|Year : 2014 | Volume
| Issue : 2 | Page : 85-91
Practical competency of Filipino nurses working in Taif city, Kingdom of Saudi Arabia
Adnan Amin Alsulaimani
Department of Pediatrics, College of Medicine, Taif University, Taif 21974, Saudi Arabia
|Date of Web Publication||20-Jun-2014|
Adnan Amin Alsulaimani
Department of Pediatrics, College of Medicine, Taif University, P. O. Box 888, Taif 21974
Source of Support: None, Conflict of Interest: None
Context: Saudi Arabia remains one of the countries where Filipino nurses sought opportunities. However, this country has a different culture where Filipino nurses are not accustomed yet, therefore patient care can be compromised. Aims: The aim of the following study is to present the practical competency of Filipino nurses working in the hospitals of Taif city, Kingdom of Saudi Arabia. It dealt with the strength of self-efficacy perception of the nurses on the practical constructs and the variations among the strength of self-efficacy perception of the nurses on the practical constructs. Settings and Design: A descriptive - evaluative study using transcultural self-efficacy tool to determine differences in the level of cognitive competency among Filipino nurses with their demographic profile. Subjects and Methods: Filipino nurses (n = 307) participated in the study. They were working in five hospitals (namely King Abdulaziz Specialist Hospital, King Faisal Hospital, Children's Hospital, Chest Hospital and Mental Health Hospital) in Taif city, Kingdom of Saudi Arabia. Statistical Analysis: Data were analyzed using analysis of variance for comparison between the various groups to specific factors. Results: The strength of self-efficacy perceptions of the nurses within the practical constructs were religious practices and beliefs, religious background and identity, aging, educational background and interest and level of English comprehension. Nonetheless, the majority of the mean score were above the mean score of seven. Conclusion: Nurses were confident in identifying the specific cultural factors that could influence their client behaviors in accepting or rejecting care interventions, and although they shows confidence in some practical construct scale, they still need to have formal education and trainings regarding transcultural nursing, Arabic language and Saudi Arabia's cultural beliefs and practices to enhance their competencies in caring for a patient with diverse cultures.
Keywords: Filipino nurses, practical competency, Saudi Arabia, self-efficacy, transcultural nursing
|How to cite this article:|
Alsulaimani AA. Practical competency of Filipino nurses working in Taif city, Kingdom of Saudi Arabia. Saudi J Health Sci 2014;3:85-91
| Introduction|| |
Nurses from the Philippines today have the reputation of qualified and respected female workers with high work ethics, and are in high demand world-wide.  Kingdom of Saudi Arabia is one of the countries wherein Filipino nurses sought opportunities. In Saudi Arabia, the majority of nurses recruited by the Ministry of Health Hospitals are from India and the Philippines . These nursing professionals often come with limited knowledge about Saudi culture and Islam.  As a result, acculturation is often difficult resulting in difficulties in understanding and meeting their patient cultural requirements. Filipino nurses, as expatriate needs to be familiar with the different cultures of their patients in order to implement nursing care effectively. Therefore, gaining credibility within a cross-cultural context is arguably the first step an expatriate should attempt to take when entering a new company in an international setting.  Measuring self-efficacy in terms of practical construct can increase Filipino nurses credibility in handling patient with different cultural background since cultural competence, as defined by the American Academy of Nursing Expert Panel on Cultural Competence, is "having the knowledge, understanding, and skills about a diverse cultural group that allows the health care provider to provide acceptable cultural care".  In addition, cultural skills and knowledge represent people's ability to conduct accurate cultural assessment and an understanding of people's values and worldviews.  Within the context of transcultural learning, practical learning skills or construct refer to communication skills, verbal and non-verbal, needed to interview patients of different cultural backgrounds about their values and beliefs.  Hence, Filipino nurses cultural skills will create understanding on how to effectively implement nursing care, since cultural beliefs and traditions greatly affect patients acceptance of the care to be given to them. Therefore, the aim of the present study was to determine the self-efficacy of Filipino nurses working in the Hospitals of Taif city, Saudi Arabia, in practical construct as part of their transcultural competency assessment.
| Subjects and Methods|| |
The present investigation is a descriptive - evaluative study to determine differences in the level of cognitive competency among Filipino nurses with their demographic profile.
