Leadership experiences of nurse managers in a Saudi Ministry of Health Hospital: A focused ethnographic study

doi:10.21203/rs.3.rs-3639725/v1

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Leadership experiences of nurse managers in a Saudi Ministry of Health Hospital: A focused ethnographic study

https://doi.org/10.21203/rs.3.rs-3639725/v1

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Background: Vision 2030, which aims to provide all Saudi citizens with high-quality healthcare, is constrained by international and domestic shortages of nursing staff. Therefore, nursing directors have recommended the introduction of a professional career path, focusing on developing nurses’ leadership skills. However, despite widespread recognition of nurse managers’ key role in recruiting, retaining and engaging nurses, few studies have explored how Saudi managers are trained and acquire leadership skills and how they deploy them. This study aimed to explore how nurse managers view and experience leadership within their workplace.

Methods: An ethnographic study into the perceptions and experiences of nurse managers regarding their leadership development was undertaken in a Saudi hospital affiliated with the Ministry of Health. Periodic study visits to the hospital over 8 months were undertaken to collect qualitative data. They involved workplace and continuing medical education observations, an examination of relevant documents, informal interviews/discussions, and semistructured interviews with 21 nurse managers. A framework approach analysis was used to interpret and summarise the data.

Findings: The data were organised into four major themes: imbalanced power dynamics, no shared vision, workplace rituals and behaviours, and the need for learning.

This paper discusses the imbalance of power, which was also in line with other international studies. The hospital had hierarchical and transactional management structures and processes and a culturally pervasive and normalised capricious leadership approach that was framed by Wasta. This is aform of nepotism normalised to Saudi business practice but now officially recognised and condemned as corrupt by state legislators. A climate of fear and intimidation induced compliance, conformity, and adaptation by managers to the directorate diktats. However, they also used other strategies to subvert and avoid some of the directorate’s authority.

Conclusion: The notion that wasta was everywhere was pervasive within the hospital organisation and reported to be the root cause behind most of the dubious directorate decisions. It was used to enhance performance, obtain financial rewards, secure favourable work assignments, obtain meritless leadership promotions, and allocate staff arbitrarily. Paradoxically, while managers disparaged their experiences of the capricious use of wasta, some more vehemently than others, they also used it to get what was they assumed should be their due and occasionally at the expense of their colleagues.

Nursing

Leadership

Nurse Managers

Wasta

Ethnography

Framework Analysis

Although the Kingdom of Saudi Arabia remains one of the world’s twenty most successful economies and spends vast resources on health care, it continues to face major structural problems resulting from the rapid rise in demands for health services from the Kingdom’s increasing levels of fertility, leading to a growing young population, increasing lifestyle diseases, and survival into old age [1–3]. One of the principal objectives of the Saudi Council of Economic and Development Affairs Vision for The Future 2030 (2016) is improving health care and individual wellbeing for all citizens. However, the largest and persistent structural challenges to the Kingdom’s health care agenda are its continuing dependence on an expatriate workforce and one of the highest nurse turnover rates in the world [4–6].

In the face of these unrelenting nurse shortages, the government sought to develop its national workforce strategy to improve Saudi professional education and the quality and efficiency of health care providers to meet rigorous international standards [7]. While nursing education and clinical practice have developed significantly in recent years, AL-Dossary [8] claims that substantial national workforce and leadership challenges remain. The Kingdom’s vigorous use of a policy to recruit, employ and retain more Saudi nurses [9, 10] has not halted the alarming rates of nurse turnover [6, 11, 12].

Although Saudi-only nursing management jobs have continued to expand, national clinical nursing shortages have persisted and are compounded by challenges in the country's pre- and post-qualification education to meet workforce demand. Aldossary [13] and Alshammari [14] attribute the difficulty in attracting and retaining Saudi nurses, to an ill-defined scope of nursing practice and the lack of leadership, which impedes professional growth and keeps the nursing profession underdeveloped.

In the current era, nurse managers are required to lead effectively to facilitate their professional staff’s challenging work and provide them with the expected support by creating a healthy work environment and a stable workforce. Saudi managers are no exception [6, 15]. Numerous studies confirm that the most significant determinants of nurse dissatisfaction in Saudi Arabia attributed to intentions to leave, and turnover were associated with the management and leadership of the service [16–20].

The literature on Saudi nursing leadership reveals that building professional and positive relationships with staff nurses is vital for enhancing organisational commitment and job satisfaction, staff retention, and patient safety [17, 21, 22]. As Al-Yami et al. [22] found, work commitment and job satisfaction appeared to improve when nurses worked with managers using a transformational leadership style. This accords with Abualrub and Alghamdi [16], who concluded that if Saudi leaders are more aware of the factors that ensure the satisfaction of the nurses, they will make changes that enhance both nurses’ and patients’ satisfaction, which in turn improves nurse retention.

