|Year : 2013 | Volume
| Issue : 1 | Page : 28-37
The role legitimacy of nurses in Saudi Arabia
Ameera Mohammed Aldossary
Department of Nursing, Prince Sultan Military College of Health Sciences in Dhahran, Saudi Arabia
|Date of Web Publication||17-Apr-2013|
Ameera Mohammed Aldossary
Department of Nursing, Prince Sultan Military College of Health Sciences in Dhahran, P.O. Box 33048, Dammam, Zip Code 31448
Context: Nationally, there is no clear scope of practice for nurses working in Saudi Arabia identifying their role legitimacy as the Nursing Board in the Saudi Commission of Health Specialties has not yet formalized a scope of nursing practice. Role legitimacy can be identified either by a supervisory body or by an agreement that may exist among individual groups.
Aims: This study aimed to identify nurses' role legitimacy in Saudi Arabia from the view of nurses, doctors, and patients.
Settings and Design: A large survey was undertaken in 2008 in 10 hospitals located in the Eastern Province of Saudi Arabia related to three major healthcare sectors (government, military, private).
Materials and Methods: A quota sample of nurses (n = 614, RR = 61.4%), doctors (n = 130, RR = 26.0%) and patients (n = 322, RR = 64.4%) was undertaken, utilizing a self-administered questionnaire that drew upon the King's Nurse Performance Scale.
Statistical Analysis Used: A descriptive analysis was undertaken, using the Chi-square test to compare the views of the participants.
Results: The domains of physical care, professional aspects and care management formed a major focus of the nurses' role, with no evidence of role legitimacy regarding the psychosocial and communication aspects of patient care.
Conclusions: There was a traditional view of the nurses' role within acute care delivery which will need to be addressed if nurses are to contribute significantly to promoting the health of people in Saudi Arabia.
Keywords: Nursing practice, role legitimacy, role of nurses, Saudi Arabia
|How to cite this article:|
Aldossary AM. The role legitimacy of nurses in Saudi Arabia. J Health Spec 2013;1:28-37
| Introduction|| |
Nursing within each country holds the responsibility of defining nursing and role legitimacy of nurses in a manner which is consistent with accepted international definitions and relevant to their population's health needs.  Within this context, nurses are expected to perform autonomous and collaborative care for individuals, families, and communities including the promotion of health, prevention of disease, and the care for ill, disabled and dying people as well as advocacy for health and contribution to health policies. 
It has been estimated that more than 60% of nurses working in Saudi Arabia are expatriates recruited from a range of countries, specially from Philippines and India,  and while they are required to speak English, they have varied cultural, training, and experiential backgrounds, suggesting different levels of skills. This has an impact on healthcare delivery particularly as Saudi Arabia has only established standards of practice for physicians and dentists. ,
Thus, with the absence of scope of nursing practice mandated at a national level, the role legitimacy of nurses and associated knowledge and skills are not clearly defined. Role clarification by a supervisory body would be necessary to support the range of knowledge and skills that nurses have and also maximize their contribution to patient care, thereby facilitating the provision of quality care. The Saudi Commission of Health Specialties was founded in 1992 to act as a supervisory body for all health professions with the nursing board joining the commission in 2002.  Although the nursing board set criteria for registration and licensure in 2003, developed accreditation standards for training and continuing education programs, and formed a code of ethics, a scope of nursing practice has not yet been formalized. ,
Machin and Stevenson  stated that role legitimacy is concerned with the appropriateness and scope of professional practice in given practice areas. Formalized role legitimacy is seen when aspects of role responsibility are defined in statute or when professional bodies (such as nurse supervisory body) recognize legitimate areas of practice. Non-formalized concerns the "greyer" areas of practice due to role overlap. Informal negotiation and "understanding" may need to exist between individual groups regarding what is or is not legitimate practice. Role legitimacy is important to consider from within a given discipline at individual, peer, subgroup, and professional levels. It is also important to consider it from outside the specific discipline, from other professional groups, managers, client groups, and the general public. Within this context, this study aimed to identify the role legitimacy of nurses working in Saudi Arabia from the view of nurses, doctors, and patients.