The study was conducted in five Ministry of Health Hospitals located in Taif city, Makkah Region, Kingdom of Saudi Arabia. Nurses were recruited for the study from King Abdulaziz Specialist Hospital, King Faisal Hospital, Children's Hospital, Chest Hospital and Mental Health Hospital. A total of 307 respondent nurses were included using the simple random sampling fishbowl technique. The nurses were selected, regardless of their position as staff nurse, assistant head nurse, head nurse, nurse educators, nurse administrator/supervisor and assistant nursing director. 167 of the nurses were from King Abdulaziz Specialist Hospital, 41 were from King Faisal Hospital, 53 were from the Children's Hospital, 24 were from the Chest Hospital and 22 nurses were from the Mental Health Hospital. The nurses were predominantly female (n = 298; 97.1%). About 30% of the nurses belong to the age group of 25-29 years, while the Moro ethnicity represented 43% of all the respondents. All the nurses who participated in the study were graduates of Bachelor of Science in Nursing (BSN), and the majority of them were working as staff nurses (84.4%). All the nurses were full-time nurses and were mostly assigned in the acute care department (79.8%). All the participating nurses had no formal training or seminars been attended on transcultural competency.
The research questionnaire was prepared based on the Cultural Competence Education Resource (CCER) toolkit.  The following research instruments were used according to CCER:
- Demographic data sheet for nurses, to gather demographic information from nurses including educational level
- Transcultural self-efficacy tool, to evaluate confidence for performing general transcultural nursing skills among diverse client populations.
Specifically the questionnaire sought answers to the following:
1. How are the profiles of the nurse respondents be described in terms of:
- Employment status;
- Work setting;
- Current work position;
- Preferred nursing position in the future;
- Prior degree completed;
- Prior transcultural competency training;
- Prior seminars attended; and
2. What is the strength of self-efficacy perceptions of the nurses within the:
- Practical construct
3. Is there a significant difference among the strength of self-efficacy perception of the nurses on the practical construct when grouped according to:
- Work setting;
- Current work position;
- Preferred nursing position in the future; and
Consent for participation was obtained from respondents after they were notified of the aims, methods, anticipated benefits and potential hazards of the research. They were informed that, each has the right to terminate his/her participation at any time and that confidentiality is always maintained for his/her responses.
The obtained data were analyzed using analysis of variance for comparison between the various groups to specific factors. These were used to determine the differences among the strength of self-efficacy perceptions of the nurses on the cognitive, practical and affective construct when group according to age, gender, work setting, department, current work position, preferred nursing position in the future and ethnicity. Differences between means were considered as significant at the level of P < 0.05.
| Results and Discussion|| |
The strength of self-efficacy perceptions of the nurses on the practical constructs is shown in [Table 1]. Among the 28 investigated variables, the highest means scores of 7.98 and 7.92 dealt with "religious practices and beliefs" and "religious background and identity", respectively. This indicates that nurses were very confident to discuss with the patient their practice of religion and beliefs and they can easily extract information from the patient about these topics. This action is known as assessment in the nursing process and the process is humanistic; based on the belief that as nurses plan and deliver care, they must consider the unique interests ideals, and desires of the patient, family and community.  Since respondents were already experienced both in the Philippines and in Saudi Arabia, they were confident in determining the patient's background and their religious identity. It has been reported that, an experience of 2-3 weeks was satisfactory to achieve sufficient level of self-confidence and belief in one's abilities as a nurse and in acceleration of development of cultural sensitivity and cultural competence.  The third, fourth, and fifth ranking practical construct dealt with "aging", "educational background and interest" and "level of English comprehension", with mean scores of 7.90, 7.83, and 7.82, respectively. This observation demonstrates that nurses were confident about their communication abilities with the patient to discuss topics related to aging, educational background and level of English comprehension, because it is their goal to gather information from patients to determine and to meet their needs. Furthermore, this observation shows that the nurses have high self-esteem. Self-esteem is defined as the personal opinion of oneself and is shaped by individuals' relationships with others, experiences, and accomplishments in life.  Moreover, those who have high sense of efficacy visualized success scenarios that provides positive guide and support for performance.  That is, persons maintain their self-esteem levels because their jobs give them a sense of purpose. 