Because Saudi Arabia has a substantial multicultural nursing workforce, Saudi managers are expected to be both culturally sensitive nurse leaders and well-educated so that they can occupy future strategic posts [20, 23]. Those who currently occupy leadership positions in the nursing profession are calling for meaningful changes and a recognised independent role [24]. However, Tumulty [25] goes beyond this and encouraged the Ministry of Health to ensure a proper representation of nursing in the Ministry’s strategic hierarchy and decision-making, in addition to national programmes of leadership development.

Unlike other countries, to date, there is no national rollout of programmes of leadership development for nurse managers. There is only a local hospital-based in-service provision of taught Continuing Medical Education programmes that may or may not include leadership skills or be quality assured [26, 27]. However, the way nurse managers acquire and practise their leadership skills cannot be developed in a single training event or in a given timeframe. Instead, it is considered that leadership skills can only be improved through continuous effective education and opportunities to practice. As Alluhidan et al. [24] argue, the country’s ambitions for high-quality health care is dependent on recognising the contribution that can be made by nurses’ leadership capability development. But the dearth of reliable data regarding nursing leadership has, according to Aljohani [28], contributed to their failure to compete with international nurses’ professional advancement. Given that effective leadership plays an essential role in the overall organisational outcome and in shaping its culture, managers ought to be provided with activities such as formal and informal education programmes to develop nurse managers’ leadership knowledge, skills, and values. Furthermore, these activities need to be cost-effective and relevant to nurse managers’ professional needs.

Social constructionist notions have emerged in reaction to the conceptual and complexities of the disparate approaches used to study leadership [29–38]. It situates leadership in the observer's mind instead of the leader's personal qualities. This might explain why no standard and common definition of leadership is available. Leadership as a social construct can be understood as the meaning created by dialogue within groups in a particular context [39]. Accordingly, Fairhurst and Grant [40] argue that the majority of social constructionists consider language as the process by which meaning is negotiated and formed. The basic assumption is that leadership is a socially constructed notion where the process is a co-construction between people who sometimes lead and sometimes follow.

Focusing on the context of leadership, according to Grint [41], leaders establish their reality within which they transform their decisions into actions. However, Uhl-Bien et al. [42] have suggested that followers must be amenable to influence by a phenomenon, they do not need to be influenced by individuals. Thus, the nurse managers' experience of leadership in their workplace is not embodied by any one leader but is a product of the managers' collective social discourse and interactions over time. The context of a hospital community is where and how the nurse managers have developed their understanding and made individual sense of their assigned workplace role.

Since little is known about how Saudi nurse managers develop their leadership skills and knowledge within the hospitals' context, a focused ethnography was undertaken to provide unique stories that articulated the managers' experiences. A study was undertaken that would allow the MOH and the hospitals’ decision-makers to understand the needs of the nurse managers and their aspirations for leadership development. It will also provide a foundation upon which to evaluate the facilitators and barriers experienced by managers' leadership development and form the basis for understanding the changes that may be required for developing Saudi nurse leaders in the future. More specifically, the research aimed to explore the perceptions and experiences of nurse managers’ leadership development in a Ministry of Health (MOH) affiliated hospital in KSA through the data collection methods of focused ethnography (FE).

First described by the German sociologist Knoblauch [43], FE is a pragmatic but efficient approach to the study of highly differentiated cultural groups. As Cruz and Higginbottom [44] explain, it narrows the study’s focus to just one cultural trait rather than attempting to study the culture in a comprehensive manner that encompasses all its manifestations. It has a shorter time frame which allowed a focus on nursing leadership, rather than every element of nursing management or nursing practice. An FE approach proved suitable for several reasons. Firstly, the approach allowed me to home in on a narrow and particular area of inquiry, nurse managers in a regional hospital in Saudi Arabia. Secondly, as a staff nurse and a Saudi national, I am already completely immersed in the complex and specific culture being investigated. A further understanding of a very specific aspect of nursing management (leadership) was required, and so sensitive, immersive, and in-depth methods were required to thoroughly investigate this area of study. Therefore, I was immersed in the nursing management culture of one MOH hospital for several months. I undertook intermittent field visits collecting data using participant observations of management meetings, clinical departments, and CME leadership lectures. I also undertook semi-structured interviews with 21 nurse managers in differing roles as well as an analysis of relevant and available hospital documentation.

The emphasis in this approach is on the communicative experiences and activities instead of on social aspects of a traditional ethnography [44–46]. The culture of Saudi Arabia is focused on social organisation, and the people observed are a group of qualified nurses (nurse managers from different managerial levels). This research involves the interpretation of their social interactions, behaviours, and perceptions related to their experiences of development for leadership in one hospital in the north of the country. Apart from the nature of leadership, the events and processes within the hospital for offering leadership practices and whether the environment was suitable and enabling for leadership captured. The aim of this was to demonstrate the complexity of leadership, and the impacts of health policy, local culture, the political structure of the organisation, and other demographic variables [47, 48].