| Background|| |
The role of nurses across countries has always been the subject for debate despite there being a clear standard for the role of nurses issued by the International Nursing Council. For example, nurses are often expected to do non-nursing duties due to a strong pressure from the management that are undertaken by porters, clerics, or domestics.  It could be argued that the determination of the role of nurses is based more on expert opinion rather than research. For example, McCloskey  described nursing as a profession of multiple images which include the "ideal role," the "real role," and the "public image." The characteristics of the "ideal role" of nurses comprise empathy, autonomy, and assertiveness, whereas the "real role" places nurses as being somewhere between autonomous practitioners and physicians' assistants. The "public image" of the role of the nurse is either as physicians' assistants or employees of doctors highlighting the potential for role conflict experienced between nurses, other healthcare personnel and patients.
This perception was reflected in Saudi Arabia in the early 1990s. For example, Mansour's  survey of medical, dentistry, and pharmacy students (n = 43) and their parents (n = 34) was noted using a questionnaire with items rated on a 3-point Likert scale. The findings suggested that the majority of the sample reported inaccurate information about nurses' giving medication and psychological care of patients. Moreover, the majority of the sample was uncertain as to whether nurses could be involved in healthcare administration, education, or research. Sixty-one percent of the students and 50% of the parents reported that nurses could not make critical decisions and 62.8% of the students and 67.7% of the parents reported that nursing was mainly carrying out following physicians' orders. These findings highlight that the role of nurses in Saudi Arabia was perceived in a similar way to McCloskey  description of the "real role" and the "public image." However, knowledge about the role of nurses has changed since Mansour's  study.
Al-Omar  conducted a survey of high school students (n = 479, response rate, 79.8%; 54% males and 44% females) in Riyadh city. The majority reported that nurses provide a comfortable environment for patients (72.9%) and promote and maintain health (72.2%). More than two-thirds of the sample (70%) reported that nursing was based on scientific knowledge and that nurses are well educated and able to educate people (60%) and provide emotional support (61%). In addition, 55% of the students reported that nurses were able to use their own initiative in their work, although less than 50% reported that nurses plan individual care in collaboration with patients. This increased knowledge regarding nurses' role indicates a step toward role legitimacy as interpreted by Machin and Stevenson. 
| Materials and Methods|| |
A quota sample of nurses, doctors, and patients was recruited from 10 hospitals across three healthcare sectors (government, military, and private) in the Eastern Province of Saudi Arabia. A minimum of 50 nurses, 25 doctors, and 25 patients being the target sample from each selected hospital. The overall response rate was 53.3% (n = 1066): nurses (n = 614, 61.4%), patients (n = 322, 64.4%), with the number of doctor participants being less than desired (n = 130 out of a target of 250).
The King's Nurse Performance Scale,  which was measuring clinical nurse performence, was utilized for this study. The King's Nurse Performance Scale was developed to produce a generic set of observable nursing actions that reflected nurse performance in clinical settings in the UK. The scale has a good estimate of reliability (Cronbach's alpha of r = 0.93).  A translated version of this scale was successfully used in a large survey in Jordan to investigate the role of medical-surgical nurses. The Cohen's Kappa coefficient for the translated version ranged from 0.61 to 1.0, suggesting substantial agreement or almost perfect agreement (0.81-1.0) for the majority of the items.  This scale includes 83 activity items within four main domains: physical needs of patient care (36 activity items), psychosocial and communication aspects of patient care (14 activity items), professional aspects of patient care (17 activity items), and patient care management (16 activity items). Participants were asked to assign each activity under each domain to the role of nurses if they thought that it should be performed by nurses or leave the activity unassigned.
