology; Outpatient Nurses were informed that returning questionnaires is con-
Department (OPD); Emergency Room (ER); Operating sidered consent to participate. There was a statement saying
Room (OR); Critical Care Unit; and Intensive Care Unit. that the nurse agrees/disagrees to participate according to the
research board in this university. Therefore, the nurse puts a
check mark that she or he agrees to participate in the study.
Demographics Collected The unit manager facilitated in distributing the questionnaire
RNs were asked for sociodemographic data, which included to their units and in collecting them afterward. The question-
age, gender, marital status, education, current work area, and naires were placed in an envelope that was hanging in the
work experience as RNs. The RNs were also asked about general information board in each unit, where nurses can
their experiences of the quality of nursing care and patient take and return the questionnaire to the unidentified return
safety at their units. The questions were as follows: envelope without direct observation from the managers. This
allowed anonymity and no coercion from the managers. On
•• To what extent do you experience and think that the completion of each unit, which took around 3 weeks, the
patients receive an optimal quality of nursing care in researcher collected the envelopes and thanked the managers
your unit? for their cooperation. The returned questionnaires by the
•• To what extent do you experience and think that the nurses that were complete comprised the sample size (469)
patients feel safe and secure with the care provided at for this study.
your unit? Data were analyzed using SPSS for Windows, version 25
(SPSS Inc., Chicago, IL, the United States). For the NPC—
The data for these questions were obtained by asking the short version, a sum score for all six competence areas was
nurse to respond using a scale ranging from a very small calculated and transformed into 1 to 100 scales, where higher
extent to very large extent. scores indicate higher nurse professional competence.
Comparison of proportions between groups was calculated
using the chi-square test. The responses to the questions
Nurse Profession Competence Scale Short
regarding the quality of nursing care and patient safety were
Version calculated and transformed into a 1 to 100 scale and further
The Nurse Professional Competence (NPC) Scale short ver- dichotomized into low/high experience of the quality of
sion in the English language was used in the present study. nursing care and patient safety using the groups’ mean value.
The NPC Scale consists of 35 items, was developed by One-way analysis of variance with Turkey post hoc test was
(Nilsson et al., 2018), and originates from the 88-item ver- used to compare values between several groups. The reliabil-
sion (Nilsson et al., 2014). Permission was obtained by the ity of the NPC Scale short version as measured by Cronbach’s
Swedish NPC Research group to use it in the present study. α was .97 for the total scale and ranged from .85 to .93 for
The scale consists of six Competence Areas (CAs): Nursing the six competence areas.
Care (CA1), Value-Based Nursing Care (CA2), Medical
and Technical Care (CA3), Care Pedagogics (CA4), Ethical Approval
Documentation and Administration of Nursing Care (CA5),
and Development, Leadership, and Organization of Nursing The institutional review board of King Saud bin Abdulaziz
Care (CA6). Psychometric properties of the NPC Scale-short University for Health Sciences approved the study (No:
version have shown satisfactory results regarding construct RJ17/021/J). Written informed consent was obtained from all
validity and reliability. The Cronbach α was .98 (Halabi participating nurses. According to the protocol, permission
et al., 2021; Nilsson et al., 2018). Response alternatives for was secured from the research bodies at the college, the uni-
each of the 35 items were given on a scale with 4 response versity research center, and the nursing departments at the
alternatives: 1 = to a very low degree, 2 = to a fairly low hospitals. Arrangement for data collection was completed
degree, 3 = to a fairly high degree, and 4 = to a very high and permission from the RNs who were invited to participate
degree. in the study was obtained.
Halabi et al. 5

Table 1. Sociodemographic Profile of the Participating Nurses.

Quality of care Patient’s safety

Total, Low, High, Low, High,

Characteristics N = 469 n = 310 n = 159 p n = 310 n = 159 p
Age, M (SD) 37.7 (9.1)
20-37 Years (%) 53.1 59.0 41.5 58.4 42.8
38-64 Years (%) 46.9 41.0 58.5 .000 41.6 57.2 .001
Gender
Female (%) 91.3 90.3 93.1 90.3 93.1
Male (%) 8.7 9.7 6.9 .205 9.7 6.9 .205
Marital status
Never married (%) 36.2 39.7 29.6 39.0 30.8
Married (%) 63.8 60.3 70.4 .019 61.0 69.2 .049
Education
Diploma (%) 29.6 30.3 28.1 32.1 24.8
Academic (%) 70.4 69.7 71.8 .359 67.9 75.2 .065
Work experience, M (SD) 14.4 (8.6)
1-12 Years (%) 51.8 57.8 40.3 56.5 42.8
13-40 Years (%) 48.2 42.2 59.7 .000 43.5 57.2 .003

