Tuesday, May 22, 2012

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.
saudi bully
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!


Dohan Diiva said...

Irtisanouduin omasta tyostani ja eilen oli viimeinen tyopaiva koululla! Osa tuosta kertomuksestasi on kuin suoraan meidan koulun ilmapiirista - kiusaamisen osalta. Oli aivan kasittamatonta kuinka opettajat kiusaavat toisiaan ja OPPILAITA. En sitten jaksanut edes vuottakaan tuossa paikassa. Toisaalta harmittaa, koska oppilaita tulee ikava, mutta toisaalta ajattelen ettei mun tartte kestaa sita kiusaamista kolleegoideni puolelta...

*Cinderella* said...

This does not surprise me at all, so glad I didn't decide to work as a nurse in Saudi. But you know I get the same treatment here, the bullying, the main reason why I quit nursing in the first place after 3 years of nursing with only one year to go I couldn't take it anymore, I was emotional breakdowns because of the way i was being treated by some of the staff, mainly because of my hijab and being an Australian revert. I had one lady who was in charge of the students after 3 years of nursing plus working as an AIN where I never had a problem with my work, tell me I don't have enough empathy to be a nurse and I should think of changing my majors cause my patients deserve someone better to take care of them. And then i found some of the students I know who wear hijab recieved similar treatment from staff and some of the saudi students I study with told me some of the stuff they were told. Makes me so angry. I knew I was a good nurse, it may have taken me a little longer to

JoHanna said...

Your blog entry is so interesting again, Laylah.
Yes, the nursing field can be so stressful in any country. Your story brings back memories for me here in the US when right after my nursing school I started to work in a mid-sized hospital in Dallas. Stress and the heavy patient load were the biggest burdens at that time for me.
However many of those issues that you mentioned are also here. Plus: nurse-to-patient ratio, mandatory overtime, how to keep boundaries between nurses and patients etc. American nursing organizations are trying to make improvements and they have been able to bring up these issues to the daylight however the nursing is so imperfect field because often times nurses don't have autonomy. We are required to please others.

I remember one time when I worked at the hospital and my peer nurse during that shift was a nursing school faculty member. According to her there are many many females who end up becoming nurses because in one point of their lives they had been abused by somebody and that's why they can put up with so much in their working environment. And if you think about it, how would someone in her right mind become a nurse?
And yet, what could be better than nursing! ;)

But at least here it is easy to do some job hopping. You can expand your horizons because nurses are still so much in demand on the job market. I've been lucky to experience with other areas of nursing: schools, nursing homes and a bit of home health. Even though right now I'm not working that much and yet my heart is yearning to go back.

Wow, the pay discrimination sounds awful if it is that obvious.
So I imagine the American educated nurses make the big bucks over there, right? Good recruiting agencies...
Sori tuli vähän pitkä... Terkut taas täältä nyt jo melko kuumasta Teksasista! :)

Geoff said...

As the holder of a blue passport, I've had all sorts of issues with trying to rectify the pay discrepancy in my own head... I will however say that I only received about a 40% pay increase to come to Saudi. Many of my lower paid colleagues have received double or triple their home country wages...it might not make the system perfect, but it does help me justify it...a little.

On the Tylenol issue though, I've worked in 3 US hospitals as a hospital based paramedic and neither us or the nurses can give anything other than ice chips without a written order. Now I never stray farther than the ER or ICU so maybe they can on the floor's, but not to my knowledge. I once had a man walk/stumble into the ER waiting room with a severe allergic reaction, bordering on anaphalactic shock. (His face was the size of a basketball). I used the emergency trauma code to pull epinephrine out of the pyxis and administered it sub-Q while a tech helped me get him on 02 and the monitor. I then started an IV and finally got the Doctors attention. Thought I'd get a pat on the back...instead I got told that practicing medicine without a license is illegal...had to do a lot of paperwork for that "stunt"

Noor said...

OH man my dh hates it at KFSh just like you said they say its American but its 100% Saudi and a lot of BS he has been under so much stress since being there the past 4 years.

Noor said...

btw do you not have a blog button I wanted to add one to my blog love list

Layla said...

kuwaitin kaunotar-valitettavan yleista siis tuo kiusaaminen. Onko siella sama homma etta passin mukaan menee palkanmaksut?

Layla said...

Sorry to hear that Angel! It's so unfortunately common within the profession, bullying that is. Believe it or not they also used the hijab as excuse for bullying of all places, in Saudi!!

Layla said...

yes it goes according to passport, not even nationality as such, since many filipinos go to Canada first to obtain the passport, then come here to get the 10x more salaries.
The comment above in Finnish also addresses the problem of bullying by teachers in the region!

Layla said...