Although the questionnaire items were derived from a validated tool, content validity was tested in order to ensure the appropriateness of the questionnaire content using a panel of experts. Further, although the second language in Saudi Arabia is English, a decision was made to translate the patient questionnaire into the Arabic language to aid response rates. However, the nurse questionnaire and the doctor questionnaire were maintained in English as it is the universal language of Saudi Arabian hospitals. , Therefore, the patient questionnaire was translated following the technique recommended by Flaherty (1988),  which is independent translation and back-translation. In addition, the questionnaire was submitted to Arabic-speaking experts who agreed that the content of the questionnaire, in terms of the language, was clear and comprehensive. In this study, the reliability of the questionnaire was measured using the "test-retest" procedure. A few items (14 out of 532) had computed Kappa results at moderate (0.41-0.60) and fair (0.21-0.40) levels with agreement less than 80%.
Ethical approval and permission to access the sample were obtained from each hospital. The purpose of the study was explained in each questionnaire front sheet emphasizing on voluntary and anonymous participation.
The data were analyzed quantitatively using the Statistical Package for the Social Sciences (SPSS, 15.0) IBM software. Analysis of participants characteristics focused upon the demographic and personal profiles of each sample group (nurses, doctors, and patients), along with the professional profiles of nurses and doctors. The nursing practice data analysis was focused upon comparing the responses of the participants regarding the assignment of activities under each domain to the role of nurses, using Chi-square test. A decision was made that more than 50% of the responses represented the majority of the sample. Thus, when more than 50% of the participants assigned an activity item to the role of nurses, this activity item was considered a role assignment. Vice versa, when more than 50% of each sample group did not assign an activity item to the role of nurses, this activity item was not considered a role assignment.
| Results|| |
The sample characteristics are detailed in [Table 1]a-c. The gender, ethnicity, and age group of the participants varied across the three sample groups.
Physical needs of patient care
As can be seen in [Table 2], there was consensus (>50%) among all participants (nurses, doctors, and patients) regarding the assignment of 32 out of the 36 activities in the domain of physical needs of patient care to the role of nurses. Despite this consensus, the Chi-square test suggested that there were no significant differences by sample group for only two items: "carrying out urine testing on the ward" (P = 0.267) and "carrying out venous cannulation" (P = 0.447). The significant differences for the remaining 30 items where there was also consensus can be accounted for by the differences in the extent to which all participants identified activities as being the role of nurses. The adjusted residuals "*" showed that a greater proportion of nurse participants assigned 19 activities to the role of nurses compared to either the doctor or patient participants, with a greater proportion of both nurse and doctor participants assigning 10 activities to the role of nurses compared to the patient participants. There was only one activity "extracting blood by venipuncture" that the nurse participants were less likely to assign to the role of nurses (n = 413, 70.6%) than either the doctor (n = 105, 82.7%) or patient (n = 273, 88.3%) (P < 0.0005) participants.
|Table 2: Participants' views regarding the role of nurses in the domain of physical needs of patient care|
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Psychosocial and communication aspects of patient care
[Table 3] shows that there was only consensus (>50%) among all participant (nurses, doctors, and patients) regarding 2 out of the 14 activities in the domain of psychosocial and communication aspects of patient care. The majority of the participants viewed the activity of "informing the patient of his/her diagnosis and prognosis" and "referring the patient to other healthcare team members if required" as not being the role of nurses. Despite this consensus, the Chi-square test suggested significant differences in the views of the participants which can be accounted for by the differences in the extent to which they did not identify these two activities as being the role of nurses. The adjusted residuals "*" showed that the doctor participants were less likely to assign either activity (n = 12, 9.4%; n = 19, 15.0%) to the role of nurses compared to either nurse (n = 113, 18.9%; n = 237, 40.3%) or patient (n = 69, 22.4%; n = 108, 36.9%) participants.
