Saudi Hospitals, Bureaucracy And Bullying

A colleague I used to work with recently asked me, don't I miss work? My first reaction was yes in a way I do miss it. I miss the patients mostly. I miss interaction with them and the opportunity of meeting so many different Saudis from all levels of society and learning about the culture and customs. Especially I miss having the Bedus as patients and seeing those smiles on the pediatric patients faces.
Read more about quirky bedouin patients here: :http://blueabaya.blogspot.com/2010/06/bedouins-as-patients.html
And more about why I love working with Saudi patients here: http://blueabaya.blogspot.com/2010/11/thank-you-my-dear-saudi-patients.html
Learn about the amazing Saudi hospitality I experienced with patients here: http://blueabaya.blogspot.com/2011/12/saudi-hospitality.html

Patient care was always the best part of the job. Naturally I miss some co-workers as well. Many, many awesome people from all over the world I was lucky to meet along the way. I made some great friends and found many like-minded people during the years. I miss the social aspect of work and of course the extra money, who wouldn't!

What I don't miss in particular however is the bureaucratic nature of the hospital. Everything is just so DIFFICULT. Things don't work anything near to how they do in the west although the hospitals claim to be run by the American model. This is 100% a Saudi model complete with a mix of discrimination against sex and nationality, pecking orders, red tape, complicated policies, gross incompetence, random unfairness, cosmetic campaigns, some unprofessional management and so forth.

I don't miss that one bit. If I could just interact with the patients and not have to deal with the rest of the load, I would be running back. But in the end I think, is it worth the stress and hassle? At the moment I feel it isn't but I might change my mind in the future, who knows.

Let me give you an example of making simple things complex. Say I have a patient complaining of headache on night shift. I assess her pain and want to give her a mild pain reliever. What I would do in Finland:  Go check her computer file for any allergies, previous medications, current medications and illnesses, then proceed to medicine cabinet, open it with the keys I have to get the pain relief of my choice based on my education, knowledge and experience and then go give it to her and document it. Taking about 3 minutes in total.

For comparison lets look at how this simple procedure in Saudi-Arabia turns into something so complex and frustrating it will have you pulling your hair out in no time. Same scenario, patient with headache. I go check her file in the automated medicine dispensing system called PYXIS and find she doesn't have a pain killer on her list of approved medicines. Then I go to her paper files to double check if there's any written orders by the physician for a Tylenol (also known as paracetamol, the only drug a physician in a Saudi hospital will write as telephone order) that has been missed by previous nurse. No luck.

Next I have to page the correct doctor. I need to check which team my patient is under and find out who is the on call doctor. If I'm lucky I find it relatively quickly but it might be under a service i'm not familiar with and I will have to do a computer search. I page the number and wait for a reply. If I'm lucky he might actually call back within minutes. According to policy I have to wait 10 minutes. The time goes by and I call again, no reply. Another 10 minutes and finally a reply, the doctor was busy (in some cases, he was sleeping).

Next I have to explain to the doctor the whole history and current condition of this patient just to get this simple medication that anyone can purchase by the truckload at any Saudi pharmacy no questions asked. He finally gives the telephone order and I write it down in the file. Another nurse has to come sign it with me as a witness. The order is STAT meaning the pharmacy should prioritize and activate it right away.

Next I have to fax the order to the pharmacy. The pharmacy staff may or may not be helpful. Usually the latter. I wait for a while next to the machine tapping my fingers on it and then decide to log in to check if the pharmacy has activated the medicine in the machine yet (nothing comes out of this machine without it being on the patients list, not even hand cream). Naturally sometimes nurses take the same drug out under other patients files but this is not the correct way to do it.

Meanwhile the patient has rang the call bell every three minutes. Because I didn't have time to go to their room and none of the Asian colleagues sitting nearby gossiping in their own language are offering help to resolve the issue, the angry relatives have now ventured out of the room to the hallway demanding for pain relief. I have a reassuring conversation trying to explain the procedure to the shouting male relative and they may or may not calm down and go back to the room.

After waiting another 10 minutes I call the pharmacy and in the most polite way possible (knowing the night shift person is usually in the worst of moods) remind him of the missing STAT order. He goes nuts on me and slams the phone on my ear. I take a deep breath and go back to the machine. Someone is using it so I have to wait until they finish. The relative is breathing down my back looking at me like I'm the most incompetent, lazy nurse in the world.

Finally I get the medicine out and can go give it to the poor patient who has had to wait in the worst case scenario for over an hour for this basic medicine. For nurses the priority is always the patient and their well-being and not being able to help because of these silly limitations imposed on the nurses is very annoying.

The nurses in Saudi hospitals are treated as incompetent, unreliable and uneducated staff. Mere maids sometimes. At least this is how the western nurses often feel about it because they are used to something very different. The lack of independence in the nursing field is the single most maddening and frustrating factor for most western nurses here. It comes up in every aspect of a nurses work in Saudi, not just giving medications, but everything. A nurse has to have doctors orders to give water to the patient after surgery, sometimes to change her position or get her out of bed, or even for applying skin moisturizer (no joke people!) Sometimes it feels as if our whole education was a just waste of time.

So as we were chatting with this colleague she told me how things are still the exact same on the ward. The same problems still exist despite a cosmetic attempt to correct some issues. Such as the bullying. This is not only a problem specific to the ward I worked on, but this particular organization as a whole and in fact the entire Saudi-Arabia wherever there are mixes of nationalities.

The reasons behind the bullying problem are complex but ultimately it has to do with human nature and psychology. Regardless of our backgrounds, religion or nationalities, humans will start acting in certain ways and displaying negative behaviors if placed under certain circumstances. When one nationality is paid 10x less for the same job than another just based on their passport color, problems will arise. When the majority of the staff are of the lower paid nationalities and there are only a small minority of personnel getting the significantly fatter paycheck, more problems arise. If management is under-educated and lacks skills to deal with workplace violence, more issues arise. If the organization and system favors bullies and allows them to easily climb the ladder to higher positions, obviously the problems worsen. And when there are no set rules or policies against bullying, the problem not only persists, but gets worse by time.
This is the sad equation in many Saudi work places, particularly hospitals where people work under extremely stressful circumstances.

The typical Saudi way of doing things at the workplace is having things appear as if something is being done, but in reality it was just for show. Posters, campaigns and workshops against bullying can be issued to make it seem as if the problem has been dealt with. Behind the scenes however if a victim of bullying steps out, or someone exposes the problem or dares talk about it, he or she will in fact be facing denial or brushing off of the issue from most of the management. In other words problems are best swept under the carpet and the people who speak out better silenced.

Now this is typical for most workplaces around the world, bullying will always be a problem and management usually won't know how to or want to deal with it. In Saudi-Arabia the issues however become more severe and the victims more vulnerable. For one the staff is mostly a mix of expats, all or most far from the support of their families, working in a land with strange culture and customs, perhaps suffering from culture shock. They work under pressure to perform and sometimes using a foreign language. The mix of nationalities can be rewarding in many ways but it can also back fire if there's a significant imbalance and one nationality feels spite for another because of the differences in treatment and salaries.

I could go on about this problem but I will leave that to another post.

So after talking to my colleague and thinking it over, I don't miss the hospital and the problems that lie within it but I DO miss the patients!