|Table 1: Factors affecting the strength of self-effi cacy perceptions on the practical construct of the Filipino nurses (n=307) working at five hospitals in Taif city, Kingdom of Saudi Arabia|
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On the other hand, the lowest five mean scores that dealt with the strength of self-efficacy perceptions of the nurses on the practical construct started with "acculturation" with a mean score of 7.45. This indicates that nurses were not confident about their interviewing abilities of patients to acquire information about acculturation. Presumably, nurses were not certain with regard to their abilities to discuss related issues openly because they themselves were not well informed yet about the Saudi culture.  and haven't been acculturate yet, as acculturation results when group of individuals having different cultures come into continuous first hand contact, with subsequent changes in the original culture patterns of either or both groups where there is progressive adoption of ideas, words, values, norms, behavior, institutions by persons or groups of a given culture.  The second, third, fourth and fifth lowest ranking variables dealt with "folk medicine tradition and use", "meaning of non-verbal behaviors", "socio-economic background" and "traditional health and illness beliefs", with mean scores of 7.53, 7.56, 7.58, and 7.59, respectively. This indicates that the respondents felt low confidence because they have minimal knowledge in in folkloric tradition and use of folk medicine. Furthermore, it could be shown that the respondents have little knowledge about the meaning of non-verbal behaviors, socio-economic background, and traditional beliefs of their patient, possibly because the nurses were not well informed about such issues, which may have contributed to their low patient interviewing abilities, this is in-line with Norman and Hyland, who explained three elements to confidence: "Cognitive" - a person's knowledge of their abilities; "performance" - their ability to do something; and "emotional" - feeling comfortable about knowledge and performance.  Therefore, developing confidence requires to accommodate each of the abovementioned elements. Moreover, the language barrier, might have contributed to the difficulty the Filipino nurses were facing in expressing themselves to determine the cultural factors that might have influenced a patient's behavior.  Furthermore, one of the behavioral traits that that exists in the Saudi context is shyness, which is demonstrated by exercising modesty and decency, especially in terms of personal appearance and the appropriate use of language. Accordingly, one should be careful not to negotiate health care decisions with the woman alone, even if the issue or procedure directly related to her care.  Therefore, patients have limited sharing of values and beliefs about their own selves, this character is being respected by Filipino nurses, consequently this have contributed to their feeling of their low confidence in this topics.  However, it can noted from the observed results, that the majority of the mean score were above the mean score of seven, which denote that nurses were confident about their abilities in identifying thru an interview, the specific cultural factors that could influence their client behaviors in accepting or rejecting care services to be given to them. Being aware of and understanding the differences and similarities of other cultures allows health care professionals to tailor the care provided to fit the cultural values, beliefs, and practices of the patient. 
[Table 2] presents the significant differences on the level of confidence of each participating nurse in the study, regarding their level of confidence in interviewing clients of different cultural backgrounds to learn about their values and beliefs when grouped according to the demographic profiles of the nurses. Difference were observed between age of the respondents and meaning of space and touch, that perception of space and touch differs and were somehow being affected by age of the nurse, which further shows that nurses are exercising their critical reflections. According to Douglas et al.,  critical reflections includes an examination of one's own cultural values that have the potential to be in conflict with the values of others, and as a result, hinder therapeutic relationships and effective patient care outcomes. Respondent nurses value the concept of touch and space differently. It could be inferred that young nurses may feel anxious about touching the patient, and may create more distant relationship to patient as compared to older nurses, especially if they don't have much experience in establishing rapport with the patient. Touch is a non-verbal way of communication and an important aspect of nursing practice, that allows a therapeutic, synchronized healing to occur. , Hand use and activity are unique to the individual and influenced by socio-cultural values, beliefs, and expectations.  Moreover, touch is related to age, gender, power, and social relationship. Seemingly, gender, age of both staff and patient during intimate task were found to have similarities and differences on staff nurse and patient perception of space and touch.  Therefore, people relatively are cautious about the use of touch in their culture, which might explain the reason for the difference between respondents' personal view of space and touch.
|Table 2: Variation in the strength of self-effi cacy on the practical construct grouped according to the demographic profiles of the Filipino nurses (n=307) working at five hospitals in Taif city, Kingdom of Saudi Arabia|
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The level of confidence of the nurses with respect to the language preference, meaning of verbal communication patterns, educational background and interests, attitudes about health care technology, role of elders, acceptance of sick role behaviors, discrimination and bias experiences, and aging showed differences between nurses when grouped according to work setting. This observation may be equated to the varying means of dealing with patients on the conduct of interviewing clients of different cultural backgrounds. According to American Institute for Research, cultural competency education for nurses has been shown to be effective in increasing knowledge, which is lacking by Filipino nurses as shown in the demographic profiles.  In addition, nursing practitioners in acute care setting are performing clinical skills such as central line catheter placement, ventilator management, and interpretation of radiographs, aside from responsibility for teaching roles, quality improvement, formulation of standards of care, and participation in research,  while in chronic care setting, patient-centered care requires a broad range of skills and attitudes, which include coordinating continuous and seamless care, relieving pain and suffering, listening and communicating, providing education and information, sharing decision-making and management and providing patient-centered care enhance involvement of patients in self-care and improve outcomes and adherence to recommended long-term therapy. It is expected that, nurses with varying degree of patient care services in different work settings and devoid of formal training in cultural competency education will communicate and interview patient differently depending on their experience and how they perceived their patient cultural knowledge and capabilities of answering questions given to them.
Among the variables that are found to differ between nurses with preferred position are: Level of English comprehension, world views, attitude about health care technology, ethnic food preference, role of children, traditional health and illness belief, gender role and responsibilities, acceptance of sick role and behavior, role of family during illness, discrimination and bias experiences, kinship ties and aging. In agreement with Bandura,  the respondents have varying degrees of self-efficacy, because the extent to which performance attainment alter perceived efficacy will depend on people's preconceptions of their capabilities, the perceived difficulty of the task, the amount of effort they expanded, their physical and emotional state at the time the amount of external aid they received and the situational circumstances under which they performed. Furthermore Bandura  stated that people have their own belief about their capabilities. It is the individual's beliefs about being able to carry out the necessary actions to achieve a desired result that determine the impact, self-perceptions actually drive people to their accomplishment rather than their actual ability. 