Results Care (M = 83.03). RNs’ working in ICU/CCU scored high-

est in competence areas of Nursing Care, Value-based
The following presents the results of self-reported profes- Nursing Care, and Medical and Technical Care. RNs’ work-
sional competence among RNs related to working in differ- ing in Pediatrics scored highest in Care Pedagogics,
ent clinical areas. Another result is self-reported professional Documentation and Administration of Nursing Care and on
competence among RNs related to working in different clini- Development, Leadership and Administration of Nursing
cal areas. Care. RNs’ working in ICU/CCU scored significantly higher
on the competence area of Medical and Technical Care than
Descriptive Data RNs’ working in OPD (p = .036). RNs’ working in pediat-
rics scored significantly higher on competence area Care
The mean age of the RNs was 37.7 years (ranging from 20 to Pedagogics than RNs’ working in OR (p = .035).
64 years), the majority of the RNs were females (91.3%), and Table 3 presents the RNs’ scored experience of the quality
about two thirds of the RNs were married. Among the RNs, of nursing care and patient safety at their respective working
about one third had a diploma degree (29.6%) and two-thirds units. The working unit where RNs worked made a signifi-
had an academic degree, for example, Bachelor’s level or cant difference (p = .000) in terms of their perception of the
higher. About half (51.8%) of the RNs had 1 to 12 years of quality of nursing care and patient safety. Comparing mean
work experience as RNs, and the other half (48.2%) had 13 scores across different working units, the highest mean score
to 40 years of work experience. for the quality of care (M = 88.85, SD = 12.15) and for
Nurses worked in different areas, including working in patient safety (M = 88.46, SD = 19.88) was reported in the
Medical–Surgical (27%); Special Care Units (10.9%); CCU/ICU units. On the contrary, the lowest mean scores
Maternal–child units (29%); Outpatient Department (7%); were reported in OR (M = 70.43, SD = 17.96; M = 69.57,
Emergency Room (8%); Operating Room (4.7%); and SD = 19.88, respectively). Similar low scoring was reported
Intensive–Critical Care Units (10.7%) in two public hospi- from OPD and Emergency Department (ER).
tals in the Western and Eastern Regions of the KSA.
Predictors of scoring higher on experienced quality of
Discussion
care and patient safety belong to a higher age group, being
married, and having longer work experience (Table 1). This cross-sectional study was undertaken to assess self-
Table 2 shows RNs’ self-reported competence distributed reported professional competence among RNs related to
in the six competence areas (CA1-CA6). The two highest working in different clinical areas, and further to illuminate
measured mean scores were Nursing Care (M = 86.96) and experiences of the quality of nursing care and patient safety
Value-based Nursing Care (M = 86.50). The two lowest at two public hospitals in KSA. The data collection process
measured mean scores were Care Pedagogics (M = 81.78) took time and effort to recruit the participants who were will-
and Development, Leadership and Organization of Nursing ing to take part and share their experiences related to
6 Journal of Transcultural Nursing 00(0)

Table 2. Professional Competence (CA1-CA6) Among Registered Nurses Working at Different Clinical Areas.

Clinical area CA1, M (SD) CA2, M (SD) CA3, M (SD) CA4, M (SD) CA5, M (SD) CA6, M (SD)
Total, n = 459 86.96 (12.45) 86.50 (12.61) 85.82 (12.98) 81.78 (14.02) 85.77 (11.18) 83.03 (11.65)
Medical, n = 63 85.48 (12.56) 84.92 (11.79) 83.60 (11.92) 81.90 (12.59) 84.84 (10.72) 81.35 (11.67)
Surgical, n = 65 87.31 (12.38) 87.58 (11.82) 87.76 (12.26) 81.23 (15.39) 85.66 (9.54) 82.31 (9.88)
Special Care Units, n = 51 87.65 (11.55) 85.79 (13.28) 86.44 (13.02) 78.67 (15.03) 84.57 (11.50) 82.97 (11.21)
Paediatrics, n = 70 87.71 (13.01) 88.82 (13.27) 87.63 (14.51) 85.43** (14.39) 88.63 (11.24) 85.35 (12.83)
Maternity, Obstetric, Gynaecology, 85.83 (12.67) 85.39 (13.05) 84.68 (12.93) 82.96 (13.21) 85.29 (12.31) 82.62 (12.23)
n = 66
Outpatient Department, n = 34 85.15 (11.51) 81.18 (13.87) 80.43** (13.68) 80.61 (12.61) 82.81 (11.34) 81.31 (11.46)
Emergency Room, n = 38 88.16 (11.18) 88.11 (12.32) 85.36 (11.35) 81.76 (12.55) 86.79 (0.91) 82.99 (10.56)
Operating Room, n = 22 85.23 (15.85) 84.32 (12.56) 82.64 (14.52) 73.10** (16.08) 84.97 (13.53) 83.52 (12.43)
Critical Care Unit, Intensive Care 89.20 (12.43) 89.50 (10.75) 89.58** (12.08) 83.17 (13.02) 86.69 (11.22) 84.44 (11.65)
Unit, n = 50