Finally, the FE approach is highly suitable for answering particular, specific, detailed questions (such as in this research) as it is characterised by the “conceptual orientation of a single researcher” [49], it is focused on the discrete organisation or social group, it is a problem-specific approach and involves selected few participants who have specific, in-depth knowledge, and it involves episodic participant observation [44, 50].

Like all public hospitals in Saudi Arabia, the hospital under study was affiliated with The Ministry of Health (MOH) which is also responsible for the supervision of primary healthcare clinics, as well as hospitals in the private sector. It is responsible for formulating health policies, strategic planning and hiring healthcare employees for its hospitals and healthcare facilities [51–53]. The nursing workforce is required to have a licence to practice and need to achieve certain CME credit hours to maintain their licensure with the registering body who recommends and approves and recommends the hospital provides [54].

Whilst Arabic is the official language, English is widely spoken as a second language by nurses [55] and required to communicate with their predominantly multicultural workforce. However, most patients do not speak English, and this can adversely impact communication between international health care workers and patients [56].

With exception of the nursing director, the MOH hospital directorate, is comprised of all-male hospital directors and deputies. The other hospital managers for clinical departments and the CME department were predominantly female and occupied administrative non-clinical roles of charge nurses, head nurses and supervisors [26].

During the first phase of my fieldwork, I immersed myself in the operations of the nursing departments to gain first-hand experience of the professional structure and social duties of nurse managers’ working environment, while also recording reflexive memos. The norm of gender separation, which is pervasive’within Saudi culture, was clearly visible throughout the hospital, with both male and female Saudi nurses and their managers rigidly adhering to this norm. Despite an overall shift in this norm and the emergence of some degree of flexibility within healthcare settings, a number of studies have found that gender separation continues to be observed in healthcare environments, particularly by female Saudi nurses [10, 17, 57]. Although the male and female nurses strictly maintained physical distance, they nevertheless communicated regularly through a WhatsApp group to coordinate their work.

Data collection

A range of qualitative methods were used to collect data for the following reasons: (1) to avoid the bias and limitations associated with a single-method approach, (2) to ensure that the data were reliable and credible and (3) to build a comprehensive image of leadership in the environment under study. Using triangulation data collection approach facilitated the discovery of fundamental phenomena and ensuring the validity of the findings [58, 59]. Data were gathered from several sources: ward rounds while sitting in on meetings as a participant-observer, training events, informal and formal semi-structured interviews, field notes, reflexive memos and the analysis of policy documents.

The nurse managers participated in five informal interviews as well as one-to-one interviews. Individual nurse managers were selected for one-to-one interviews from a sample of those who had previously completed a hospital leadership development programme. The sample size was n = 21, which though small, nevertheless yielded rich data [44, 60] and produced the necessary data saturation for obtaining reliable and dependable findings [61].

Data analysis

The information collected during the interviews was triangulated with observations of various events and documentary analysis to produce comprehensive data which could then be analysed [62]. Each method of data collection allowed for the collation and comparison of various strands of information about leadership events, leading to a well-rounded understanding of the subject. Thus, a problem which came to light during a workshop could be examined in greater detail during a semi-structured interview, or highlighted, assessed and developed further by referring to the documents. This does not imply that one particular method of data collection is better than another; rather, each method required the performance of independent analysis and comparison. Consequently, the convergence of the findings would confirm their validity in spite of the use of different data collection methods [63–65].

Framework analysis (FA) was chosen as the data analysis method because it is best suited to analysing data linked to an interpretive methodology [66]. Moreover, while it is not closely associated with any particular methodology [67], FA is frequently used in nursing research studies [68].

FA provides an overall structure within which to code the data before each category is examined. The resulting overview could be subjected to a detailed evaluation before the underlying elements are determined through a careful inductive analysis. Researchers who deploy FA must constantly question their initial data and move between different levels, following the spiral configuration of the data abstraction process. This type of analysis is designed to enable recognition of similarities and differences between the data, which facilitates confirmation of their meaning and importance in addressing the research questions [68]. Ritchie and Lewis [69] pointed out that one of the strengths of FA lies in its comprehensive yet flexible approach, while also being systematic and demonstrating the significance of linkages between the data.

The data was organised into four major themes: Imbalanced power dynamics, No shared vision, Workplace rituals and behaviours, Need for learning. This paper will discuss the first major theme of the Imbalance of Power which encapsulates three sub-themes Wasta is everywhere, Personal relationships, and Directors’ influence.

Imbalanced Power Dynamics

The hospital confirmed the description of an Arab organization as classically described by Hofstede [70], who classified an organisation into four dimensions on how a management organisations’ culture can be socially structured and shaped. Here, culture was not innate but a form of

“…collective programming of the mind that distinguishes the members of one group or category of people from others.” [71]

This programming influences the mental modeling or patterns of thinking which are expressed as human emotions of fear, anger, love, joy, sadness, and shame. The mental models are all culturally learnt, observed, and modified from both the social environment and uniquely personal experiences. Although criticised, Obeidat et al. [72] contend that the concepts continue to retain their relevance. Whilst there may be similarities between national cultures and organisational cultures, they are not the same; some factors influence people to join them, stay, or leave, but no one is completely immersed in them forever.