|Table 3: Participants' views regarding the role of the staff nurse in the domain of psychosocial and communication aspects of patient care|
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Professional aspects of patient care
[Table 4] shows that there was consensus (>50%) among all the participants (nurses, doctors, and patients) regarding assigning all the activities (17 activities) in the domain of professional aspects of patient care to the role of nurses. Despite this consensus, the Chi-square test suggested that there was no significant difference for only one item: "maintaining the privacy and dignity of patients" (P = 0.602). The significant differences (P < 0.0005) in the participants' views for the remaining 16 activities can be accounted for by the differences in the extent to which the participants identified the activities as being the role of nurses. The adjusted residuals "*" showed that a greater proportion of nurse participants (n = 554, 94.5%) assigned the activity of "establishing a professional relationship with the patient and family" to the role of nurses compared to the doctor (n = 99, 78.0%) and patient (n = 174, 60.2%) participants, with a greater proportion of both nurse and doctor participants assigning the remaining 15 activities to the role of nurses compared to the patient participants.
|Table 4: Participants' views regarding the role of nurses in the domain of professional aspects of patient care|
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Patient care management
[Table 5] shows that there was consensus (>50%) among all the participants (nurses, doctors, and patients) views regarding 13 out of the 16 activities in the patient care management domain. The majority of the participants viewed 12 of these activities as being the role of nurses, while they viewed the activity of "diagnosing a range of common conditions" as not being the role of nurses. Although there was consensus in the participants' views regarding 13 activities, the Chi-square test suggested significant differences (P < 0.0005). Again, these can be accounted for by the differences in the extent to which the participants identified the activities as being or not being the role of nurses. Where there was consensus but a statistically significant difference (13 activities), the adjusted residuals "*" showed that a greater proportion of nurse participants assigned six activities to the role of nurses compared to the doctor and patient participants, with a greater proportion of both nurse and doctor participants assigning a further six activities to the role of nurses compared to the patient participants. For the activity of "diagnosing a range of common conditions," the adjusted residuals showed that doctor (n = 37, 28.9%) and patient (n = 99, 33.4%) participants were less likely to assign the role to nurses compared to the nurse participants (n = 260, 45.5%).
|Table 5: Participants' views regarding the role of the staff nurse in the domain of patient care management|
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| Discussion|| |
Physical needs of patient care
The participants assigned almost all the activities listed in the domain of physical needs of patient care to the role of nurses. Interestingly, the participants identified activities that were previously performed by doctors, (e.g., catheterization, venous cannulation, venipuncture, and administration of intravenous medication/fluid)  to be within the role of nurses. This suggests evidence of a shift relating to higher levels of technical care activities to substitute for doctors, who are not ward-based healthcare personnel. The inclusion of these activities within the role of nurses promotes continuity of patient care by reducing the fragmentation of activities to deliver the total care of the acutely ill adult. , This doctor-shift of role has occurred in developed healthcare systems. , In addition, the participants assigned some activities, (e.g., ambulating patients, dressing patients, and weighing patients) that were recently perceived as support workers' role, (e.g., nurse aide, healthcare assistant, and practical nurse) 
to the role of nurses. Thus, the findings of the role assignment suggest that nurses in Saudi Arabia have achieved role legitimacy within the domain of meeting the physical care needs of patient care.
Psychosocial and communication aspects of patient care
In contrast to the data relating to the physical needs of patient care, nurses appeared to have no legitimate role within the domain of psychosocial and communication aspects of patient care as there was no clear consensus across the participants' views. However, there was clear consensus that the two activities: "informing the patient of his/her diagnosis and prognosis" and "referring the patient to other healthcare team members if required" were not the legitimate role of nurses.
Within this domain, there were different views between nurse participants and doctor and patient participants regarding assigning activities to the role of nurses. For example, the nurse participants assigned most of the activities listed in the domain of psychosocial and communication aspects of patient care to the role of nurses, whereas doctor and patient participants assigned no activities to the role of nurses.
Although there was consensus in the doctor participants' views regarding assigning most of the activities in the physical needs of patient care domain to the role of nurses, they were reluctant to assign many activities in the psychosocial and communication aspects of patient care domain to the role of nurses. Their reluctance may be due to their beliefs that patient education and interdisciplinary communication involves the control of knowledge which should be the role of doctors as they are in a superior position. Similarly, patient participants assigned no activities to the role of nurses which may reflect their beliefs that these activities should be the role of doctors who may have better knowledge of their medical condition than other lower grade healthcare personnel such as nurses. This has been noted by others , with patients preferring doctors over nurses as providers of information related to their health status.