Note. CA1 = Nursing Care; CA2 = Values-based Nursing Care; CA3 = Medical Technical Care; CA4 = Care Pedagogics; CA5 = Documentation and
Administration of Nursing Care; CA6 = Development, Leadership, and Organization of Nursing Care.
**Indicating statistical significant difference at p < .05.

Table 3. Registered Nurses Experiences of Quality of Nursing Care and Patient Safety at Their Clinical Areas (N = 469).

Quality of nursing care, M (SD) Patient’s safety, M (SD)

Clinical area p = .000 p = .000
Total 82.69 (15.26) 83.24 (14.72)
Medical, n = 64 77.81a (15.58) 80.93j (15.30)
Surgical, n = 69 83.19b (13.98) 84.06k (13.97)
Special Care Units, n = 51 84.31c (14.04) 83.53l (13.09)
Paediatrics, n = 71 85.63d (14.81) 84.79m (13.29)
Maternity, Obstetric, Gynaecology, n = 66 86.96e (15.09) 86.97n (13.81)
Outpatient Department, n = 35 77.14f (13.84) 79.43 (13.27)
Emergency Room, n = 38 78.95g (15.38) 80.53 (15.76)
Operating Room, n = 23 70.43h (17.96) 69.57o (19.88)
Critical Care Unit, Intensive Care Unit, n = 52 88.85i (12.15) 88.46p (12.73)

Note. 1-16 Indicating statistical significant difference.

a
Mat/Obst/Gyn, CCU/ICU. bOR. cOR. dOR. eMedical, outpatient, OR. fMat/Obst/Gyn, CCU/ICU. gCCU/ICU. hSurgical, Specialized care units, Pediatrics,
Mat/Obst/Gyn, CCU/ICU; iMedical, Outpatient, ER, OR. jOR. kOR. lOR. mOR. nOR. oMedical, Surgical; Specialized care units, Pediatrics, Mat/Obst/Gyn,
CCU/ICU. pOR.

professional competence, quality of nursing care, and patient (CA2) were scored highest, and “Care Pedagogics” (CA4)
safety. The workload of the nurses might have limited their and “Development, Leadership and Organization of Nursing
participation, especially the ones who are expatriates coming Care” (CA6) were scored the lowest. These findings follow
from different countries. The study has the strength of being similar trends as reported in previous studies (Gardulf et al.,
the first conducted in KSA regarding RNs’ experiences of the 2019; Nilsson et al., 2018). Competencies in “Nursing Care”
quality of nursing care and patient safety. (CA1), “Value-based Nursing Care” (CA2), and “Medical
Study results showed a relationship between nurses’ char- Technical Care” (CA3) were scored highest among nurses
acteristics and their experiences with the quality of nursing working in intensive care. This result can be explained by the
care and patient safety. Nurses who were older, being married, fact that RNs working in the ICU have received continued
and having longer work experience assessed both areas higher and education on advanced level to assume the role of spe-
than others. Being older and having work experience has in a cialist nurses in critical care units. The scope of practice for
previous study by Halabi et al. (2021) showed to be signifi- RNs with education on an advanced degree involves provid-
cantly associated with all self-reported professional compe- ing a holistic bedside nursing care for the patient (WHO,
tence areas in the NPC Scale short version. 2005, 2009). In line with the international scope of practice
The study assessed the RNs’ professional competence and the job description of ICU nurses, the practicing nurses
related to their work in different clinical areas. Among the in KSA possess a high degree of management of medical and
total sample of nurses in this study, the Competence Areas technical equipment and products that is common in ICU
“Nursing Care” (CA1), and “Value-based Nursing Care” (Falk & Wallin, 2016). These units necessitate intensive care
Halabi et al. 7