The hospital organisation was observed to be a highly centralised structure, where a few directors have all the power and make all decisions to which employees are expected to obey. Using Hofstede et al. [71] power-distance analogy, the director's interpersonal influence exerted on the nurse managers depended on how nurse managers accept that this power over them will be exerted disproportionately. However, this power can be passed to certain individuals which makes the power imbalanced.

1st Sub-theme: Wasta Is Everywhere

The imbalance of power within the hospital was best illustrated in the findings on the concept of Wasta; the Arabic name for a middle man or go-between and refers to a form of indigenous nepotism [73–75].

Whilst observing a meeting a senior manager commented:

“(Smiling) We should put individuals with a strong back in a good position, so they will get our back” Department 16 Observation

This was an overt declaration that giving support by employing someone as a favour, comes with the expectation of receiving them in return. According to Tlaiss and Kauser [73], doing favours for influential and powerfully connected people. Even if they have never met them, they can still exponentially increase a manager's connections, and access to benefit for them and their friends or family [76].

During the interviews with managers, when the mention of how wasta was used, it was nearly always accompanied by nervous laughter or other non-verbal gestures for instance:

“As I told you, if you have wasta or certain years of experience, with a little wasta of course (giggling), then you will be more likely to get promoted; not only in nursing but in other hospital departments. Wasta is stronger than anything else. I believe that wasta is not ‘good practice’, but if I don’t use it somebody who doesn’t deserve the position will take it (raising eyebrows, widely opening arms).” P2

This culturally pervasive power was normalised by a form of capricious leadership attributed to Wasta. Regarded as a form of Arab nepotism it is normalised to Saudi business practice, which is now officially recognised and condemned as corrupt by state legislators.

The hospital nurse managers, albeit that the majority were ambivalent about the morality of doing so it was used widely. The paradox of being widely used yet disparaged is common, as is the denial of the abuse of power [77]. However, in 2015, wasta has been identified by the National Anti-Corruption Commission (Nazaha) as the most corrupt practice in Saudi society with its prevalence attributed to the country’s administrative complexity and outdated laws [78].

But as Weir et al. [79] argue, wasta is simply regarded as part of the countries lifestyle choice where favouritism occurs based on race, region, religion, tribe, or family, and has similarities to Europe, Africa and China [74]. But in Saudi society, it is considered more important than any organisational goal and runs deep within the infrastructures of relationships. However, it is not an Islamic tradition and should not be judged from a religious or even a moral perspective, instead, the judgement should be based on its Arabic foundations. Simply put, it can be regarded as a form of western social capital, and whether wasta is used for good or bad will depend on the intentions of the individuals concerned [80].

2nd Sub-theme: Personal Relationships

the power of personal relationships often plays a critical role in determining who receives opportunities, resources, or benefits. Foucault [81] argues when power is exercised it becomes exposed which in turn allows it to be resisted or thwarted. Meaning that no matter what position nurses have within the hospital they can take advantage of this exposure. However, they used combinations of acceptance and using it to their advantage, confronting and condemning it, or silently communicating their passive resistance. For example, in another observation, the managers appeared to accept that change was a problem for them during the exchange but emphasized the power of the relationships:

…don’t pretend that you don’t know that … her brother is in the HR dept. So even if I give her feedback, what’s the point? (Looking dissatisfied), nobody can touch her, she has a strong back. She will call her brother, and nothing will happen, everything will stay as it is and this is our problem.

P22

During interviews, it was again accepted but used to advantage too:

“ I know personally, and please this is top-secret (laughing), I know some people here get promoted and receive incentives because they know someone up there (moves the right hand up). This is unfair, but unfortunately, it is obvious here in our hospital.” P5

“When I returned from my ------ I contacted my cousin in the Ministry of Health and he promised me that he will get me promoted to a good position once I returned to work, and he did.” P4

So personal relationship is a form of extraordinary power in social and professional settings that may be regarded as an abuse of power by Western organisations, but it is used as a form of arbitration or mediation to obtain a benefit that may be expected to be difficult to obtain [82]. In the Middle East, it is considered necessary to expedite official paperwork and procedures.