The reliance upon expatriate nurses ,, who may not be able to communicate effectively with patients resulting in language difficulties which may become one of the hindering factors of providing effective patient education  and communication affecting patients' satisfaction in receiving information. , This may explain some of the doctor and patient participants' reluctance to assign activities within the domain of psychosocial and communication aspects of patient care to the role of nurses. Having language competence is essential for optimum clinical practice involving psychosocial support. ,,,,
Interestingly, these contrasting role assignments that lead to unclear role legitimacy are not unique to the Saudi Arabian healthcare system. In Jordan, Shuriquie  investigated the role legitimacy of medical-surgical nurses from the perspective of nurses, doctors, and patients. She also noted that all activities listed in the domain of psychosocial and communication aspects of patient care were not assigned to the role of nurses. Both Shuriquie's  findings and those of this study highlight that doctors and patients located in different areas of the Middle-East hold the same views regarding the role of nurses in providing health-related information, which may suggest underlying cultural beliefs regarding healthcare roles.
Professional aspects of patient care
The study findings suggested role legitimacy for nurses in the domain of professional aspects of patient care. There was consensus across participants' views regarding all activities belonging to the role of nurses. All activities in the domain of the professional aspects of patient care represent three principle elements of nursing ethics: respect for human rights, accountability for practice, and development of competence by continuing education.  The role assignment indicated a general consensus across the healthcare personnel (nurse and doctor participants) working in Saudi Arabia and patient participants regarding role legitimacy within the domain of the professional aspects of patient care, which suggests the emergence of professionalism of nursing in Saudi Arabia. Thus, professionalism is not only about competency in practicing the profession but also about conduct of ethical practice. ,
Patient care management
The findings suggested incomplete role legitimacy for nurses in the domain of patient care management. According to the data, nurses working in Saudi Arabia were expected to carry out assessment, planning, implementation, and evaluation of patient care, which are all elements of the nursing process, but were not expected to carry out "diagnoses" although it is a key element of the nursing process.  Normally, "diagnoses" is the responsibility of the doctor; however, nurses gather a lot of information when they assess their patients so that they are able to make nursing decisions. 
Indeed, the ability of nurses to process information and make sound judgments has been identified as one of the key components of quality practice.  This activity "diagnosing a range of common conditions" may have had a dual meaning to the participants as the nursing process includes a nursing diagnosis prior to care planning and is an essential component of nursing practice which draws upon nurses' cognitive skills. However, it may be the case that the study participants considered the term "diagnosis" as not belonging to the nurses' role.
This incomplete role legitimacy may affect the future of the nursing profession in Saudi Arabia as nurses are not decision makers. Decision making advances nursing practice as nurses are able to demonstrate more effective integration of theory practice and experiences along with increasing degrees of autonomy in judgments and interventions.  In addition, the ICN (2012)  identified decision making as part of the nurses' role in order to be able to perform collaborative care. Therefore, healthcare policy makers in Saudi Arabia should consider empowering nurses to become decision makers. Nurses in Saudi Arabia need to be allowed to perform the nursing process in its entirety (assessment, diagnosis, planning, implementing, and evaluation) in order to improve their critical thinking/analysis and develop their decision-making skills. , This may also ultimately have a positive impact on the nurses' job satisfaction and the quality of patient care being delivered.  Interestingly, this incomplete role legitimacy was also noted in a study of Jordanian nurses. 
As a conclusion, the consensus that emerged across all participants regarding nurses' practice suggested that nurses achieved role legitimacy within the domain of meeting the physical needs of patient care, the professional aspects of patient care, and patient care management, with unclear evidence of role legitimacy regarding the psychosocial and communication aspects of patient care. The doctor and patient participants compared to the nurse participants were reluctant to assign activities within the domain of the psychosocial and communication aspects of patient care to the role of nurses perhaps reflecting medical domination, patients' preferences, and nurse-patient communication barriers.