and very close observation and extra caution to be given to team collaboration are related to the quality of care and patient
the quality of care and patient safety. safety. This is in contrast to the OR nurses whose work depends
Competencies in “Care Pedagogics” (CA4), “Documentation on the patients that are well-prepared at the general surgical
and Administration of Nursing Care” (CA5), and “Development, ward before reaching the OR and by the anesthetist as well as
Leadership and Organization of Nursing Care” (CA6) were the postoperative recovery room (von Vogelsang et al., 2020).
scored highest among RNs working in pediatric care. The Length of work experience as a nurse, for example, in the
scope of practice for RNs working in pediatric care is to a high ambulance service, is an important factor associated with
degree related to the specialized education on the advanced higher professional competence (Jansson et al., 2020). Aiken
level and continuous training of RNs in relation to the care pro- et al.’s (2012) study across Europe showed that nurses rated the
vided for both children and their parents. This care often takes quality of patient care and safety as poor or fair and related that
part in the designated care unit in the hospital and is performed to the work environment and professional nurse staffing.
according to the job description of each nurse. Therefore, hospital management needs to assure that health
In contrast, specialist nurses working in the OR scored care is given in suitable work environments, besides the reten-
their competence in “Care Pedagogics” (CA4) as lowest. tion of qualified nurses in order to guarantee safeguarding qual-
Largely, this can be explained by the nature of the work in ity nursing care and patient safety. This is not limited to a
OR and within the scope of practice in such a unit. The specific country but could apply to all countries around the
patient status requires, to a lower degree, the practice of world as for example in KSA.
patient education in this unit. Moreover, the patients to a high The expatriate nurses are hired after a thorough process
degree are sedated and or sleeping during surgical interven- of evaluation and reevaluation as explained earlier. The
tion, which might not require any special patient education guidelines adopted by the SCFHS (2018) ensure the recruit-
from the RNs side (von Vogelsang et al., 2020). Another ment of qualified nurses who can offer quality and safe
explanation could be the fact that RNs working in the clinical patient care. Each nurse brings with her/him the experi-
areas of OR/ER do not come in close caring-encounters and ences and skills gained in their home country and this
working relationship with patients who come to the surgical enriches the application of standardized nursing care. With
operation and emergency care only for a specific short time. the continuous education that is required from each practi-
Patients in OR for example are almost anesthetized and usu- tioner, nurses are exposed to different information and
ally transferred from this clinical area as soon as the surgical skills in dealing with the culture and patients from that cul-
operation is finished. ture. The Saudi and expatriate nurses are working in teams
Nurses working in the OPD scored lowest on all compe- where they learn from each other, and support each other in
tence areas except “Care Pedagogics” (CA4). In the OPD, it providing culturally sensitive care to their patients. We rec-
could be assumed that giving information and patient educa- ommend that the hospital management should enhance con-
tion can be limited and therefore not highly emphasized. One tinuing education sessions to provide opportunities for
possible explanation could be that OPD is the mostly physi- multicultural nurses to work together in building their com-
cian-led area and that nurses mainly have a role of assisting munication and practical skills of providing care to their
the physician in patient preparation and examination, a pro- patients. Training interventions and hospital management
cess that is usually short, quick, and superficial visit. support would improve safe and quality nursing care which
The study investigated the experiences of nurses related contributes to overall patient welfare. It is recommended to
to the quality of nursing care and patient safety. It is impor- conduct further investigation of how the nurses’ profes-
tant to remember that how nurses assess the quality of care sional and cultural background impact quality care and
given in addition to the safety assurance of all patients is safety when involved in patient care.
crucial in nursing care. Quality of care and patient safety are
of prime importance and reveal the commitment of the Saudi
Conclusion
government to upgrade the patient safety situation in the
country. This topic has received great attention from MOH The conclusion from this study is that a relationship exists
and all concerned authorities and health care providers, each between the quality of nursing care, patient safety, and the
on their own level of practice. The MOH established the nurses’ characteristics and their experiences with self-
“Saudi Patient Safety Center.” Their primary responsibility reported professional competence areas in the NPC Scale.
was to develop a National Strategy aiming at improving The RNs professional competence is related to the clinical
patient safety and reducing many medical errors and conse- areas in which they work. Nurses do acknowledge the impor-
quently prevent harm from occurring to all patients. tance of maintaining patient safety and providing quality
In this study, quality of care and patient safety were experi- nursing care. The NPC Scale can identify professional com-
enced highest among nurses working in the ICU and lowest petence areas that need to be further developed and the units
among nurses working in the OR. Working in interprofessional that need further tracing and assessment. It is also of great
teams is common in ICU and being in-charge of very few use for the health care organizations in securing high-quality
patients, and being able to give holistic nursing care. Factors care and patient safety by investing in continuous support for
such as the number of patients to care for, work climate and professional development of nurses.
8 Journal of Transcultural Nursing 00(0)