3rd Sub-theme: Directors’ Influence

This sub-theme arose as distinct from the others, because of the perceived influence of wasta power exerted by external and hospital executives. During one of the interviews with the managers, the hospital’s organisational chart was drawn on a piece of paper. It was a hierarchal structure with the hospital director at the top and two deputies. The nursing director was drawn as reporting to one of these two hospital deputies, in a middle management opposition position. Assuming that the hospital organisational chart demonstrated the accepted line of management, if not leadership accountability and responsibility, the managers were asked if that meant anyone wanting to contact the hospital director had to do so through the deputy or nursing director. The answer was surprising:

“Oh no, this is just the chart (laughing loudly, shaking head). Please, I will explain it to you, you are my guest today, this chart or hierarchy, if you like, has existed in all hospitals throughout the Kingdom, of course, I mean hospitals of the Ministry of Health because the Ministry created this hierarchy.” P10

This is an example of how Focaults [81] discourse on power was subverted and altered to allow this manager to undermine the official power structure. But what is also interesting, isthat the imposition of external power could be imposed on the hospital director and have the same effect as on the directors' staff. For example, one manager explained:

“When someone even bigger than the hospital director, let’s say from the general directorate, wants to transfer his cousin or friend so the hospital director, they won’t be able to stop him.” P4

The power of the directors was exemplified in the letters of appointment or transfer that were examined, the first statement in each is as follows: “Based on the authority that has been given to us by the MOH…” Considering wasta to be pervasive, Algumzi [77] argued that the exercise of managerial power is socially constructed and might not be the same as the typical understanding of power in Saudi society, referring instead to a key component of the social hierarchy of management and being employed as a tool of control. This control was evident in the examples from the observations, where the managers felt their authority was being undermined by the executive, and from their revelations on the effects this has on their morale and motivation:

…imagine that you are responsible for your staff who are all nurses, and suddenly you receive a call from the hospital director or as I told you a letter saying that nursing staff X will be transferred to Department Y, would you accept that? This is just disrespectful treatment of your staff… If you make decisions on our behalf, then why have us there. There is no need for me to play the role of the nurse manager, because yes, my title is nurse manager, but in fact, I just do what my superiors want me to do. I am sorry you may not want to hear this, but I can show you the letters in my office. If you were me, you would resign right?... Not always, but sometimes, I say to myself that maybe in the future things will change. Let’s hope for that” P10.

During a field observation, one manager was flaunting their use of their wasta by bypassing all the other line managers in the hospital structures and dealing with the hospital director directly. When asked how they were able to do that, the response was:

“…thank God, I have a good relationship with the hospital director and he believes in me.” Observation Department 3.

This paper offers a partial but unique insight into how Saudi nurse managers adapted to the capricious use of societies culturally pervasive use of wasta power, its impact on their commitment, understanding of their role expectations and the climate of their hospital community. Although leadership involves the use of power, it is neither a necessary nor a sufficient condition for leadership to exist [83]. However, the acceptance by others of the status of a person or persons within an organisation is central to their ability to exercise the power of leadership.

Wasta was not found to be an innocuous concept because it was reported as being used to enhance performance financial rewards, bestow favourable work assignments, meritless promotions and dubious staffing allocations. The nurse managers were observed to use their wasta to maintain what can be regarded as their in-group relationships with the directorate, sometimes at the expense of their out-group colleagues [84–86]. The paradox in these findings was akin to Algumzi [77] findings that the impact of wasta was both frequently experienced and personally used to get what was should be due. At the same time, the use of wasta was widely disparaged by all of the managers, the less connected more vehemently.

The nurse managers compliance, collusion, or resistance towards both the status and authority of the directorate depended upon their interpersonal relationships. Such relationships are often cited as based on the Arabic cultural factors of the tribe and extended kinship [20, 72, 87–89]. Therefore, if the notion of the power of the directorate was essentially based on the freedom of the managers to act out one of the three responses, and ensured the leadership remained capricious or arbitrarily enacted [90, 91].

Strengths and limitations of the study

This study had a number of strengths and weaknesses. A key strength was its design as a detailed, multi-method qualitative study for examining nurse managers’ experiences of leadership in the workplace. This approach is closely aligned with the healthcare component of the Saudi Vision 2030. Moreover, the study had a broad scope, and its unique findings are consistent with those revealed in the wider literature and research in the field of national and international leadership. However, the study also had a number of limitations. Although the research focused on nursing managerial leadership, the nurse managers working at MOH-affiliated hospitals are not expected to care for patients directly. Moreover, some clinical impacts of nurse managers’ leadership were included in the study but were not examined in great depth. Thus, further studies are required to explore these impacts. Additionally, only one MOH-affiliated hospital was examined in this research, which affects the generalizability of the findings. Specifically, they cannot be applied to other Saudi hospitals that are not affiliated with the MOH (i.e. those affiliated with the Armed Forces, National Guard, and the private sector).

FE: Focused Ethnography

FA: Framework Analysis

CME: Continuous Medical Education

HMC: Hospital Management Committee

Ethics approval and consent to participate

Ethical approval for this study was sought from the Ethics Committee of Research Panel at the University of Edinburgh (NURS037) and the Hospital Management Committee (HMC) where the study was conducted for ethical approval as well as extended access to nurse manager participants and all methods were conducted following the relevant guidelines and regulations (e.g., Declaration of Helsinki). All observations and one-to-one interviews arranged with the nurse managers during this research were preceded by a summary of the study’s aims and objectives, and an explanation of how and why the research would be undertaken. These information was provided through a Participant Information Sheet. Written consent forms were obtained before each interview and observation session.

Consent for publication

Not applicable.