Variations were observed between the nurses and in their self-efficacy perceptions if they were to interview patients in topics related to the variables of ethnicity, language preference, acculturation, attitudes about health care technology, ethnic food preferences, role of elders, role of children, folk medicine tradition and use, gender role and responsibility, acceptance sick role behaviors, role of family during illness, discrimination and bias experiences, home environment, kinship ties and aging. This can be attributed to the nurse individual breed of culture. However, according to Posadas,  Filipinos generally demonstrate a respect for and emphasis on family respect, loyalty, and dependency. "Ideally, maintaining kin bonds takes precedence over achieving individual goals, for personal identity and self-worth flow directly from familial relationships". In addition, the influence of cultural norms, especially respect for family and authority, plays a significant role in shaping the worldview of the Filipino.  Adding to this, Filipinos are taught to seek consensus and defer to the wishes of a group rather than initiate a confrontation by introducing information or expressing opinions that might be disruptive of cohesion. Aside from this, Filipino parents tries to instill a sense of humility or shame within their children, as an example is trying to win the approval of others opinion especially elders on something is very important. Similarly, loyalty to and care of family are very important values to the Filipino people, the absence of long-term care facilities in the Philippines, where the elderly and infirm were cared for by family, and respect for family and the elderly often makes Filipino nurses excellent care providers for residents in long-term care facilities.  These notation of Filipino culture is an influential factor to consider in shaping the way how these respondent nurses handle their patient in terms of eliciting information. In addition to shaping their acculturation directly, economics and family are represented as influencing the nurses' decisions to enter nursing school and their preliminary decision to emigrate. Upon entering nursing school, these factors still inspired the nurses, but the additional influences of their professors, chief nurses, and clinical instructors affected the nurses' acculturation primarily through formal and informal learning experiences. 
Seemingly, in the Saudi Arabian culture, family is an important component of Saudi society; grandparents are held in high esteem and have a significant level of decision-making authority concerning family matters.  Spiritual healing is widely practiced by Saudi people for many diseases, including diseases which cannot be cured, poisonous stings, jinn possession, and the negative effect of evil-eye. Honor is about personal reputation, respect and the values individuals are to uphold, which acknowledged by others in the society, factors that can lead to feeling shame include (but are not limited to) meanness, mistreating older or weaker people, being passed over for special favors, and immoral sexual conduct of a female family member clear understanding of these concepts assists in the comprehension and appreciation of Saudi behaviors. These Saudi Arabia's culture will have great impact on how the respondents will integrate this cultural beliefs and traditions as they plan or manage the care to be given to their patients.  Cultural competence is constructed as cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. Respondent nurses were inferred to have cultural knowledge, skills, encounters, and desires, since they are here for a minimum of 1 year. Nonetheless, these knowledge and skills were gotten from informal learning, may give further explanation for variations between our nurses regarding their perceived self-efficacy at different levels. Furthermore, Culture is the way people think, act, live, and communicate perhaps the simplest way to explain culture and its relationship to communication is to say that people are different - we live, work, and play in different societies, environments, and climates, and we adapt to these in different ways.
| Conclusion|| |
Filipino nurses practical construct as part transcultural competency shows that even if they don't have formal education regarding transcultural nursing or even seminars attended, Filipino nurses felt very confident in identifying through an interview, the specific cultural factors that could influence their client behaviors in accepting or rejecting care services to be given to them. They felt very confident that they can discuss different topics regarding culture specific health care. However, they presented differences in their self-efficacy perception in some practical construct scale when equated with their demographic profile.
Cultural awareness as defined by Campinha-Bacote in her transcultural model is the self-examination and in-depth exploration of one's own cultural and professional background.  This process involves the recognition of one's biases, prejudices, and assumptions about individuals who are different. Without being aware of the influence of one's own cultural or professional values, there is risk that the health care provider may engage in cultural imposition. Cultural imposition is the tendency of an individual to impose their beliefs, values, and patterns of behavior on another culture. Based on this definition, there is a need for Filipino nurses to undergo formal trainings or education regarding transcultural nursing, aside from formal language training on Arabic language for them to easily comprehend what patient want and communicate effectively what nursing care is needed for their specific illness state or situation. Therefore, it is recommended to Hospital Administrators and Nursing Director to conduct seminars and trainings to new nurses regarding transcultural nursing, Saud Arabia's Culture and Arabic language. In addition, Colleges and Universities in the Philippines should include in their BSN curriculum, transcultural nursing.
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[Table 1], [Table 2]