Implications P., Moreno-Casbas, M. T., Tishelman, C., Scott, A., Brzostek,

T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D.,
The study has implications for nursing practice and manage- Sjetne, I. S., Smith, S. L., & Kutney-Lee, A. (2012). Patient
ment to continue nurses’ professional development. Another safety, satisfaction, and quality of hospital care: Cross sectional
implication is to have a strong organizational vision and surveys of nurses and patients in 12 countries in Europe and
proper means for assessing nurse’s professional competence the United States. British Medical Journal, 344, Article e1717.
regularly. Identifying gaps in nurses’ experienced compe- [Link]
tency is useful both on an individual and team level, in rela- Alhawsawi, A., Wazzan, A., & Alwahabi, S. (2017). Essentials
tion to lifelong learning, and to development in nursing. of patient safety (1st ed.). Saudi Commission for Health
Specialties.
Al-Hazmi, H. (2015). Role of duration of catheterization and length
Author’s Note
of hospital stay on the rate of catheter-related hospital-acquired
Jan Nilsson is also affiliated with Innland Norway University of urinary tract infections. Research and Reports in Urology, 7,
Applied Sciences, Norway and not affiliated with Japanese Red 41-47. [Link]
Cross Institute for Humanitarian Studies, Tokyo, Japan. Aljohani, K. A., & Alomari, O. (2018). Turnover among Filipino
nurses in Ministry of Health hospitals in Saudi Arabia: Causes and
Acknowledgments recommendations for improvement. Annals of Saudi Medicine,
The authors would like to acknowledge the generous contribution 38(2), 140-142. [Link]
of all nurses from the participating hospitals toward the data used in Almutairi, A. F. (2015). A case study examination of the influence of
this study. cultural diversity in the multicultural nursing workforce on the
quality of care and patient safety in a Saudi Arabian hospital
Author Contribution [Doctoral dissertation, Queensland University of Technology].
[Link]
Study conception/design: Jehad Halabi, Jan Nilsson and Margret Alomran, S., Alhosni, A., Alzahrani, K., Alamodi, A., & Alhazmi,
Lepp. R. (2017). The reality of the Saudi health workforce during
Development of questionnaire: Jehad Halabi, Jan Nilsson and the next ten years 2018-2027. Saudi Commission for Health
Margret Lepp. Specialties.
Data collection: Jehad Halabi. Alsafi, E., Baharoon, S., Ahmed, A., Al-Jahdali, H.H., Al Zahrani,
Data analyses: Jehad Halabi. S., & Al Sayyari, A. (2015). Physicians’ knowledge and
Drafting of manuscript: Jehad Halabi, Jan Nilsson and Margret practice towards medical error reporting: A cross-sectional
Lepp hospital-based study in Saudi Arabia. Eastern Mediterranean
Critical revisions for important intellectual content: Jehad Halabi, Health Journal (EMHJ), 21(9), 655-664. [Link]
Jan Nilsson and Margret Lepp. org/10.26719/2015.21.9.655
Al-Yateem, N., AlYateem, S., & Rossiter, R. (2015). Cultural
Declaration of Conflicting Interests and religious educational needs of overseas nurses work-
The author(s) declared no potential conflicts of interest with respect ing in the Kingdom of Saudi Arabia and the United Arab
to the research, authorship, and/or publication of this article. Emirates. Holistic Nursing Practice, 29(4), 205-215. https://
[Link]/10.1097/HNP.0000000000000095
Funding Berman, A., Snyder, S. J., & Frandsen, G. (2016). Kozier and Erb’s
The author(s) received no financial support for the research, author- fundamentals of nursing (10th ed.). Pearson.
ship, and/or publication of this article. Dreyfus, J., Gayle, J., Trueman, P., Delhougne, G., & Siddiqui,
A. (2018). Assessment of risk factors associated with hos-
Ethical Approval pital-acquired pressure injuries and impact on health care
utilization and cost outcomes in US hospitals. American
The institutional review board of King Saud bin Abdulaziz
Journal of Medical Quality, 33(4), 348-358. [Link]
University for Health Sciences approved the study design and pro-
org/10.1177/1062860617746741
cedures, King Saud bin Abdulaziz University for Health Sciences
Dunagan, P. B., Kimble, L. P., Gunby, S. S., & Andrews, M. M.
(No: RJ17/021/J). Written informed consent was obtained from all
(2014). Attitudes of prejudice as a predictor of cultural compe-
participating nurses.
tence among baccalaureate nursing students. Journal of Nursing
Education, 53(6), 320-328. [Link]
ORCID iD
20140521-13
Jehad O. Halabi [Link] Elmontsri, M., Almashrafi, A., Banarsee, R., & Majeed, A. (2017).
Status of patient safety culture in Arab countries: A system-
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