Availability of data and materials

The author only used primary data that were collected from the participants during semi-structured interviews and informal discussions as well as fieldnotes for the sake of this study. Therefore, the database is in the author's possession and can be available on request from the author.

Competing interests

The author declares no conflict of interest, financial or otherwise.

Funding

This study has been funded by the Deputyship for Research and Innovation, Ministry of Education in Saudi Arabia.

Acknowledgments

The author expresses his gratitude to the Deputyship for Research and Innovation, Ministry of Education in Saudi Arabia for funding this research work through the project number (IF-2020-NBU_226). Also, to all the nurse managers who participated in this study and to the administrative staff at the hospital where this study was conducted.

Authors' contributions

I.A. Conceptualised the study’s aim, developed the design, conducted the fieldwork that consisted of multiple field visits, collected and analysed the data, and prepared this manuscript for publication.

WHO. World health statistics 2014. Geneva: WHO; 2014.
The Council of Economic and Development Affairs of the Kingdom of Saudi Arabia. National transformation program. 2016. https://www.vision2030.gov.sa/en/programs/NTP. Accessed 12 Nov 2020.
Saleh A, Otaibi AA. An overview of health care system in Saudi Arabia. Int J Manag Adm Sci. 2017;4:1–12.
Bozionelos N. Expatriation outside the boundaries of the multinational corporation: a study with expatriate nurses in Saudi Arabia. Hum Resour Manag. 2009;48:111–34.
Almutairi KM. Culture and language differences as a barrier to provision of quality care by the health workforce in Saudi Arabia. Saudi Med J. 2015;36:425–31.
Falatah R, Salem OA. Nurse turnover in the Kingdom of Saudi Arabia: an integrative review. J Nurs Manag. 2018;26:630–8.
Saudi Arabia’s Vision. 2030. National transformation program 2020. [cited 2021 Aug 11]. 2016. Available from: http://vision2030.gov.sa/sites/default/files/NTP_En.pdf.
Al-Dossary RN. The Saudi Arabian 2030 vision and the nursing profession: the way forward. Int Nurs Rev. 2018;65:484–90.
Alboliteeh M, Magarey J, Wiechula R. The profile of Saudi nursing workforce: a cross-sectional study. Nurs Res Pract. 2017;2017:1–9.
Mebrouk JJ. Saudization of nursing. Doctoral dissertation. Birmingham: Birmingham City University; 2018.
Falatah R, Salem OA. Nurse turnover in the Kingdom of Saudi Arabia: An integrative review. J Nurs Adm Manag. 2018;26(6):630–8.
Al-Haroon HI, Al-Qahtani MF. Assessment of organizational commitment among nurses in a major public hospital in Saudi Arabia. J Multidiscip Healthc. 2020;13:519–26.
Aldossary AM. The role legitimacy of nurses in Saudi Arabia. J Health Spec. 2013;1:28–37.
Alshammari F. Leadership styles of the nursing directors at the Ministry of Health, Kingdom of Saudi Arabia. POJ Nurs Pract Res. 2018;2:1–5.
Albejaidi F, Nair KS. Building the health workforce: Saudi Arabia's challenges in achieving Vision 2030. Int J Health Plann Manage. 2019;34:e1405–16.
Abualrub RF, Alghamdi MG. The impact of leadership styles on nurses’ satisfaction and intention to stay among Saudi nurses. J Nurs Manag. 2012;20:668–78.
Alotaibi J, Paliadelis PS, Valenzuela FR. Factors that affect the job satisfaction of Saudi Arabian nurses. J Nurs Manag. 2015;24:275–82.
Saleh U, O'Connor T, Al-Subhi H, Alkattan R, Al-Harbi S, Patton D. The impact of nurse managers' leadership styles on ward staff. Br J Nurs. 2018;27:197–203.
Al-Aameri AS. Job satisfaction and organizational commitment for nurses. Saudi Med J. 2000;21(6):531–5.
Algarni NA, McLaughlin P, Alqarni NM, Alotaibi MM. The effects of cultural aspects and leadership practices on the healthcare organisa-tions' performance: the case of Saudi Arabia. J Organ Manag Stud. 2020;1:1–18.
Al-Aameri AS. Job satisfaction and organizational commitment for nurses. Saudi Med J. 2000;21:531–5.
Al-Yami M, Galdas P, Watson R. Leadership style and organisational commitment among nursing staff in Saudi Arabia. J Nurs Manag. 2018;26:531–9.
Suliman WA. Leadership styles of nurse managers in a multinational environment. Nurs Adm Q. 2013;33:301–9.
Alluhidan M, Tashkandi N, Alblowi F, Omer T, Alghaith T, Alghodaier H, et al. Challenges and policy opportunities in nursing in Saudi Arabia. Hum Resour Health. 2020;18:98.
Tumulty G. Professional development of nursing in Saudi Arabia. J Nurs Scholarsh. 2001;33:285–90.
Alkhazim MA, Althubaiti A, Al-Ateeg H, Alkhwaiter M, AlNasser MM. Delivering effective continuous medical education in Saudi Arabia: some critical issues. Health Prof Educ. 2015;1:43–9.