Thus, the role legitimate of nurses in Saudi Arabia appeared to be shaped within the traditional role of nursing as they are not involved in patient education and intrapersonal communication. This traditional role needs to be addressed if nurses are to contribute significantly to improving the health of patients. Unlike other countries, Saudi Arabia faces a number of challenges to improve the role legitimacy of nurses. For example, the healthcare policy makers need to consider: empowering nurses to be decision makers in order to advance nursing practice in Saudi Arabia; reforming the nurse registration requirements to ensure language competence; recruiting more nurses from other Middle-East countries, thereby assuring the sharing of the same language with patients; providing a good quality interpretation service to improve nurse-patient communication; and increasing the number of Saudi nurses in the nursing workforce.
In addition, more research is needed to understand the nature of nursing practice in the Middle-East and Saudi Arabia in particular, and the perspective of patients as consumers of nursing practice.
| Acknowledgment|| |
The author thanks all study participants for sharing their responses and views with her.
The author is grateful to the Medical Services Division of the Ministry of Defense in the Kingdom of Saudi Arabia for providing her full sponsorship to conduct her study.
| References|| |
|1.||International Council of Nurses (ICN). Position statement on scope of nursing practice, 2004. Available from: http://www.icn.ch/psscope.htm. [Last accessed 2012 Jul 05]. |
|2.||International Council of Nurses (ICN). The ICN definition of nursing, 2012. Available from: http://www.icn.ch/definition.htm. [Last accessed 2012 Jul 05]. |
|3.||Aldossary A, While A, Barriball L. Health care and nursing in Saudi Arabia. Int Nurs Rev 2008;55:125-8. |
|4.||Brown C, Busman M. Expatriate healthcare workers and maintenance of standards of practice factors affecting service delivery in Saudi Arabia. Int J Health 2003;16:347-53. |
|5.||Saudi Commission for Health Specialties (SCFHS). Professional Registration and Classification, 2012. Available from: http://www.eng.scfhs.org/Registration/Registration_1.php. [Last accessed 2012 Mar 19]. |
|6.||Abu-Znadah S. The inspection of nursing regulation in Saudi Arabia, 2005. Available from: http://www.moh.gov.om/nursing/The%20inception%20of%20nursing%20regulation%20in%20KSA.htm. [Last accessed 22 Oct 2007]. |
|7.||Omer T. Nursing scientific board at the Saudi commission for health specialties. The 4 th International MSD Nursing Conference, 2012. Jeddah, Saudi Arabia. |
|8.||Machin T, Stevenson C. Towards a framework for clarifying psychiatric nursing roles. J Psychiatr Ment Health Nurs 1997;4:81-7. |
|9.||Lewis S. Extent of shortage will be known only when nurses spend all their time nursing. BMJ 2002; 325:1362. |
|10.||McCloskey J. Redefining the role of the nurse. Imprint 1986;33:53-62. |
|11.||Mansour AA. Nursing in Saudi Arabia as perceived by university students and their parents. J Nurs Educ 1992;31:45-6. |
|12.||Al-Omar BA. Knowledge, attitudes and intention of high school students towards the nursing profession in Riyadh city, Saudi Arabia. Saudi Med J 2004;25:150-5. |
|13.||Fitzpatrick JM, While AE, Roberts JD. Measuring clinical nurse performance: Development of the King's Nurse Performance Scale. Int J Nurs Stud 1997;34:222-30. |
|14.||Shuriquie, M. The legitimate role of the medical-surgical staff nurse in Jordon: the view of patients, doctors and nurses. Ph.D. London: King's College London, Florence Nightingale School of Nursing and Midwifery; 2006. p. 321-24. |
|15.||Tumulty G. Professional development of nursing in Saudi Arabia. J Nurs Scholarsh 2001;33:285-90. |