JoHanna-thanks for the comment, very interesting to read!
what do you mean by nurse patient ratio, it is too high there?
I heard that some of these issues were in the U.S too, but never thought they would be treated with so much suspicion and mistrust as the nurses here are. I guess I was wrong! Funny how the american nurses complain so much then! They should come to Finland to work for a while and then experience the Saudi way and the complete shock of how different things can be.

Yes the highest pay are american and australian next comes europe..well not all european countries are even the same! I will write a post on it because it seems to interest ppl so much!

Layla said...

Geoff-you're right, the issue is not as simple as it seems..

I am honestly shocked that nurses are not trusted in the U.S to give a simple tylenol. I mean in Finland I can even give a tylenol #3 without dr orders, if I see it necessary. For stronger narcotics I need another nurse witness and those medicines are closely controlled.
You would think that leads to lot of abuse and medication errors, but it's not the case.

Man that is just not right at all..I recommend you go work in Scandinavian countries next to be respected as professional and a colleague, not servant of doctors!

Layla said...

Noor I am clueless to blog buttons and such lol how do I get one? I wish I had the tweet and FB buttons ut they don't show up :(

JoHanna said...

Well, especially night shift nurses may have 8-9 patients to take care of, during the day the number may be around 5-6. It's a lot if you have to give many IV piggy bags, meds, change IV sites, communicate with docs, family, do stupid run around tasks e.g. ice chips for the patients and the list goes on and on... And then do not forget the endless documentation, don't even get me started with that.
I guess in Finland being a nurse is so different because ther you don't need to worry about the possible law suits. Here it is "if it wasn't documented, it wasn't done!"

Talal said...

It is a shame that you're talking about what some consider the best hospital in Riyadh, how about KSMC (alshemisy) where I work , things will soon get worse in KFSH as it having some management from ministry of health now.

yam2020 said...

Hope u r doing fine. I am very curious to know your update. Have you moved to Saudi? both ways wish you all the best.

yam2020 said...

Assuming that you have moved to Prince Nurah University, I am very curious to know ur update and ur reflection on our Saudi Culture.
All the best.

Anonymous said...

My aunt has worked at KFSH for over 20 years and the stories of abuse and bullying she has received over the years are maddening even though she's Saudi. It's a toxic work environment .

Dohan Diiva said...

Ei passi tietaakseni palkkaa muokkaa. Tuo koulun toiminta oli muuten aivan alyton

Pearl said...

Do doctors get bullied as well?

Layla said...

Pearl-They do, but in different ways. You know how the residents get "teased" and taunted by the higher ranking md's, something like this I guess goes on all over the world. I've noticed female residents have to be extremely tough to be able to tolerate the pressure and sometimes arrogance coming from their male colleagues.

Layla said...

flawlessvelvet-Oh gosh, sorry to hear that! Is she a nurse?

Layla said...

It is a shame really!

Anonymous said...

I wasn't really surprised when i read this. I'm Saudi and i expect these kind of things to happen in anything that is run by the government (that's not to say the private sector is any better). Corruption, bureaucracy, putting people in positions even though they're not qualified for them are things i don't expect to disappear at all. Now that you've mentioned how hospitals are run, ( i can tell by the picture that you work in THE TOP hospital in the country) things don't look so good, i'm a medical student and i don't plan to stay here after graduation, i don't have the capacity to deal with these sort of things.

Anonymous said...

Reminds me all too well of my experiences as a nurse in KSA! Just came across your blog while surfing the internet, have really enjoyed reading it. Please continue posting. And warmest congratulations on the birth of your beautiful baby boy...

Anonymous said...

I am American RN working here in Saudi. I've been in Critical Care for my entire career. I work in a fairly large ICU here with a 24h Intensivist so getting orders in a timely manner isn't too difficult. Dealing with the pharmacy and other departments is very frustrating and time consuming. Coming from the US,I can tell you that in no way,shape or form are things being done the American way...I have never worked in a more inefficient place in my life!
As far as pay...yes Americans are paid the most here, but I gotta tell you I made almost double what I make here back in USA....(I'm here for personal reasons ;)..)
I love our Nursing Director...but I'm not too impressed by the nurse manager.
The nurse to patient ratio here is 1:1...piece of cake...
The work schedule here is awful..shifting from nights to days and no consistency...WE do not do this in USA....you're either a day nurse or a night nurse with most places being self scheduling.
As far as respect...I have earned my respect from the doctors here and collaborate with them on the patient's care. I really don't give them a choice...lol
Also in the US we have standing orders for Critical Care patients regarding pain meds, electrolyte replacement, cardiac rhythm changes etc..
I am Muslim and I do wear hijab..here and in the US. No one ever said anything about it back home...besides..I dare them to...Here of course its not even an issue. I do love the patients here...human beings are the same all over the planet...:)

Layla said...

Thank you for sharing your views and experiences!