Al-Shehri AM, Alhaqwi AI, Al-Sultan MA. Quality issues in continuing medical education in Saudi Arabia. Ann Saudi Med. 2008;28:378–81.
Aljohani KAS. Nursing education in Saudi Arabia: history and development. Cureus. 2020;12:1–6.
Meindl JR. The romance of leadership as a follower-centric theory: a social constructionist approach. Leadersh Q. 1995;6:329–41.
Moir MJ. Contextual leadership: the social construction of leadership in a comprehensive healthcare system. Doctoral dissertation. Ohio: Antioch University; 2009.
Grint K, Jackson B. Toward socially constructive social constructions of leadership. Manag Commun Q. 2010;24:348–55.
Maxwell CI, Greenhalgh AM. Images of leadership: a new exercise to teach leadership from a social constructionist perspective. Organ Manag J. 2011;8:106–10.
Billsberry J. Teaching leadership from a social constructionist perspective. J Manag Organ. 2013;19:679–88.
Konja V, Matic D, Lalic D. Social constructionist perspective of the leadership in Serbia. Eng Econ. 2014;25:437–49.
Martin TE. Framing leadership: the social construction of leadership within the academic field of communication studies. Cogent Soc Sci. 2017;3:1328794.
Lusiani M, Langley A. The social construction of strategic coherence: practices of enabling leadership. Long Range Plan. 2019;52:101840.
Northouse P. Leadership: theory and practice. London: SAGE Publications; 2018.
De Klerk R. The social construction of leadership: a follower-centric investigation into integrated re-porting. Doctoral dissertation. Hatfield: University of Pretoria; 2019.
Ospina S, Schall E. Leadership (re) constructed: How lens matters. InAPPAM Research Conference 2001 Nov (pp. 1–21).
Fairhurst GT, Grant D. The social construction of leadership: a sailing guide. Manag Commun Q. 2010;24:171–210.
Grint K. Problems, problems, problems: the social construction of ‘leadership’. Hum Relat. 2005;58:1467–94.
Uhl-Bien M, Riggio RE, Lowe KB, Carsten MK. Followership theory: a review and research agenda. Leadersh Q. 2014;25:83–104.
Knoblauch H. Focused ethnography. Forum. 2005;6:44–58.
Cruz EV, Higginbottom G. The use of focused ethnography in nursing research. Nurse Res. 2013;20:36–43.
Roper J, Shapira J. Ethnography in nursing research. Thousand Oaks, CA: SAGE Publications, Inc.; 2000.
Hammersley M, Atkinson P. Ethnography: principles in practice. Abingdon: Routledge; 2019.
Hartley J, Benington J. Leadership for healthcare. Bristol: Policy Press; 2010.
Jasper M, Jumaa M. Effective healthcare leadership. Oxford: Blackwell Publishing; 2019.
Higginbottom GM, Pillay JJ, Boadu NY. Guidance on Performing Focused Ethnographies with an Emphasis on Healthcare Research. Qualitative Rep. 2013;18(17):1–6.
De Chesnay M, editor. Nursing research using ethnography: qualitative designs and methods in nursing. Springer Publishing Company; 2014.51. Albejaidi FM. Healthcare system in Saudi Arabia: an analysis of structure, total quality management and future challenges. J Altern Perspect Soc Sci. 2010;2:794–818.
Ministry of Health, Kingdom of Saudi Arabia. Key indicators. 2016. https://www.moh.gov.sa/en/Ministry/Statistics/Indicator/Pages/Indicator. Accessed 13 May 2019.
Al Yousuf M, Akerele TM, Al Mazrou YY. Organization of the Saudi health system. East Mediterr Health J. 2002;8:645–53.
Ali A, Ali I. Quality issues in continuing medical education in Saudi Arabia. Ann Saudi Med. 2008. 10.5144/0256-4947.2008.378.
Mohammad A. Factors affecting English proficiency of Arabic student nurses: Future directions for educational developers in Saudi Arabia. Int J Adv Appl Sci. 2022. 10.21833/ijaas.2022.09.019.
Alshammari M, Duff J, Guilhermino M. Barriers to nurse–patient communication in Saudi Arabia: an integrative review. BMC Nurs. 2019;18:61.
Alghamdi MG, Topp R, AlYami MS. The effect of gender on transformational leadership and job satisfaction among Saudi nurses. J Adv Nurs. 2018;74:119–27.
Angrosino MV. Naturalistic observation. New York: Routledge; 2016.
Creswell JW, Poth CN. Qualitative inquiry and research design: choosing among five approaches. Thousand Oaks, CA: Sage; 2018.
Morse JM. Determining sample size. Qual Health Res. 2000;10:3–5.
Denzin NK, Lincoln YS. The SAGE handbook of qualitative research. Thousand Oaks, CA: SAGE Publications; 2017.
Flick U. Triangulation in data collection. In: Janice M, Lory J, editors. The SAGE handbook of qualitative data collection. Los Angeles, California: SAGE; 2018. pp. 524–38.
Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. BMJ. 2000;320:50–2.