|16.||Flaherty J, Gaviria F, Pathal D, Mitchell T, Wintrob R, Richman J and Birz S. Development instrument for cross cultural research. J Nerv Ment Dis 1988; 5:257-63. |
|17.||Allen D, Lyne P. Nurses' flexible working practice: some ethnographic insights into clinical effectiveness. Clin Eff Nurs 1997;1:131-40. |
|18.||Allen D. The nursing-medical boundary: a negotiated order? Sociol Health Illn 1997;19:498-520. |
|19.||Dowling S, Martin R, Skidmore P, Doyal L, Cameron A, Lloyd S. Nurses taking on junior doctors' work: A confusion of accountability. BMJ 1996;312:1211-4. |
|20.||Allen D. Re-reading nursing and re-writing practice: Towards an empirically based reformulation of the nursing mandate. Nurs Inq 2004;11:271-83. |
|21.||McKenna HP, Hasson F, Keeney S. Patient safety and quality of care: The role of the health care assistant. J Nurs Manag 2004;12:452-9. |
|22.||Dilorio C, Manteuffel B. Preference concerning epilepsy education: opinions of nurses, physician and persons with epilepsy. J Neurosci Nurs 1995;27:29-34. |
|23.||Holmes KL, Lenz ER. Perceived self-care information needs and information - Seeking behaviors before and after elective spinal procedures. J Neurosci Nurs 1997;29:79-85. |
|24.||Luna L. Culturally competent health care: A challenge for nurses in Saudi Arabia. J Transcult Nurs 1998;9:8-14. |
|25.||Aboul-Enein FH. Personal contemporary observations of nursing care in Saudi Arabia. Int J Nurs Pract 2002;8:228-30. |
|26.||Reeve K, Byrd T, Quill BE. Health promotion attitudes and practices of Texas nurse practitioners. J Am Acad Nurse Pract 2004;16:125-33. |
|27.||Freeman GK, Rai H, Walker JJ, Howie JG, Heaney DJ, Maxwell M. Non-English speakers consulting with the GP in their own language: A cross-sectional survey. Br J Gen Pract 2002;52:36-8. |
|28.||Aboul-Enein FH, Ahmed F. How language barriers impact patient care: A commentary. J Cult Divers 2006;13:168-9. |
|29.||Fitzpatrick J, While A and Roberts J. The role of the nurses in high-quality patient care: a review of the literature. JAN 1992. 10:1210-19. |
|30.||Butterworth T, Bishop V. Identifying the characteristics of optimum practice: Findings from a survey of practice experts in nursing, midwifery and health visiting. J Adv Nurs 1995;22:24-32. |
|31.||Oermann MH. Consumers' descriptions of quality health care. J Nurs Care Qual 1999;14:47-55. |
|32.||Oermann MH, Templin T. Important attributes of quality health care: Consumer perspectives. J Nurs Scholarsh 2000;32:167-72. |
|33.||Oermann MH, Harris CH, Dammeyer JA. Teaching by the nurse: How important is it to patients? Appl Nurs Res 2001;14:11-7. |
|34.||International Council of Nurses (ICN). The ICN Code of Ethics for Nurses. Geneva, Switzerland: International Council of Nurses; 2005. p. 6. |
|35.||Nursing and Midwifery Council (NMC). Make the care of people your first concern, treating them as individuals and respecting their dignity. The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London, United Kingdom: Nursing and Midwifery Council; 2008. p. 2-3. |
|36.||Rosdahl C, Kowalski M. Nursing process. Textbook of basic nursing. London: Lippincott Williams and Wilkins; 2003. p. 119. |
|37.||Royal College of Nursing (RCN). Defining nursing. London, United Kingdom: Royal College of Nursing; 2003. p. 2-3. |
|38.||Murray M, Atkinson L. Critical thinking in nursing. Understanding the Nursing Process in a Changing Care Environment. 6 th ed. New York: McGraw-Hill; 2000. p. 8-9. |
|39.||Marquis B, Huston C. Decision making, problem solving, critical thinking. Leadership Roles and Management Functions in Nursing Theory and Application. 4 th ed. Philadelphia: Lippincott Williams and Wilkins; 2003. p. 2. |
|40.|| Lu H, While AE, Barriball KL. Job satisfaction among nurses: A literature review. Int J Nurs Stud 2005;42:211-27. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]