Denzin NK. Triangulation 2.0. J Mix Methods Res. 2012;6:80–8.
Yeasmin S, Rahman KF. Triangulation research method as the tool of social science research. BUP J. 2012;1:154–63.
Pope C, Mays N. Qualitative research in health care. Malden, Mass: Wiley; 2013.
Hackett A, Strickland K. Using the framework approach to analyse qualitative data: a worked example. Nurse Res. 2019;26:8–13.
Smith J, Firth J. Qualitative data analysis: the framework approach. Nurse Res. 2011;18:52–62.
Ritchie J, Lewis J. Qualitative research practice: a guide for social science students and researchers. London: SAGE Publications; 2003.
Hofstede G. Culture's consequences: comparing values, behaviors, institutions and organisations across nations. Thousand Oaks, CA: SAGE Publications; 2001.
Hofstede G, Hofstede GJ, Minkov M. Cultures and organisations: software of the mind. New York: McGraw – Hill; 2010.
Obeidat BY, Shannak RO, Masa’deh R, Al-Jarrah I. Toward better understanding for Arabian culture: implications based on Hofstede’s cul-tural model. Eur J Soc Sci. 2012;28:512–22.
Tlaiss H, Kauser S. The importance of wasta in the career success of Middle Eastern Managers. J Eur Ind Train. 2011;35:467–86.
Alreshoodi SA. Negative institutional influences in the Saudi public sector: wasta, public service moti-vation and employee outcomes. Doctoral dissertation. Cardiff: Cardiff University; 2016.
Ramady MA. The political economy of wasta: use and abuse of social capital networking. New York: Springer International Publishing; 2016.
El-Said H, Harrigan J. You reap what you plant: social networks in the Arab world—the Hashemite Kingdom of Jordan. World Dev. 2009;37:1235–49.
Algumzi A. The impact of Islamic culture on business ethics: Saudi Arabia and the practice of Wasta. Doctoral dissertation. Lancaster: Lancaster University; 2017.
Alshalan A. Corrupt practices in Saudi Arabia: an analysis of the legal provisions and the influence of social factors. Thesis. Indiana: Indiana University; 2017.
Weir D, Sultan N, Van De Bunt S. Wasta: a scourge or a useful management and business practice? In: Ramady MA, editor. The political economy of wasta: use and abuse of social capital networking. New York: Springer; 2016. pp. 23–31.
Kropf A, Newbury-Smith TC. Wasta as a form of social capital? An institutional perspective. In: Ramady M, editor. The political economy of wasta: use and abuse of social capital networking. Cham: Springer International Publishing; 2016. pp. 3–21.
Foucault M. Power/knowledge: selected interviews and other writings, 1972–1977. New York: Vintage; 1980.
Cunningham RB, Sarayrah YK. Wasta: the hidden force in middle eastern society. Westport, CT: Praeger Publishers; 1993.
Bolden R. Distributed leadership in organizations: a review of theory and research. Int J Manag Rev. 2011;13:251–69.
Tajfel H, Turner JC, editors. An integrative theory of intergroup conflict. Organztional Identity Read. 2004;:56–65.
Kreindler SA, Dowd DA, Star ND, Gottschalk T. Silos and social identity: the social identity approach as a framework for understanding and overcoming divisions in health care. Milbank Q. 2012;90:347–74.
Brown R. The social identity approach: appraising the Tajfellian legacy. Br J Soc Psychol. 2020;59:5–25.
Lewis R. When cultures collide: leading across cultures. Boston: Nicholas Brealey International; 2010.
Almutairi A, McCarthy A. A multicultural nursing workforce and cultural perspectives in Saudi Arabia: an over-view. Health. 2012;3:71–4.
Alogaili KA. The influence of national culture on leadership styles in Saudi Arabia (Doctoral dissertation, University of Hull). 2017.
Pfeffer J. Power, capriciousness, and consequences. Harv Bus Rev. 2013;91:36–7.
Abbink K, Harris D. In-group favouritism and out-group discrimination in naturally occurring groups. PLoS ONE. 2019;14:e0221616.

No competing interests reported.

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Leadership experiences of nurse managers in a Saudi Ministry of Health Hospital: A focused ethnographic study

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Version 1

Abstract

Background: Saudi health care challenges

Nursing leadership in Saudi Arabia

Methodological considerations

Data collection methods

Study setting

Data collection

Data analysis

Findings

Imbalanced Power Dynamics

1st Sub-theme: Wasta Is Everywhere

2nd Sub-theme: Personal Relationships

P22

3rd Sub-theme: Directors’ Influence

Conclusion

Strengths and limitations of the study

List of abbreviationsMOH: Ministry of Health

Declarations

References

Additional Declarations

Status:

Version 1